Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases

Abstract

Background: Little is known about the diagnosis of head and neck carcinoma in primary care. We sought to estimate the general prevalence of symptoms reported by patients with head and neck carcinomas and to determine the association between detection patterns of head and neck cancer cases in primary care and survival.

Methods: In a cross-sectional survey, we used a questionnaire to estimate the general prevalence of symptoms associated with head and neck cancer from a sample of 5646 primary care visits in 25 randomly selected health centres over 4 weeks throughout Finland. A population-based retrospective cohort study involved the 221 patients resident in one primary health care district (population about 700,000) in whom head and neck carcinoma was diagnosed between Jan. 1, 1986, and Dec. 31, 1996. Data on the initial primary care visit, clinical characteristics and survival were obtained from patient charts.

Results: Of 5646 visits to a primary care practitioner, 11% (617) were made because of the same symptoms as those initially reported by patients later found to have head and neck cancer. According to the cohort data, the detection rate of these carcinomas in primary care was 1 per 63,000 visits. At the initial visit of 221 patients later found to have cancer, 56% (123) received referrals, 24% (53) follow-up appointments and 20% (45) neither ("overlooked"). At 3 years, the risk of death was significantly higher among patients whose disease was overlooked (adjusted hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.03-3.45). The excess risk associated with being overlooked, however, was confined to subjects with tongue or glottic tumours (HR 4.25, 95% CI 1.59- 11.4) (number needed to harm 3.0, 95% CI 1.9-6.7).

Interpretation: Despite the rarity of patients with head and neck carcinoma in primary care, patients with symptoms of these diseases and especially with symptoms of tongue and glottic carcinomas should be initially referred for further care or followed up.

Fig. 1: Flow of participants through the cohort study.

Fig. 2: Association between the outcome of the initial visit in primary care and disease-specific death in a cohort of 221 head and neck carcinoma patients in Finland. At 3 years, 31% of patients who were referred for further care had died (95% confidence interval [CI] 23%–39%), 30% of those who were followed up had died (95% CI 17%–43%), and 45% of those whose disease was overlooked had died (95% CI 30%–60%). The absolute increase in the risk of death was 14% (95% CI –3 to 31, p = 0.027) between referred patients and those overlooked, and –1% (95% CI –16 to 14, p = 0.97) between the patients referred and those followed up, by log-rank test).