Rapid access clinics for head and neck cancer: impact on diagnostic and treatment timelines in a regional centre

Introduction

Head and neck cancers (HNCs) represent a diverse group of malignancies involving the oral cavity, oropharynx, larynx, nasal cavity, paranasal sinuses, salivary glands, thyroid, parathyroids, and head and neck skin and associated structures. Despite accounting for only 3% of new cancer diagnoses in Australia, HNC is associated with considerable morbidity and mortality, with profound effects on speech, swallowing, and quality of life (1-3).

According to the Australian Institute of Health and Welfare (AIHW), approximately 5,200 Australians were diagnosed with HNC in 2023, with a five-year relative survival rate of 69% (4). These data likely underestimate the overall burden, as HNC statistics may not routinely include thyroid/endocrine, salivary gland malignancies, and melanoma. Overall survival is strongly stage-dependent, and patients diagnosed at an advanced stage face substantially poorer prognosis, regardless of the primary site of their cancer. Socioeconomic disadvantage, geographical remoteness, and Aboriginal and Torres Strait Islander (ATSI) status are associated with later stage at presentation, and worse overall outcomes (5,6).

Risk factors for HNC will vary on the specific subset of malignancy however common factors include tobacco use, heavy alcohol consumption, and, increasingly, infection with high-risk subtypes of the human papillomavirus (HPV), particularly for oropharyngeal cancers (7). Non melanoma skin cancers (NMSCs) and cutaneous melanoma are associated with ultraviolet (UV) light exposure and subsets of thyroid cancer associated with radiation exposure (8-10). With a range of genetic risk factors for different HNC (11). Symptoms also vary depending on the type of malignancy, however early disease is typically non-specific and can easily be misinterpreted as benign conditions, contributing to diagnostic delays (12).

Recognising these challenges, Cancer Australia’s Optimal Care Pathway (OCP) for HNC recommends urgent referral to an ears, nose and throat (ENT) surgeon for individuals with certain cardinal symptoms persisting for more than 2 weeks (13). However, evidence indicates that patients frequently experience delays from referral to review, diagnosis, and treatment commencement, particularly in regional and rural settings (14,15).

To address these gaps, rapid access clinics (RACs) have been developed internationally. In the United Kingdom (UK), the implementation of “two-week wait” pathways and rapid diagnostic clinics has improved compliance with Faster Diagnosis Standards and reduced median time to diagnosis (1-18). These were established due to the long wait times for patients with HNC referrals with the UK data showing that only 61% of HNC patients were commencing treatment within 62 days from initial referral (18). Studies showed an improvement in time to referral since implementing this pathway with a statistically significant mean wait time difference of 54 days and 110 days (19). While such models are well-established in Europe, there is limited Australian evidence evaluating RAC effectiveness within the local healthcare context.

In 2023, a regional tertiary hospital in New South Wales (NSW) implemented a dedicated RAC for suspected HNC based upon validated risk-assessment surveys developed in the UK (16). The RAC pathway was implemented to include dedicated outpatient clinic and operating theatre resources to facilitate timely diagnosis, streamline healthcare resources, and expedite treatment of patients with suspected HNC. After reviewing the patients journey from referral to treatment, the team designed a four stage RAC pathway (refer to Table 1 and Figure 1).

Figure 1 Systems flow diagrams of the patients’ journey through the head and neck cancer RAC from initial referral to diagnosis and commencement of treatment. CNC, clinical nurse consultant; ENT, ears, nose and throat; HNC, head and neck cancer; HNCCC, head and neck cancer care coordinator; MDT, multidisciplinary team; PET, positron emission tomography; RAC, rapid access clinic; SRMO, senior resident medical officer; WL, waitlist.

The first stage involved referral and triage, during which all referrals were reviewed by an ENT registrar in conjunction with a consultant head and neck surgeon. Referrals were risk stratified using a validated HNC screening and risk calculator (16), which incorporates patient demographics, social history, and the presence or absence of key symptoms and clinical signs. Symptoms were considered significant if present for three weeks or longer, with the exception of stridor, which was treated as an acute presentation. Based on the calculated probability of malignancy, referrals were allocated to appropriate urgency categories, with high-risk cases directed to the RAC pathway for expedited assessment. The risk stratification tool, however, was only appropriate for mucosal HNC. Other cancer subsites were reviewed as per national guidelines.

