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Purpose The main aim of this paper is to present baseline demographic and clinical characteristics and HRQOL in the two groups of the Patient Concerns Inventory (PCI) trial. The baseline PCI data will also be described. Methods This is a pragmatic cluster preference randomised control trial with 15 consultant clusters from two sites either ‘using' (n = 8) or ‘not using’ (n = 7) the PCI at a clinic for all of their trial patients. The PCI is a 56-item prompt list that helps patients raise concerns that otherwise might be missed. Eligibility was head and neck cancer patients treated with curative intent (all sites, stage of disease, treatments). Results From 511 patients first identified as eligible when screening for the multi-disciplinary tumour board meetings, 288 attended a first routine outpatient baseline study clinic after completion of their treatment, median (IQR) of 103 (71–162) days. At baseline, the two trial groups were similar in demographic and clinical characteristics as well as in HRQOL measures apart from differences in tumour location, tumour staging and mode of treatment. These exceptions were cluster (consultant) related to Maxillofacial and ENT consultants seeing different types of cases. Consultation times were similar, with PCI group times taking about 1 min longer on average (95% CL for the difference between means was from − 0.7 to + 2.2 min). Conclusion Using the PCI in routine post-treatment head and neck cancer clinics do not elongate consultations. Recruitment has finished but 12-month follow-up is still ongoing.

Purpose The patient concerns inventory (PCI) is a prompt list allowing head and neck cancer (HNC) patients to discuss issues that otherwise might be overlooked. This trial evaluated the effectiveness of using the PCI at routine outpatient clinics for one year after treatment on health-related QOL (HRQOL). Methods A pragmatic cluster preference randomised control trial with 15 consultants, 8 ‘using’ and 7 ‘not using’ the PCI intervention. Patients treated with curative intent (all sites, disease stages, treatments) were eligible. Results Consultants saw a median (inter-quartile range) 16 (13–26) patients, with 140 PCI and 148 control patients. Of the pre-specified outcomes, the 12-month results for the mean University of Washington Quality of Life (UW-QOLv4) social-emotional subscale score suggested a small clinical effect of intervention of 4.6 units (95% CI 0.2, 9.0), p = 0.04 after full adjustment for pre-stated case-mix. Results for UW-QOLv4 overall quality of life being less than good at 12 months (primary outcome) also favoured the PCI with a risk ratio of 0.83 (95% CI 0.66, 1.06) and absolute risk 4.8% (− 2.9%, 12.9%) but without achieving statistical significance. Other non-a-priori analyses, including all 12 UWQOL domains and at consultant level also suggested better HRQOL with PCI. Consultation times were unaffected and the number of items selected decreased over time. Conclusion This novel trial supports the integration of the PCI approach into routine consultations as a simple low-cost means of benefiting HNC patients. It adds to a growing body of evidence supporting the use of patient prompt lists more generally.

We studied the progression from dysplasia to invasive carcinoma and subsequent second primaries or locoregional recurrences in 11 patients with recurrent squamous cell carcinoma (SCC). Between one and six samples were sequenced/patient. DNA samples were prepared, and libraries multiplexed to between 40 and 80 samples/lane of an Illumina HiSeq 3000 and sequenced with 2 × 100 bp paired end sequencing. Copy number data were generated by CNAnorm (Bioconductor package). Samples of recurrent SCC showed unique patterns of descent when compared with earlier samples from the primary tumour, and three main patterns emerged. In four patients there was convincing evidence that the later lesion was descended directly from cells from the first, and in a further four there were no detectable genomic events between the two lesions. Three patients had some shared events between the early and later lesions, but although there were enough differences to deduce that the two lesions had a shared ancestor, they were not directly descended from each other. We present the patients’ characteristics in detail, including the overall survival in each group. There was a distinct genomic pattern after a second episode of SCC in all the groups. A larger study that uses similar methods and a longer duration could provide reliable conclusions with respect to survival. With the use of new techniques, genomic data can be available to clinical teams during the planning of treatment.

Oral squamous cell carcinoma is the most common intraoral malignancy, for which we advocate radical primary resection with adjuvant treatment where indicated. The main aims of this paper are to identify the overall survival of a consecutive series of patients and to relate survival to clinical and pathological factors. Kaplan-Meier curves were produced for site, sex, TNM status, and use of postoperative radiotherapy. The data were analysed using IBM SPSS Statistics for Windows and probabilities of less than 0.05 were accepted as significant. A total of 921 patients were recorded in the database with a diagnosis of oral squamous cell carcinoma out of a total of 1958 with salivary gland conditions or other cancers of the head and neck (43.1%). The earliest date of diagnosis was 1973, and the data were censored at 31 March 2016. The database comprised 340 women (36.9%) and 581 men (63.1%). A total of 339 patients died (34.5%): 117 women (33.7%) and 222 men (65.5%). The mean (range) age at death was 73.4 (31.4-97.5) years for women and 68.7 (33.3-95.5) years for men (t (337)=3.28, p=0.001). Our overall survival was somewhat better than the 56% five-year survival reported for oral cancer in England in 2010, which may be a reflection of the treatment. This work supports the view that aggressive management may improve overall survival.

