Validity of a rapid diagnostic programme for head and neck cancer

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Alda Cardesin Revilla, Mariana Campos Motamayor, Juan José Díaz Argüello, Angels Martínez Arias, Clara Martínez Vila" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Rosa" "apellidos" => "Rosell Ferrer" "email" => array:1 [ 0 => "rrosell@tauli.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Anton" "apellidos" => "Aguilà Artal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Yolanda" "apellidos" => "Escamilla Carpintero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Alda" "apellidos" => "Cardesin Revilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Mariana" "apellidos" => "Campos Motamayor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Juan José" "apellidos" => "Díaz Argüello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Angels" "apellidos" => "Martínez Arias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Clara" "apellidos" => "Martínez Vila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oncología Médica, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validez de un programa de diagnóstico rápido del cáncer de cabeza y cuello" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2521 "Ancho" => 2091 "Tamanyo" => 350951 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Form to be completed by the GP to refer the patient for consultation through the RDP." ] ] ] "textoCompleto" => "IntroductionOncological processes of the head and neck area usually present with symptoms that are common to benign disorders of the same area. These common symptoms (dysphonia, odynophagia, persistent cough, pharyngeal paresthesias, cervical adenopathies, etc.) are often attributed to benign, infectious or inflammatory conditions, of the upper aerodigestive tract and if the primary care physician does not suggest there is any malignancy, delayed diagnosis of the neoplasic processes may result.Many of the epidemiological and aetiopathogenic factors of head and neck squamous cell carcinoma (HNSC) are known, but no screening programmes for these tumours have proven their efficacy.In view of the absence of HNSC screening programmes, we put forward the usefulness of introducing a rapid diagnosis programme (RDP) in HNSC management to improve early diagnosis and the survival of these patients, given that the main prognostic factor is the stage at diagnosis and we are aware of both the initial symptoms and risk factors of these tumours.The aim of this study was to analyse whether the existence of a rapid diagnosis programme for head and neck cancer, coordinated with primary care physicians, would create an increase in stage I and II squamous cell head and neck cancer diagnoses and a reduction of stages III and IV diagnoses.Material and methodsA prospective, observational study of patients referred due to suspicion of tumour in the ENT region and finally diagnosed in the ENT service of the Parc Taulí Hospital Universitari, for 24 consecutive months, between March 2014 and February 2016. This was considered a pilot study since no studies were found in the literature on the effectiveness of any similar programme.Inclusion criteria in the study were patients with suspected HNSC referred from the primary care centres following RDP, and patients referred to our service with indication of suspected tumour, originating from any other source.Exclusion criteria was that of patients referred to our service with a previous ENT cancer diagnosis that had already been confirmed.Diagnostic criteria was considered to be anatomical-pathological diagnosis of the tumour. All patients with malignant tumours of the head and neck were assessed by the tumour committee of our hospital.The main variable analysed was the stage at diagnosis which was classified and registered according to the applicable version of TNM at the beginning of the study (7.a). Secondary variables were defined as the initial symptom, disease progression duration from onset of first symptom and location of the tumour. Epidemiological gender and age variables were also recorded as were the history of tobacco and alcohol consumption.The data obtained were compared with a control group (pre-RDP). This group included patients diagnosed with HNSC in our service during the 4 years prior to starting the RDP. During these 4 years, the examination protocol and diagnostic tests made during the first patient visit were the same as during the duration of the study.A referral form was created (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) which had to be completed by the primary care physician (Family Doctor [GP]). This form contained a list of symptoms and signs the absence or presence of which added up from 0 to 2 points. The patient had to score a minimum of one of the “inclusion criteria”. The aeotiopathogenic and epidemiological factors of the head and neck tumours were to be found under the “referral criteria” section. A score above or equal to 5 referred the patient to the hospital to be visited at least 2 weeks within a RDP.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>On arrival at the hospital, the patient was visited by the ENT specialist who, when the visit was over, completed a second data collection form with the same information and the same criteria as those which had been used by the GP (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>For those patients who did not come through the RDP, who had been referred for consultation with a suspected ENT tumour (e.g. patients referred with suspected tumours from the emergency services or another service of the same hospital, and patients attended by the ENT services in primary care centres), only this second form was completed.Based on the number of cases which are annually diagnosed in our centre, we calculated a duration of 2 years for the obtainment of a sample comprising approximately 70 patients.Statistical, descriptive analysis, with qualitative variable frequencies (such as staging and diagnosis) and means of quantitative variables. In comparative analyses between the 2 groups of patients before and after the study we used the Pearson Chi squared test and the exact Fisher test.Patient data were anonymous on entering the study. We considered that informed consent in addition to that already used in patients who consult and are diagnosed by the hospital from other centres was unnecessary, since the procedures and tests would be the same as those of normal clinical practice.The study required no more check-ups or examinations than those which had already been performed on these patients, it only required facilitating the mechanisms for allowing appointments and visits of patients to be made in the agreed time. It did require the recruiting of the GPs of all reference areas with training sessions in their primary care centres.The study was presented and approved by the Ethics and Research Committee of the Parc Taulí Hospital Universitari before its commencement and was carried out by strictly following the ethical principles of biomedical research and prevailing legislation. All participating personnel were committed to adhering to the good clinical practice standards of the International Harmonization Conference during this procedure.ResultsDuring the study period 201 patients were included. The reason for the request for consultation was suspected tumour in the ENT area. There were 156 men (77.6%) and 45 women (22.4%), with a mean age of 63.4, standard deviation (SD) of 12.8, and range of 27 to 90 27–90 years.Of the 201 patients, 136 (67.7%) had been referred to the hospital by GPs through the RDP, and of these, 2 cases were excluded due to the lack of data with 134 remaining valid patients; 37 patients (18.4%) were referred by non ENT physicians of the same hospital (internal medicine, infectious or emergency services) and 28 (13.9%) by ENT specialists from primary care centres and who were patients whose GPs had not suspected a tumour. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the total of patients, according to origin and according to the absence or confirmation of a tumour.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Out of the total of 199 patients included, a tumour was confirmed in 82 (41.2%) and of these 63 were HNSC. In the remaining 19 patients 4 thyroid tumours, 8 salivary gland and 7 lymphomas were diagnosed.Of the 82 patients for whom a tumour was confirmed, 47 cases (57.3% of all tumours) were not referred through the RDP since there had been was no suspected tumour by their GP.Of the patients who were referred by their GP through RDP, 26.1% had some type of tumour, compared with 59.5% of patients referred by doctors in the hospital and 89.3% of those suspected by the ENT service.Analysis of the correlation between the form scores, when the GP completed the first questionnaire for referral through RDP, revealed that 134 patients validly referred received scores between 4 and 12 points, with a mean of 6.66 and a median of 7.With the same information recorded by the ENT specialist, on completing the second questionnaire the scores ranted from 1 to 13, with a mean of 6.4 and a median of 6. There was an over scoring of approximately one point by the GPs compared with ENT scoring.However, in the majority of cases there is concordance between both scores, since out of the 134 patients the score obtained in the visit to the GP and that of the ENT was the same in 100 (74.6%) of them, whether or not they had a tumour.A total of 23 patients (17.1%), when assessed by the ENT service, did not get a score of 5, and they therefore should not have been referred by this area. In 2 of these patients, a parotid salivary gland Martin tumour was diagnosed and in the others no tumour was confirmed.