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A simple tool for rapid access to a symptomatic breast clinic
EJSO (2004) 30, 248–251
www.ejso.com
A simple tool for rapid access to a symptomatic breast clinic C. Campbella,b,*, P. Durningb, I. Cheemab, G. Naisbyb a
School of Social Sciences and Law, University of Teesside, Borough Road, Middlesbrough TS1 3BA, UK James Cook University Hospital, Middlesbrough, UK
b
Accepted for publication 13 November 2003
KEYWORDS Breast cancer; Decision making; Referral; Primary care
Summary Aim. The introduction of a rapid referral system has led to an increase in the number of patients with benign disease using clinic appointments. This situation could delay those patients, who do have cancer but are not referred within these rapid referral guidelines. Existing guidelines fail to benefit those patients with lower risk symptoms. We reviewed prospective audit data from patients referred to a symptomatic breast unit with the aim of introducing a referral schema based upon symptoms, age and relative risk of cancer. Method. Demographic details, mode of referral, history and presenting symptoms were collected from each of the 2064 patients referred to the James Cook University Hospital (JCUH) breast unit from April 2001 to March 2002. Results. Odds Ratios (OR) from eight dependent variables gave a 30% improvement in prediction accuracy of breast cancer. From these findings a breast referral schema is presented that is designed to expedite referral from primary care of those patients most at risk. Conclusions. Use of the schema within primary care could lead to an increase in the early referral of patients with breast cancer. Q 2004 Elsevier Ltd. All rights reserved.
Introduction Within the United Kingdom, individuals presenting in primary care with breast symptoms can be referred to a symptomatic breast clinic and expect to be seen within this clinic, within two weeks of referral.1 Rapid access to symptomatic breast clinics is to be welcomed.2 Such a referral system is, nevertheless, open to misuse. The incidence of breast cancer amongst symptomatic patients presenting to a breast clinic is approximately 7%.3 The relative risk of cancer within symptom groups of patients referred to a *Corresponding author. Tel.: þ 44-1642-342385. E-mail address: [email protected]
symptomatic clinic is predictable.4 The incidence of breast cancer in the group of patients referred within this two week window may be higher.5 Despite an increase in the number of patients being diagnosed with breast cancer, many patients referred within the two weeks are found to have benign disorders. Large numbers of patients referred inappropriately may compromise those patients with cancer but who are not referred within the rapid referral guidelines. Most patients who present to primary care practitioners are naturally anxious, but anxiety alone should not be an indication for referral. The fast track referral to a breast clinic of a patient who does not have cancer can also have adverse effects due to a further heightening of anxiety6 and related distress.7
0748-7983/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2003.11.010
A simple tool for rapid access to a symptomatic breast clinic
One possible reason for these referral patterns is that existing guidelines fail to recognise those patients with lower risk symptoms.8 Several factors/presenting symptoms have been identified but are often viewed independently of each other. Models that highlight the predictive values of symptoms need to assist in the referral process from primary care. Here we present the findings from our symptomatic breast unit prospective audit data, based on the widely accepted opinion based guidelines of the British Association of Surgical Oncology (BASO), with the aim of introducing a referral schema incorporating symptoms, age and relative risk for cancer.
Method Data were collected prospectively from each patient referred to the JCUH breast clinic from April 2001 to March 2002. There were 2064 consecutive patients. Based on the BASO guidelines9 audit data describing demographic details; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer (peau d’orange, dimpling, deformity and ulceration); HRT use and family history (high risk being low age; multiple first degree relatives with breast cancer; and first degree relatives with bilateral cancer) were collated.
Demographics The mean age of the entire sample was 45.5 years (range 9 –95 years). From this sample 323 individuals presented with a breast lump and 565 with breast lumpiness. Four hundred patients reported breast pain, 75 reported nipple discharge and 53 individuals reported a previous diagnosis of breast cancer. The majority ðn ¼ 1810Þ were not using HRT. In relation to family history, 174 patients reported that their mother had been diagnosed with breast cancer, 93 patients reported a sister with breast cancer. One hundred and forty-one patients were diagnosed with cancer. Four hundred and five patients were referred within 2 weeks. There were 62 cancers within this group, more than double the incidence seen within the sample of patients referred in the usual way.
