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Persistent sore throat combined with other symptoms may indicate laryngeal cancer
Persistent sore throat plus either otalgia, dyspnea or dysphagia was a stronger indicator of laryngeal cancer than hoarseness alone, according to findings recently published in the British Journal of General Practice.
“It is unclear which symptoms from the disparate range reported in previous research are associated with laryngeal cancer in primary care,” Elizabeth A. Shepherd, PhD, CPsychol, and research fellow at the University of Exeter Medical School in Exeter, England, and colleagues wrote.
Researchers compared symptoms of 806 patients with laryngeal cancer vs. 3,559 control patients from the United Kingdom’s Clinical Practice Research Datalink. All patients were aged 40 years and older.
Shepherd and colleagues found patients with hoarseness had the highest individual risk for laryngeal cancer at 2.7%. This risk increased to 5% or more when the patient had sore throat with recurrent dyspnea, otalgia or dysphagia. The risk dropped to 3% or more when the hoarseness was accompanied by these same symptoms as well as mouth symptoms and insomnia.
Other symptoms significantly associated with laryngeal cancer were first visit for sore throat (OR = 6.2; 95% CI, 3.7-10); second visit for sore throat (OR = 7.7; 95% CI, 2.6-23); recurrent chest infection (OR = 4.5; 95% CI, 2.4-8.5); and raised inflammatory markers (OR = 2.5; 95% CI, 1.5-4.1).
“This study has resulted in an evidence base for the identification of possible laryngeal cancer in primary care patients who are symptomatic,” Shepherd and colleagues wrote.
“However, selection of patients for investigation is not simply a matter of totting up symptoms and [positive predictive values]. Clinical experience — although almost impossible to measure — adds to skillful decision making.” – by Janel Miller
Disclosures: Shepherd reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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This article raises awareness of larynx cancer in the primary care community. Ear, nose and throat cancers are currently among the least understood in the United States, largely because primary care physicians do not get a lot of classroom time devoted to it in medical school and exposure to these conditions is limited during residency. In addition, many other conditions provide a visual clue that something could be wrong, such as a lump on the breast prompting a mammogram, but these clues often do not present themselves for larynx cancer until the disease is well-advanced. Primary care physicians also have limited tools that hinder their ability to evaluate the back of the nose, back of the throat or voice box, which can also delay the cancer diagnosis.
Further complicating diagnosis efforts is that many of the symptoms associated with larynx cancer — both the new ones Shepherd et al identified: repeated sore throat, otalgia, recurring dyspnea, mouth symptoms, recurrent chest infection, insomnia and raised inflammatory markers, as well as the symptoms we already about: repeated hoarseness, pain, dysphagia, neck lump, wheeze, stridor, bleeding, sore throat, otalgia and weight loss — are often associated with an infection or an allergy, not larynx cancer, leading to potentially inappropriate tests and perhaps delaying diagnosis.
For all these reasons, the diagnosis of larynx cancer in primary care can be a challenging one. Larynx cancer has one of the longest primary care delay intervals (from initial patient visit to primary care providers to referral to cancer specialist). Thus, PCPs should consider using Shepherd and colleagues’ collective findings and refer patients to a Head and Neck Cancer specialist, especially in patients that have symptoms lasting more than 2-3 weeks without improvement on antibiotics or allergy treatment, and who smoke and/or drink alcohol regularly (as these are the biggest risk factors in the development of larynx cancer). Doing so could potentially save a life.