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> contains these 134 patients referred through RDP, with the 35 cases in which a tumour was confirmed, grouped by inclusion or initial symptom criterion. Approximately 22% of the patients referred for consultation due to dysphonia and 17% of those referred due to odynophagia were diagnosed with a tumour, with the percentage rising to 42% in those referred due to the appearance of a cervical mass.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The epidemiological characteristics of the 63 patients who were diagnosed with an HNSC during the study period were compared with a control group formed by 137 patients from our database diagnosed with HNSC during the 4 years prior to RDP and this is shown on <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. There are no significant differences between both groups in patient gender and age.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Regarding toxic substance habits, we observed a tendency for the number of moderate smokers and ex-smokers in the RDP group to rise, compared with the control group patients and this was statistically significant of (p = .00005), together with a decrease in heavy smokers (p = .009).Regarding alcohol consumption, the tendency appears to be the same with an increase in the percentage of moderate consumption and a decrease in heavy consumption, but the differences were not statistically significant.TNM analysis on diagnosis, the main study variable, revealed that 27% (17 in total) of the 63 patients were diagnosed in early stages (i y ii), and 73% (46 patients) in advanced stages (iii and iv). In the pre-RDP control group, 32.1% (44 patients) were diagnosed in initial stages compared with 67.9% (93 cases) in advanced stages (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The table also shows the stages at which patients were diagnosed, divided by patient origin, during the period of study duration and in the control group. No statistically significant differences were obtained.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In these patients diagnosed with HNSC, 3 symptoms/initial manifestations were analysed with the highest number of patients (dysphonic, odynophagia and cervical tumour) and an analysis was performed relating the initial symptom and the diagnostic stage and comparing it with pre-EDP patients referred for the same medical reason. Results are contained in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. Although a worsening in diagnoses was observed in the early staging during the study period when the initial symptom was dysphonia, none of the variations were statistically significant.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Regarding the time between presentation of clinical /initial symptoms and diagnosis confirmation, the introduction of the RDP did not achieve a statistically significant shortening of time. The time passing from onset of symptoms to diagnosis was 5.5. months mean with a median of 3.3 months and SD of 4.9. In the control group the mean was 5.1 months, median 3.8 months and SD 4.8.Regarding location, of the 63 patients diagnosed with HNSC in the study, 29 were laryngeal tumours, 26 pharyngeal, 4 oral cavity, 2 metastasis adenopathies of unknown origin and 2 other locations (sinonasal carcinoma and cancer of the cervical esophagus).<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the staging at diagnosis for each of these tumour locations during the study and in the years prior to this. It highlights that during the study period all hypopharyngeal tumours were diagnosed in advanced stages, but in neither this nor the other tumour locations were any differences statistically significant to the control group.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>DiscussionCancer of the head and neck is the sixth most common cancer in Spain, with an estimated incidence for the year 2020 of approximately 10,668 new tumours, a ratio of 5.6 men/1 women.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> This type of tumour includes all those originating from mucous membranes in the head and neck region (lip, oral cavity, tongue, oropharynx, hypopharynx, nasopharynx, larynx, nose and paranasal sinuses).Prognosis for these tumours in early stages is good,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> but diagnosis is usually delayed. These processes present symptoms which are shared with non neoplasic diseases in the same region. These common symptoms (dysphonia, odynophagia, persistent cough, etc. ) is often attributed to benign disease of the upper aerodigestive tract, delaying diagnosis of the neoplasic processes in this area. Furthermore, the HNSC patient profile corresponds to a population group who rarely consult the healthcare system.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>In recent years a change has been seen, in terms of incidence, in the distribution of tumours in the different locations of this region, due to a change in the prevalence of risk factors: campaigns for reducing alcohol and tobacco consumption, on the one hand and on the other the increase in tumours connected with the human papillomavirus (HPV).<a class="elsevierStyleCrossRef" href="#bib0030">6</a> In a recent study by León et al.,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> whose hospital centre is in the same geographic area as ours, the incidences by gender and age of the patients diagnosed with SCC of the head and neck during the decade from 2006 to 2017 coincide with those of our study population. They also coincide with the populations in overall toxic substance consumption, although in their case the subgroup with heavy consumption is higher than that of our population.Incidence and prevalence of risk factors were based on the items used in our form, but we did not include questions aimed at sexual habits which could have had a repercussion in the tumours relating to HPV, nor any specific clinical symptoms indicative of rhinopharyngeal tumours: our aim was to enhance the collaboration of GPs in our area, with a fast and easy-to-complete questionnaire and we focused on the reason for consultation, age, gender and toxic substance consumption of the patient.No validated reference was found for the creation of these forms. They were designed from epidemiological data and HNSC contrasted risk factors and from the health questionnaire questions asked of the patients with HNSC in reviewed studies.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>As with other locations of the tumour disease, abundant documented references are present regarding differences in survival when the lesions are diagnosed in early or late stages.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> In these studies it has been observed that therapeutic strategies are changing, improving the preservation of the organ but that survival rates remain poor. There has been no substantial improvement in survival by stage and the main prognostic factor it is associated with is the diagnosis in early or late stages, concluding that the best tool for improving survival would be an early stage diagnosis.For years several attempts have been made to use a “screening” system for head and neck cancer which would lead to early-stage diagnosis and an improvement in survival.<a class="elsevierStyleCrossRefs" href="#bib0015">3,10,12</a> We undertook a review of the literature to discover what the situation was.In our review, the studies with the highest number of patients were conducted in India or Taiwan. In relation to oral cavity cancer, both are areas of great associated prevalence and mortality and where, apart from alcohol, tobacco and HPV variables, other risk factors such as the consumption of the areca or betel nut have an impact.<a class="elsevierStyleCrossRefs" href="#bib0065">13–19</a> Several studies analysed different factors, but one interesting conclusion of this review is that, although the need for examination of the oral cavity is insisted upon by some of the GPs and deontologists, there is no sufficient evidence to suggest that the periodical oral examination of the general population leads to, or does not lead to an improvement in diagnosis. The only factor which appears to prove its importance in earlier diagnosis is how informed the general population is on this pathology. This was assessed by education programmes in rural areas of India, in Australian aborigines and in media campaigns in Taiwan.Another relevant group and location is nasopharyngeal cancer which is prevalent in the south of China, with clear epidemiological factors including EBV infection and regional, family and racial aggregation. With screening for early detection using serum markers for EBV and studies with endoscopy and magnetic resonance in positive patients, favourable results were obtained in early diagnosis and survival.