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.