Sir, the recent article on Mouth cancer: presentation, detection and referral in primary dental care1 highlighted the importance of the general practitioner in aiding early diagnosis of oral cancer and appropriate urgent referral to secondary care, as per NICE guidelines.2
As a dental core trainee working in a busy maxillofacial unit, we see many cases of non-malignant and pre-malignant oral conditions.
A high amount of patients are also seen on the suspected cancer (SCA) two-week referral pathway. Dentists are required to assess for oro-mucosal lesions and refer for specialist review as deemed appropriate.
It can often be difficult to distinguish which referral pathway is appropriate, due to the constraints of assessing patients in general practice3 and the rise in so-called 'defensive referring' with the increase in GDC fitness to practise cases linked to delayed diagnosis of oral cancer.4
However, it remains the case that although oral cancer diagnosis rates are improving, only a small proportion of patients referred to the urgent pathway are in fact diagnosed with malignant conditions.
We decided to undertake a retrospective audit of SCA referrals, over 12 months, sent to the Oral and Maxillofacial Unit by GMPs and GDPs.
Of 155 head and neck referrals sent in 2018, 12 patients were diagnosed with oral cancer. Of the remaining 143 referrals, the majority of patients were diagnosed with potentially malignant and pre-malignant conditions, predominantly lichen planus, and the rest had no abnormal findings at all.
The relatively low proportions of oral cancer diagnosis reported across maxillofacial units nationally5 suggest that the urgent cancer pathway is being overused.
This poses the question of how the appropriateness of referrals can be assured to improve effectiveness and reduce significant strain on secondary care services.
Whilst it is clearly in patients' best interests that primary care practitioners are sending all cases for a specialist second opinion, or in fear of missing serious conditions, it could be suggested that further training and guidance may be needed for practitioners to direct patients to the correct referral pathway.
This would decrease the impact on service provision in secondary care and ultimately improve patient outcomes.
References
Lewis M. Mouth cancer: presentation, detection and referral in primary dental care. Br Dent J 2018 225: 833-840.
National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline [NH12]. 2015 but updated July 2017. Available at https://www.nice.org.uk/guidance/ng12/chapter/1-recommendations-organised-by-site-of-cancer#head-and-neck-cancers. (accessed April 2019)
McGurk M, Scott S. The reality of identifying early oral cancer in the general dental practice. Br Dent J 2010; 208: 347-351.
Gibson J. Oral cancer - CPD and the GDC. Br Dent J 2018; 225: 884-888.
Roy S, Anjum K. The two-week wait - a qualitative analysis of suspected head and neck cancer referrals. Br Dent J 2018; 225: 159-163.
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Tajmehr, N. Appropriateness of referrals on the suspected cancer referral pathway - a secondary care perspective. Br Dent J 226, 539–540 (2019). https://doi.org/10.1038/s41415-019-0283-x
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DOI: https://doi.org/10.1038/s41415-019-0283-x
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