The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis

Role of mammography in the triple assessment of single-quadrant breast symptoms

Background

Most women over the age of 35 years referred to a breast clinic have single-quadrant symptoms and undergo mammography (MMG) as part of the triple assessment of these. A proportion of these women has no abnormality clinically or on ultrasonography (P1 U1). The aim of this study was to assess the additional contribution of MMG in diagnosing cancer in patients with P1 U1 findings and to consider whether it is safe to be more selective when requesting MMG.

Methods

Over a 2-year interval the clinical and radiological details of women whose single-quadrant breast symptoms were assessed as P1 U1, and who were then sent for MMG, were entered into a database. The results of further investigations initiated by a non-benign MMG report were recorded, and the patients reviewed to establish how many cancers were diagnosed purely by MMG and whether these were located at the site of symptoms.

Results

There were 454 women in the study group, representing 17·5 per cent of all new referrals. Twenty-one patients (4·6 per cent) were recalled following a non-benign MMG result, ten of whom required image-guided biopsy. Cancer was diagnosed in three patients (0·7 per cent of the study group), located in the contralateral breast in two women and a different ipsilateral quadrant in one.

Conclusion

MMG in this subset of patients did not increase the cancer detection rate at the site of symptoms and therefore constituted screening. The rationale for requesting MMG in these patients, and indeed for applying the triple assessment rule, should be reconsidered.

Breast lump detection: who is more accurate, patients or their GPs?

AIMS

A breast lump is the most commonly presenting complaint given by GPs when making a referral to the local breast unit. This does not necessarily mean that this was the breast symptom for which the woman consulted her GP. This study aimed to assess the accuracy of women and their GPs in detecting true breast lumps.

MATERIALS AND METHODS

Between October 2008 and March 2009, the patients' symptoms, the signs elicited by the GP and the examination findings of the specialist breast clinician (BC) were recorded and compared for every consecutive new referral to the symptomatic breast clinic. A true lump was considered to present if it was detectable by the BC.

RESULTS

Of the 282 referrals, 228 (81%) were for a lump. Women were 95% sensitive and 59% specific in detecting a true lump. GPs were 98% sensitive and 34% specific. Forty-six patients were referred by their GP with a lump but denied that one was present in themselves. Cancer was diagnosed in four of these women, three of whom suffered from dementia.

DISCUSSION

Patients' and GPs' breast assessments are highly sensitive in detecting breast lumps. The specificity of GPs' assessments is low. The results reflect the high level of awareness that breast cancer usually presents as a lump and the priority given to not missing cancer. In the subgroup of cognitively unimpaired women referred with a lump, but who themselves deny that one is present, the patient will be correct and the GP incorrect in their assessment in 96% and 95% of patients respectively.

CONCLUSION

If a woman consults her GP with breast symptoms, but has not found a lump, it is safe for her GP not to find one either. Such patients can be reassured and reviewed after a month with a view to referral, if symptoms persist.