Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case‐control study

Abstract

Objectives: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. Design: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. Main outcome measures: Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival.Results: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P < .0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P < .02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. Conclusions:An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between

Remote triage incorporating symptom‐based risk stratification for suspected head and neck cancer referrals: A prospective population‐based study

“…Reports of dysphagia in the presence of a normal upper aerodigestive tract examination should prompt urgent esophageal endoscopy to rule out more distal lesions. 26 This study confirmed the finding of a third of cancers on the suspected HNC referral pathway being non‐HNCs and corroborated previous reports. 23 …”

Treatment of Merkel Cell Carcinoma With Mohs Micrographic Surgery Is Associated With Shorter Delays to Surgery in the United States

“…Indeed, previous work on pharyngolaryngeal/esophagogastric malignancies, which often require referrals between head and neck surgery and gastroenterology, has found that interspecialty cancer referrals lead to delays in diagnosis and poorer patient survival. 4 Interestingly, this effect in our study was independent of pathologic lymph node evaluation, suggesting that even cases referred to another surgical specialty for SLNB or elective lymph node dissection receive more timely excision when undergoing MMS. Nevertheless, for cases treated with MMS, pathologic lymph node evaluation was also associated with an increased likelihood of treatment delays.…”

Letter to the Editor in reference to: Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case‐control study

“…The article by Bird et al is an interesting read and I wish to strongly support their recommendations of a more coherent multidisciplinary approach to dysphagia 1 . UEMS‐ORL are currently in the early stages of forming either an MJC (Multidisciplinary Joint Committee) in Swallowing Disorders or a Thematic Federation in Dysphagia with European colleagues in other relevant specialties, and this publication will certainly assist our endeavours.…”