Fast Track Referrals

1. Fast Track Referrals Richard Sim Consultant ENT Surgeon

2. 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/referral.htm

4. Timeline • 2/52 – Referral to appointment. • 31/7 – Referral to investigation. • 62/7 – Referral to treatment.

5. 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.

6. 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.

7. 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.

9. What’s important • Age • Smoking history • Alcohol history • (PMH / DH)

10. 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.

11. 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).

12. Dysphagia • Dysphagia – “Does food actually stick”; “Describe an episode”; “What types of food” – not pills / fruit skin.

13. 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.

14. 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.

15. Cervical Lymphadenopathy - Children Palpable lymphadenopathy is common – 55% of children aged 6-12/12 and 41% of children aged 2-5 years.

16. 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

17. Cervical Lymphadenopathy - Children Investigation Consider USS - most useful non-invasive? CXR FBC Viral titres – may help in 10% of cases Bartonella Toxoplasma CMV EBV

18. Cervical Lymphadenopathy - Children If investigations unhelpful and nodes persistent or enlarging - consider need for excision biopsy.

19. 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?

20. 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?

21. 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.

22. Thyroid lumps – BTA guidelines • Patients with thyroid nodules who may be managed in primary care (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. • 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): • 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.

23. Thyroid lumps • Investigations: • TFTs • Ultrasound Scan (USS) • Fine needle aspiration cytology – under USS guidance where appropriate.

24. Thyroid lumps – ATA guidelines

25. 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.

26. 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

27. 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.

28. 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.

29. Thankyou