<a class="elsevierStyleCrossRefs" href="#bib0100">20–22</a>If we do not take into account these specific situations, the studies regarding screening programme validity to the general population have not proven to be cost-effective. Shuman et al.,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> in the analysis of a screening programme, in HNSC conducted between 1996 and 2009, and which included 761 people, revealed that up to 5% presented with findings of suspected cancer, but only 1% of the patients had some type of premalignant or malignant tumour and concluded, like Dedhia et al.,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> that for these programmes to be cost-effective they have to be aimed at population groups selected by risk factors and not at the population in general. Along these lines, Hapner and Wise<a class="elsevierStyleCrossRef" href="#bib0125">25</a> conducted a study with 568 patients with risk habits and observed that up to 43% of the smoker patients presented with some type of pathological finding, although no malignancy characteristics were involved.One interesting study along these lines is that of Dwojak et al.,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> in which knowledge of HNSC was assessed in the American Indian population of South Dakota. A questionnaire was undertaken asking about symptoms and warning signs, and a complete ENT examination. The HNSC is more common in this population than in the White American population and more aggressive, this being a population where the HPV prevalence is similar but where tobacco and alcohol consumptions habits are higher. In this study an increase in early stage diagnosis of patients who went for consultation was observed and for those who in the questionnaire responses demonstrated high knowledge of the disease. The questionnaire used in this study was one of the sources from which ours was taken.Our study was not aimed at carrying out a screening programme on either a general population level or with patients with risk habits, and therefore our percentages of malignant tumour findings are not comparable to the studies reviewed where there was a screening of the population or the population group at risk.<a class="elsevierStyleCrossRefs" href="#bib0115">23,25</a> However, with the knowledge that we have of this pathology, and with the studies published which suggest a better knowledge of this, an earlier diagnosis could be made.<a class="elsevierStyleCrossRefs" href="#bib0045">9,17</a> In our study GPs were trained to have greater awareness of the symptoms and signs of these tumours and to facilitate fast access of the patient to consultation with a specialist.RDP use by the GP was mostly adequate, since the 134 patients who were referred for consultation met with the criteria of suspicion and in 100 cases, whether the patient had a tumour or not, the assessment coincided with that made by the ENT specialist.In patients referred with dysphonic or odynophagia as a symptoms, a head and neck tumour was confirmed, in 22% and in 17% of cases, respectively, and in those who were referred by presenting with a cervical tumour, a head and neck tumour was confirmed in 42% of cases, including those of non squamous type. Overall, 26% of patients referred for consultation through RDP for presenting with suspected tumour criteria effectively presented with a tumour. In this sense, although we had no validated questionnaire with which to contrast it, we believe the algorithm was effective. From the outcomes obtained we may decide whether it would be better to change the value the different symptoms and signs should have in the weighting.Notwithstanding, most patients diagnosed with an ENT tumour during the duration of the study (57.3%) were not referred by their GP with suspicion of this and did not come through the RDP. Similarly, the reviewed studies where improvement was assessed in an early diagnosis were related to the level of information of the patients,<a class="elsevierStyleCrossRefs" href="#bib0045">9,17,18</a> without other screening measures being achieved. The use of this programme during the 2 years of the study duration did not demonstrate an improvement in the analysed items either.ConclusionsThe initiation of a rapid diagnosis programme for the patients who consulted their GP and who, depending on the algorithm created, were suspected of presenting with HNSC did not involve an increase in the diagnosis of HNSC at stages I and II or a reduction in diagnosis at stages iii and iv in our centre.Although the use of the RDP by GPs was mostly accurate and one out of every 4 patients referred by their GP through the RDP for suspicion of head and neck tumour did present with it, most of the patients diagnosed with head and neck tumours during the study period had not been suspected of having this by their GP.In the absence of valid screening, and given the aetiopathogenic factors involved—common to other cancers—, it would seem that, on the one hand, only the policies aimed at avoiding toxic habits and increasing awareness of self-care, and on the other, improving the examination capacity in primary care, could lead to an improvement in the rate and prognosis of HNSC.FinancingThis study received a Taulí Research Grant, CIR2015/066: “Cost-effectiveness of a fast ENT cancer diagnosis programme”.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1572029" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1416155" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1572028" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1416156" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack554959" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-27" "fechaAceptado" => "2020-06-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1416155" "palabras" => array:3 [ 0 => "Head and neck cancer" 1 => "Screening" 2 => "Rapid diagnosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1416156" "palabras" => array:3 [ 0 => "Cáncer de cabeza y cuello" 1 => "Cribado" 2 => "Diagnóstico rápido" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectives: Given the epidemiological knowledge of squamous cell carcinomas of the head and neck (SCHN), the prognosis in survival according to the staging at diagnosis and the absence of screening programmes that have proven cost-effective, we undertook a rapid diagnosis programme. The objective of this study was to analyse whether a rapid diagnostic programme (RDP) to be used by General Practitioners (GP) would achieve a change in the proportion of diagnoses in early versus late stages in these tumours. MethodsA prospective observational study of patients diagnosed with a tumour of ENT location in our centre, was carried out for 24 consecutive months. A “suspicion algorithm” was designed and we established a rapid remission route for these patients. The data obtained (age, sex, toxic substance consumption, initial manifestations, tumour location and extension) were compared with the data of the patients in our ENT Service database diagnosed in the four years prior to the start of the study. Results199 patients were included, and 82 ENT tumours diagnosed. The GPs sent to the Hospital via the RDP a total of 136 patients and 35 (26.1%) had a tumour. However, most of the tumours diagnosed in this period by our ENT Department (47 patients, 57.3% of all tumours diagnosed), were not suspected by the GP and were not sent via the RDP.Of the patients, 27% were diagnosed in stages I and II, and 73% in stages II and IV, there were no significant differences with the control group. The most frequent initial signs and symptoms were dysphonia, cervical mass and dysphagia, the relationship between initial symptom and stage at the moment of diagnosis was analysed, and in neither case did we obtain any significant variation. ConclusionsThe implementation of a rapid diagnosis pathway for patients who, according to the algorithm created, had a suspected head and neck cancer, has not led to an increase in the diagnosis of these tumours in early stages or a decrease in diagnoses in advanced stages." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosDado el conocimiento epidemiológico del carcinoma escamoso de cabeza y cuello, pronóstico y supervivencia según el estadio al diagnóstico, y ante la ausencia de programas de cribado que hayan demostrado ser coste-efectivos, nos propusimos evaluar un programa de diagnóstico rápido. El objetivo del presente estudio fue analizar si la existencia de un circuito de diagnóstico rápido desde atención primara, en base a una ponderación de síntomas y signos, supondría un cambio en la proporción de diagnósticos en estadios iniciales versus tardíos en estos tumores. MétodosSe ha realizado un estudio observacional prospectivo de pacientes remitidos con la sospecha de un tumor en el área ORL en nuestro centro durante 24 meses consecutivos. Se creó un algoritmo con síntomas y signos de sospecha para utilización por el médico de familia y un circuito de remisión rápida de los pacientes candidatos. Se registraron también los pacientes con sospecha de tumor provenientes de fuentes distintas a este circuito. Los datos obtenidos (edad, sexo, consumo de tóxicos, tiempo y clínica de presentación, localización del tumor y extensión), se han comparado con los de los pacientes recogidos en la base de datos de tumores del Servicio ORL diagnosticados durante los cuatro años previos al inicio del estudio. ResultadosSe incluyeron en el estudio 199 pacientes y se diagnosticaron 82 tumores del área ORL. Los médicos de familia remitieron por el circuito de diagnóstico rápido creado un total de 136 pacientes y 35 (26,1%), presentaban una tumoración. Sin embargo la mayoría de tumores diagnosticados durante este período en el Servicio ORL (47 pacientes, 57,3% de todos los tumores diagnosticados), no fueron sospechados por su MF y no fueron remitidos al Hospital utilizando el circuito de diagnóstico rápido.Un 27% de los pacientes fue diagnosticado en estadios I y II, y un 73% en estadios III y IV, no hubo diferencias estadísticamente significativas con el grupo control, y tampoco en los porcentajes de tumores recibidos por localizaciones (laringe, faringe, cavidad oral, primario desconocido, otros).Los síntomas iniciales más repetidos fueron la disfonía, la aparición de una masa cervical y la odino-disfagia. Se analizó la relación entre el síntoma inicial y el estadio al diagnóstico. En ninguno de los casos se obtuvieron diferencias significativas respecto al grupo control. ConclusionesLa puesta en marcha de un circuito de atención rápida a los pacientes que según el algoritmo creado tenían una sospecha de padecer cáncer de cabeza y cuello, no ha supuesto un aumento de los diagnósticos en estadios precoces y una disminución de los diagnósticos en estadios avanzados en nuestro centro." