Consider Larynx Cancer for Persistent Sore Throat: Study

Nicky Broyd

January 29, 2019

New research is recommending GPs consider cancer of the larynx in patients with persistent sore throat, especially if it's combined with dysphagia, dyspnoea, or otalgia.

It's thought the study, Recognising laryngeal cancer in primary care: a large case–control study using electronic records , published in the British Journal of General Practice (BJGP) may help GPs select the most appropriate patients to be referred for suspected laryngeal cancer, and could lead to earlier detection.

Each year in England more than 1700 people, mostly men, are diagnosed with laryngeal cancer.

In the absence, until now, of any primary care studies the current NICE (National Institute for Health and Care Excellence) guideline is based on clinical consensus and suggests urgent referral for suspected laryngeal cancer in patients with persistent unexplained hoarseness or unexplained neck lump.

The Study

The new study used patient records from more than 600 GP practices as part of the UK’s Clinical Practice Research Datalink.

It was led by the University of Exeter Medical School and looked at 806 patients ≥40 diagnosed with cancer of the larynx along with 3559 controls.

A total of 34 symptoms and 14 investigations were considered at the start of the study; of those, 10 remained significant in the final model.
 

Findings

The study found hoarseness was the symptom with the highest individual risk of laryngeal cancer, at 2.7% (approaching the 3% NICE investigation threshold). 

The risk increased to >3% when hoarseness was supplemented with dysphagia, mouth symptoms, insomnia, otalgia, or recurrent dyspnoea.

Patients reporting symptom combinations not currently identified in NICE guidance — such as sore throat with dysphagia, with recurrent dyspnoea, or with otalgia — had risk estimates of >5%. 

The highest risk was for hoarseness with sore throat (12%) or raised inflammatory markers (15%).

Unexpectedly, the study authors found no association between neck lumps and laryngeal cancer.  However, they say unexplained neck masses are high-risk symptoms for lymphoma and, therefore, warrant referral.

Prof Willie Hamilton, one of the study authors, said in a press statement: "This research matters – when NICE guidance for cancer investigation was published there was no evidence from GP practices to guide this – nor to inform GPs. Crucially, hoarseness serious enough to be reported to GPs does warrant investigation. Furthermore, our research has shown the potential severity of some symptom combinations previously thought to be low-risk." 
 

Strengths and Limitations 

The study used primary care data and included more than 800 patients with laryngeal cancer from across the UK. Another strength is that it searched online patient forums and existing literature for possible symptoms and so the authors think it unlikely any pertinent symptoms were left out.

A possible limitation is that the researchers were dependent on the quality of GP recording and some data will have been omitted or written in the free-text section, which researchers were unable to access.

This study was funded by the National Institute for Health Research (NIHR),through the NIHR Policy Research Unit in Cancer Awareness, Screening, and Early Diagnosis and the NIHR Programme Grants for Applied Research.

Prof William Hamilton was clinical lead on the 2015 revision of the National Institute for Health and Care Excellence (NICE) guidance on the investigation of suspected cancer. His contribution to the article is in a personal capacity, and does not represent the view of the guideline development group, or of NICE itself.

Br J Gen Pract 28 January 2019; bjgp19X700997. DOI: https://doi.org/10.3399/bjgp19X700997

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