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\begin{document}

\title{Routes to diagnosis of Hypopharyngeal cancer: A Single Centre Experience}



\author[1]{Helen Pearce}%
\author[1]{David Hamilton}%
\author[2]{Linda Sharp}%
\author[2]{Jennifer Deane}%
\author[3]{Matthew Kennedy}%
\author[1]{James O'Hara}%
\affil[1]{Freeman Hospital}%
\affil[2]{Newcastle University Population Health Sciences Institute}%
\affil[3]{Royal Victoria Infirmary}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\textbf{Routes to diagnosis of Hypopharyngeal cancer: A Single Centre
Experience}

\textbf{INTRODUCTION}

In the United Kingdom, hypopharyngeal cancer accounts for 3\% of head
and neck cancers, with an age standardised reported incidence of 0.63
per 10,000. (1). Cancer of the hypopharynx often presents late. Cardinal
symptoms of hypopharyngeal cancer include evidence of a neck mass, sore
throat, dysphagia, hoarseness and referred otalgia. Referral pathways in
patients with suspected head and neck cancer vary (1). They include but
are not limited to referral from a primary care setting, acute
presentation to secondary care and inter-departmental referral.

In 2015, the National Institute for Clinical Excellence (NICE)
established guideline NG12; Suspected Cancer, Recognition and Referral
Guidelines, which defined the symptoms indicating a possible head and
neck (H\&N) cancer that warrant further investigation (2). The two
symptoms pertinent to timely referral of hypopharyngeal cancer are
persistent hoarseness and neck lump. The Northern Cancer Alliance (NCA)
has used the NICE guideline to refine its 2 Week Wait (2WW) proforma to
be used by healthcare practitioners when cases of H\&N cancer are
suspected (3). Symptoms that were originally included on the 2WW
proforma, and pertinent to hypopharyngeal cancer, included dysphagia,
sore throat and referred otalgia. The NCA proforma does not include
these symptoms and only includes those recommended by NICE NG12
guidance. At the request of general practitioners (GPs), `unexplained,
persistent, unilateral enlargement or ulceration of the tonsil or
adjacent soft palate' were included. The proforma does include a free
text box encouraging primary care clinicians to describe concerning
symptoms that do not fit with the NICE NG12 symptoms. The other
symptoms/signs included on the NCA 2WW proforma relate to oral cavity
cancer detection. 2WW proformas vary across regional Cancer Alliances in
England, with many including dysphagia, sore throat and otalgia. This
study aimed to evaluate routes to diagnosis of hypopharyngeal cancer in
a large teaching hospital to establish if the current NCA 2WW proforma
is appropriate to capture suspected cases of hypopharyngeal cancer.

\textbf{METHODS}

\textbf{Basic settings and patient selection}

This was an observational case review study of all patients with a
diagnosis of hypopharyngeal cancer at a large teaching hospital in
England between December 2019- July 2022. The audit was registered and
approved by the local hospital trust governance department prior to data
collection. A total of 68 patients were identified from a prospective
H\&N audit database. The patient's NHS number was used to search the
hospitals electronic patient record system.

\textbf{Collected data}

The following parameters were extracted for each case: patient
demographics, referral route, time from initial referral to first
appointment, Tumour (T), Node (N), Metastases (M) stage, first treatment
modality and socio-economic factors; smoking status and index of
multiple deprivation decile which was calculated based on the patient's
postcode. A number from one to ten was generated; 1- most deprived
lower-layer super output areas (LSOAs) nationally, 10- least deprived
10\% of LSOAs nationally. Information regarding referral criteria was
recorded from the NCA 2WW proforma. Practitioners could select one or
more of the following categories to instigate the 2WW referral pathway:

\begin{enumerate}
\tightlist
\item
  A persistent, unexplained lump in the neck or parotid region of recent
  onset.
\item
  Persistent (not intermittent or fluctuating), unexplained hoarseness
  (over the age of 45 years).
\item
  Unexplained, persistent, unilateral enlargement or ulceration of the
  tonsil or adjacent soft palate.
\item
  \textbf{Analysis}
\end{enumerate}

Descriptive data was collated on a spreadsheet and analysed. Analysis
adhered to STROBE guidelines.