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rosell Ferrer R, Aguilà Artal A, Escamilla Carpintero Y, Cardesin Revilla A, Campos Motamayor M, Díaz Argüello JJ, et al. Validez de un programa de diagnóstico rápido del cáncer de cabeza y cuello. Acta Otorrinolaringol Esp. 2021;72:271–279." ] ] "multimedia" => array:8 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2521 "Ancho" => 2091 "Tamanyo" => 350951 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Form to be completed by the GP to refer the patient for consultation through the RDP." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3030 "Ancho" => 2091 "Tamanyo" => 374268 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Form to be completed by the ENT specialist in patients who consulted on suspicion of a tumour, referred by their GP through RDP or referred by other centres when the request for consultation was due to suspicion of cancer." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1108 "Ancho" => 2091 "Tamanyo" => 107682 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Patients analysed, origin, confirmation or non confirmation of training and tumour origin in positive cases." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GP: Family doctor (General practitioner) ; RDP: Rapid diagnosis programme." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients referred through RDP by their GP</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reason for remission/initial symptom</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Confirmation of the tumour</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dysphonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Odynophagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cervical tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blood in the mouth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oropharyngeal tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dysnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693304.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Initial symptom of presentation in patients referred to the hospital by their GP through RDP, number of patents for each initial symptom and confirmation of the tumour for each of them." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HNSC: Head and neck squamous cell carcinoma; RDP: Rapid diagnosis programme." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RDP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pre-RDP \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 137 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 (87.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">122 (89.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (12.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (10.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean/SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.7/13.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.6/14.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tobacco habit</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (18.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ex/moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (54.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (24.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heavy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (36.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 (56.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alcohol</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (38.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (41.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ex/moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (30.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heavy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (19%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (27.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693303.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological characteristics of the patients diagnosed with HNSC, during the study and the control group." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ENT: Ear, nose and throat; GP: Family doctor (general practitioner); HNSC: Head and neck squamous cell carcinoma; RDP: Rapid diagnosis programme." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Referral \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% Pre-RDP n = 137</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total pat. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (27%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (73%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (24%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (76%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (94.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ENT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693307.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Stages in which patients were diagnosed with HNSC, according to where patient was referred from." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "RDP: rapid diagnosis programme." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First symptom \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dysphonia</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dysphagia</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cervical mass</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diag. stage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Study pat. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (11.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (88.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (94.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pre-RDP pat. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (61.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (38.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (15.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (84.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 (96.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693305.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Tumour diagnostic stage divided into initial presentation symptoms in patients." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Cav: cavity; Diag: diagnosis; P. Unknown: primary site unknown; Pat: patients." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Larynx</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oropharynx</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hypopharynx</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oral cavity</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P unknown \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diag. stage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I + II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III + IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Study pat. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44,8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55,2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12,5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87,5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pre-RDP pat. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n = 137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13,0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57,1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42,9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693306.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Tumour locations and diagnosis stage for each of them in study patients and in the control groups." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GLOBOCAN 2012 v1.0. 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Validity of a rapid diagnostic programme for head and neck cancer

Validez de un programa de diagnóstico rápido del cáncer de cabeza y cuello

Rosa Rosell Ferrera,

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rrosell@tauli.cat

Corresponding author.

