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Delay in diagnosis in breast cancer
COMMENTARY
CORRESPONDENCE Delay in diagnosis in breast cancer Sir—I was fascinated by the conflicting messages about the effect of delay in presentation and diagnosis on survival in breast cancer conveyed by Michael Richards (April 3, p 1119)1 and Richard Sainsbury (April 3, p 1132) 2 and their colleagues. The latter workers’ conclusions do not sit easily with the current surgical rationale of sentinel node biopsy, and the notion of biological predeterminism is supported yet again. I presume that it would now be possible for the York data to be analysed together with the much larger ICRF data base. Would this further analysis substantially modify Richard and colleagues’ conclusions? E A Benson Leeds Cancer Centre, General Infirmary at Leeds, Leeds, West Yorkshire LS1 3EX, UK 1
Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. 2 Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35.
Sir—Michael Richards and Richard Sainsbury and their colleagues’ reports,1,2 and Alan Coates in his accompanying commentary, 3 draw attention to the importance of both patient and system delay in the presentation of breast cancer symptoms. However, the near absence of any discussion, and exclusion from the meta-analysis by A J Ramirez and colleagues (April 3, p 1127)4 of data for women whose symptoms have benign causes is, in our view, short-sighted. Patients do not know the cause of their symptoms when they begin, nor do they enter the doctor’s consulting room with a final diagnostic label attached. Of course, the group of women who turn out to have cancer will tend to have a different demographic profile from those who do not, but the overlap is substantial. We have been investigating delay in women with breast symptoms before a diagnosis has been established and have recorded that, although the distribution is highly skewed, patients’ delay in those who are diagnosed with
2154
cancer (n=87) has a median of 7 days versus 14 days in those with benign conditions (n=605), which is a nonsignificant difference (p=0·38, Wilcoxon rank sums test). System delay was less in those later diagnosed with malignant disease (median 14 days versus 18 days for the others; p<0·001). Although some women had an inkling as to their eventual diagnosis, which was sometimes correct, those who thought that they had cancer did not delay significantly less than the others. The psychological processes underlying evaluation and attribution of symptoms are a critical determinant of presentation speed and hence prognosis, according to Richards and colleagues, and will only be fully understood when all women with breast-related symptoms are studied. Chiara Nosarti, Tim Crayford, Jonathan Roberts, Kwame McKenzie, *Anthony David GKT School of Medicine, and King’s College Hospital, London, Denmark Hill, London SE5 8AZ, UK 1
Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. 2 Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35. 3 Coates AS. Breast cancer: delays, dilemmas, and delusions. Lancet 1999; 353: 1112–13. 4 Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richard MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 1999; 353: 1127–31.
Sir—R Sainsbury and colleagues 1 have shown that delays by providers of 3 months or more does not affect outcome for breast cancer patients. They suggest that the drive to see patients with suspected breast cancer within 14 days will divert resources from other services. We have undertaken a prospective audit of general practitioner (GP) referrals to our specialist breast clinic. Over 3 months we reviewed GP referral letters and recorded the following: urgency of referral as designated by GP, waiting time to clinic
appointment, presenting symptom, and final diagnosis. We also applied NHS guidelines for referral of patients with breast problems2 to these referral letters before seeing the patient. 321 patients attended 14 clinics over the study period. 35% (111 patients) were referred urgently, 62% (72) of urgent referrals were seen within 5 working days of referral, and 55% (115) of non-urgent referrals were seen within 15 working days. 19% (21) of urgent referrals had a final diagnosis of cancer but 81% (90) had a benign diagnosis. 5% (10) of non-urgent referrals had a final diagnosis of breast cancer. 28% (31) of urgent referrals and 37% (78) of non-urgent referrals did not meet the NHS criteria for referral to a specialist breast clinic. Rigorous application of NHS guidelines to these referrals would not have excluded any patients with breast cancer. A recent proliferation of clinical guidelines and political targets have suggested variously that patients referred urgently to specialist breast clinics must be seen within 5 working days (BASO3 and SIGN4 guidelines), or within 14 days (recent government target). These guidelines fail to acknowledge that greater public awareness of and media attention to breast cancer has resulted in increasing demand for access to specialist breast clinics, without a corresponding increase in provision of these services. One-stop breast clinics were initially designed to offer rapid diagnosis for patients with malignant disease but are becoming victims of their own success as large numbers of worried well women demand access to these clinics and expect the same level of service as patients at high risk of malignant disease. Our figures show that more than a quarter of urgent referrals and more than a third of non-urgent referrals to breast clinics are unnecessary. It would be more appropriate to enforce existing guidelines for referral of patients to breast clinics, rather than to insist on arbitrary periods within which patients must be seen. *Rajan Patel, David Smith, Iona Reid Victoria Infirmary, Glasgow G42 9TY, UK
THE LANCET • Vol 353 • June 19, 1999
CORRESPONDENCE Delay in diagnosis in breast cancer Sir—I was fascinated by the conflicting messages about the effect of delay in presentation and diagnosis on survival in breast cancer conveyed by Michael Richards (April 3, p 1119)1 and Richard Sainsbury (April 3, p 1132) 2 and their colleagues. The latter workers’ conclusions do not sit easily with the current surgical rationale of sentinel node biopsy, and the notion of biological predeterminism is supported yet again. I presume that it would now be possible for the York data to be analysed together with the much larger ICRF data base. Would this further analysis substantially modify Richard and colleagues’ conclusions? E A Benson Leeds Cancer Centre, General Infirmary at Leeds, Leeds, West Yorkshire LS1 3EX, UK 1
Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. 2 Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35.