The second stage consisted of outpatient review conducted through weekly, consultant led RAC clinics supported by an ENT senior resident medical officer (SRMO). During these clinics, patients underwent comprehensive evaluation, including detailed history taking, targeted head and neck examination, and flexible nasendoscopy where indicated. The risk stratification score was reviewed alongside clinical findings to guide further investigation and escalation, allowing refinement of pre-test probability and ensuring appropriate use of diagnostic resources.

The third stage focused on diagnostic work-up, with dedicated institutional resources aligned to support the RAC pathway. These included access to weekly positron emission tomography (PET) imaging, interventional radiology-guided biopsy services, and fortnightly operating theatre lists reserved for diagnostic procedures. This coordinated access facilitated timely histological confirmation and staging, minimising delays between initial assessment and definitive diagnosis.

The final stage involved multidisciplinary team (MDT) review and treatment planning. Completed diagnostic work-ups were presented at the weekly head and neck MDT meeting, where consensus management decisions were made involving surgical, medical oncology, radiation oncology, radiology, pathology, and allied health representatives. The aim of this model was to complete definitive treatment plans within one-two week of RAC attendance, enabling rapid transition from diagnosis to initiation of appropriate oncological care.

This study evaluates the effectiveness of the RAC in reducing the interval from referral to first ENT review, assesses its impact on diagnostic and treatment timelines, and systematically identifies operational strengths and barriers within the RAC model to inform optimisation and future scale-up.

Methods

The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-73/rc).

Ethics

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approval for this study was granted by the Human Research Ethics Committee (HREC) at Hunter New England Local Health District, the governing health authority for John Hunter Hospital and the hospital audit committee as a quality improvement audit [approval No. (#AU202407-01)], and individual consent for this retrospective analysis was waived.

Study design and setting

This study was a retrospective comparative cohort analysis evaluating outcomes for patients managed through the RAC against a pre RAC control group. The investigation was undertaken at a tertiary referral centre located in NSW, which serves a large catchment area encompassing both metropolitan and regional or rural populations, approximately totalling nearly 1 million Australians.

Study population

The study population was comprised of two cohorts: The RAC cohort included patients referred with suspected HNC reviewed in the RAC between July 2023 and June 2024. The control cohort consisted of patients with HNC referred between January and December 2019, prior to the implementation of the RAC system. For consistency of comparison, the control group was extracted exclusively from patients discussed at the head and neck MDT meeting database who had previously been seen and referred to the LDH ENT outpatient clinic. All patients from the control group had a confirmed malignancy.

Inclusion and exclusion criteria

For the RAC cohort, all patients seen in the clinic during the study period were included, with exclusions applied to those with missing data or lost to follow-up. For the control cohort, only patients with a confirmed head and neck malignancy who had been reviewed through the ENT outpatient clinic and discussed at the MDT were included. Patients with incomplete records or lost to follow-up were excluded to maintain data integrity and comparability between groups.

Data collection

Data was collected retrospectively from medical records and institutional databases. Demographic variables included age, gender, geographical remoteness as defined by the Modified Monash Model (MMM), and ATSI status. Clinical variables included cancer type, anatomical site, stage, date of diagnosis via histological confirmation and date of commencement of treatment. Key time intervals were measured to assess the impact of the RAC model, including the time from referral to first ENT review, time from initial review to diagnosis, and time from review to initiation of treatment.

Bias limitation

To address potential sources of bias, the study relied on comprehensive records from both the MDT database and ENT outpatient clinic documentation, ensuring that all relevant patient information was captured. In accordance with Local Health District (LHD) policy, all newly diagnosed HNC cases are presented at a single MDT meeting, which is the sole HNC MDT within the LHD. Of note, oral cavity cancers may be referred to the Department of Oral and Maxillofacial Surgery, and thus not all were captured in this RAC pathway during both the study and control periods, but these new cancer diagnoses were all presented at the HNC MDT regardless. This represents a constant confounder, not affected by the RAC design.

Comparisons were made with a control group from the same institution, which reduced variability in referral patterns, clinical assessment, and management practices. Additionally, all data were collected and analysed using predefined criteria to limit observer bias and maintain consistency across both cohorts.