, Anton Aguilà Artala, Yolanda Escamilla Carpinteroa, Alda Cardesin Revillaa, Mariana Campos Motamayora, Juan José Díaz Argüelloa, Angels Martínez Ariasa, Clara Martínez Vilab

a Servicio de Otorrinolaringología, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain

b Servicio de Oncología Médica, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Oncological processes of the head and neck area usually present with symptoms that are common to benign disorders of the same area&#46; These common symptoms &#40;dysphonia&#44; odynophagia&#44; persistent cough&#44; pharyngeal paresthesias&#44; cervical adenopathies&#44; etc&#46;&#41; are often attributed to benign&#44; infectious or inflammatory conditions&#44; of the upper aerodigestive tract and if the primary care physician does not suggest there is any malignancy&#44; delayed diagnosis of the neoplasic processes may result&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Many of the epidemiological and aetiopathogenic factors of head and neck squamous cell carcinoma &#40;HNSC&#41; are known&#44; but no screening programmes for these tumours have proven their efficacy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the absence of HNSC screening programmes&#44; we put forward the usefulness of introducing a rapid diagnosis programme &#40;RDP&#41; in HNSC management to improve early diagnosis and the survival of these patients&#44; given that the main prognostic factor is the stage at diagnosis and we are aware of both the initial symptoms and risk factors of these tumours&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to analyse whether the existence of a rapid diagnosis programme for head and neck cancer&#44; coordinated with primary care physicians&#44; would create an increase in stage I and II squamous cell head and neck cancer diagnoses and a reduction of stages III and IV diagnoses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective&#44; observational study of patients referred due to suspicion of tumour in the ENT region and finally diagnosed in the ENT service of the Parc Taul&#237; Hospital Universitari&#44; for 24 consecutive months&#44; between March 2014 and February 2016&#46; This was considered a pilot study since no studies were found in the literature on the effectiveness of any similar programme&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inclusion criteria in the study were patients with suspected HNSC referred from the primary care centres following RDP&#44; and patients referred to our service with indication of suspected tumour&#44; originating from any other source&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Exclusion criteria was that of patients referred to our service with a previous ENT cancer diagnosis that had already been confirmed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnostic criteria was considered to be anatomical-pathological diagnosis of the tumour&#46; All patients with malignant tumours of the head and neck were assessed by the tumour committee of our hospital&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main variable analysed was the stage at diagnosis which was classified and registered according to the applicable version of TNM at the beginning of the study &#40;7&#46;<span class="elsevierStyleSup">a</span>&#41;&#46; Secondary variables were defined as the initial symptom&#44; disease progression duration from onset of first symptom and location of the tumour&#46; Epidemiological gender and age variables were also recorded as were the history of tobacco and alcohol consumption&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The data obtained were compared with a control group &#40;pre-RDP&#41;&#46; This group included patients diagnosed with HNSC in our service during the 4 years prior to starting the RDP&#46; During these 4 years&#44; the examination protocol and diagnostic tests made during the first patient visit were the same as during the duration of the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A referral form was created &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; which had to be completed by the primary care physician &#40;Family Doctor &#91;GP&#93;&#41;&#46; This form contained a list of symptoms and signs the absence or presence of which added up from 0 to 2 points&#46; The patient had to score a minimum of one of the &#8220;inclusion criteria&#8221;&#46; The aeotiopathogenic and epidemiological factors of the head and neck tumours were to be found under the &#8220;referral criteria&#8221; section&#46; A score above or equal to 5 referred the patient to the hospital to be visited at least 2 weeks within a RDP&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">On arrival at the hospital&#44; the patient was visited by the ENT specialist who&#44; when the visit was over&#44; completed a second data collection form with the same information and the same criteria as those which had been used by the GP &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">For those patients who did not come through the RDP&#44; who had been referred for consultation with a suspected ENT tumour &#40;e&#46;g&#46; patients referred with suspected tumours from the emergency services or another service of the same hospital&#44; and patients attended by the ENT services in primary care centres&#41;&#44; only this second form was completed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Based on the number of cases which are annually diagnosed in our centre&#44; we calculated a duration of 2 years for the obtainment of a sample comprising approximately 70 patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Statistical&#44; descriptive analysis&#44; with qualitative variable frequencies &#40;such as staging and diagnosis&#41; and means of quantitative variables&#46; In comparative analyses between the 2 groups of patients before and after the study we used the Pearson Chi squared test and the exact Fisher test&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patient data were anonymous on entering the study&#46; We considered that informed consent in addition to that already used in patients who consult and are diagnosed by the hospital from other centres was unnecessary&#44; since the procedures and tests would be the same as those of normal clinical practice&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study required no more check-ups or examinations than those which had already been performed on these patients&#44; it only required facilitating the mechanisms for allowing appointments and visits of patients to be made in the agreed time&#46; It did require the recruiting of the GPs of all reference areas with training sessions in their primary care centres&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The study was presented and approved by the Ethics and Research Committee of the Parc Taul&#237; Hospital Universitari before its commencement and was carried out by strictly following the ethical principles of biomedical research and prevailing legislation&#46; All participating personnel were committed to adhering to the good clinical practice standards of the International Harmonization Conference during this procedure&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">During the study period 201 patients were included&#46; The reason for the request for consultation was suspected tumour in the ENT area&#46; There were 156 men &#40;77&#46;6&#37;&#41; and 45 women &#40;22&#46;4&#37;&#41;&#44; with a mean age of 63&#46;4&#44; standard deviation &#40;SD&#41; of 12&#46;8&#44; and range of 27 to 90 27&#8211;90 years&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Of the 201 patients&#44; 136 &#40;67&#46;7&#37;&#41; had been referred to the hospital by GPs through the RDP&#44; and of these&#44; 2 cases were excluded due to the lack of data with 134 remaining valid patients&#59; 37 patients &#40;18&#46;4&#37;&#41; were referred by non ENT physicians of the same hospital &#40;internal medicine&#44; infectious or emergency services&#41; and 28 &#40;13&#46;9&#37;&#41; by ENT specialists from primary care centres and who were patients whose GPs had not suspected a tumour&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the total of patients&#44; according to origin and according to the absence or confirmation of a tumour&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Out of the total of 199 patients included&#44; a tumour was confirmed in 82 &#40;41&#46;2&#37;&#41; and of these 63 were HNSC&#46; In the remaining 19 patients 4 thyroid tumours&#44; 8 salivary gland and 7 lymphomas were diagnosed&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 82 patients for whom a tumour was confirmed&#44; 47 cases &#40;57&#46;3&#37; of all tumours&#41; were not referred through the RDP since there had been was no suspected tumour by their GP&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Of the patients who were referred by their GP through RDP&#44; 26&#46;1&#37; had some type of tumour&#44; compared with 59&#46;5&#37; of patients referred by doctors in the hospital and 89&#46;3&#37; of those suspected by the ENT service&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Analysis of the correlation between the form scores&#44; when the GP completed the first questionnaire for referral through RDP&#44; revealed that 134 patients validly referred received scores between 4 and 12 points&#44; with a mean of 6&#46;66 and a median of 7&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">With the same information recorded by the ENT specialist&#44; on completing the second questionnaire the scores ranted from 1 