Attitudes to the Implementation of Speech and Language Therapist Led Low Risk Two Week Wait Clinic in the UK: A Survey Exploration Using Normalization Process Theory.

OBJECTIVES: The aim of this study was to identify the factors which might shape the implementation of speech and language therapist led low risk 2 week wait clinic (SLTLR-2WW). STUDY DESIGN: An online survey was designed, piloted, and disseminated through UK speech and language professional groups. The survey asked questions about, the skills of, and equipment available, to SLT respondents. Using a modified NoMAD instrument (based on Normalization Process Theory) the survey explored attitudes to the prospect of the development of the SLTLR-2WW clinical model in the UK. Responses were tallied and calculated as percentage of responses. The free text question responses were analyzed using a qualitative content approach, responses were coded and grouped into categories and mapped onto the Normalization Process Theory domains by the two authors. RESULTS: There were 129 responses to the survey questions from SLTs from all regions of the UK and 72 respondents supplied free text comments for analysis. CONCLUSIONS: The collected responses indicate there is enthusiasm for the potential development of SLTLR-2WW clinics. The survey demonstrates that there are disparities in terms of resource availability, departmental, management and clinical support, around the UK. There is limited but successful experience of SLTLR-2WW in the UK but the survey responses indicate there is potential for expanding the scope of practice for SLTs into the delivery of clinical care for patients referred as suspected cancer with hoarseness and swallowing issues. The responses to the NoMAD derived questions and free text analysis identify some factors which could impede the development of this new service model include, resistance, lack of training, supervision, and support from colleagues and management.

Factors shaping the implementation and use of Clinical Cancer Decision Tools by GPs in primary care: a qualitative framework synthesis.

OBJECTIVE: Clinical Cancer Decision Tools (CCDTs) aim to alert general practitioners (GPs) to signs and symptoms of cancer, supporting prompt investigation and onward referral. CCDTs are available in primary care in the UK but are not widely utilised. Qualitative research has highlighted the complexities and mechanisms surrounding their implementation and use; this has focused on specific cancer types, formats, systems or settings. This study aims to synthesise qualitative data of GPs' attitudes to and experience with a range of CCDTs to gain better understanding of the factors shaping their implementation and use. DESIGN: A systematic search of the published (MEDLINE, CINAHL, Web of Science and EMBASE) and grey literature (July 2020). Following screening, selection and assessment of suitability, the data were analysed and synthesised using normalisation process theory. RESULTS: Six studies (2011 to 2019), exploring the views of GPs were included for analysis. Studies focused on the use of several different types of CCDTs (Risk Assessment Tools (RAT) or electronic version of RAT (eRAT), QCancer and the 7-point checklist). GPs agreed CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. They had concerns about the impact on trust in their own clinical acumen, whether secondary care clinicians would consider referrals generated by CCDT as valid and whether integration of the CCDTs within existing systems was achievable. CONCLUSIONS: CCDTs might be a helpful adjunct to clinical work in primary care, but without careful development to legitimise their use GPs are likely to give precedence to clinical acumen and gut instinct. Stakeholder consultation with secondary care clinicians and consideration of how the CCDTs fit into a GP consultation are crucial to successful uptake. The role and responsibilities of a GP as a clinician, gatekeeper, health promoter and resource manager affect the interaction with and implementation of innovations such as CCDTs.

Rapid implementation of an evidence-based remote triaging system for assessment of suspected referrals and patients with head and neck cancer on follow-up after treatment during the COVID-19 pandemic: Model for international collaboration.

BACKGROUND: Outpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation. METHODS: For suspected referrals with cancer, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10 244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value, and area under the curve of 0.89. For follow-up patients, a symptom inventory generated from 5123 follow-up consultations was used. A customized Excel Data Tool was created, trialed across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol, and registration link for the project. Stakeholder support was obtained from national bodies. RESULTS: No remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centers show that 77.1% of patients were discharged directly or have had their appointments deferred. DISCUSSION: Significant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC-V.2 is feasible and the authors welcome international collaboration.

Concurrent HPV-related oropharyngeal carcinoma in four couples.

