title: Refining the head and neck cancer referral guidelines: a two-centre analysis of 4715 referrals.
abstract: OBJECTIVE
  To identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting.
  
  
  METHODS
  Statistical analysis of referral criteria and outcomes.
  
  
  METHODS
  Two tertiary care cancer centres in the United Kingdom.
  
  
  METHODS
  4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010.
  
  
  METHODS
  Parameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve (AUROC).
  
  
  RESULTS
  The majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3 weeks, dysphagia >3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3 weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (P < 0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html.
  
  
  CONCLUSIONS
  This study presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.
authors.affiliation: Department of Otolaryngology, Head-Neck Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: T
authors.initials: T
authors.lastname: Tikka
authors.affiliation: Department of Otolaryngology, Head-Neck Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: P
authors.initials: P
authors.lastname: Pracy
authors.affiliation: Department of Otolaryngology, Head-Neck Surgery, Freeman Hospital, Newcastle upon Tyne University Hospitals NHS Trust, Newcastle upon Tyne, UK.|Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: V
authors.initials: V
authors.lastname: Paleri
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006258:Head and Neck Neoplasms / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012017:Referral and Consultation / Q000592:standards*; D055815:Young Adult