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

Clin Otolaryngol. 2016 Feb;41(1):66-75. doi: 10.1111/coa.12597.


Objectives: 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.

Design: Statistical analysis of referral criteria and outcomes.

Setting: Two tertiary care cancer centres in the United Kingdom.

Participants: 4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010.

Main outcome measures: Parameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve (AUROC).

Results: 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 nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3 weeks, dysphagia >3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3 weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the 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

Conclusions: This study 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.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Female
  • Head and Neck Neoplasms / diagnosis*
  • Humans
  • Male
  • Middle Aged
  • Practice Guidelines as Topic*
  • Referral and Consultation / standards*
  • Young Adult