September 20, 2020
Camille Joyce O. Cruzada, MD
Laryngeal cancer accounted for 1% of new cases and 2% of mortalities from cancer worldwide. These numbers are comparable to that of the Philippines where it accounted for 1.09% of new cases and 0.98% of deaths from cancer in both sexes last 20181,2. Laryngeal cancer was ranked 21st in terms of cancer prevalence worldwide.
As uncommon laryngeal cancer may be, it presents with a symptom too common in primary care that it leads to frequent misdiagnosis, delay in appropriate management, and poor prognosis16,17. With professional diagnostic delay identified as an independent predictor for survival17, primary care must rise up to the challenge of facilitating properly timed intervention.
I. Tempo: The slow progression of symptom evaluation
The difficulty in diagnosing early stage laryngeal cancer lies on the absence of a simple screening test and tumor marker for its detection25. Guidelines have identified persistent, progressive hoarseness to warrant an urgent referral to a specialist4-6. However, this symptom has often been overlooked despite its straightforward presentation4. To quote Dr. Mackenty “in no other situation in the body does cancer give such early or such easily recognizable warning of its presence” yet, we often fail to see it immediately4.
A patients’ poor health seeking behavior contributes to missing out on the early diagnosis of laryngeal cancer7-11. Patients are often unaware or have limited knowledge of the danger signs of cancer 7-8,10,11. They do not often associate cancer to hoarseness or difficulty in swallowing7. They are less likely to seek consult unless with sensory manifestation such as bleeding or pain12 and would attribute other symptoms to more benign conditions13-15. These, together with the fear of wasting the doctor’s time over something trivial7,9, widen the gap between patients and early intervention.
The medical field also has its own shortcomings7,16,17. Physicians are often presented with vague symptom characterization which makes it difficult to streamline differential diagnosis23. Hoarseness is present in a wide array of diseases from simple, acute infections such as laryngitis or tonsillitis to chronic ones such as syphilis and tuberculosis.
Voice overuse as in vocal nodules, diseases such as gastroesophageal reflux, psychiatric conditions like eating disorders, and laryngeal nerve paralysis either from a mass or previous surgical intervention also present with hoarseness. Multiple referrals are done in these cases before a diagnosis is made4,6,17-19.
Indirect laryngoscopy helps but is not guaranteed to catch suspicious lesions since it can be technically challenging for primary care physicians to perform17. As a result, a safety net in the form of an observation period is given to better understand the presenting symptom23,24. Unfortunately, patients fail to follow-up once a benign diagnosis is made further contributing to time lost in evaluation16.
II. Pitch: Hitting the right note for diagnosis
Current guidelines are already in place to facilitate early recognition of symptoms pointing to laryngeal cancer5,6. The American Academy of Otolaryngology considers altered voice quality, pitch, loudness or increased vocal effort for communication as manifestations of hoarseness. This requires laryngoscopy if without resolution after 4 weeks or if with risk factors pointing to a more serious cause6.
The National Institute for Health and Care Excellence guidelines warrant urgent specialist referral for patients with persistent unexplained hoarseness or unexplained neck lump. However, these are based on clinical consensus alone, on how patients present upon admission, lacking information from primary care studies until now20-22.
A pioneer study published by Shepard, E. et al. last January 2019 shed light on the recognition of laryngeal cancer in primary care. It performed a large case-control study using electronic records with data on the year prior the diagnosis was made and identified 10 symptoms significantly associated with laryngeal cancer.
The 10 symptoms are hoarseness, sore throat (initial and recurrence), dysphagia, otalgia, recurrent dyspnea, mouth symptoms, recurrent chest infection, insomnia, and elevated inflammatory marker. Hoarseness had the highest individual positive predictive value (PPV) of 2.7%.
Hoarseness is a symptom warranting urgent referral, more so when associated with insomnia, otalgia, recurrent dyspnea, sore throat and elevated inflammatory markers (PPV 5.2%, 6.3%, 7.9%, 12%, and 15% respectively).
The study dismissed neck lump as a symptom associated with laryngeal cancer but advised work-up for lymphoma if present. It introduced sore throat with recurrent dyspnea, otalgia or dysphagia (PPV 5.2%, 6.3% and 6.9% respectively) as a new combination of symptoms for urgent referral as well.
Data was limited by the variability and availability of general practitioner records and biased symptom reporting in favor of the cases than control. Despite these, the study is still able to provide important information that changed how laryngeal cancer is evaluated at the level of primary care. Caution should still be exercised in its application in practice to arrive at a sound evaluation.
III. Accent: Pushing the emphasis on primary care
Knowing the roadblocks to delay, it is clear that majority of the burden falls on primary care. As front liners, general practitioners (GPs) participate in the direct diagnosis of 85% of cancer cases23 and are expected to be equipped in identifying suspicious symptoms other than advocating for risk reduction and screening23,24.
As guardians of their health, patients note changes in their well-being and are expected to be knowledgeable on when to seek consult. However, GPs are often viewed inadequately skilled for cancer recognition and pressured to fulfill that role. Moreover, they deal with anxious patients and might miss appropriate referrals23,24.
Patients are filled with fear for ill health and either ignore or over-report changes in their body7. With these contributing to diagnostic delay, the solution becomes a shared responsibility between the two parties, raising the need to educate patients, empower GPs, and develop a better referral system.
GPs face limited resources for cancer recognition17,20-24. There are few studies on how cancer presents in primary care17,23. Standard pathways for referral for nonspecific but suspicious symptoms are not available and no interaction between GPs and specialists exist once referral has been made23,24. These produce uncertainty and deter proactive effort24.
Professional delay and the decision to make a referral should be the targets for research, training, and inter-professional communication to allow GPs to better carry the burden of cancer recognition and improve the prognosis of laryngeal cancer17,23.
Patients, on the other hand, have a pre-conceived fear of cancer, which stems from the perspective that cancer is a silent, unpredictable and indestructible killer27-29. A recent meta-analysis identified that patients’ assumption of their risk in getting the disease, cancer’s link to mortality, and misconceptions about the disease and its associations further compound this fear30.
The patient’s anxiety does not necessarily translate to increased consultation or regular screening. It paralyzes the patient, allowing him or her to fall into a fatalistic attitude23,30. There is therefore a need for research on behavior modification and correction of misconceptions to allow patients to have access to proper information and achieve better control of their health.
Until these are accomplished, our efforts will remain whispers— lacking the strength for properly timed diagnosis to be heard.
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 American Academy of Otolaryngology- Head and Neck Surgery CPG: Hoarseness (Dysphonia) (Update)
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