Mouth cancer: dentists and GPs should be able to refer patients straight for tests

To help GPs and dentists diagnose patients faster, we recently launched our new Oral Cancer Toolkit in partnership with the British Dental Association and the Royal College of General Practitioners. Here, Professor Richard Shaw, a mouth cancer specialist who helped create it, explains why the toolkit recommends a departure from the recently published NICE referral guidelines.

If we want to improve the UK’s survival rates, early diagnosis matters. Indeed, the recent debate over future NHS cancer policy has focused heavily on the UK’s lagging survival rates compared with other similar countries. And our tendency to diagnose some patients later, when survival can be poorer, has come under scrutiny as a key factor.

Why might the UK diagnose cancers less effectively? As Professor Sean Duffy, NHS England’s Clinical Director for Cancer, recently told a meeting of cancer surgeons, many suspect that our cancer patients are getting trapped in ever more complex and growing waiting lists, and that GPs are acting perhaps too effectively as gatekeepers for getting worrying symptoms properly checked out.

In an attempt to improve things, in June the National Institute for Health and Care Excellence (NICE) recently published new Referral Guidelines for Suspected Cancer. The aim was to make it easier for GPs to refer patients, for either tests or to see a specialist, sooner and shift the stage patients are diagnosed to an earlier point in their disease.

While providing such rapid diagnosis and investigation will challenge the NHS’s already hard-pressed resources, such a shift in culture will undoubtedly save lives.

But the guidelines aren’t perfect and, in particular, many of us who treat patients diagnosed with oral cancers believe NICE has got it slightly wrong. So when I found myself invited onto the advisory group to work on Cancer Research UK’s new oral cancer toolkit, I saw an opportunity to influence things. And I found that other experts in the group shared similar views to mine.

Oral cancer – early diagnosis is crucial

I’ve seen first-hand the effect of diagnosing oral cancers late – Prof Richard Shaw

Over the 15 years I’ve been practicing, I’ve seen first-hand the effects of diagnosing oral cancers late. Stage I and II disease can have excellent outcomes, with around eight or nine out of ten patients surviving for five years or more, often after relatively simple treatment.

But patients with more advanced stages (III and IV) often need complex treatment – radiotherapy, even chemotherapy – and even so, just three or four out of ten survive for five years.

Unfortunately around half of the patients I see fall into this latter category.

Clearly, there are improvements to be made – especially when, in many cases, the suspicious symptoms are relatively clear cut.

Spotting it early

It’s generally agreed that all patients with worrying symptoms such as persistent oral ulcers or lumps should be referred for specialist opinion promptly. But crucially, it’s also become clear that dentists, as well as GPs, can play a role in spotting these signs – particularly as they have a higher level of expertise and experience in oral examination.

And here lies an unfortunate paradox: while only around half the UK population is registered with a dentist, or regularly goes for check-ups, oral cancer rates are higher among people who don’t have easy access to a dentist – particularly people from lower-income groups.

In part, this is thought to be linked to their often higher rates of things that increase the risk of oral cancer, such as smoking and drinking alcohol.

So clearly, both GPs and dentists have a role to play in referring people with signs of mouth cancer.

The guidelines

According to the NICE guidelines, for certain symptoms a GP should cross-refer a patient to a dentist, to get a second opinion – the idea being that the latter are better equipped to spot less serious conditions, and so spare hard-pressed diagnostic clinics.

But those of us who ultimately treat and manage the disease are extremely worried that this extra step merely introduces further delays in the system, and for some patients this could ultimately lead to them doing worse.

This issue is potentially made worse when you consider that some patients don’t fully appreciate the seriousness of their cross-referral and, effectively, get lost in the system.

So cross-referral would seem to fly in the face of the ethos of the new guidelines – namely to open up NHS diagnostic services to more patients, spot more cancers earlier, improve the care and patients subsequently receive – and ultimately their chances of long-term survival.

For this reason, when we drew up the Oral Cancer Toolkit, we decided to take the unusual step of deviating from NICE guidelines, instead making a more simple recommendation:  that GPs and dentists should consider referring patients directly for further investigation if they have:

• Ulcers lasting more than 3 weeks
• A lump in the mouth or on the lip
• A lump in the neck
• Red or red and white patches in their mouths

This wasn’t a decision we took lightly – but given the huge impact an earlier diagnosis has on a patient’s experience and outcome, it was one we felt was necessary.

Together with the new educational content aimed at both dentists and doctors, we hope that many cases will be referred much earlier in the future, and more patients will ultimately survive oral cancer.

– Professor Richard Shaw is a surgeon specialising in head & neck and oral cancers, based at the University of Liverpool

• You can find the toolkit for GPs here (requires a doctors.net login), the toolkit for dentists here, and you can also download our new posters which aim to make the new guidelines more accessible.