\textbf{RESULTS}

Of the 68 patients, 34 (50\%) presented via a 2WW pathway, all from GP
referrals. 23 (34\%) were referred on non-2WW pathways: eight patients
were referred by their GP on a routine basis, eight same site
inter-departmental referrals and seven referrals were from another
hospital site (no 2WW proforma). Three referrals were identified through
routine departmental follow-up (FU) within ENT. Eight patients presented
to the ENT service via an emergency route and were not previously known
to the service (Figure 1). Characteristics of the patient group are
shown in Table 1.

Data on the time from initial referral to first appointment date was
available for 50 of the 68 patients. 97\% (n=33) of patients referred on
the 2WW pathway were seen within 14 days of initial referral date. One
patient waited 23 days, having rescheduled their appointment. The median
time from initial 2WW referral to first appointment date was nine days
(range 2-23 days). Of the 50 patients in total, median time from initial
referral to first appointment was 10 days (range 2-117 days).

18 patients were lacking data detailing initial referral to first
appointment. Eight patients presented via an emergency route and were
reviewed by ENT services at the time of presentation. Three patients
were identified by routine departmental follow-up, and were lacking an
initial referral date. Six patients were referred from other hospital
sites with a previous diagnosis of hypopharyngeal cancer and one patient
referred on a routine basis from GP was lacking referral documentation.

Of the 16 patients referred into ENT services on non-2WW pathways, seven
patients presented with dysphagia (44\%), five patients presented with
odynophagia (31\%), two patients presented with a sore throat (13\%),
one patient presented with globus (6\%). One patient was referred after
incidental findings on previous imaging (6\%). Of those 16 patients,
median time from initial referral to initial appointment was 14 days
(range 6-117 days). Of those presenting with dysphagia specifically, the
mean time from referral to initial appointment was 11 days (range 6-14
days).

Of the 34 2WW referrals from general practice, 23 patients were referred
with a neck lump, 13 patients with persistent hoarseness and two
patients with tonsillar ulceration. For all 2WW referrals, practitioners
provided additional clinical information in the `reason for referral'
box. 44\% of patients presenting via the 2WW pathway with a
pre-treatment T category of T4. Analysis of pre-treatment category shown
in table 2.

26 patients (38\%) received palliative radiotherapy as their first
treatment modality. Of those referred by the 2WW pathway, 13 (38\%)
received palliative radiotherapy and four (12\%) received radical
radiotherapy. Analysis of primary treatment modality categorised via
referral route is shown in table 3.

\textbf{DISCUSSION}

The NCA adopted the NICE NG12 symptom to refine their 2WW suspected
cancer referral proforma. Our data suggests that choosing to not include
those symptoms that may be suggestive of hypopharyngeal cancer;
dysphagia, sore throat and otalgia, does not seem to have negatively
impacted on the referral of patients with hypopharyngeal cancer. The
majority of patients were seen in a timely manner. McKie et al. (8)
evaluated referral patterns and diagnostic efficacy of the UK 2WW
pathway, and demonstrated 21.4\% of H\&N cancers were diagnosed via 2WW
pathway. The results from our study showed that half of patients
diagnosed with hypopharyngeal cancer were referred on the 2WW pathways.
Round et al. (9) demonstrated that over the past decade 2WW referrals
for all types of suspected cancer have increased significantly.

The `reason for referral' box was populated in 100\% of cases. This
suggests that if the patient's general practitioner was sufficiently
concerned to detail the patients presenting symptoms, they would do so.
Pooled data from previous studies of patients referred with suspected
H\&N cancer presenting with dysphagia indicated that head and neck
cancer was diagnosed in only 5.6\% of cases (4,7,8,10). In our study,
the patients referred from primary care, via a non-2WW pathway,
presenting with dysphagia had a median time from referral to first
appointment was 11 days. Even in the absence of a 2WW proforma, this
implies that referrals in to our centre were likely marked as urgent by
the triaging ENT clinician reviewing these, based on the appropriate
information provided by the referring practitioner. Together, these
suggest that the 2WW proforma and written communication between primary
and secondary care is an effective approach.

The 2WW system is a balance of promoting earlier diagnosis with the
capacity to investigate patients within 14 days (7). Dysphagia, sore
throat and otalgia are clearly concerning symptoms when they occur
together and are observed in patients who smoke and/or drink alcohol to
excess (1). As individual symptoms, they can be vague and common in
nature, overlapping with many of the benign persistent throat symptoms
that are commonly assessed in ENT clinics. Patients with these symptoms
can overload the capacity of the 2WW referral system thereby potentially
delaying the system's ability to assess higher risk symptoms in a more
timely manner (7).