Study size

The study size was determined based on the total number of patients referred with suspected HNC during the designated study periods. For the RAC cohort, all patients seen between July 2023 and June 2024 were included to capture a full year of clinic activity. The control cohort was identified from historical records in the calendar year of 2019, representing all patients meeting the inclusion criteria. No formal power calculation was undertaken, as this study was exploratory and focused on real-world implementation outcomes, and we matched a 12-month intake period for the same clinic and department but preceding the study term. 2019 was selected as this was the most recent entire year where data would not be confounded by the COVID-19 pandemic’s effect on clinical workflow nationwide.

Statistical analysis

All data were analysed to summarise patient characteristics, cancer diagnoses, and key time intervals. Continuous variables, including age and times from referral to review, diagnosis, and treatment, were reported as means, medians, ranges, and standard deviations. Categorical variables, such as gender, geographical remoteness, ATSI status, and cancer site, were summarised using counts and percentages. Tests of skewness were performed on continuous variables to assess distribution. As these data were not normally distributed and the data ordinal, the Mann-Whitney U test was used to evaluate differences between the RAC and control cohorts for the key time intervals. Descriptive overviews of outcomes and trends within the RAC and historical control cohorts were also reported. Statistical significance is defined as P<0.05.

Results

Patient demographics

A total of 118 patients were reviewed through the RAC between July 2023 and June 2024, with a median age of 65.5 (range, 2–96) years. Males accounted for 64.0% of this cohort (n=76). Half of the patients resided in rural or regional areas (n=59), and 7.6% identified as ATSI (n=9). Of the RAC cohort, 50 patients were diagnosed with malignancy resulting in a 42.4% cancer diagnosis rate within the RAC clinic (refer to Table 2).

The RAC cancer cohort therefore included 50 patients, with a median age of 68 (range, 18–96) years. Males accounted for 76.0% of this cohort (n=38). Nearly half (48.0%) of the patients resided in rural or regional areas as per MMM (n=24), and 4.0% identified as ATSI (n=2) (refer to Table 3).

The control cohort included 47 patients with diagnosed HNC, with a median age of 66 (range, 29–87) years. Males represented 74.5% (n=35), and 55.3% were from rural or regional locations as per MMM (n=26). Two ATSI patients were identified in this group (refer to Table 3).

Comparison of demographic variables between the two groups showed no statistically significant differences. A Mann-Whitney U test indicated no difference in age between the RAC and control cohorts (U =1142.5, z =−0.23, P=0.82). Similarly, a Chi-squared test demonstrated no difference in gender distribution between the groups, χ²(1, N=97) =0.03, P=0.87.

Cancer subtypes

The distribution of cancer diagnoses differed between cohorts. Within the RAC cohort, the most frequent primary sites were the oropharynx (n=18, 36.0%), followed by cutaneous malignancies (n=14, 28.0%), larynx (n=6, 12.0%), nasopharynx (n=3, 6.0%), nasal and sinus (n=3, 6.0%), oral cavity (n=2, 4.0%), parotid (n=3, 6.0%) and thyroid (n=1, 2.0%). In the control cohort, oropharyngeal cancers (n=11, 23.4%) and cutaneous malignancies (n=11, 23.4%) were most common, followed by laryngeal (n=9, 19.1%), oral cavity (n=7, 14.9%), and parotid (n=9, 19.1%) (refer to Table 4).

Non cancer diagnosis from the RAC

In addition to malignant cases, a proportion of patients reviewed through the RAC were found to have identifiable non-malignant pathology (n=68). These diagnoses encompassed a broad spectrum of conditions, 26.4% benign tumours (n=18), 7.4% inflammatory conditions (n=5), 4.4% infections (n=3) and 47.1% functional disorders (n=32). In addition, incidental radiological abnormalities detected on a range of imaging modalities but without clinical significance were reported in 14.7% of patients (n=10) (refer to Table 5).