(age; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer; HRT use and family history) were able to predict breast cancer morbidity, multivariate analyses using logistic regression models were performed. OR were calculated in addition to 95% confidence Intervals (CI).
Results Multiple logistic regression analyses were used to determine the ability of the eight independent variables to predict breast cancer morbidity. These were age; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer; HRT use and family history. The diagnosis of cancer was the dependent variable. These eight predictor variables gave a 30% improvement in prediction accuracy of breast cancer. The patients with a breast lump were significantly more likely to have breast cancer than patients without a lump (OR ¼ 5.0765, CI ¼ [3.06662 –8.4047], p , 0:001). The likelihood of cancer increased with age (OR ¼ 1.0808, CI ¼ [1.0712 – 1.0906], p , 0:001). Pain was least likely to indicate the presence of breast cancer (OR ¼ 0.1351, CI ¼ [0.0664 – 0.2749], p , 0:001), as was breast lumpiness (OR ¼ 0.3192, CI ¼ [0.1718 – 0.5930], p , 0:003), nipple discharge (OR ¼ 0.5337, CI ¼ [0.1821 – 1.5647], p . 0:05) HRT use (OR ¼ 0.6995, CI ¼ [0.4431 – 1.1042, p . 0:05) and signs of cancer (OR ¼ 0.6842, CI ¼ [0.4156 – 1.1265], p . 0:05). Family history was not statistically significant within our model. The data related to breast lump, breast pain and breast lumpiness are represented graphically in Figs. 1 – 3, respectively.
Statistical analysis The data were analysed using the Statistical Package for Social Scientists version 9.0. In order to determine, whether any of the single variables
249
Figure 1 Presenting symptoms of breast lump.
250
C. Campbell et al.
Figure 2 Presenting symptoms of breast pain.
Increasing age and the presence of a discrete lump are thus significant discriminatory predictors of breast cancer. We have thus produced a simple schema (Fig. 4) to aid the referral of patients from primary care to a symptomatic breast unit. This schema could be used to calculate the probability of breast cancer within prospective patients using a computer-based spreadsheet using the OR.
Discussion Our previous findings5 have highlighted that the rapid referral system gives a pick-up rate for cancers within a 6-month period on an average of 8%. Since then the overall incidence of breast cancer within this clinic has fallen to 6.8%. Within the population referred within 2 weeks, the annual incidence of breast cancer across the last 3 years was 20, 16.7 and 15.3%, respectively. These data indicate that the introduction of this referral system has improved the detection of patients presenting to the clinic within a 2-week window with breast cancer. These data indicate the efficacy of a rapid referral system, but there remains a substantial number of patients whom are referred within this
Figure 3 Presenting symptoms of breast lumpiness.
2-week time period who do not have cancer but are referred because of their greater anxiety. These patients use clinic appointments that could be available for those patients who are at greater risk of breast cancer. Open access to symptomatic breast clinics may be a better method to both improve outcomes and reduce anxiety, but the provision of evidence based patient information leads to better-informed patients and improves patient co-operation, whilst reducing demand for clinic slots. This may be a better way to allay anxiety, as the inappropriate referral to a symptomatic breast clinic may be counterproductive. The referral schema produced from the audit data presented here could easily be used in primary care to prioritise those patients most at risk. The schema provides a rapid and convenient method to determine relative risk. It can easily be adapted to paper and electronic communication. A computer-based spreadsheet with these regression coefficients calculates the probability of any presenting patient having breast cancer. The ratio of patients referred with a cancer should thus improve, with more individuals being seen appropriately within twoweeks. This referral strategy should lead to less psychological sequelae among referred patients.10
Figure 4 Breast referral schema that can be used in paper, electronic and computer-based spreadsheet formats. Odds ratios are shown within each column.
