Refining the head and neck cancer referral guidelines: a two centre analysis of 4715 referrals

Theofano Tikka, Paul Pracy, Vinidh Paleri

Research output: Contribution to journalArticlepeer-review

12 Citations (Scopus)


Our aim was 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. We analysed the referral criteria and outcomes from two tertiary care cancer centres in the United Kingdom. Between 2007 and 2010, 4715 patients were referred via the fast track system with a suspected HNC. The main outcome measures were the parameters of diagnostic efficacy, a multivariate regression model to calculate estimated probability of HNC and the area under the receiver operating characteristic curve (AUROC). We found that 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 9 symptoms to be linked with HNC. Of these, only 4 are included in the latest NICE guidelines. The best fit predictive model for this dataset included the following symptoms: hoarseness>3 weeks, dysphagia>3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, presence of blood in mouth with concurrent sensation of lump in throat, and 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 This paper 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.

Original languageEnglish
Pages (from-to)141-50
Number of pages10
JournalBritish Journal of Oral and Maxillofacial Surgery
Issue number2
Early online date7 Feb 2016
Publication statusPublished - 29 Feb 2016


  • area under curve
  • deglutition disorders
  • guidelines as topic
  • head and neck neoplasms

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