Timeline outcomes

The median time from referral to first ENT review was 16 [interquartile range (IQR), 9–27] days for RAC patients compared with 38 (IQR, 13–50) days in the control cohort, this corresponded to a 57.9% reduction in time to initial review. Time from review to diagnosis was similarly shortened, with a median of 6 (IQR, 1–20) days in the RAC group versus 14 (IQR, 8–23) days in controls, resulting in a 57.1% reduction in time to diagnosis. A Mann-Whitney U test showed that patients in the RAC group had a significantly shorter time to diagnosis compared to the control group, U =807, z =−2.38, P=0.017. Finally, the interval from review to initiation of treatment was also reduced, with a median of 36 (IQR, 22–47) days in the RAC cohort compared with 49 (IQR, 36–75) days in controls and a 26.5% reduction in time to treatment initiation. A Mann-Whitney U test showed that patients in the RAC group had a significantly shorter time to treatment compared to the control group, U =516, z =3.89, P=0.0001 (refer to Table 6).

Discussion

The implementation of the RAC for suspected HNC has demonstrated significant improvements in diagnostic and treatment timelines when compared to historical controls. These findings align closely with national and international standards that emphasise the importance of early referral and prompt assessment in suspected malignancy. According to the Cancer Australia OCP for HNCs, patients presenting with red flag symptoms such as persistent dysphonia, dysphagia, or unexplained neck masses should ideally be reviewed by an ENT specialist within 2 weeks of referral (13,20). The RAC model achieved median times of 16 days from referral to review, 6 days from review to diagnosis, and 36 days from review to treatment, all of which compare favourably with these benchmarks. These improvements reflect not only compliance with the OCP but also a meaningful enhancement of patient care.

The importance of these reductions lies in their potential to influence stage at diagnosis and ultimately survival outcomes (21). Delays in assessment and treatment have been repeatedly shown to increase the likelihood of advanced disease at presentation, with corresponding decreases in survival rates (22). International experiences, particularly from the UK, have demonstrated that rapid diagnostic clinics can reduce the delay referral review and improve access to curative treatment (17,23). A study in the UK found that with implementation of RAC’s there was a significant improvement in time to diagnosis (18). There was also improvement reported in other European studies with fast track clinics allowing patients to be seen with in an average time of 12 days (24).

The current study adds to this body of evidence but providing an Australian context, demonstrating that similar models can be successfully adapted to local health systems to achieve these international-benchmark results. While long-term survival data from this RAC are not yet available, the acceleration of diagnosis and treatment observed in this study strongly supports its role in addressing one of the most pressing issues in head and neck oncology, particularly in public health systems worldwide: delayed presentation and treatment initiation.

Several factors contributed to the success of the RAC. First, the incorporation of a validated risk stratification tool, the HNC Risk Questionnaire (16), allowed for the systematic triage of referrals. This validated tool ensured that high-risk patients were promptly flagged and prioritised for RAC attendance, minimising the chance of serious pathology being overlooked. Second, the requirement for mandatory registrar-consultant discussion at the time of triage added a further layer of clinical oversight, ensuring that flagged patients were appropriately reviewed by a specialist after the initial registrar review, and thus delays due to inappropriate referrals or incomplete information were minimised.

The streamlining of diagnostics also played a critical role. Dedicated access to PET scans, interventional radiology for biopsies, and fortnightly dedicated RAC operating lists are instrumental to enable such timely completion of investigations that would otherwise be additional bottlenecks in the diagnostic process. The integration of weekly RAC clinics with the established MDT meeting allowed for streamlined case discussion, staging, and treatment planning, ensuring that patients moved efficiently from diagnostic workup to management decisions, and that all involved (or potentially involved) specialties were made aware of each new patient. Furthermore, the presence of a dedicated ENT SRMO and cancer care coordinator provided continuity of care and accountability, ensuring that patients were actively tracked throughout their journey, and patients were not lost in the complex workup process. This clear allocation of responsibility, combined with well-defined timelines and goals, reinforced a culture of urgency that permeated all stages of the pathway, with significant “buy-in” and participation from all stakeholders: surgery, medical oncology, radiation oncology, radiology, operating theatres, and (very essentially) hospital administration.