A simple tool for rapid access to a symptomatic breast clinic
We need to know whether primary care practitioners will use this method to improve referrals. The aim is to provide an accessible and evidence-based tool that balances their patients’ needs with the principles of this rapid referral system. Use of the schema within primary care should lead to greater numbers of patients with breast cancer being seen early within symptomatic breast units and impact on related mortality should be significant. This model now needs to be tested.
References 1. McPherson K, Steel CM, Dixon JM. ABC of breast diseases: breast cancer—epidemiology, risk factors and genetics. BMJ 2000;321:624—628. 2. Sauven P. Specialists, not GPs may be best qualified to assess urgency. BMJ 2001;323:864. 3. Cochrane RA, Singhal H, Monypenny IJ, Webster DJ, Lyons K, Mansel RE. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. Eur J Surg Oncol 1997;23:198—201.
251
4. Gui GP, Allum WH, Perry NM, Wells CA, Curling OM, McLean A, Oommen R, Sullivan M, Denton S, Carpenter R. Clinical audit of a specialist symptomatic breast clinic. J R Soc Med 1995;88:330—333. 5. Durning P, Clason A, Akthar Y, Barber T, McIlvenny C, Woods M. Women need to be educated about the risks of breast cancer. BMJ 2000;321:236—237. 6. Durning P, Morris E, Gash A, Gray J. An assessment of anxiety levels of women attending for the first outpatient appointment for breast care. Eur J Cancer 1998;34(S5): S124. 7. Nosarti C, Roberts JV, Crayford T, McKenzie K, David AS. Early psychological adjustment in breast cancer patients: a prospective study. J Psychosom Res 2002;53:1123—1130. 8. Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ 2001;322:1555—1556. 9. The Breast Surgeons Group of the British Association of Surgical Oncology, Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom. London: BASO, 1995. 10. Fallowfield LJ, Rodway A, Baum M. What are the psychological factors influencing attendance, non-attendance and re-attendance at a breast screening centre? J R Soc Med 1990;83:547—551.
www.ejso.com
A simple tool for rapid access to a symptomatic breast clinic C. Campbella,b,*, P. Durningb, I. Cheemab, G. Naisbyb a
School of Social Sciences and Law, University of Teesside, Borough Road, Middlesbrough TS1 3BA, UK James Cook University Hospital, Middlesbrough, UK
b
Accepted for publication 13 November 2003
KEYWORDS Breast cancer; Decision making; Referral; Primary care
Summary Aim. The introduction of a rapid referral system has led to an increase in the number of patients with benign disease using clinic appointments. This situation could delay those patients, who do have cancer but are not referred within these rapid referral guidelines. Existing guidelines fail to benefit those patients with lower risk symptoms. We reviewed prospective audit data from patients referred to a symptomatic breast unit with the aim of introducing a referral schema based upon symptoms, age and relative risk of cancer. Method. Demographic details, mode of referral, history and presenting symptoms were collected from each of the 2064 patients referred to the James Cook University Hospital (JCUH) breast unit from April 2001 to March 2002. Results. Odds Ratios (OR) from eight dependent variables gave a 30% improvement in prediction accuracy of breast cancer. From these findings a breast referral schema is presented that is designed to expedite referral from primary care of those patients most at risk. Conclusions. Use of the schema within primary care could lead to an increase in the early referral of patients with breast cancer. Q 2004 Elsevier Ltd. All rights reserved.
