Analysis of the impact of deprivation on urgent suspected head and neck cancer referrals in the Mersey region between January 2004 to December 2006

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Abstract

Serious delay in patients presenting with head and neck cancer is associated with poor outcomes. We aimed to examine the influence of deprivation on professional delay in the Mersey region from 2004 to 2006. The study sample comprised 6681 patients who were referred between January 2004 and December 2006. The dataset was dominated by the largest hospital (H1), which received 48% of all cases. Median referral overall was 12 days (IQR 8–15 days), and 74% of patients were referred in 14 days or less. Professional delay (percentage 14 days or less) was associated with hospital (from 58% H1 to 97% H5), year of referral (from 64% in 2004 to 80% in 2006), age (from 69% under 55 years to 80% over 75 years), and deprivation (Index of Multiple Deprivation 2000 from 67% most deprived (IMD 1) to 85% least deprived (IMD 5)). Hospital location was associated with these factors and the results imply that by far, the most important variable in predicting professional delay was the hospital that received the referral. Trends over time in age, and to a lesser extent, for deprivation were noted in H1, but were largely absent across other hospitals. Some of them needed to make substantial improvements to meet the two-week referral pathway and it would be interesting to compare these results with current practice. This study highlights the importance of maintaining the standards of the current policy on two-week referrals for suspected head and neck malignancy.

Introduction

The incidence of oral cancer is increasing. Five-year survival rates have remained static (50–70%),1 and the rate of second primary tumours is high (3–7% per annum).2 The most important factor behind these dire statistics is diagnostic delay3, 4, 5 as over 60% of patients present with stage III and IV disease.6 Management of late lesions is complex and multidisciplinary, and involves combinations of operation with radiotherapy or chemoradiotherapy. By contrast, early-stage cancers are more likely to be treated easily by primary surgery. A recent study showed that the 5-year survival for stage I disease was 96% compared with 57% for disease at stage IV.7

Theoretically, delays can be produced at a number of levels, which include patients, primary care professionals, and secondary care. From the perspective of patients, reported barriers to seeking help have been attributed to a number of factors including knowledge of oral cancer, beliefs about the symptoms, and the perceived ability to seek help from a healthcare professional.8, 9, 10 Patients’ individual circumstances have also been cited, and include the severity of life events during the period of delay, and from a socioeconomic perspective, material deprivation.10

From a review of published papers, low socioeconomic status is significantly associated with an increased risk of oral cancer.11 However, the precise nature of the association and the types of mediating variables that might exist are not clear.12, 13 For example, in a Scottish study, Conway et al. found that deprivation (OR = 4.66, 95% CI 1.79–12.18) and unemployment (OR = 2.27, 95% CI 1.21–4.26) had a significant association with the incidence of oral cancer, but this was lost when adjustments were made for smoking and consumption of alcohol.14 However, in a large multicentred study across Europe, Conway et al. found that all measures of low socioeconomic status were significantly associated with the risk of cancer of the upper aerodigestive tract in men, and low educational attainment remained significant after making adjustments for smoking, alcohol, and diet (OR = 1.29; CI = 1.06–1.57).15

In terms of delay by patients, Scott et al. showed that material deprivation is significantly associated, although the effect of the odds ratio in the study was small (OR = 1.05; 95% CI = 1.01–1.09; p < 0.05),11 and earlier studies by Wildt et al.16 and Rogers et al.17 found no association.Across Merseyside and Cheshire, a “hub and spoke” head and neck cancer service uses a standardised two-week urgent referral form for suspected head and neck cancer. Maxillofacial referrals are accepted by 8 NHS Trusts serving a population of roughly 2 million people. The regional surgical centre for this service is located at University Hospital Aintree, Liverpool. National Institute for Health and Clinical Excellence (NICE) guidelines18 suggest that patients with suspected oral cancer should be referred within two weeks, and roughly half the referrals into the service with suspected cancer were from primary care dentists.19 Overall, published papers suggest that the level of awareness for risk factors and clinical signs among dentists is good,20, 21 although it seems that general medical practitioners may not recognise all the signs associated with early disease.22, 23, 24, 25, 26

Given the increased risk of oral cancer that is associated with material deprivation, and its potential influence on health-related behaviour including non-attendance, it seems that professionals need to be more vigilant with these patients. The aim of this study was therefore to examine the impact of deprivation on patients with urgent referrals for suspected head and neck cancer in the Mersey region between January 2004 and December 2006 to find out whether there was an association between professional delay and the level of material deprivation of those being referred.

Section snippets

Method

The study population comprised consecutive patients referred to head and neck cancer units at one hub and eight satellite hospitals in Merseyside. Audit departments at the nine hospitals were approached, and following a small pilot that found inconsistencies in the extent of detail recorded across the region, a limited collection of data items was obtained electronically for January 2004 to December 2006. Ethical approval was given by Sefton Research Ethics Committee (07/Q1501/75).

The data

Results

The initial combined dataset comprising 7046 patients’ records with referrals from 1 January 2004 to 31 December 2006 was reduced to 6814 after duplicate records with the same date of referral had been removed. For one of the smaller satellite hospitals professional delay could not be computed so this hospital (with 51 records) was excluded. Another 82 records for which professional delay or age were not known were also removed. The IMD score was not known for 496 records (including the whole

Discussion

To our knowledge this is the first study to examine the role of material deprivation in professional delay in suspected head and neck malignancy. As the audit was undertaken over a three-year period across such a broad geographical region, it also shows how the satellite hospitals and the hub unit in Merseyside performed during that time, and forms a useful benchmark with which to compare future performance. This is particularly useful now that Trusts are instructed to comply with the

Conflict of interest

None.

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