Early cancer detection correlates with improved survival rates (5).
Previous studies suggest that patients presenting via an emergency route
are more likely to present with more advanced disease (5,10). Therefore,
emergency presentations with advanced disease remains an area of concern
to clinicians. This study highlights the link that patients presenting
at a late stage, more commonly present via an emergency route, typically
go on to have palliative treatment.

\textbf{CONCLUSION}

This study suggests that removal of non-NICE guidance H\&N symptoms from
the NCA 2WW proforma, when combined with an appropriate secondary care
triaging system, has not negatively impacted on time from initial
referral to diagnosis of hypopharyngeal cancer.

\textbf{KEYWORDS}

Hypopharyngeal cancer, referral route, diagnosis, 2WW pathway,
non-urgent pathway

\textbf{KEY POINTS}

\begin{itemize}
\tightlist
\item
  In the UK, hypopharyngeal cancer accounts for approximately 3\% of
  head and neck cancers.
\item
  In our centre, 50\% of all cases of hypopharyngeal cancer in our study
  period were referred via a 2WW pathway.
\item
  An effective secondary care triaging service aids in the recognition
  of hypopharyngeal referred via a non-2WW route.
\item
  Patients presenting via an emergency route, typically go on to have
  poorer outcomes.
\item
  The current NCA 2WW proforma when utilised by primary care clinicians
  has not negatively impacted on route to diagnosis of patients with
  hypopharyngeal cancer.
\end{itemize}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Pracy P, Loughran S, Good J, Parmar S, Goranova R. Hypopharyngeal
  cancer: United Kingdom National Multidisciplinary Guidelines.\emph{J
  Laryngol Otol.} 2016; \textbf{130} (Suppl 2): S104--S110.
\item
  National Institute for Health and Care Excellence. Referral guidelines
  for suspected cancer. London: National Institute for Health and Care
  Excellence. 2015. Available at: http://www.nice.org.uk/guidance/
  ng12/chapter/1-Recommendations-organised-by-site-of-cancer\#head-
  and-neck-cancers. (Accessed 12th April 2023).
\item
  National Health Service: Northern Cancer Alliance. Suspected cancer in
  adults Head and Neck 2ww. 2020. Available at:
  https://northerncanceralliance.nhs.uk/wp-content/uploads/2021/12/NCA-2WW-HEAD-NECK-V7.pdf.
  (Accessed 15th April 2023).
\item
  Allam A, Nijim H. Persistent Unilateral Sore Throat: Should It Be
  Included in the 2-Week Wait Referral Criteria by NICE. \emph{Int J
  Otolaryngol} . 2019; 1-6.
\item
  Rogers SN, Brown JS, Woolgar JA, et al. Survival following primary
  surgery for oral cancer. \emph{Oral Oncol.} 2009;\textbf{45}
  (3):201--11.
\item
  McPhail S, Swann R, Johnson SA, Barclay ME, Elkader H, Alvi, R. Risk
  factors of and prognostic implications of diagnosis of cancer within
  30 days after an emergency hospital admission (emergency
  presentation): An International Cancer Benchmarking Partnership (ICBP)
  population-based study. \emph{Lancet Oncol} . 2022. \textbf{23} (1):
  587-600.
\item
  Tikka T, Pracy P, Paleri V. Refining the head and neck cancer referral
  guide- lines: a two-centre analysis of 4715 referrals\emph{. Clin
  Otolaryngol} . 2016; \textbf{41} (1): 66--75.
\item
  McKie C, Ahmad UA, Fellows S, Meikle D, Stafford FW, Thomson PJ et al.
  The 2-week rule for suspected head and neck cancer in the United
  Kingdom: referral patterns, diagnostic efficacy of the guidelines and
  compliance. \emph{Oral Oncol.} 2008; \textbf{44} (9):851--856.
\item
  Round T, Ashworth M, L'Esperance V, Moller H. Cancer detection via
  primary care urgent referral in England 2009/10 to 2018/19 and the
  association with practice characteristics. \emph{Br J Gen Pract.}2021;
  \textbf{71} (712): e826-e835.
\item
  Tikka T, Kavanagh K, Lowit A, Jiafeng P, Burns H, Nixon IJ, et al.
  Head and neck cancer risk calculator (HaNC-RC)-V.2. Adjustments and
  addition of symptoms and social history factors. \emph{Clin
  Otolaryngol.} 2020;\textbf{45} (3):380-8.
\end{enumerate}

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