Discussions
The number of two-week-wait referrals to our regional specialist unit during the study period saw an decline of 7.3% compared to pre-pandemic data.4 This trend conforms with other studies, which also showed a decrease in urgent HNC referrals during the pandemic.5,6 The trend is likely results from limited access to primary care and altered health-seeking behaviours during Covid-19.7
Nine percent (9.2%) of patients referred on the two-week-wait pathway were diagnosed with cancer. This conversion rate is comparable to that in current literature which is reported to be between 6 % and 11.8%.8–10 Recent studies have observed a national downwards trend of the HNC two-week-wait conversion rates, this is suggested to be mainly due to an increase in the number of two-week-wait referrals from the community.8 This reflects the trend seen in our regional unit with a rise in the number of two-week-wait referrals over the years, outside pandemic times. There are concerns that this trend could potentially overwhelm secondary specialist services.11
In our study, despite pandemic disruption, 100% of the urgent referrals were able to be accommodated within 14 days without significant impact on the waiting times of routine referrals. It is possible that telephone clinics are more efficient than traditional face-to-face appointments and result in an improved patient flow.12,13
Historically the most common types of malignancy diagnosed from the HNC urgent pathway have been cancer of the oral cavity, lymphoma, laryngeal and thyroid cancer.10,14 The same pattern was observed in this study. This may suggest that covid-19 has not caused any major deviations from the pre-pandemic HNC referral patterns.
Under the current two-week-wait pathway, patients with cancer should receive their initial diagnosis within 28 days of the initial referral.10 With this rule in mind, three cases in the study cohort were diagnosed outside of this window and therefore are considered to be late diagnoses. There is limited data on the late or missed diagnosis rate of the HNC two-week-wait pathway. Recent communication from ENTUK suggests that telephone consultations are 1.4% more likely to result in a missed cancer diagnosis compared to face-to-face consultations.1 A recent 16-weeks prospective study suggested that the late diagnosis rate of HNC two-week-wait pathway was 0.6% overall.15 This is comparable to the 0.28% found in our study.
The inability to perform physical examinations and diagnostic flexible nasoendoscopes during telephone consultations is unequivocally a major reason why these cases were missed. It could be speculated that the missed cases would otherwise have been diagnosed by direct visualisation in a face-to-face consultation.
Interestingly, two out of the three missed cases had presented with hoarse voice. A recent study has shown there is limited value in assessing voice disorders over the phone.16 Clinicians can easily misjudge the severity of hoarseness during a telephone consultation and offer these patients deferred appointments. Future studies could look at associations between presenting symptoms and late diagnoses in the urgent HNC telephone clinics on a larger scale.
Late diagnosis does not inevitably lead to worse clinical outcome. Among the late diagnoses in the study, only one case, with a longer time to follow up, required escalated intervention due to late diagnosis, overall prognosis was however deemed to be unaffected. The other two cases although managed outside the 31/62 days pathway did not receive altered or escalated treatment. This is likely accounted for by the closer follow-up reviews to their first appointments at 4 and 6-weeks.
The limitation of the study lies within the relatively small sample group. Only three late diagnoses were identified which makes any further analysis into factors associated with late diagnoses not meaningful. A larger sample group could be obtained by extending the study period. However, this would defeat the purpose of the study as part of the objectives was to evaluate the impact of Covid-19 on the HNC two-week-wait pathway. Whilst it was not the objective of this study to determine the predictive accuracy of HaNC-RCv2 since this has already been covered by multiple studies.17–19 It is interesting to observe that 20% of the study cohort with a positive cancer diagnosis were stratified as low risk including all three of the late diagnosis cases.
Although cases of Covid-19 are on the decline, telephone clinics will likely remain in some capacity after the pandemic. This study reported the initial experience of adapting telemedicine for the HNC urgent referral pathway and found a small proportion of cancer cases were missed. Clinicians will be mindful that telephone clinics while a pragmatic means to maintain patient flow during the pandemic, could result in risk of late diagnosis and harm compared to traditional face-to-face appointments.