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Remote triage incorporating symptom‐based risk stratification for suspected head and neck cancer referrals: A prospective population‐based study

Background Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established. Methods A 16‐week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator. Results Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6‐month follow‐up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face‐to‐face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382). Conclusions Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments. Lay Summary This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic. The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months. Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

Thank you to everyone who is taking part The majority of referrals were low risk (70.0% , n=1,069/1,528) with larger volume centres showing less spread (see funnel plot). Only one of 30 centres was outside three standard errors of the mean, likely related to incomplete data submitted by the unit.
Following telephone triage, 17.5% of referrals (1.6% of high risk and 24.4% of low risk) were discharged on the basis of the telephone consultation alone. Less than half of all referrals (45.3% , n=768/1,404) were planned for urgent clinic review and/or investigation (urgent Rv/Ix; see radar chart); thus, 54.7% of suspected HNC patients avoided an urgent hospital visit during the peak of the pandemic. All centres except two were within three standard errors of this mean figure; the centre with the lowest rate of urgent Rv/Ix (20.9%) was declared the epicentre of COVID-19 in the early days of the pandemic outbreak in the UK.
An investigation was performed as the first urgent contact in 56.7% (n=250/441) with 75.2% (n=188/250) of these either being subsequently discharged or offered delayed follow up only; thus avoiding an urgent face to face review during the worst of the pandemic. Among patients who were recommended urgent Rv/Ix, 6.6% (n=42/636) have been diagnosed with cancer by the time of this interim submission.

Introduction
This report provides a snapshot of early experience with rapid implementation of a remote triaging system for assessment of suspected head and neck cancer (HNC) referrals, based on the head and neck cancer risk calculator (HaNC-RC) 1, 2 . Remote triaging has never been used in such a large scale for new head and neck cancer (HNC) referrals or follow-up patients, and thus no prior data exists. This interim report aims to achieve the following: • Allow comparison of local performance against the national average • Provide information on the proportion of low and high risk referrals, and their triage outcomes • Provide early insight into the oncological outcomes of the remote triage implementation This is an opportunity to radically reform the system, arisen due to a unique need to rationalise healthcare. A key priority of a service implementation such as this should be to ensure a safe system that does not miss out cancers following remote triage. Generated from over 10,000 patients, HaNC-RC has a high negative predictive value, with only a 1.4% chance of missing cancers in patients categorised as low risk. A large proportion of low risk patients were still urgently investigated or reviewed from our data and so it is hoped this chance is even lower for these patients triaged during the pandemic. However, this is a new implementation of the calculator in a new population and so it's safety needs to be robustly evaluated.
An important measure to assure patients and clinicians will be to assess the HNC status in those patients who have been discharged, or have their appointments deferred on the basis of the triage, at a defined period in the future. Based on the natural history of HNCs, it is reasonable to confirm cancer status at 6 months from the date of the initial referral, and use this as the gold standard. We would therefore urge all centres to make a special effort to submit complete data for further reports as patients migrate through the diagnostic pathway.
This also is an opportunity to evolve the HaNC-RC based on the data emerging from the real world implementation. As experience with the system increases, it has become evident that the remote triaging process can be cumbersome. Work is progressing apace to allow patients to complete their symptomatology electronically (subsequently risk stratified by the HaNC-RC) and to submit these data alongside audio recordings, photos and videos as applicable, to allow asynchronous remote triaging based on the most relevant and informative data.

Impact of the findings
The pressure on resources placed by the suspected cancer referrals system prior to the pandemic is well known and described in the literature. Cancer Research UK estimates that 2,300 cancer cases per week are likely to go undiagnosed every week across the UK during the pandemic 5 .
Across all cancers, it has been estimated that a delay of three months across all 94,912 patients who would have had surgery to remove their cancer over the course of a year would lead to an additional 4,755 deaths in England 6 . Thus, the pressure on resources for provision of cancer care, both diagnosis and treatment, is likely to be even greater in the coming months. Even when clinical services resume, more clinic time and PPE resources are needed to evaluate patients as the assessment of the majority within this patient group involve aerosol generating procedures. Any appropriate reduction in hospital visits, face to face assessment and investigations will thus be beneficial. The proportion of patients discharged following remote triage alone (17.5%), is an immediate resource gain.

Next steps
In 2018/19, 207,501 suspected HNC referrals were seen within NHS England. While HNC specialty associations have generated guidelines for the management of confirmed cancers 7 , none exist for these suspected cancer referrals. Unlike other cancers (lung, breast, prostate) no screening tests exist for HNCs; however, symptom inventories seem to be an efficient way to separate the high risk individuals referred in from primary care. In our parallel survey, 92.3% of respondents indicated that the remote triaging system was likely to carry on at their centre for at least the next 3 months.