Guidelines for the referral of suspected oral cancer patients
Introduction
Worldwide, oral cancer has one of the lowest survival rates and remains unaffected
despite recent therapeutic advances. [1] Early diagnosis and referral is a cornerstone to
improve survival and to reduce diagnostic delay.[2] Unfortunately, almost one half of the
oral cancers are diagnosed at advanced stages (III or IV), with 5-year survival rates
ranging from 20% to 50% depending on tumors site.[3]
However, several authors have identified insufficient educational preparedness of medical
and dental professionals to reduce the burden of oral cancer through effective cancer
control strategies such as reducing tobacco consumption, suggesting healthier diet and
lifestyles and, particularly, performing early detection through screening examinations and
appropriate follow-up. [4] The introduction of guidelines for the referral of suspected
cancer is an important step towards primary care practitioners identifying patients with
oral malignancy.
Importance of Referral for Oral, Head and Neck cancers
Delays in referral of suspected oral cancer cases for treatment caused by the clinicians
have been identified by several reports. Thus, the design of a simple, clear, fail-safe
referral scheme may greatly diminish the length of the delay.[5] The ability of the
examiners to make a correct positive detection of oral cancer (sensitivity, Sn) shows a
broad range worldwide: reported Sn scores varied from 0.4 to 0.9. [6] The specificity (Sp)
ranged to 0.3 to 0.92, [6] low values scores for the screening of oral cancer would mean
that patients with oral cancer may not be adequately referred for the decisive diagnosis
and treatment.
The use of the clinical guideline for referral of patients seems to significantly increase the
diagnostic specificity for oral cancer and also to reduce the possibility of not referring an
oral cancer case, and thus increasing the diagnostic delay. This phenomenon has also been
described when the use of referral guidelines was studied in primary care settings.
An audit of this initiative revealed a high proportion of non-malignancies were referred
via the fast track system to the hospitals due to low sensitivity of visual detector
guidelines. [7] Moreover, a worrying ignorance on oral changes associated to early forms
of oral cancer (early diagnosis secondary prevention) particularly about leucoplastic,
erythroplastic or leucoerythroplastic lesions amongst medical and dental professionals. [8]
The implementation of clinical guidelines for dental professionals aimed at reinforcing
these topics may increase diagnostic sensitivity and specificity when dealing with lesions
suspicious for oral cancer. The clinical practice guideline for referral of oral cancer
suspicious lesions has been elaborated by a panel of experts synthesizing the best
available scientific evidence. The objective of the implementation of clinical practice
guideline is to increase knowledge, to change behaviors and attitudes in clinical practice
and to improve the quality of the clinical care.[9-10]
1
REFERRAL GUIDELINES AND PROCESS
Clearly is essential that undergraduate and postgraduate medical and dental education
should include the characteristics of a good referral guide in order to improve standards.
Therefore, it is important that all members of the primary healthcare team are aware of
oral cancer, of the importance of encouraging regular dental attendance, and of their role
in the identification and appropriate referral of individuals with oral mucosal complaints
which last longer than three weeks (Table 1).
Table 1. Warning feature suggestive of oral cancers
Red lesions
Extraction socket not healing
A lump
Induration beneath a lesion, i.e. a firm
infiltration beneath the mucosa
Granular appearance
Ulcer with fissuring or raised exophytic
Fixation of lesion deeper tissues or to
margins
overlying skin or mucosa
Abnormal blood vessels supplying a lump
Voice change
Pain or numbness
Lymph node enlargement
Loose tooth
Weight loss
The Rapid Access Route
General medical and dental practitioners are encouraged to refer patient with a high index
of suspicious cancer as a matter of urgency using the 2 week wait referral proforma
(Appendix ‫)الملحق هو استمارة اإلاحال‬.
A High Index of Suspicion of cancer (urgent)
- Ulceration of tongue / oral mucosa > 3
- Oral / Facial swelling > 3wks
- Red or & white patch of oral mucosa
- Unexpected tooth mobility not associated with periodontal disease
- Un-resolving neck / salivary / thyroid mass >3 wks
- Orbital mass
- Neuropathy of cranial nerve
- Hoarseness > 6 wks
- Dysphagia > 3wks
- Persistent sore throat
General practitioners should be encouraged to:
- Make referrals using the appropriate referral pro-forma for patients in whom there is
a high index suspicion cancer as defined above.
