Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: a matched case-control study.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: a matched case-control study.:

Related Articles

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: a matched case-control study.

Clin Otolaryngol. 2020 Jan 26;:

Authors: Bird JH, Williams E, Heathcote KJ, Ayres L, De Zoysa N, King EV, Parry SD, Nouraei S

Abstract

OBJECTIVES: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of Interspecialty Cancer Referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology.

DESIGN: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex, and cancer subsite.

MAIN OUTCOME MEASURES: Information about the patient age and presenting symptoms were recorded. The relationship between symptoms and ICR risk were examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t-test. Cox regression was used to identify independent predictors of overall survival.

RESULTS: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43±50 days for control patients to 115±140 days for ICR patients (p<0.0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56) and classic gastrointestinal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; p<0.02; log-rank test). Two systemic causes were poor visualisation of pharynx and larynx by per-oral endoscopy for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow for evaluating the oesophageal mucosa.

CONCLUSIONS: An Interspecialty Cancer Referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

PMID: 31984641 [PubMed - as supplied by publisher]