An evidence-based approach to the urgent referral of suspected oral cancer in England

Background Reports that UK outcomes for several cancers, including oral, were inferior to comparable European countries prompted the UK Government’s ‘NHS Cancer Plan’; a central aim was reduction of late presentation. One key policy was the English ‘two-week rule’ (TWR) system for suspected cancer, specifying a maximum of 14 days between referral and specialist consultation. For oral cancer, little research has been undertaken on several key areas including its influence on stage on presentation and how the system might be improved. Aim To conduct evidence-based evaluation of the policy for urgent referral of suspected oral cancer in England and conduct 4 studies in areas where important evidence is absent or sparse. Methods (1) A time-series study examining stage on diagnosis of oral cancer before and after the TWR (2) A qualitative study comparing the views of specialists in England and the Netherlands on their head and neck cancer referral systems (3) A systematic review comparing oral cancer referrals from doctors and dentists (4) A Delphi study of expert opinion on the priority of the methods of encouraging early oral cancer diagnosis. Findings English/UK outcomes for oral cancer are probably genuinely worse than the European best. The causes are multiple and complex, although late diagnosis is an important cause. A time-series study of 1483 patients between 1992-2012 suggests the TWR system has not influenced the trend in late oral cancer presentation. Socio-economic differences in late presentation are reducing but persist and oral cancer presentation is increasing. A qualitative study highlighted similarities between the English TWR system and the more flexible Dutch system but also differences. The Dutch system featured more direct professional communication, greater flexibility and more rapid referral of head and neck cancer. A systematic review confirmed both GPs and dentists refer oral cancer. Overall, dentists may refer earlier stage disease and refer some cancers following routine inspections, in the absence of symptoms. In a Delphi study experts consider rapid referral systems high priority for oral cancer but a range of measures were also considered useful. Conclusions The current TWR urgent referral system alone may be limited in reducing late oral cancer presentations. Earlier referral may be improved by more flexible referral systems with better communication and by improving access to regular dental inspections, particularly for those at high risk.