to 13&#44; with a mean of 6&#46;4 and a median of 6&#46; There was an over scoring of approximately one point by the GPs compared with ENT scoring&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">However&#44; in the majority of cases there is concordance between both scores&#44; since out of the 134 patients the score obtained in the visit to the GP and that of the ENT was the same in 100 &#40;74&#46;6&#37;&#41; of them&#44; whether or not they had a tumour&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A total of 23 patients &#40;17&#46;1&#37;&#41;&#44; when assessed by the ENT service&#44; did not get a score of 5&#44; and they therefore should not have been referred by this area&#46; In 2 of these patients&#44; a parotid salivary gland Martin tumour was diagnosed and in the others no tumour was confirmed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> contains these 134 patients referred through RDP&#44; with the 35 cases in which a tumour was confirmed&#44; grouped by inclusion or initial symptom criterion&#46; Approximately 22&#37; of the patients referred for consultation due to dysphonia and 17&#37; of those referred due to odynophagia were diagnosed with a tumour&#44; with the percentage rising to 42&#37; in those referred due to the appearance of a cervical mass&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The epidemiological characteristics of the 63 patients who were diagnosed with an HNSC during the study period were compared with a control group formed by 137 patients from our database diagnosed with HNSC during the 4 years prior to RDP and this is shown on <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; There are no significant differences between both groups in patient gender and age&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding toxic substance habits&#44; we observed a tendency for the number of moderate smokers and ex-smokers in the RDP group to rise&#44; compared with the control group patients and this was statistically significant of &#40;p&#160;&#61;&#160;&#46;00005&#41;&#44; together with a decrease in heavy smokers &#40;p&#160;&#61;&#160;&#46;009&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding alcohol consumption&#44; the tendency appears to be the same with an increase in the percentage of moderate consumption and a decrease in heavy consumption&#44; but the differences were not statistically significant&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">TNM analysis on diagnosis&#44; the main study variable&#44; revealed that 27&#37; &#40;17 in total&#41; of the 63 patients were diagnosed in early stages &#40;<span class="elsevierStyleSmallCaps">i</span> y <span class="elsevierStyleSmallCaps">ii</span>&#41;&#44; and 73&#37; &#40;46 patients&#41; in advanced stages &#40;<span class="elsevierStyleSmallCaps">iii and iv</span>&#41;&#46; In the pre-RDP control group&#44; 32&#46;1&#37; &#40;44 patients&#41; were diagnosed in initial stages compared with 67&#46;9&#37; &#40;93 cases&#41; in advanced stages &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The table also shows the stages at which patients were diagnosed&#44; divided by patient origin&#44; during the period of study duration and in the control group&#46; No statistically significant differences were obtained&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">In these patients diagnosed with HNSC&#44; 3 symptoms&#47;initial manifestations were analysed with the highest number of patients &#40;dysphonic&#44; odynophagia and cervical tumour&#41; and an analysis was performed relating the initial symptom and the diagnostic stage and comparing it with pre-EDP patients referred for the same medical reason&#46; Results are contained in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Although a worsening in diagnoses was observed in the early staging during the study period when the initial symptom was dysphonia&#44; none of the variations were statistically significant&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Regarding the time between presentation of clinical &#47;initial symptoms and diagnosis confirmation&#44; the introduction of the RDP did not achieve a statistically significant shortening of time&#46; The time passing from onset of symptoms to diagnosis was 5&#46;5&#46; months mean with a median of 3&#46;3 months and SD of 4&#46;9&#46; In the control group the mean was 5&#46;1 months&#44; median 3&#46;8 months and SD 4&#46;8&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Regarding location&#44; of the 63 patients diagnosed with HNSC in the study&#44; 29 were laryngeal tumours&#44; 26 pharyngeal&#44; 4 oral cavity&#44; 2 metastasis adenopathies of unknown origin and 2 other locations &#40;sinonasal carcinoma and cancer of the cervical esophagus&#41;&#46;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the staging at diagnosis for each of these tumour locations during the study and in the years prior to this&#46; It highlights that during the study period all hypopharyngeal tumours were diagnosed in advanced stages&#44; but in neither this nor the other tumour locations were any differences statistically significant to the control group&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">Cancer of the head and neck is the sixth most common cancer in Spain&#44; with an estimated incidence for the year 2020 of approximately 10&#44;668 new tumours&#44; a ratio of 5&#46;6 men&#47;1 women&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> This type of tumour includes all those originating from mucous membranes in the head and neck region &#40;lip&#44; oral cavity&#44; tongue&#44; oropharynx&#44; hypopharynx&#44; nasopharynx&#44; larynx&#44; nose and paranasal sinuses&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Prognosis for these tumours in early stages is good&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but diagnosis is usually delayed&#46; These processes present symptoms which are shared with non neoplasic diseases in the same region&#46; These common symptoms &#40;dysphonia&#44; odynophagia&#44; persistent cough&#44; etc&#46; &#41; is often attributed to benign disease of the upper aerodigestive tract&#44; delaying diagnosis of the neoplasic processes in this area&#46; Furthermore&#44; the HNSC patient profile corresponds to a population group who rarely consult the healthcare system&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In recent years a change has been seen&#44; in terms of incidence&#44; in the distribution of tumours in the different locations of this region&#44; due to a change in the prevalence of risk factors&#58; campaigns for reducing alcohol and tobacco consumption&#44; on the one hand and on the other the increase in tumours connected with the human papillomavirus &#40;HPV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In a recent study by Le&#243;n et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> whose hospital centre is in the same geographic area as ours&#44; the incidences by gender and age of the patients diagnosed with SCC of the head and neck during the decade from 2006 to 2017 coincide with those of our study population&#46; They also coincide with the populations in overall toxic substance consumption&#44; although in their case the subgroup with heavy consumption is higher than that of our population&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Incidence and prevalence of risk factors were based on the items used in our form&#44; but we did not include questions aimed at sexual habits which could have had a repercussion in the tumours relating to HPV&#44; nor any specific clinical symptoms indicative of rhinopharyngeal tumours&#58; our aim was to enhance the collaboration of GPs in our area&#44; with a fast and easy-to-complete questionnaire and we focused on the reason for consultation&#44; age&#44; gender and toxic substance consumption of the patient&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">No validated reference was found for the creation of these forms&#46; They were designed from epidemiological data and HNSC contrasted risk factors and from the health questionnaire questions asked of the patients with HNSC in reviewed studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">As with other locations of the tumour disease&#44; abundant documented references are present regarding differences in survival when the lesions are diagnosed in early or late stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> In these studies it has been observed that therapeutic strategies are changing&#44; improving the preservation of the organ but that survival rates remain poor&#46; There has been no substantial improvement in survival by stage and the main prognostic factor it is associated with is the diagnosis in early or late stages&#44; concluding that the best tool for improving survival would be an early stage diagnosis&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">For years several attempts have been made to use a &#8220;screening&#8221; system for head and neck cancer which would lead to early-stage diagnosis and an improvement in survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;12</span></a> We undertook a review of the literature to discover what the situation was&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In our review&#44; the studies with the highest number of patients were conducted in India or Taiwan&#46; In relation to oral cavity cancer&#44; both are areas of great associated prevalence and mortality and where&#44; apart from alcohol&#44; tobacco and HPV variables&#44; other risk factors such as the