We describe our two-year experience of a nurse led clinic (NLC) in a tertiary centre oral and maxillofacial surgical (OMFS) department. The clinic is run by a specialist nurse, in parallel with a consultant's clinic and focuses on the management and review of non-malignant lesions. Increased clinical flexibility, reduced waiting times, and tailored educational resources have contributed to an improved experience for the patients.

The study of the relationships between pre-cancer and cancer and identification of early driver mutations is becoming increasingly important as the value of molecular markers of early disease and personalised drug targets is recognized, especially now the extent of clonal heterogeneity in fully invasive disease is being realized. It has been assumed that pre-cancerous lesions exhibit a fairly passive progression to invasive disease; the degree to which they, too, are heterogeneous is unknown. We performed ultra-deep sequencing of thousands of selected mutations, together with copy number analysis, from multiple, matched pre-invasive lesions, primary tumours and metastases from five patients with oral cancer, some with multiple primary tumours presenting either synchronously or metachronously, totalling 75 samples. This allowed the clonal relationships between the samples to be observed for each patient. We expose for the first time the unexpected variety and complexity of the relationships between this group of oral dysplasias and their associated carcinomas and, ultimately, the diversity of processes by which tumours are initiated, spread and metastasize. Instead of a series of genomic precursors of their adjacent invasive disease, we have shown dysplasia to be a distinct dynamic entity, refuting the belief that pre-cancer and invasive tumours with a close spatial relationship always have linearly related genomes. We show that oral pre-cancer exhibits considerable subclonal heterogeneity in its own right, that mutational changes in pre-cancer do not predict the onset of invasion, and that the genomic pathway to invasion is neither unified nor predictable. Sequence data from this study have been deposited in the European Nucleotide Archive, Accession No. PRJEB6588.

Verrucous carcinoma of the oral cavity (OVC) is considered a subtype of classical oral squamous cell carcinoma (OSCC). Diagnosis is problematic, and additional biomarkers are needed to better stratify patients. To investigate their molecular signature, we performed low-coverage copy number (CN) sequencing on 57 OVC and exome and RNA sequencing on a subset of these and compared the data to the same OSCC parameters. CN results showed that OVC lacked any of the classical OSCC patterns such as gain of 3q and loss of 3p and demonstrated considerably fewer genomic rearrangements compared to the OSCC cohort. OVC and OSCC samples could be clearly differentiated. Exome sequencing showed that OVC samples lacked mutations in genes commonly associated with OSCC (TP53, NOTCH1, NOTCH2, CDKN2A and FAT1). RNA sequencing identified genes that were differentially expressed between the groups. In silico functional analysis showed that the mutated and differentially expressed genes in OVC samples were involved in cell adhesion and keratinocyte proliferation, while those in the OSCC cohort were enriched for cell death and apoptosis pathways. This is the largest and most detailed genomic and transcriptomic analysis yet performed on this tumour type, which, as an example of non-metastatic cancer, may shed light on the nature of metastases. These three independent investigations consistently show substantial differences between the cohorts. Taken together, they lead to the conclusion that OVC is not a subtype of OSCC, but should be classified as a distinct entity.

The Adult Comorbidity Evaluation (ACE)-27 is a validated scoring system for comorbid conditions. We have evaluated the correlation between it and the duration of hospital stay, readmission within 30 days, complications, and two-year survival in patients having primary surgical treatment for squamous cell carcinoma (SCC) of the head and neck. We studied patients with SCC who had selective neck dissection, resection of the tumour, and reconstruction between 2007 and 2013. Patients who had palliative procedures were excluded. We studied the casenotes of 231 patients and recorded the following outcome measures: TNM staging, ACE-27 score, number of days spent in hospital, readmission within 30 days, complications, and mortality at two years.The relation between the ACE-27 score and duration of hospital stay was significant (p=0.000001). The relations between complications and ACE-27 score, and complications and tumour stage, were also significant (p

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

A busy head and neck or oral and maxillofacial (OMFS) National Health Service (NHS) clinic treats patients with many different conditions. A large proportion will have cancer of the head and neck, and they will be at different stages of their treatment. Their clinical needs may be different from a larger group of patients who have been referred through the “two-week wait” referral pathway, and who are present in the same clinic for their biopsy results. We present our early experience of “fast-track” referrals and their potential effect on the overall volume of work. They are only a small number of the patients who are typically seen in a nurse-led clinic.

