Download Fast Track Referrals

Fast Track Referrals
Richard Sim
Consultant ENT Surgeon
Background
• ‘Referral guidelines for suspected cancer’
published by the Department of Health in
2000.
• NICE – updated 2005
• www.nice.org.uk/CG027
• http://nww.dorsetcancernetwork.nhs.uk/ref
erral.htm
ONLY REFER AS FAST TRACK IF ONE OR MORE OF THE FOLLOWING CRITERIA ARE MET
Please tick all that apply:
ORAL CANCERUnexplained mass or ulceration of oral mucosa for >3 wks
Unexplained red and/or white patches of oral mucosa
PLUS
pain
or swelling
or bleeding
Undiagnosed suspicious lesion/symptom of oral cavity persisting for >6 wks
NASAL - Any patient with unexplained persistent sore or painful throat
PHARYNX – As above
LARYNXHoarseness persisting for >3 wks
Identify additional risk factors: - >50 yrs old
smoker
heavy drinker
OTHER CANCERS :Un-resolving neck lump persistent >3 -6 wks
Unexplained, persistent swelling
- parotid
or sub mandibular gland
Unexplained unilateral pain in the head and neck area for > 4 wks associated with
earache (otalgia) BUT normal otoscopy
Is patient aware of a possible Cancer diagnosis
Yes
No

Please provide date(s) patient unavailable in next 14 days:

If patient does not fulfil the criteria- please consider urgent/routine referral.
All current Problems, Medication and Allergies will automatically be populated from GP clinical system.
Please enter any other significant additional information here:
Timeline
• 2/52 – Referral to appointment.
• 31/7 – Referral to investigation.
• 62/7 – Referral to treatment.
Problems
• Who is going to benefit:
– Some patients clearly have cancer and early
diagnosis is not going to change outcome.
– Some 2/52 wait patients clearly do not have cancer.
• Number (majority?) of patients with cancer do
not come through fast track system.
• Can be difficult to remove from fast track – some
patients will need multiple investigations.
Problems
• Knock on effect –
• “To see patients without a waiting list the
capacity must exceed mean demand by an
amount proportional to the square root of the
mean.”
• Thomas SJ, Williams MV, Burnet NG, Baker CR.
How much surplus capacity is required to
maintain low waiting times? Clin Oncol.
2001;13:24–28.
Size of problem
• Incidence of head and neck cancer
•
7.7-15.3 / 100,000 / year.
• ENT population 440,000 = 34-67 cancers.
• Estimated 1 cancer for every 7.5
appointments.
• Need 255 – 502 appointments to pick up
these cases.
Fast Track Referrals West Dorset and East
Somerset
500
450
400
Number
350
300
250
200
150
100
50
0
2000
2002
2004
2006
Year
2008
2010
2012
What’s important
• Age
• Smoking history
• Alcohol history
• (PMH / DH)
What’s important
• Does it all fit?
– Unlikely to present with first quinsey in middle
age.
– Unlikely to present with branchial cyst for first
time in middle age.
– Supraclavicular lymph nodes are not normal.
Voice Change
• Voice Change – Persistent “Does it ever
come back to normal”
• Need CXR prior to referral to exclude lung
pathology (mobile patients with
investigations in multiple centres).
Dysphagia
• Dysphagia – “Does food actually stick”;
“Describe an episode”; “What types of
food” – not pills / fruit skin.
What’s important
• Voice Change – Persistent “Does it ever
come back to normal”- Need CXR
• Dysphagia – “Does food actually stick”;
“Describe an episode”; “What types of
food” – not pills / fruit skin.
• Haemoptysis – but often more appropriate
to respiratory.
• Weight Loss – untoward / without effort.
Diagnostic Approach
• Adults - Full ENT examination including
nasendoscopy, FNAC, imaging as
appropriate – clinical suspicion,
anatomical site etc.
• Children – may have clear diagnosis eg
branchial cyst but more commonly seen
with lymphadenopathy.
• Thyroids – more didactic pathway.
Cervical Lymphadenopathy Children
• Palpable lymphadenopathy is common –
55% of children aged 6-12/12 and 41% of
children aged 2-5 years.
Cervical Lymphadenopathy Children
• Worrying Features
– Night sweats
– Weight loss
– Palpable liver or spleen
– Larger size and progressive (>3cm)
– Supraclavicular
– Malaise
However - Majority of nodes will be benign
Cervical Lymphadenopathy Children
• Investigation
– Consider USS - most useful non-invasive?
– CXR
– FBC
– Viral titres – may help in 10% of cases
•
•
•
•
Bartonella
Toxoplasma
CMV
EBV
Cervical Lymphadenopathy Children
• If investigations unhelpful and nodes
persistent or enlarging - consider need for
excision biopsy.
Thyroid lumps
• Common – Palpable nodules in 5% of
women and 1% of men worldwide.
• Ultrasound can detect nodules in 19-67%
of randomly selected individuals – more
common in women and the elderly.
• How do we select for further investigation /
treatment?
Thyroid lumps
• Differentiated Thyroid cancer – 90%.
• Incidence of papillary thyroid cancer
increasing – 49% of increase <1cm and
87% <2cm.
• Due to increased detection and early
diagnosis with USS?
Thyroid lumps
• Prognostic factors:
– Family Hx, Radiation to neck, thyroiditis.
– Age - <10 - >40.
– Size >4cm / enlarging on serial scanning.
– Vocal cord palsy.
– Sex – Male > Female.
– Histology – generally papillary better than
follicular but roughly equal when other
confounding effects removed.
– Tumour extent / metastases.
Thyroid lumps – BTA guidelines
•
Patients with thyroid nodules who may be managed in primary care (IV, C):
–
–
•
Patients who should be referred non-urgently (IV, C):
–
–
–
•
Patients with nodules who have abnormal thyroid function tests (TFTs). These patients should be referred to
an endocrinologist; thyroid cancer is very rare in this group.
Patients with a history of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid
cyst).
Patients with a thyroid lump which is newly presenting or increasing in size over months.
Symptoms needing urgent referral (2-week rule)50 (IV, C):
–
–
–
–
•
Patients with a history of a nodule or goitre which has not changed for years and who have no other
worrying features (ie adult patient, no history of neck irradiation, no family history of thyroid cancer, no
palpable cervical lymphadenopathy).T
Patients with a non-palpable asymptomatic nodule <1 cm in diameter discovered coincidentally by imaging
of the neck without other worrying features.
Unexplained hoarseness or voice changes associated with a goitre.
Thyroid nodule in a child.
Cervical lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular region).
A rapidly enlarging painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and
usually associated with anaplastic thyroid cancer or thyroid lymphoma).
Symptoms needing immediate (same day) referral (IV, C):
–
Stridor associated with a thyroid lump.
Thyroid lumps
• Investigations:
– TFTs
– Ultrasound Scan (USS)
– Fine needle aspiration cytology – under USS
guidance where appropriate.
Thyroid lumps – ATA guidelines
Thyroid lumps
• FNA Results
– Thy1 – Non-diagnostic
– Thy2 – Benign.
– Thy3 - Follicular lesion
• Thy3a – Atypia of undetermined significance
• Thy3f – Follicular neoplasm
– Thy4 – Suspicious for malignancy.
– Thy5 – Diagnostic for malignancy.
Thyroid lumps
•
•
•
•
•
•
Thy1 – Repeat – USS guidance.
Thy2 – Consider interval USS and repeat.
Thy3a – MDT - Repeat biopsy / surgery
Thy3f – MDT - Surgery
Thy4 – MDT - Surgery
Thy5 – MDT - Surgery
DCH Neck Lump Clinic
• Wednesday afternooon.
• Consultant ENT, consultant radiologist,
cytological assessment in clinic.
• One stop service where possible – allows
reassurance for majority of patients and
prompt treatment where necessary.
Summary
• Happy to see any neck lump in ENT.
• Facial lesions (not eye lids)
• Easier to upgrade to fast track than
downgrade from fast track (particularly
thyroid).
• Neck lump clinic available with USS and
cytology.
Thankyou