- Take the history of smoking and alcohol consumption.
- Provide information on all current medication.
- Observe the results of all recent investigations as Scan, FBS, LFTs and U&Es
results
2
Quality in Referral Letters Sent for Maxillofacial centers
Members of the primary dental health team must ensure they are aware of the local
referral arrangements for oral cancer. It is best to establish these referral pathways before a
patient with a suspicious oral lesion is seen in the dental practice (Table 2).
Information required in referral letters for suspected malignancy:
A) Administrative Data include:
 Marked as urgent
 Patient’s name
 Patient’s address
 Patient’s tel. no.
 Patient’s date of birth
 Patient’s gender
 Previous visited hospital
 Referrer’s name
 Referrer’s address
 Referrer’s tel. no.
Clinical Data include:
 Description of site
 Diagram of lesion
 Size of lesion
 Shape of lesion
 Duration of lesion
 Symptoms
 Clinical appearance
 Risk factors
 Medical history
If a referral is to be made, telephone contact should be made followed-up with a formal
letter of referral. The referral letter should be marked ‘URGENT’ and addressed
personally to a named consultant, and must include the details shown in table 2.
The referring dentist should be aware of the likely scenario when the patient first attends
the specialist unit. The patient may be advised to expect a biopsy (usually under local
anaesthetic with or without sutures being placed) and that this is the only way to
definitively diagnose the lesion. Clinical photographs are usually taken for the case notes
as a matter of routine. Radiographical assessment of the head and neck may be performed,
and blood may also be taken for analysis. It is important to realize that following referral
the primary dental health teams have a continuing role. If oral cancer is diagnosed, the
patient’s life is never going to be the same again. The dental practice should have an ‘open
door’ policy and patients should be encouraged to return for further discussion and
support as they feel they need. A formal follow-up appointment is a good way to show
that they are not being abandoned into hospital care, without any support mechanism in
place.
3
Table 2 Information required in URGENT Referral letter
General Dental Practice:
Date:
Oral Cancer Specialist Unit:
Dear Named Specialist:
Re: Patient’s details: Name, Address/Postcode,
Telephone number:
Date of birth:
Name of patients General Medical Practitioner:
Further to our telephone conversation I would be grateful if you could see the above
named patient, as a matter of priority.
 Reasons for referral: Presenting complaint
History of presenting complaint, including previous treatment
 Social history: Occupation, family details,
Smoking: number per day /number of years
Alcohol: number of units /day
 Medical and drug history
 Clear statement of clinical examination
 The patient’s level of understanding and concerns about their mucosal
abnormality.
Yours sincerely,
General Dental Practitioner
Diagnostic delays
Patient delay is generally defined as the time from the patient's first awareness of a
symptom to seeking their first consultation with a healthcare professional. [11,12]
Professional delay is defined either as the time from the first consultation with a
healthcare professional to the first consultation with a treating specialist, [12,13]or to the
definitive diagnosis being made, , [14,15] or to the patient being admitted for definitive
treatment, or as the time from the first consultation until a referral letter is sent to a
specialist unit. [16] We would suggest the use of professional delay for the whole time from
the patient's first consultation to their commencing definitive treatment. This is made up of
referral delay (time from consultation to referral being made), appointment delay (time to
appointment at specialist centre) and treatment delay (time from diagnosis to definitive
treatment commencing). [16] The timely diagnosis and subsequent management of
malignant lesions is well known to provide the best prognosis. Dental professionals are
ideally situated to recognize potentially malignant lesions in the oral cavity. [17] A
systematic extra-oral and intra-oral examination of the oral, head and neck region should
be an integral part of all routine dental examinations and is considered as the most suitable
screening method for malignant and premalignant lesions.
Patient factors also play an important role in the early detection, as some patients do not
attend regular dental assessments for social and financial reasons. [11] The delay in
identification, referral and diagnosis will increase the chance of metastatic spread and
therefore upstage the disease. [18] The five-year survival will therefore reduce from 90%
for stage I disease to 30–40% for stage IV disease. [19]
4
Conclusions
The primary dental healthcare practitioner and team, being in regular contact with patients
and their families, are in the ideal position to give advice on the risk factors associated
with oral cancer and to examine for oral cancer and potentially malignant lesions.