Background It is frequently assumed that pre-invasive lesions are simpler precursors of cancer and will contain a limited subset of the genomic changes seen in their associated invasive disease. Driver mutations are thought to occur early, but it is not known how many of these are present in pre-invasive lesions. These assumptions need to be tested with the increasing focus on both personalised cancer treatments and early detection methodologies. Methods We examined genomic copy number changes in 256 pre-invasive and invasive samples from 69 oral cancer patients. Forty-eight samples from 16 patients were further examined using exome sequencing. Results Evidence of a shared ancestor of both dysplasia and carcinoma was seen in all but one patient. One-third of dysplasias showed independent copy number events. The remainder had a copy number pattern that was similar to or simpler than that of the carcinoma. All dysplasias examined contained somatic mutations absent in the related carcinoma. Previously observed copy number changes and TP53 mutations were very frequently observed, and almost always shared between dysplasia and carcinoma. Other gene changes were more sporadic. Pathway analysis confirmed that each patient’s disease developed in a different way. Examining the numbers of shared mutations and the rate of accumulation of mutations showed evidence that all samples contain a population of sub-clones, with little evidence of selective advantage of a subset of these. Conclusions These findings suggest that most of the genomic changes driving oral cancer occur in the pre-cancerous state by way of gradual random accumulation rather than a dramatic single event. Electronic supplementary material The online version of this article (doi:10.1186/s13073-017-0442-0) contains supplementary material, which is available to authorized users.

Oral dysplastic lesions may have an increased chance of becoming oral squamous cell carcinoma, but to date their management remains controversial. The aim of this survey was to explore the current practical aspects of the management of patients with dysplasia by oral and maxillofacial consultants in the UK. In the survey we asked consultants about the numbers of patients they see with oral premalignant lesions, the frequency and specialty of designated hospital clinics, their use of photographs and biopsy, factors that influence their decision whether to biopsy a lesion at the first appointment, the procedure for treatment and follow-up and their use (if any) of chemopreventive agents. We found a wide variation in the practical aspects of managing patients with dysplasia, and the lack of consistency among clinicians supports the idea of an initiative to establish more robust national guidelines to use as a gold standard in the future.

Histological analysis of tumour resection for squamous cell carcinoma (SCC) of the tongue yields prognostic information. We analysed histological slides of biopsy and tumour resection specimens using an adapted malignancy grading score and analysed variables of neck dissections. There was moderate correlation between biopsy and tumour resection using malignancy grading scores (correlation coefficient 0.45); good agreement of tumour grade (79%), tumour depth (76%), and type of invasive front (80%), but correlation was only fair to moderate (κ = 0.38, κ = 0.51, and κ = 0.41, respectively). Correlation of the biopsy grading score and invaded nodes in the neck, extra capsular spread, and soft tissue disease was not significant.

Patients who present with squamous cell carcinoma (SCC) in the head and neck have a serious risk of coincident thoracic malignancy. The aim of this study was to identify the incidence of thoracic malignancy in newly diagnosed, previously untreated, oral and oro-pharyngeal SCC, and to evaluate the role of thoracic computed tomography (CT) in its management. Of 116 consecutive patients who were identified prospectively 81(70%) had oral and 35 (30%) oropharyngeal SCC. Ten patients (9%) had suspicious thoracic CT findings. After investigation or follow up, four (3.5%) of these patients were shown to have coincident thoracic malignancies. This large prospective series of newly diagnosed oral and oropharyngeal SCC had a lower incidence of coincident thoracic malignancy than had previously been shown.

In a previous publication we reviewed the future career plans of 169 dental graduates who entered medical school from 1986 to 1991 inclusive. The aim of the present study was to find out what happened to this group after qualification from medical school. The 169 individuals were traced and a questionnaire was sent to them by mail. A reminder was sent and some data for non-respondents were obtained from public sources such as registers and directories. In the original study, 120 of the 154 respondents (78%) intended to become oral and maxillofacial surgeons. We found in this follow up survey that the overall return rate to oral and maxillofacial surgery (OMFS) had dropped to 66%. For those not returning to the speciality, a wide range of alternative specialities had been chosen, with general medical practice (n=9) and oral medicine (n=8) being the most popular. Amongst those returning to OMFS, most undertook basic surgical training in general surgery and trauma. Two thirds of those eligible possessed the FRCS, with 43 (83%) holding the FRCS (Clinical Surgery in General) and six (12%) having the FRCS Ed (oral and maxillofacial surgery). Within the group, opinions were mixed about the changes caused by ‘Hospital doctors: training for the future’ (Calman Report) [Working Group on Specialist Medical Training. Hospital doctors: training for the future. London: Department of Health, 1993]. Concerns were voiced about the potential reduction in clinical experience, comparatively longer training for OMFS, and particularly the abrupt end of training with no protection whilst seeking a consultant appointment. Half thought that OMFS will become concentrated in supraregional centres, or head and neck units with related specialities.