consumption of the areca or betel nut have an impact&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;19</span></a> Several studies analysed different factors&#44; but one interesting conclusion of this review is that&#44; although the need for examination of the oral cavity is insisted upon by some of the GPs and deontologists&#44; there is no sufficient evidence to suggest that the periodical oral examination of the general population leads to&#44; or does not lead to an improvement in diagnosis&#46; The only factor which appears to prove its importance in earlier diagnosis is how informed the general population is on this pathology&#46; This was assessed by education programmes in rural areas of India&#44; in Australian aborigines and in media campaigns in Taiwan&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Another relevant group and location is nasopharyngeal cancer which is prevalent in the south of China&#44; with clear epidemiological factors including EBV infection and regional&#44; family and racial aggregation&#46; With screening for early detection using serum markers for EBV and studies with endoscopy and magnetic resonance in positive patients&#44; favourable results were obtained in early diagnosis and survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">If we do not take into account these specific situations&#44; the studies regarding screening programme validity to the general population have not proven to be cost-effective&#46; Shuman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> in the analysis of a screening programme&#44; in HNSC conducted between 1996 and 2009&#44; and which included 761 people&#44; revealed that up to 5&#37; presented with findings of suspected cancer&#44; but only 1&#37; of the patients had some type of premalignant or malignant tumour and concluded&#44; like Dedhia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> that for these programmes to be cost-effective they have to be aimed at population groups selected by risk factors and not at the population in general&#46; Along these lines&#44; Hapner and Wise<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> conducted a study with 568 patients with risk habits and observed that up to 43&#37; of the smoker patients presented with some type of pathological finding&#44; although no malignancy characteristics were involved&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">One interesting study along these lines is that of Dwojak et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in which knowledge of HNSC was assessed in the American Indian population of South Dakota&#46; A questionnaire was undertaken asking about symptoms and warning signs&#44; and a complete ENT examination&#46; The HNSC is more common in this population than in the White American population and more aggressive&#44; this being a population where the HPV prevalence is similar but where tobacco and alcohol consumptions habits are higher&#46; In this study an increase in early stage diagnosis of patients who went for consultation was observed and for those who in the questionnaire responses demonstrated high knowledge of the disease&#46; The questionnaire used in this study was one of the sources from which ours was taken&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Our study was not aimed at carrying out a screening programme on either a general population level or with patients with risk habits&#44; and therefore our percentages of malignant tumour findings are not comparable to the studies reviewed where there was a screening of the population or the population group at risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;25</span></a> However&#44; with the knowledge that we have of this pathology&#44; and with the studies published which suggest a better knowledge of this&#44; an earlier diagnosis could be made&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17</span></a> In our study GPs were trained to have greater awareness of the symptoms and signs of these tumours and to facilitate fast access of the patient to consultation with a specialist&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">RDP use by the GP was mostly adequate&#44; since the 134 patients who were referred for consultation met with the criteria of suspicion and in 100 cases&#44; whether the patient had a tumour or not&#44; the assessment coincided with that made by the ENT specialist&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In patients referred with dysphonic or odynophagia as a symptoms&#44; a head and neck tumour was confirmed&#44; in 22&#37; and in 17&#37; of cases&#44; respectively&#44; and in those who were referred by presenting with a cervical tumour&#44; a head and neck tumour was confirmed in 42&#37; of cases&#44; including those of non squamous type&#46; Overall&#44; 26&#37; of patients referred for consultation through RDP for presenting with suspected tumour criteria effectively presented with a tumour&#46; In this sense&#44; although we had no validated questionnaire with which to contrast it&#44; we believe the algorithm was effective&#46; From the outcomes obtained we may decide whether it would be better to change the value the different symptoms and signs should have in the weighting&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Notwithstanding&#44; most patients diagnosed with an ENT tumour during the duration of the study &#40;57&#46;3&#37;&#41; were not referred by their GP with suspicion of this and did not come through the RDP&#46; Similarly&#44; the reviewed studies where improvement was assessed in an early diagnosis were related to the level of information of the patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17&#44;18</span></a> without other screening measures being achieved&#46; The use of this programme during the 2 years of the study duration did not demonstrate an improvement in the analysed items either&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0255" class="elsevierStylePara elsevierViewall">The initiation of a rapid diagnosis programme for the patients who consulted their GP and who&#44; depending on the algorithm created&#44; were suspected of presenting with HNSC did not involve an increase in the diagnosis of HNSC at stages I and II or a reduction in diagnosis at stages <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span> in our centre&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Although the use of the RDP by GPs was mostly accurate and one out of every 4 patients referred by their GP through the RDP for suspicion of head and neck tumour did present with it&#44; most of the patients diagnosed with head and neck tumours during the study period had not been suspected of having this by their GP&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In the absence of valid screening&#44; and given the aetiopathogenic factors involved&#8212;common to other cancers&#8212;&#44; it would seem that&#44; on the one hand&#44; only the policies aimed at avoiding toxic habits and increasing awareness of self-care&#44; and on the other&#44; improving the examination capacity in primary care&#44; could lead to an improvement in the rate and prognosis of HNSC&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financing</span><p id="par0270" class="elsevierStylePara elsevierViewall">This study received a <span class="elsevierStyleGrantSponsor" id="gs0005">Taul&#237; Research Grant</span>&#44; <span class="elsevierStyleGrantNumber" refid="gs0005">CIR2015&#47;066</span>&#58; &#8220;Cost-effectiveness of a fast ENT cancer diagnosis programme&#8221;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2020-04-27"
    "fechaAceptado" => "2020-06-05"
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            0 => "Head and neck cancer"
            1 => "Screening"
            2 => "Rapid diagnosis"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "C&#225;ncer de cabeza y cuello"
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            2 => "Diagn&#243;stico r&#225;pido"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#58; Given the epidemiological knowledge of squamous cell carcinomas of the head and neck &#40;SCHN&#41;&#44; the prognosis in survival according to the staging at diagnosis and the absence of screening programmes that have proven cost-effective&#44; we undertook a rapid diagnosis programme&#46; The objective of this study was to analyse whether a rapid diagnostic programme &#40;RDP&#41; to be used by General Practitioners &#40;GP&#41; would achieve a change in the proportion of diagnoses in early versus late stages in these tumours&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study of patients diagnosed with a tumour of ENT location in our centre&#44; was carried out for 24 consecutive months&#46; A &#8220;suspicion algorithm&#8221; was designed and we established a rapid remission route for these patients&#46; The data obtained &#40;age&#44; sex&#44; toxic substance consumption&#44; initial manifestations&#44; tumour location and extension&#41; were compared with the data of the patients in our ENT Service database diagnosed in the four years prior to the start of the study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">199 patients were included&#44; and 82 ENT tumours diagnosed&#46; The GPs sent to the Hospital via the RDP a total of 136 patients and 35 &#40;26&#46;1&#37;&#41; had a tumour&#46; However&#44; most of the tumours diagnosed in this period by our ENT Department &#40;47 patients&#44; 57&#46;3&#37; of all tumours diagnosed&#41;&#44; were not suspected by the GP and were not sent via the