The Changing Face of Head and Neck Cancer; How the Head and Neck One-Stop Clinic Has Evolved Since Conception

Abstract

Purpose

The purpose of this study was to compare the patient journey through the head and neck clinic across 13 years of service improvement. We aimed to compare pick-up rates of cancer; number of patients receiving tissue diagnoses at first visit; and number of patients who were discharged on their first visit.

Methods

In the one-stop head and neck cancer clinic, the demographic data, investigations and outcomes for 277 patients who attended in 2004 were compared to those of 205 patients who attended in 2017. The number of patients receiving ultrasonography and fine needle aspiration cytology was compared. Patient outcomes were analysed: specifically, the number discharged on first visit and the number of malignancies diagnosed.

Results

The pick-up rate for malignancy from 2004 to 2017 has remained stable (17.3% vs 17.1%). The number of patients receiving ultrasound has remained stable from 264 (95%) in 2004 to 191 (93%) in 2017. The number undergoing FNA has decreased from 139 (50%) to 68 (33%) (p < 0.01). The number of patient’s discharged on the first visit has significantly increased from 82 (30%) in 2004 to 89 (43%) in 2017 (p < 0.01).

Conclusion

The one-stop clinic provides an effective and efficient means of head and neck lump assessment. Since inception of this service, the accuracy of diagnostic investigation has improved over time.

Introduction

Cancer of the head and neck comprises malignancies originating from multiple primary sites including the oral cavity, nasal cavity, pharynx, larynx, thyroid and salivary glands [1, 2]. They represent the sixth most common cancer worldwide, and current trends suggest an increasing incidence [3]. Epithelial squamous cell carcinomas are considered the most common histological variant [4]. In England in 2016, over 12,000 new diagnoses of head and neck cancer were reported, with over 3500 associated deaths (see Table 1 for a detailed description) [5, 6].

Table 1.

Incidence and mortality of head and neck cancer by primary site [2, 3]

Site	ICD-10 code	No of registrations	Incidence per 100,000	Deaths
Mouth, lip and oral cavity	C00-C06	4311	16.9	1150
Salivary glands	C07-08	588	2.2	200
Pharynx	C09-14	2677	10.4	1065
Nasal cavity, ear and sinus	C30-31	505	2	130
Larynx	C32	1771	7.3	671
Thyroid	C73	3105	11.6	319
Total		12,957	50.4	3535

In 2004, the United Kingdom’s National Institute for Health and Care Excellence (NICE) published detailed guidance on the referral, investigation and treatment of head and neck cancers [7]. As part of this management strategy, they supported the use of ‘one-stop neck lump clinic’ which should include assessment by a clinician from a suitable specialty such as otolaryngology or oral and maxillofacial surgery, imaging with ultrasound (US) and if appropriate preliminary cytology results using fine-needle aspiration (FNAC). This approach to the initial assessment of suspected cancer presenting as a lump has been widely adopted [8, 9].

Multiple studies have shown that upon initial implementation of such services, they have been efficient and effective [10–12]. However, there remained some concern that a one-stop clinic was not the best way to evaluate patients presenting with suspected head and neck cancer [13].

This format has been used in Derriford Hospital, Plymouth for over a decade. We feel that not only is this service efficient, but it has also improved over time. The aim of this study was to evaluate the changes seen in the service over the last 10 years. We have studied whether the number of patients undergoing ultrasound and FNA has remained stable and whether we are now discharging more patients on the first visit.

Methods

All patients who attended the one-stop head and neck lump clinic at Derriford Hospital, Plymouth, in 2004 and 2017 were retrospectively studied.

A detailed proforma is completed for all patients who attend the one-stop head and neck clinic. Information pertaining to their presenting complaint, findings of their clinical examination, ultrasound and initial FNAC results (where applicable) is concisely documented. These written records, along with relevant results stored in the hospital electronic database, were accessed to collect data on all patients who attended the clinic in 2017.

In addition to patient demographics, data on a number of predefined clinical parameters were collected. This included reason for referral, clinical findings, investigative study undertaken, and relevant results. The outcome of the clinic appointment was also recorded and classified as to whether it involved discharge, further investigations or surgical intervention. A final diagnosis at the time of data collection was recorded where this differed from initial diagnosis in clinic.

These data were then compared to the corresponding information collected for patients who attended the same format one-stop head and neck clinic, in 2004. The number of patients undergoing US, FNAC and being discharged at first visit was compared across the two data sets and analysed using a chi-squared statistical test.

Results

The demographics for the patients included are shown in Table 2. They have remained largely consistent from 2004 to 2017. Men in their fifth decade comprise approximately 45% of attendances; however, the average age if malignancy is confirmed has risen from 60 to 69 years.

Table 2.

Demographics of patients attending the one-stop clinic in 2004 and 2017

Year	Patients	Male (%)	Average age (years)	Average age if malignancy (years)
2004	277	44	53	60
2017	205	43	56	69

The content and outcome of the clinic for individual patients are outlined in Table 3.

Table 3.

