Current patterns of referral in breast disease

Identifying suspected breast cancer: development and validation of a clinical prediction rule

BACKGROUND

An evidence-based approach is needed to identify women with breast symptoms who are most likely to have breast cancer so that timely and appropriate referral can take place.

AIM

To report the development and validation of a clinical prediction rule for the diagnosis of breast cancer.

DESIGN AND SETTING

Cohort study with two prospective groups of women: those presenting to a symptomatic breast clinic (derivation cohort) and a separate cohort presenting to 11 general practices (validation cohort) in Tayside, Scotland.

METHOD

Regression analysis was used to derive a clinical prediction rule from presenting symptoms, personal and family history, and clinical findings. Validation consisted of estimating the number of breast cancers predicted to occur compared with the actual number of observed breast cancers across deciles of risk.

RESULTS

In the derivation cohort of 802 patients, 59 (7%) were diagnosed with breast cancer. Independent clinical predictors for breast cancer were: increasing age by year (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] = 1.07 to 1.13); presence of a discrete lump (AOR 15.20, 95% CI = 4.88 to 47.34); breast thickening (AOR 7.64, 95% CI = 2.23 to 26.11); lymphadenopathy (AOR 3.63, 95% CI = 1.33 to 9.92); and lump ≥ 2 cm (AOR 5.41, 95% CI = 2.36 to 12.38). All eight patients with skin tethering had breast cancer. The regression model had good predictive power, identifying all five breast cancers in the validation cohort of 97 patients in the top two deciles of risk.

CONCLUSION

The clinical prediction rule discriminates between patients at high risk of breast cancer from those at low risk, and can be implemented as an evidence-based recommendation to enhance appropriate referral from general practice to a symptomatic breast clinic. Ongoing validation in further populations is required.

The UK Government two-week rule and its impact on melanoma prognosis: an evidence-based study

INTRODUCTION

In order to tackle increasing waiting lists the UK Government's 'two-week rule' was introduced for a number of cancers, including melanoma, in 2000. Whilst there is evidence that secondary prevention (i. e. early diagnosis) improves patient outcome, particularly in melanoma where early surgical excision is the only intervention to improve survival, there is as yet no evidence base for a 2-week limit. Any survival benefit from this Government target will not be demonstrable until long-term follow-up is available, realistically 10-year mortality figures in 2010.

PATIENTS AND METHODS

To investigate an evidence base for the two-week rule in melanoma, we performed a retrospective study on patients with suspected skin cancers referred to a rapid access Pigmented Lesion Clinic (PLC) over a 4-year period with long-term survival data, and compared them to a historical control group.

RESULTS

A total of 4399 patients attended the PLC from January 1993 to December 1996 and all were seen within 2 weeks. Ninety-six melanomas were diagnosed during this period with 96% treated within 2 weeks of GP referral, the majority (74%) excised on the day of PLC attendance. Melanoma patients (n = 78) diagnosed in the 2 years prior to the inception of the PLC waited 3-34 days for consultation and 4-74 days for treatment. Melanoma patients diagnosed in the PLC had significantly thinner tumours (Mann Whitney test, P < 0.001) and improved overall survival (chi(2) 18.1924; P < 0.001) compared with melanoma patients diagnosed before the inception of the clinic.

CONCLUSIONS

This is, to our knowledge, the first example that consultation within a 2-week time-frame of GP referral impacts patient survival and the first evidence base behind Government guidelines for this particular cancer.

Triaging referral to a specialist breast clinic

BACKGROUND

The aim of this study was to determine the effectiveness of a triage system in predicting patients with malignancy among those referred to a specialist breast clinic.

METHODS

A retrospective study of all referrals seen at the specialist breast clinic from January 2002 to June 2002 was conducted. The triage system allocated an urgent appointment if (i) urgent referral was requested by the referring physicians or (ii) 'non-urgent referral' was made and any one of the following 'high-risk' criteria were present: aged more than 50 years when presenting with breast lump, lump larger than 3 cm, bloody nipple discharge or physical signs suggestive of malignancy. Routine appointment was given if these conditions were not met. The outcomes of individual groups were assessed.

RESULTS

Three hundred and sixty-three referrals were analysed and 44 cancers (13.2%) were diagnosed. The mean waiting time for urgent and routine appointments was 19 and 154 days, respectively. There were 108 urgent referrals and 21 (19.4%) cancers were diagnosed. Ninety-two patients were given an urgent appointment because of the presence of high-risk criteria, and 21 cancers were detected (22.8%). After the two-stage triage, breast cancer was subsequently diagnosed in only 2 out of the remaining 163 patients (1.2%) given a routine appointment.

CONCLUSION

Most of the patients with cancer (96%) were given an urgent appointment through the triage system. In addition to the assessment by referring physicians, certain high-risk criteria are helpful to select patients who should be seen urgently.

Analysis of surgical and diagnostic quality at a specialist breast unit

The quality of a specialist breast unit was analysed prospectively, comparing data from 1998, with data from 2003. The analysis is based on 5451 new referrals and 632 major breast cancer operations. The period was characterized by an increasing number of surgical specialists and improvements in diagnostic resources. There was statistically significant improvement in the following parameters: frequency of excision biopsies fell from 17.3% to 10.4%; preoperative cancer diagnosis without excision biopsy rose from 67.4% to 95.1%; percentage of women receiving breast conserving surgery rose from 24.4% to 44.7%. Cases where less than 10 lymph nodes were removed at axillary dissection fell from 5.8% to 0.5%. Severe postoperative bleeding fell from 4.1% to 0.8%, severe wound infection from 4.7% to 1.1% and severe skin necrosis from 3.7% to 0.2%. It is concluded that centralization of surgical and diagnostic expertise at a high volume institution contributes positively to the quality of care.

Impact of the '2 week wait' on referrals to breast units in the UK

Thirty six per cent of women with breast cancer were not identified as requiring an urgent clinic appointment by their general practitioner. In contrast, large numbers of women with benign disease are graded as urgent by their general practitioner. Classification of patients with breast symptoms requiring hospital referral by general practitioner does not accurately differentiate between women with benign and malignant breast disease.

Evaluation of the U.K. 2-week referral rule for skin cancer

BACKGROUND

In 1997 the U.K. government introduced the target that all patients seen in primary care, and whose general practitioner suspected a possible diagnosis of any cancer, would be seen by a specialist within 2 weeks. Several individual departmental reports suggest that this has generated a high volume of 'urgent' referrals and has been unachievable without impact on other patients.

OBJECTIVES

To determine the views of dermatologists, with audit and database information where possible, on the overall impact of the 2-week rule referral standard for suspected skin cancers.

METHODS

A questionnaire was sent to consultant dermatologists in the U.K. requesting views and numerical data.

RESULTS

There were 139 responses, some on a departmental basis, representing 272 individuals (nearly two-thirds of all consultant dermatologists in post in the U.K). Based on 52 formal audit studies or database information, the overall proportion of confirmed skin cancers among 2-week rule referrals was 12%, but only 42% of tumours were referred by this route. Correct suspicion of melanoma was generally better than that of squamous cell carcinoma. Information on standard referral proformas was only considered to be 'usually adequate' by 34% of departments. Considering all replies, only 27% of respondents felt that the 2-week rule works well; the major problems are an excess of benign lesions, the lack of opportunity to prioritize referrals and the displacement of other urgent problems.

CONCLUSIONS

There are significant problems with the perception and application of the 2-week referral standard for possible skin cancers, including a high volume of nonrelevant lesions and displacement of other urgent conditions. Increasing the specificity of referral guidelines, and increased education regarding recognition of benign lesions, are the favoured options for improvement.