RDP&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Of the patients&#44; 27&#37; were diagnosed in stages I and II&#44; and 73&#37; in stages II and IV&#44; there were no significant differences with the control group&#46; The most frequent initial signs and symptoms were dysphonia&#44; cervical mass and dysphagia&#44; the relationship between initial symptom and stage at the moment of diagnosis was analysed&#44; and in neither case did we obtain any significant variation&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">The implementation of a rapid diagnosis pathway for patients who&#44; according to the algorithm created&#44; had a suspected head and neck cancer&#44; has not led to an increase in the diagnosis of these tumours in early stages or a decrease in diagnoses in advanced stages&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Dado el conocimiento epidemiol&#243;gico del carcinoma escamoso de cabeza y cuello&#44; pron&#243;stico y supervivencia seg&#250;n el estadio al diagn&#243;stico&#44; y ante la ausencia de programas de cribado que hayan demostrado ser coste-efectivos&#44; nos propusimos evaluar un programa de diagn&#243;stico r&#225;pido&#46; El objetivo del presente estudio fue analizar si la existencia de un circuito de diagn&#243;stico r&#225;pido desde atenci&#243;n primara&#44; en base a una ponderaci&#243;n de s&#237;ntomas y signos&#44; supondr&#237;a un cambio en la proporci&#243;n de diagn&#243;sticos en estadios iniciales versus tard&#237;os en estos tumores&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un estudio observacional prospectivo de pacientes remitidos con la sospecha de un tumor en el &#225;rea ORL en nuestro centro durante 24 meses consecutivos&#46; Se cre&#243; un algoritmo con s&#237;ntomas y signos de sospecha para utilizaci&#243;n por el m&#233;dico de familia y un circuito de remisi&#243;n r&#225;pida de los pacientes candidatos&#46; Se registraron tambi&#233;n los pacientes con sospecha de tumor provenientes de fuentes distintas a este circuito&#46; Los datos obtenidos &#40;edad&#44; sexo&#44; consumo de t&#243;xicos&#44; tiempo y cl&#237;nica de presentaci&#243;n&#44; localizaci&#243;n del tumor y extensi&#243;n&#41;&#44; se han comparado con los de los pacientes recogidos en la base de datos de tumores del Servicio ORL diagnosticados durante los cuatro a&#241;os previos al inicio del estudio&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron en el estudio 199 pacientes y se diagnosticaron 82 tumores del &#225;rea ORL&#46; Los m&#233;dicos de familia remitieron por el circuito de diagn&#243;stico r&#225;pido creado un total de 136 pacientes y 35 &#40;26&#44;1&#37;&#41;&#44; presentaban una tumoraci&#243;n&#46; Sin embargo la mayor&#237;a de tumores diagnosticados durante este per&#237;odo en el Servicio ORL &#40;47 pacientes&#44; 57&#44;3&#37; de todos los tumores diagnosticados&#41;&#44; no fueron sospechados por su MF y no fueron remitidos al Hospital utilizando el circuito de diagn&#243;stico r&#225;pido&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Un 27&#37; de los pacientes fue diagnosticado en estadios I y II&#44; y un 73&#37; en estadios III y IV&#44; no hubo diferencias estad&#237;sticamente significativas con el grupo control&#44; y tampoco en los porcentajes de tumores recibidos por localizaciones &#40;laringe&#44; faringe&#44; cavidad oral&#44; primario desconocido&#44; otros&#41;&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas iniciales m&#225;s repetidos fueron la disfon&#237;a&#44; la aparici&#243;n de una masa cervical y la odino-disfagia&#46; Se analiz&#243; la relaci&#243;n entre el s&#237;ntoma inicial y el estadio al diagn&#243;stico&#46; En ninguno de los casos se obtuvieron diferencias significativas respecto al grupo control&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">La puesta en marcha de un circuito de atenci&#243;n r&#225;pida a los pacientes que seg&#250;n el algoritmo creado ten&#237;an una sospecha de padecer c&#225;ncer de cabeza y cuello&#44; no ha supuesto un aumento de los diagn&#243;sticos en estadios precoces y una disminuci&#243;n de los diagn&#243;sticos en estadios avanzados en nuestro centro&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rosell Ferrer R&#44; Aguil&#224; Artal A&#44; Escamilla Carpintero Y&#44; Cardesin Revilla A&#44; Campos Motamayor M&#44; D&#237;az Arg&#252;ello JJ&#44; et al&#46; Validez de un programa de diagn&#243;stico r&#225;pido del c&#225;ncer de cabeza y cuello&#46; Acta Otorrinolaringol Esp&#46; 2021&#59;72&#58;271&#8211;279&#46;</p>"
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                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients referred through RDP by their GP</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Odynophagia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cervical tumour&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood in the mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oropharyngeal tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dysnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Initial symptom of presentation in patients referred to the hospital by their GP through RDP&#44; number of patents for each initial symptom and confirmation of the tumour for each of them&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">HNSC&#58; Head and neck squamous cell carcinoma&#59; RDP&#58; Rapid diagnosis programme&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RDP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pre-RDP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">n&#160;&#61;&#160;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">n&#160;&#61;&#160;137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;87&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;89&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;12&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean&#47;SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;18&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ex&#47;moderate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;54&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;24&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Heavy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;36&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;56&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Alcohol</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;38&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57 &#40;41&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ex&#47;moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;42&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;30&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Heavy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;27&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Epidemiological characteristics of the patients diagnosed with HNSC&#44; during the study and the control group&#46;</p>"
        ]
      ]
      5 => array:8 [
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ENT&#58; Ear&#44; nose and throat&#59; GP&#58; Family doctor &#40;general practitioner&#41;&#59; HNSC&#58; Head and neck squamous cell carcinoma&#59; RDP&#58; Rapid diagnosis programme&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Referral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37; Pre-RDP n&#8239;&#61;&#8239;137</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage I&#160;&#43;&#160;II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage III&#160;&#43;&#160;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage I&#160;&#43;&#160;II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage III&#160;&#43;&#160;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total pat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;73&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;5&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;94&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">85&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ENT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
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        ]
      ]
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First symptom&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diag&#46; stage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III&#160;&#43;&#160;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&#160;&#43;&#160;II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III&#160;&#43;&#160;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I&#160;&#43;&#160;II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III&#160;&#43;&#160;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Study pat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;11&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;88&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;5&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;94&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#160;&#61;&#160;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2693305.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Tumour diagnostic stage divided into initial presentation symptoms in patients&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0040"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Cav&#58; cavity&#59; Diag&#58; diagnosis&#59; P&#46; Unknown&#58; primary site unknown&#59; Pat&#58; patients&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t">Pre-RDP pat&#46;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2020.06.008

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