Sir—Michael Richards and Richard Sainsbury and their colleagues’ reports,1,2 and Alan Coates in his accompanying commentary, 3 draw attention to the importance of both patient and system delay in the presentation of breast cancer symptoms. However, the near absence of any discussion, and exclusion from the meta-analysis by A J Ramirez and colleagues (April 3, p 1127)4 of data for women whose symptoms have benign causes is, in our view, short-sighted. Patients do not know the cause of their symptoms when they begin, nor do they enter the doctor’s consulting room with a final diagnostic label attached. Of course, the group of women who turn out to have cancer will tend to have a different demographic profile from those who do not, but the overlap is substantial. We have been investigating delay in women with breast symptoms before a diagnosis has been established and have recorded that, although the distribution is highly skewed, patients’ delay in those who are diagnosed with
2154
cancer (n=87) has a median of 7 days versus 14 days in those with benign conditions (n=605), which is a nonsignificant difference (p=0·38, Wilcoxon rank sums test). System delay was less in those later diagnosed with malignant disease (median 14 days versus 18 days for the others; p<0·001). Although some women had an inkling as to their eventual diagnosis, which was sometimes correct, those who thought that they had cancer did not delay significantly less than the others. The psychological processes underlying evaluation and attribution of symptoms are a critical determinant of presentation speed and hence prognosis, according to Richards and colleagues, and will only be fully understood when all women with breast-related symptoms are studied. Chiara Nosarti, Tim Crayford, Jonathan Roberts, Kwame McKenzie, *Anthony David GKT School of Medicine, and King’s College Hospital, London, Denmark Hill, London SE5 8AZ, UK 1
Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. 2 Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35. 3 Coates AS. Breast cancer: delays, dilemmas, and delusions. Lancet 1999; 353: 1112–13. 4 Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richard MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 1999; 353: 1127–31.
Sir—R Sainsbury and colleagues 1 have shown that delays by providers of 3 months or more does not affect outcome for breast cancer patients. They suggest that the drive to see patients with suspected breast cancer within 14 days will divert resources from other services. We have undertaken a prospective audit of general practitioner (GP) referrals to our specialist breast clinic. Over 3 months we reviewed GP referral letters and recorded the following: urgency of referral as designated by GP, waiting time to clinic
appointment, presenting symptom, and final diagnosis. We also applied NHS guidelines for referral of patients with breast problems2 to these referral letters before seeing the patient. 321 patients attended 14 clinics over the study period. 35% (111 patients) were referred urgently, 62% (72) of urgent referrals were seen within 5 working days of referral, and 55% (115) of non-urgent referrals were seen within 15 working days. 19% (21) of urgent referrals had a final diagnosis of cancer but 81% (90) had a benign diagnosis. 5% (10) of non-urgent referrals had a final diagnosis of breast cancer. 28% (31) of urgent referrals and 37% (78) of non-urgent referrals did not meet the NHS criteria for referral to a specialist breast clinic. Rigorous application of NHS guidelines to these referrals would not have excluded any patients with breast cancer. A recent proliferation of clinical guidelines and political targets have suggested variously that patients referred urgently to specialist breast clinics must be seen within 5 working days (BASO3 and SIGN4 guidelines), or within 14 days (recent government target). These guidelines fail to acknowledge that greater public awareness of and media attention to breast cancer has resulted in increasing demand for access to specialist breast clinics, without a corresponding increase in provision of these services. One-stop breast clinics were initially designed to offer rapid diagnosis for patients with malignant disease but are becoming victims of their own success as large numbers of worried well women demand access to these clinics and expect the same level of service as patients at high risk of malignant disease. Our figures show that more than a quarter of urgent referrals and more than a third of non-urgent referrals to breast clinics are unnecessary. It would be more appropriate to enforce existing guidelines for referral of patients to breast clinics, rather than to insist on arbitrary periods within which patients must be seen. *Rajan Patel, David Smith, Iona Reid Victoria Infirmary, Glasgow G42 9TY, UK
THE LANCET • Vol 353 • June 19, 1999