Prevention in the form of smoking cessation and sensible drinking advice should be
offered. Dentists should consider this in terms of a common risk factor approach: as
smoking is relevant to oral cancer, but also to periodontal disease and general health. [20]
Examination of the oral mucosa should form part of all patients’ routine checkup. Dentists
have an important initial and continuing counseling role for patients with suspected oral
cancer and for those diagnosed. To facilitate this, communication pathways should be
established between primary and secondary care and referral protocols should be in place.
There is a need for improved awareness of the roles of the oral cancer specialist care team
and of the general dental practitioner by each other, to establish a greater integrated
approach in the overall management of patients with oral cancer making the patient
journey smoother, more effective and improving outcome.
SUMMERY TABLE 1. APPROACH TO ORAL CANCER SCREENING
1. Examination for Every patient must be explored for potential malignant and
early diagnosis of premalignant lesions each time a dental check-up is performed. A
oral cancer
particularly thorough examination is required on smokers, heavy
drinkers or on patients elder than 40.
2. Referral scheme When
a
suspicious
- If the clinician feels qualified
for oral lesions lesion is detected, biopsy
and confident, he/she can
suspicious
for is the only method to
perform the biopsy and refer the
Malignancy
ascertain whether or not
patient to a specialized centre in
it is malignant. The
case of malignancy.
clinician can opt for two
- Refer the patient directly to a
actions:
specialized
centre
or
(maxillofacial surgery).
3. Information to It is essential for the Patient data: address, age, telephone
include
in
the consultant to know number in order to contact the patient.
referral letter
certain data about the Brief medical history: relevant
patient, the lesion and systemic disorders, medication he/she
the clinical diagnosis in is taking and patient's physician and
order
to
establish dentist telephone numbers.
priorities within the Relevant facts of patient's social
waiting list. Relevant history, including alcohol and tobacco
data are:
consumption.
A detailed description of the lesion:
data of appearance, site, size, color and
consistency.
Clinical diagnosis in order to allow
categorization of the referral urgency.
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SUMMERY TABLE 2. DENTAL COUNCIL REFERRAL SCHEME FOR
LESIONS SUSPICIOUS FOR ORAL CANCER.
Referral
Example
Refer to
type
Preferential
- Ulceration that persists more than 14 Oral and Maxillofacial
days after removing its hypothetical cause. surgery
Service,
- White, red or white-reddish lesions that Stomatology Service or
cannot be scrapped off.
any other specialized unit.
- Evident lump
- Localized pigmented lesion.
Referral paths should be
- Any oral lesion with suspicious features: agreed in advance with the
rapid growth, infiltration, induration, local specialized units.
fixation.
- Non-visible but palpable intraoral lumps.
- Non-explained orofacial pain that
persists longer than 4 weeks.
- Unexplained recent neck lump.
- Unexplainde dysphagia lasting longer
than 3 weeks.
- Unexplained dental mobility lasting
longer than 3 weeks that cannot be related
to trauma or periodontal disease.
- Unexplained osseous lesion.
- Decrease of orofacial sensitivity and
paralysis of unknown origin.
Normal
- Any other disorder requiring medicosurgical treatment.
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‫استمارة اإلحالة ألمراض الفم‬
.......... ‫دائرة صح‬
........... ‫قطاع الرعاي الصحي األولي في‬
............... ‫أسم مركزالرعاي الصحي األولي في‬
..................‫أو أسم المركز التخصصي لطب األسنان‬
........... ‫إحالة إلى شعبة جراحة الوجه والفكين في مستشفى‬
....... :‫عنوان المستشفى المحال اليها‬
-: ‫التاريخ‬
-: ‫العمر‬
-: ‫رقم الهاتف‬
-: ‫اسم المريض‬
-: ‫الجنس‬
-: ‫العنوان‬
Chief complaint:History of present complaint:Medical and drug history:Previous treatment:Occupation:Social history:Smoking:number per day :Alcohol:number of units /day:Clinical examination:- Type of lesion:Size of lesion :Any associated symptoms:Lymph nodes involvement:Investigations:-
family details :number of years:Site of lesion:Duration of lesion:-
Differential diagnosis:Spot diagnosis:…………………………………………… ………………………………………………
………………………………………….. …………………………………………….
‫ختم المركز‬
-: ‫اسم وتوقيع طبيب األسنان الممارس‬
7
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