Introduction Within the United Kingdom, individuals presenting in primary care with breast symptoms can be referred to a symptomatic breast clinic and expect to be seen within this clinic, within two weeks of referral.1 Rapid access to symptomatic breast clinics is to be welcomed.2 Such a referral system is, nevertheless, open to misuse. The incidence of breast cancer amongst symptomatic patients presenting to a breast clinic is approximately 7%.3 The relative risk of cancer within symptom groups of patients referred to a *Corresponding author. Tel.: þ 44-1642-342385. E-mail address: [email protected]
symptomatic clinic is predictable.4 The incidence of breast cancer in the group of patients referred within this two week window may be higher.5 Despite an increase in the number of patients being diagnosed with breast cancer, many patients referred within the two weeks are found to have benign disorders. Large numbers of patients referred inappropriately may compromise those patients with cancer but who are not referred within the rapid referral guidelines. Most patients who present to primary care practitioners are naturally anxious, but anxiety alone should not be an indication for referral. The fast track referral to a breast clinic of a patient who does not have cancer can also have adverse effects due to a further heightening of anxiety6 and related distress.7
0748-7983/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2003.11.010
A simple tool for rapid access to a symptomatic breast clinic
One possible reason for these referral patterns is that existing guidelines fail to recognise those patients with lower risk symptoms.8 Several factors/presenting symptoms have been identified but are often viewed independently of each other. Models that highlight the predictive values of symptoms need to assist in the referral process from primary care. Here we present the findings from our symptomatic breast unit prospective audit data, based on the widely accepted opinion based guidelines of the British Association of Surgical Oncology (BASO), with the aim of introducing a referral schema incorporating symptoms, age and relative risk for cancer.
Method Data were collected prospectively from each patient referred to the JCUH breast clinic from April 2001 to March 2002. There were 2064 consecutive patients. Based on the BASO guidelines9 audit data describing demographic details; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer (peau d’orange, dimpling, deformity and ulceration); HRT use and family history (high risk being low age; multiple first degree relatives with breast cancer; and first degree relatives with bilateral cancer) were collated.
Demographics The mean age of the entire sample was 45.5 years (range 9 –95 years). From this sample 323 individuals presented with a breast lump and 565 with breast lumpiness. Four hundred patients reported breast pain, 75 reported nipple discharge and 53 individuals reported a previous diagnosis of breast cancer. The majority ðn ¼ 1810Þ were not using HRT. In relation to family history, 174 patients reported that their mother had been diagnosed with breast cancer, 93 patients reported a sister with breast cancer. One hundred and forty-one patients were diagnosed with cancer. Four hundred and five patients were referred within 2 weeks. There were 62 cancers within this group, more than double the incidence seen within the sample of patients referred in the usual way.
(age; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer; HRT use and family history) were able to predict breast cancer morbidity, multivariate analyses using logistic regression models were performed. OR were calculated in addition to 95% confidence Intervals (CI).
Results Multiple logistic regression analyses were used to determine the ability of the eight independent variables to predict breast cancer morbidity. These were age; presenting symptoms of lump, lumpiness, pain, and nipple discharge; signs of cancer; HRT use and family history. The diagnosis of cancer was the dependent variable. These eight predictor variables gave a 30% improvement in prediction accuracy of breast cancer. The patients with a breast lump were significantly more likely to have breast cancer than patients without a lump (OR ¼ 5.0765, CI ¼ [3.06662 –8.4047], p , 0:001). The likelihood of cancer increased with age (OR ¼ 1.0808, CI ¼ [1.0712 – 1.0906], p , 0:001). Pain was least likely to indicate the presence of breast cancer (OR ¼ 0.1351, CI ¼ [0.0664 – 0.2749], p , 0:001), as was breast lumpiness (OR ¼ 0.3192, CI ¼ [0.1718 – 0.5930], p , 0:003), nipple discharge (OR ¼ 0.5337, CI ¼ [0.1821 – 1.5647], p . 0:05) HRT use (OR ¼ 0.6995, CI ¼ [0.4431 – 1.1042, p . 0:05) and signs of cancer (OR ¼ 0.6842, CI ¼ [0.4156 – 1.1265], p . 0:05). Family history was not statistically significant within our model. The data related to breast lump, breast pain and breast lumpiness are represented graphically in Figs. 1 – 3, respectively.
Statistical analysis The data were analysed using the Statistical Package for Social Scientists version 9.0. In order to determine, whether any of the single variables
249
Figure 1 Presenting symptoms of breast lump.
250
C. Campbell et al.
Figure 2 Presenting symptoms of breast pain.