Despite these successes, several barriers to optimal timelines were identified. Patient-related delays were among the most common, with non-attendance at appointments due to work commitments, geographical distance, and anxiety, potentially leading to disruption of the carefully structured pathway. These challenges are particularly relevant in a regional tertiary referral centre, where a significant proportion of patients travel long distances for specialist review and may have their general practitioner (GP) or healthcare “home” elsewhere. Resource constraints also posed limitations, with high demand occasionally leading to delays in access to the RAC operating list, though this was thankfully uncommon. Although fortnightly lists were established, the complexity and number of cases requiring biopsy at times exceeded available capacity, and the theatre staff allocated to these fortnightly RAC lists was, on occasion, rostered elsewhere in times of acute traumas at the hospital, leading to delays in diagnosis and care even within this RAC model. Similarly, patients with significant comorbidities often experienced delays while awaiting preoperative medical clearance, a reminder that improvements in pathway efficiency must also account for broader systemic factors. Finally, some patients faced out-of-pocket costs when directed to private diagnostic facilities, which introduced inequities in access to timely investigations. While our RAC model lies entirely within the public health system, many patients from regional and remote areas can experience these financial burdens if there are no public or bulk-billing providers in their areas, and thus may experience financial hardship in obtaining an initial evaluation nearer to home, whether that be from their GP or a specialist.

Equity considerations remain central to the ongoing refinement of the RAC model. While this study demonstrated improvements in timelines in the RAC, disparities amongst vulnerable populations, including rural and remote patients and ATSI, may persist. Indigenous Australians are more likely to present with advanced-stage disease and have poorer overall survival outcomes from HNC (4,5,25). For this reason, culturally safe care, active engagement with Aboriginal health workers, and community partnership must be embedded within RAC pathways. Consideration for rural populations is also required as the incidences of HNC increase with geographical remoteness with rural patient more likely to die from a cancer related death compare to patient living in an urban setting (26,27). With 28 percent of the Australian population living in rural and remote Australia it is important to ensure that these models do not simply improve access for the majority but also address entrenched inequities will be essential for their long-term success.

This study represents the first report of an Australian evaluation of a dedicated RAC model for HNC and demonstrates the feasibility of implementing such a pathway within an existing tertiary referral centre. Importantly, it highlights the adaptability of RAC frameworks, showing that they can be successfully integrated into established MDT structures to optimise the diagnostic and treatment journey. While the RAC model demonstrated improvements in streamlining assessment and diagnosis, further refinement is required to better target malignant pathology and optimise pathway efficiency. Notably, despite expedited review, the median time from initial referral to initiation of treatment remained greater than one month, highlighting ongoing opportunities to reduce downstream delays and further improve timeliness of definitive care.

Nevertheless, limitations must be acknowledged. The retrospective design is inherently subject to selection bias, and the relatively small sample size limits the generalisability of findings. It should be noted that there are a wide range of HNC included in this study, variations in tumour subsites distribution between cohorts may also have influenced outcomes. Differences in tumour biology, symptom onset and typical diagnostic pathways across subsites may contribute to variability in referral pathways and time-based metrics independent from the RAC itself. Moreover, the absence of survival outcomes restricts the conclusions that can be drawn regarding the long-term clinical impact of RAC implementation.

Future research will focus on prospective evaluation of the RAC, including longitudinal follow-up of patients through oncosurveillance, analysis of stage at diagnosis, and survival outcomes. Expansion of the model across multiple centres within the LHD will enable broader evaluation and facilitate multicentre trials. Incorporating patient-reported outcomes, including quality of life and satisfaction, will provide critical insight into the holistic impact of RAC pathways. Finally, policy advocacy is warranted to align RAC implementation with statewide cancer service strategies, such as the NSW Health Cancer Services Plan, ensuring sustained resourcing and integration across the public health system (28).

Conclusions

The introduction of a RAC for suspected HNC has reduced delays in review, diagnosis, and initiation of treatment when compared with historical practice. By aligning closely with Cancer Australia’s OCP and NSW Health benchmarks, the RAC has demonstrated both feasibility and effectiveness in improving compliance with national standards. Key features underpinning its success included validated risk stratification, consultant-led triage, streamlined diagnostic access, and seamless integration with MDT decision-making.

Future directions will involve prospective evaluation of patient outcomes, expansion across the health care district, and integration of patient-reported measures to capture the broader impact of the pathway. The RAC model represents a critical step toward reducing diagnostic and treatment delays, improving equity of access, and optimising outcomes for patients with HNC.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-73/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-73/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-73/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-2025-1-73/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approval for this study was granted by the Human Research Ethics Committee (HREC) at Hunter New England Local Health District, the governing health authority for John Hunter Hospital and the hospital audit committee as a quality improvement audit [approval No. (#AU202407-01)], and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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