Percentage of patients undergoing US and FNA and being discharged on first visit in 2004 and 2017

Year	Patients	US (%)	FNA (%)	Discharged on first visit (%)
2004	277	95	50	30
2017	205	93	33	43

While the pick-up rate for malignancy has remained relatively unchanged from 2004 to 2017 (17.3% vs 17.1%), there has been a significant reduction in the number of patients undergoing FNA. Just over 50% (139/277) underwent the procedure in 2004 compared with 33% (68/205) in 2017 (p < 0.01).

Furthermore, there has also been a significant increase in the number of patients discharged on the first visit; in 2004, only 82 (30%) were discharged compared to 89 (43%) in 2017 (p < 0.01). A high proportion of patients in both respective years underwent an ultrasound scan (93–95%).

Discussion

The one-stop neck lump clinic was established to provide a streamlined assessment of patients deemed most at risk of having early or established head and neck cancer. After the single one-stop clinic, patients are either discharged or placed on a waiting list for further assessment and management. It is generally used as part of a nationally adopted 2 week expedited waiting list [14].

The success of such initiatives is in part augmented by public health campaigns which have proven effective in encouraging self-examination and health seeking attitudes towards head and neck cancer [15]. In turn, the vast majority of patients referred to the one-stop clinic are from primary care, either from general dental practitioners or family physicians. It follows that patients booked on the clinic must have passed the threshold of suspicion for malignancy or have displayed a red flag symptom in order to be accepted for referral. Surprisingly, however, the volume of patients being referred for assessed has slightly reduced, albeit the detection rate—as discussed further below, has remained the same. Such findings are in contradiction to contemporary medical literature whereby heightened patient expectation and the fear of medical litigation have resulted in an increased volume of inappropriate hospital referrals [16, 17]. The authors surmise that improved familiarity with head and neck cancer risk, combined with a greater emphasis on reducing health service costs, and adherence to guidelines by primary care clinicians, has resulted in an overall reduced number, but more appropriate, ‘high risk’ referrals.

Despite overall increasing trends in head and neck cancer diagnosis, the detection rate in the one-stop clinic run in Derriford hospital over the studied 13 year period has remained stable [3]. Geographic variation, increasing age, referral volume and detection methods are among several factors likely to impact on this finding. Though it would be favourable to infer that cancers are not otherwise being missed due to the consistent detection rate, it is probable that evolving aetiological variation still prevails. The national average cancer pick-up rate in routine outpatient head and neck clinics is significantly lower, thus reinforcing the merit of the current one-stop practice [13].

Traditionally, alcohol and tobacco consumption were considered the primary aetiological factors in the development of the disease, with older men being most affected [18]. However, epidemiological studies in recent years have highlighted the evolving nature of the disease with increased numbers of younger patients presenting, particularly with oral and oropharyngeal malignancies [3, 19]. Such changes are widely attributed to the oncogenic effects of human papillomavirus (HPV) infection. However, such findings are not mirrored in the current study. The average age at diagnosis is marginally higher in 2017 compared with 2004, representing a deviation from current trends.

A further change identified relates to the increased confidence on behalf of the overseeing clinicians in excluding malignancy as a differential diagnosis. Patients attending the one-stop head and neck cancer clinic are now more likely to be discharged with no further follow-up on their first visit, following assessment and examination. Although human factors such as improved clinical acumen and increased confidence in the system overall may play a role, it is more likely related to enhanced reliability of preliminary investigations. In the clinic, both ultrasound and FNAC are available chairside to aid in diagnosis. They are favoured due to their ability to rapidly image patients with an undiagnosed neck lump or suspected metastatic disease in the neck [20].

Concomitantly, advances in ultrasonography have given more weight to a radiological diagnosis in comparison with a histological diagnosis. This is evidenced by a dramatic reduction in FNAC employed between 2004 and 2017, when compared with ultrasound investigations which have remained consistent in the same period. Although ultrasound is widely accepted as being significantly operator dependent, the clinic in Derriford is run in conjunction with a consultant radiologist undertaking the investigations. The high proportion of patients undergoing an ultrasound scan suggests that the patients seen in the one-stop clinic were appropriate for that clinic template and required at least an ultrasound scan to aid diagnosis.

Conclusion

Head and neck cancers remain a significant source of morbidity and mortality. The 5 year survival rate is directly related to the stage at diagnosis, however, due to frequent late presentations, it remains relatively poor with an overall survivorship of approximately 50% [21].

Approaches such as the one-stop clinic to evaluate neck lumps are instrumental in ensuring prompt diagnosis and provide a vital framework in the overall management of head and neck cancer. Over the studied 13 year period, the service in Derriford hospital has proven an effective and efficient means of responding to referrals for head and neck lump suspicious for cancer. The service has evolved, resulting in more efficient discharges involving fewer visits to hospital and fewer unnecessary invasive procedures, ultimately preserving health service resources while providing a consistently high standard of patient care.

Funding

No funding was received in undertaking this research.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Declarations

Conflict of Interest

All authors declare that they have no conflict of interest.

Ethical Approval

This research complied with local ethical standards. All patient information has been anonymised.