OBJECTIVES: Typically, HPV-related cancers are sexually transmitted, however, the natural history of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is unclear. HPV16 transmission has been reported previously between five couples with OPSCC. We report the clinico-pathological features of a further four couples with HPV-related OPSCC and compare them with the published cases. PATIENTS AND METHODS: We identified four couples in long-term heterosexual relationships that all had HPV-related OPSCC. The couples were treated at three UK hospitals and presented between 2009 and 2015. HPV tests included p16 immunohistochemistry, high-risk HPV DNA in-situ hybridisation and Roche Cobas HPV test. DNA sequencing was used to determine the HPV variant. RESULTS: The four couples represented < 2% of patients with HPV-related OPSCC at the three contributing hospitals (8 of 457 consecutive patients). The couples' tumours all contained HPV16. The mean age was 63 years old (range 52-72 years). The interval between the index cancer and the partner's cancer was 16, 24, 26 and 64 months respectively. The majority of patients had Stage I disease (UICC TNM8). Six of eight patients are disease free, one patient is alive with disease and there was one death from loco-regional recurrence. CONCLUSION: This report highlights the occurrence of HPV-related OPSCC in heterosexual couples and raises the possibility of transmission of HPV16. Despite increasing prevalence of HPV-related OPSCC and increased awareness of the disease, there is a paucity of couples with the disease, suggesting either under-reporting or that the development of OPSCC following HPV transmission between couples is a rare event.

Gastrostomy in head and neck cancer: current literature, controversies and research.

PURPOSE OF REVIEW: This article explores the literature on the role of gastrostomy tube feeding use in the management of head and neck cancer, with special attention to its indications, timing of insertion, advantages, complications and quality of life issues. RECENT FINDINGS: The current guidelines in place across different countries and two ongoing randomized controlled trials are discussed in detail, and placed in the context of current evidence. SUMMARY: There remains a lack of consensus about when and which enteral feeding routes (gastrostomy or nasogastric tube) should be used and controversy about the long-term effects on swallowing function as well as quality of life for patients. Local guidelines should be used or generated to guide practice or patients enrolled into existing trials until higher level evidence is generated.

Gastroesophageal and extraesophageal reflux symptoms: similarities and differences.

OBJECTIVES/HYPOTHESIS: The association between extraesophageal reflux (EER) and symptoms of gastroesophageal reflux disease (GERD) is inadequately understood. We used the Comprehensive Reflux Symptom Scale (CReSS) to evaluate EER and reflux-symptom prevalence in gastroenterology and otolaryngology outpatients and symptom awareness among UK gastroenterologists. STUDY DESIGN: Cross-sectional cohort survey. METHODS: Six hundred thirty-nine participants were surveyed: 103 controls, 359 patients undergoing esophagogastroduodenoscopy (EGD), and 177 otolaryngology clinic patients with throat symptoms. Participants completed the CReSS questionnaire. The study was undertaken in the Endoscopy Unit and the Department of Otolaryngology-Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle-upon-Tyne, United Kingdom. Registered members of the British Gastroenterology Society were asked to rate how frequently reflux patients might complain of each CReSS item. RESULTS: The median CReSS total in volunteers (4) was significantly lower (P < .002) than in ear, nose, and throat (ENT) patients (26) or EGD patients with (42) or without (32) esophageal inflammation. All items were scored as ≥1 by >15% of ENT patients and 28% of EGD patients. Three major, robust CReSS factors: esophageal, pharyngeal, and upper airway emerged. Of 259 gastroenterologists, >20% scored 8 of the 34 symptoms as never being reported by reflux patients. CONCLUSIONS: Endorsement of each EER CReSS item by 28% to 58% of patients with endoscopic evidence of GERD supports the Montreal consensus on an EER-GERD continuum. Gastroenterologists vary considerably in their appreciation of EER symptom relevance. The advantages of CReSS include standardized, comprehensive capture of patient experience; discriminant validity of ENT and GERD patients from volunteers; and discrete esophageal, pharyngeal, and upper airway subscales. LEVEL OF EVIDENCE: 4.

Branchial cleft cyst carcinoma: fact or fiction?

PURPOSE OF REVIEW: With the recent changes in the cause of head and neck cancer and the association of cystic metastatic neck squamous cell carcinoma with human papilloma virus (HPV), patients who are diagnosed with a cystic lesion in their upper neck need thorough investigation before commencing any treatment. RECENT FINDINGS: The differential diagnosis of a cystic mass in the upper neck of an adult over the age of 40 years is a branchial cleft cyst, cystic metastatic squamous cell carcinoma or a branchial cleft cyst carcinoma (BCCC). Investigation must include diagnostic imaging, biopsy or excision biopsy of likely primary sites, such as oropharyngeal sub-sites, and testing for HPV, Epstein-Barr virus immunological status. SUMMARY: The existence of BCCC is an exceptional diagnosis, with less than 40 cases considered proven. Consensus agreement has been proposed on making such a diagnosis. The diagnosis of a BCCC should be one of exclusion rather than presumption, after all other possible diagnoses have been considered and excluded.

