Moles, David Richard; (2003) Inequalities in oral cancer incidence and access to NHS general dental services in England. Doctoral thesis (Ph.D), UCL.

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Abstract

Background: The burden of oral cancer to both the individual and to society is great. The study of inequalities in oral cancer incidence, stage at presentation, access to care and referral pathways are of both aetiological and public health importance. Such information aids the understanding of the determinants of the disease, individual susceptibility and health outcomes and informs effective health service policy. Previous UK studies of the role of general dental practitioners (GDPs) in the referral of oral cancer patients have been subject to selection bias and none have utilised population-based data. Aims: A) To investigate inequalities in oral cancer incidence and stage at presentation in relation to geographical area, socio-economic status, and ethnicity. B) To establish the role of NHS GDPs in the oral cancer referral pathway and the effect of the maldistribution of NHS GDPs on referrals. Methods: Population-based sources of oral cancer incidence data; deprivation indices; population denominators; dental contract data; and hospital episode statistics (HES) were linked. A validated name recognition algorithm (SANGRA) was used to identify people of south Asian ethnicity. Age standardised incidence rates were calculated and compared. Poisson and logistic regression were used to explore factors affecting incidence, stage at presentation and referrals to secondary care. Case note reviews of referral pathways were undertaken in two clinical settings and the results compared to those obtained from the national population-based HES data. Results: A) Socio-economic status affects oral cancer incidence but not stage at presentation. It captures differences in incidence between south Asian and non-south Asian males, but not females. Religious affiliation as a surrogate measure of cultural practices is associated with differences in incidence in females. B) Dentists refer few oral cancer patients to secondary care and this is influenced by the availability of NHS GDPs. People from minority ethnic backgrounds with oral cancer are less likely to present at a GDP than a general medical practitioner (GMP). GDP referrals to secondary care are more likely to be to an appropriate speciality than GMP referrals. Conclusions: A) The poorer survival experienced by people living in deprived areas is a consequence of factor(s) acting subsequent to diagnosis and not related to the stage at presentation. Differences in oral cancer risk among differing south Asian groups are culturally related. B) The referral pathway for the majority of oral cancer patients does not include general dental practice, but those who do present at a GDP are more likely to receive an appropriate referral. Robust information that is required to inform policy decisions is still lacking in this area.

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