Increasing age and the presence of a discrete lump are thus significant discriminatory predictors of breast cancer. We have thus produced a simple schema (Fig. 4) to aid the referral of patients from primary care to a symptomatic breast unit. This schema could be used to calculate the probability of breast cancer within prospective patients using a computer-based spreadsheet using the OR.
Discussion Our previous findings5 have highlighted that the rapid referral system gives a pick-up rate for cancers within a 6-month period on an average of 8%. Since then the overall incidence of breast cancer within this clinic has fallen to 6.8%. Within the population referred within 2 weeks, the annual incidence of breast cancer across the last 3 years was 20, 16.7 and 15.3%, respectively. These data indicate that the introduction of this referral system has improved the detection of patients presenting to the clinic within a 2-week window with breast cancer. These data indicate the efficacy of a rapid referral system, but there remains a substantial number of patients whom are referred within this
Figure 3 Presenting symptoms of breast lumpiness.
2-week time period who do not have cancer but are referred because of their greater anxiety. These patients use clinic appointments that could be available for those patients who are at greater risk of breast cancer. Open access to symptomatic breast clinics may be a better method to both improve outcomes and reduce anxiety, but the provision of evidence based patient information leads to better-informed patients and improves patient co-operation, whilst reducing demand for clinic slots. This may be a better way to allay anxiety, as the inappropriate referral to a symptomatic breast clinic may be counterproductive. The referral schema produced from the audit data presented here could easily be used in primary care to prioritise those patients most at risk. The schema provides a rapid and convenient method to determine relative risk. It can easily be adapted to paper and electronic communication. A computer-based spreadsheet with these regression coefficients calculates the probability of any presenting patient having breast cancer. The ratio of patients referred with a cancer should thus improve, with more individuals being seen appropriately within twoweeks. This referral strategy should lead to less psychological sequelae among referred patients.10
Figure 4 Breast referral schema that can be used in paper, electronic and computer-based spreadsheet formats. Odds ratios are shown within each column.
A simple tool for rapid access to a symptomatic breast clinic
We need to know whether primary care practitioners will use this method to improve referrals. The aim is to provide an accessible and evidence-based tool that balances their patients’ needs with the principles of this rapid referral system. Use of the schema within primary care should lead to greater numbers of patients with breast cancer being seen early within symptomatic breast units and impact on related mortality should be significant. This model now needs to be tested.
References 1. McPherson K, Steel CM, Dixon JM. ABC of breast diseases: breast cancer—epidemiology, risk factors and genetics. BMJ 2000;321:624—628. 2. Sauven P. Specialists, not GPs may be best qualified to assess urgency. BMJ 2001;323:864. 3. Cochrane RA, Singhal H, Monypenny IJ, Webster DJ, Lyons K, Mansel RE. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. Eur J Surg Oncol 1997;23:198—201.
251
4. Gui GP, Allum WH, Perry NM, Wells CA, Curling OM, McLean A, Oommen R, Sullivan M, Denton S, Carpenter R. Clinical audit of a specialist symptomatic breast clinic. J R Soc Med 1995;88:330—333. 5. Durning P, Clason A, Akthar Y, Barber T, McIlvenny C, Woods M. Women need to be educated about the risks of breast cancer. BMJ 2000;321:236—237. 6. Durning P, Morris E, Gash A, Gray J. An assessment of anxiety levels of women attending for the first outpatient appointment for breast care. Eur J Cancer 1998;34(S5): S124. 7. Nosarti C, Roberts JV, Crayford T, McKenzie K, David AS. Early psychological adjustment in breast cancer patients: a prospective study. J Psychosom Res 2002;53:1123—1130. 8. Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ 2001;322:1555—1556. 9. The Breast Surgeons Group of the British Association of Surgical Oncology, Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom. London: BASO, 1995. 10. Fallowfield LJ, Rodway A, Baum M. What are the psychological factors influencing attendance, non-attendance and re-attendance at a breast screening centre? J R Soc Med 1990;83:547—551.