Treatment of hypopharyngeal carcinoma with primary chemoradiotherapy: functional morbidity.

PURPOSE OF REVIEW: This review aims at unravelling the medical literature which has reported on the treatment of 'larynx preserving' chemoradiotherapy strategies and separating the treatment sites, larynx and hypopharynx, from each other and reporting on the adverse effects and functional outcomes of patients with hypopharyngeal cancer. RECENT FINDINGS: The literature reports on the treatment of advanced laryngeal and hypopharyngeal cancer with chemoradiotherapy together as a 'common cancer site'. Although the chemotherapeutic drugs affect the tumour and the normal tissues similarly in both the larynx and hypopharynx, their effects on the patient groups are different, mainly affecting swallow, airway protection mechanisms and voice/speech to a greater or lesser extent. Pretreatment symptoms and function should be documented subjectively and objectively prior to commencing nonsurgical treatment. Hypopharyngeal cancer should be reported separately, and preferably stratified into the three subsites, according to the T stage of disease rather than TNM stage. Equipment for such testing and the process for such documentation are available in most clinical areas, worldwide. SUMMARY: Future analysis relies on the conscientious monitoring of adverse effects of all treatment modalities and an assessment of function as well as quality of life impact on the patient. Thus, the specialty can make informed decisions on the most appropriate and most suitable mode of treatment for individual patients based upon their tumour, their preoperative organ function, their likely future organ function and the likelihood of cure.

Update on the management of parapharyngeal tumours.

PURPOSE OF REVIEW: Parapharyngeal space (PPSp) tumours are uncommon and hence the 'generalist expertise' for diagnosis and treatment is limited. Recent improvements in radiology and cytopathology mean the likely diagnosis is more certain and hence the recommended surgical treatment can be more definitive. RECENT FINDINGS: A wide spectrum of primary pathologies are reported to involve the PPSp; the majority (80%) are benign neoplasms. Radiological imaging, computed tomography (CT) and MRI, with diagnostic fine needle aspiration cytology (FNAC), have continued to increase preoperative diagnostic accuracy. Thus, it is easier to identify the patients whose external surgery may rarely require a mandibulotomy. Only highly selected cases can be safely excised via a transoral approach. SUMMARY: All tumours of the PPSp require accurate diagnosis, using modern diagnostic imaging and FNAC. Surgery, in most cases, remains the treatment of choice. Many neurogenic tumours and paragangliomas can be observed in elderly patients. The optimum surgical approach for complete excision needs to be selected on an individual basis. Each patient must be adequately informed of the associated morbidity and possible complications, likelihood of cure and the risk of tumour recurrence - short and long term. Most tumours can be excised safely, and with low risk of recurrence and short hospitalization, with a cervical-parotid approach.

Searching for metachronous tumours in patients with head and neck cancer: the ideal protocol!

PURPOSE OF REVIEW: As treatment changes in the management of head and neck cancer, patients are reportedly living longer; therefore, their death may be due to comorbidity, metastatic disease or the development of a metachronous second primary tumour (MSPT). This review describes recent developments in the identification of MSPTs of head and neck cancer, oesophagus and lung, and suggests/recommends an 'ideal surveillance protocol'. RECENT FINDINGS: The rate of MSPT development ranges between 6 and 9% annually for life. Improved accuracy in the detection of mucosal asymptomatic premalignant and early cancer has been enhanced by incorporating fluorescence spectroscopy in addition to modern flexible endoscopic techniques in the outpatient setting. Newer imaging has replaced old techniques (chest radiograph, barium swallow, etc.) by using radiotracer PET-computed tomography to detect local tumour activity. Further advances are anticipated in optical diagnostics and the incorporation of radiopharmaceuticals with labelled antibodies to enhance PET imaging, thus making tumour identification more accurate. Genetic classification of head and neck cancer has already identified high-risk patient groups, thereby allowing expensive tumour screening techniques to be used selectively and specifically. Patients who continue to smoke and abuse alcohol must be helped and encouraged to quit. SUMMARY: It is now possible to review traditional follow-up policy for treated head and neck cancer patients, to encourage the implementation of an evidence-based surveillance protocol, to identify only patients who are at high-risk of developing a MSPT, to incorporate modern targeted expensive tumour screening and to allow treatment of early cancer and effective treatment, thereby improving patients' quality of life and increasing survival.