Outcomes Following Urgent Referral for Head & Neck Ultrasound Dr Anna ffrench-Constant Dr Mandy Williams

Introduction 2WW initiative designed to speed up referral of patients suspected of having cancer ‘Trigger symptoms’ warranting urgent referral agreed by NICE USS +/- FNA or biopsy quick initial diagnostic investigation for suspected head & neck malignancy

NICE Guidance June 2015 Consider 2WW suspected cancer referral pathway for the following: Laryngeal cancer in people aged ≥45 with – persistent unexplained hoarseness or – unexplained neck lump Thyroid cancer in people with – unexplained thyroid lump

NICE Guidance June 2015 Oral cancer in people with – unexplained ulceration in oral cavity >3 weeks or – persistent and unexplained neck lump or – lump on the lip or oral cavity consistent with oral cancer or – red or white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia As assessed by a dentist

Aims Identify number of head & neck USS performed following 2WW referral in a 3 month period at UHBristol NHS Trust Look at the appropriate use of the 2WW referral pathway and compare our results to published data regarding conversion rates for Head and Neck cancer from 2WW referrals.

Standard Conversion rates for Head and Neck Ca known to be poor. GP conversion rates from Sussex GP data Laryngeal Ca <1% Oropharyngeal 2% Thyroid-<1% Lymphoma- 4%

Standard Our referrals predominantly from out px – ENT/Max Fax/oral medicine or haematology/ oncology not GP so expect conversion rate to be higher. One stop clinic data- Derriford published data- 17% px had cancer. Expect all 2WW referrals to be less than this. Standard therefore set at 15% of 2WW USS referrals to have malignancy.

Methods All patients referred to the Trust for neck USS between 1/10/14 and 31/12/14 identified on CRIS 2WW scans identified by referral grading on CRIS (7) Outcome of imaging reviewed on CRIS Outcome of biopsies reviewed on ICE Diagnosis based on USS and FNA/biopsy results as well as any follow-up imaging/biopsies

Results Total USS scans % px referred for USS on 2ww- 166 scans. Of the 2WW scans 16.9% had a malignant diagnosis, compared to 4.4% overall.

Results Suspicious 4 Total number of scans = 639 Scans referred via 2WW pathway = 166 (26% of all scans) Malignant outcome in 16.9% of 2WW scans (4.4% of all scans)

Comparison of 2WW scan outcomes between new and follow-up patients n = 118n = 7 n = 41 No. of patients

Malignant Diagnoses DiagnosisNew patientsFollow-up patientsTotal Squamous cell carcinoma448 Diffuse large B cell lymphoma527 Hodgkin Lymphoma112 Follicular lymphoma112 Adenoid cystic carcinoma112 MALT lymphoma11 Small B lymphocytic lymphoma11 Metastatic non-small cell cancer11 Medullary thyroid cancer11 Papillary carcinoma11 Parotid adenocarcinoma11 Cutaneous adenosquamous carcinoma11 Total14 28

Benign Diagnoses Reactive Lymph Nodes 41 Benign Thyroid Nodules 21 Multinodular Goitre 7 Benign Thyroid Cyst 5 Pleomorphic Adenoma 4 Lipoma 4 Benign Parotid Cyst 3 Sialosis 3 Warthin’s Tumour 3 Sialadenitis 3 Other 16 Total = 110

Outcome by Scan Location Scans performed at St Michael’s Hospital (STMH) and Bristol Dental Hospital (BDH) STMH one-stop neck lump clinic designed for urgent referrals BDH – 124 urgent scans – 22 malignant outcomes (17.8%) – 3 suspicious STMH – 42 urgent scans – 6 malignant outcomes (14.3%) – 1 suspicious

Outcome by Referral Location Referral LocationTotal scans2WW scansMalignant Outcome (from 2WW scans only) STMH (15.5%) BDH (21.4%) GP17110 (0%) BRI53131 (7.7%) BHOC2683 (37.5%) BEH200 (0%) BHI200 (0%) Dentist100 (0%)

Summary 16.9% of 2WW referrals had malignant outcome SCC and lymphoma commonest malignant diagnoses Reactive lymph nodes and benign thyroid nodules commonest benign diagnoses STMH actually has slightly lower malignant outcome rate than BDH. GPs do not request many 2WW scans

Conclusions 2WW referrals met the standard set of 15% conversion. Highest risk in px with previous Head and Neck Ca or lymphoma. Most px diagnosed with malignancy had SCC or lymphoma. Rare cancers inc salivary and thyroid Ca.

Future work… Compare outcomes to other 2WW pathways within UHBristol trust Compare outcomes to other trusts Investigate how many malignant outcomes arise from non-urgent referrals Investigate GP referrals - should GPs be using the 2WW referral system more often?