STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
The following signs and symptoms should be investigated if they persist for more than three weeks, and especially if more than one symptom is present:
- mouth ulcer or mass
- unexplained tooth mobility and/or non-healing dental extraction site
- white or red patches of oral mucosa (leukoplakia)
- persisting lip ulcers or patches
- changes in the voice, such as hoarseness
- persistent sore throat (particularly together with earache) or cough
- difficulty or pain when swallowing or chewing
- coughing up blood (including spitting up blood)
- persistent unexplained neck or parotid lump or sore
- pain, pressure, unilateral ringing in the ear, or hearing loss
- unilateral paralysis of the muscles in the face
- unilateral numbness, tingling, pins and needles or formication (feeling of insects crawling on the skin)
- unilateral blockage of the nose, especially if associated with swelling or other problems with the eyes such as double vision
- trismus (lockjaw) or reduced jaw opening
- unexplained weight loss.
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of head and neck cancer.
Presenting symptoms should be promptly and clinically triaged with a health professional.
General practitioner examinations and investigations may include (but should not delay specialist assessment):
- structural imaging with ultrasound, CT and/or MRI
- ultrasound-guided fine-needle aspiration cytology (USgFNAC) of a node, if malignancy is suspected or a neck lump persists or grows (including lumps in the thyroid, salivary gland or lymph node).
Excisional biopsy of potentially malignant lesions should not be undertaken. Appropriately trained practitioners can consider biopsy of a primary site but this should not delay referral. Lymph nodes should not have incisional or excisional biopsy without specialist input.
Signs and symptoms (listed in 2.1) should be investigated if they persist for more than three weeks, especially if more than one symptom is present.
If the cancer diagnosis is confirmed or the results are inconsistent or indeterminate, the general practitioner or dental practitioner must refer the patient to an appropriate specialist to make the diagnosis. For suspected or confirmed head and neck cancer, referral should be to a head and neck surgeon connected to a head and neck multidisciplinary team. For suspected or confirmed oral cancer, referral could also be made to a maxillofacial surgeon.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed head and neck cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
The first specialist appointment should take place within two weeks of the initial referral from the general or dental practitioner.
The patient must be informed about the improved outcomes achieved at centres that treat higher numbers of complex head and neck cancer cases.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- management of physical symptoms including ear/throat pain, trouble swallowing/talking and weight loss
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
