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Image-detected ‘probably benign’ breast lesions: A significant reason for referral from primary care
ARTICLE IN PRESS The Breast (2006) 15, 683–686
THE BREAST www.elsevier.com/locate/breast
SHORT REPORT
Image-detected ‘probably benign’ breast lesions: A significant reason for referral from primary care M.E. Brennana,, N. Houssamia,b a
NSW Breast Cancer Institute, Westmead Hospital, PO Box 143, Westmead NSW 2145, Sydney, Australia Screening and Test Evaluation Program, School of Public Health, The University of Sydney, Australia
b
Received 2 September 2005; received in revised form 10 November 2005; accepted 8 December 2005
KEYWORDS Benign breast disease; Imaging; Diagnosis; Primary care
Summary In Australia, and many health care provider systems, primary care physicians are the first to see women with breast symptoms and are responsible for making decisions on whether to investigate and when to refer to specialist teams. We present an audit of new patient referrals from primary care triaged to a ‘lowrisk’ (low likelihood of cancer) clinic on the basis of benign findings. The most common reason for referral was ‘breast lump’ (38%) followed by ‘image-detected’ abnormality (26%.) We have identified that (outside of population screening services) many women are being referred from primary care to specialist clinics for management of screen-detected lesions considered benign on imaging. Further research is needed to identify the reasons for such referrals and to develop appropriate educational strategies and clinical policy, both for the primary care and the specialist breast practitioner. & 2005 Elsevier Ltd. All rights reserved.
Introduction As the ‘gate keepers’ of the health care system in many parts of the world, such as Australia and North America, primary care (family) physicians or general practitioners (GPs) are the first to see women with breast symptoms. They must decide which patients they will refer for investigation and at what point during investigation and treatment Corresponding author. Tel.: +61 2 9845 6728;
fax: +61 2 9845 7246. E-mail address: [email protected] (M.E. Brennan).
they will refer to specialists. Whereas GPs refer patients whose initial assessment suggests possible breast cancer to specialists, little is known about the management of women with benign findings in the primary care setting. The experience of clinicians working in multidisciplinary breast centres suggests that many patients are also referred when their symptoms and clinical and imaging findings show that malignancy is unlikely. The study centre, a multidisciplinary breast service, has established a ‘low-risk’ breast clinic which supports GPs in the management of women with breast problems that are not considered to be
0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2005.12.002
ARTICLE IN PRESS 684 suspicious (‘probably benign’). The referring doctor performs the initial assessment, which includes clinical breast examination and any other tests deemed necessary by the referring physician (these may include mammography, ultrasound, and sometimes percutaneous needle biopsy). If the responsible (referring) doctor wants to refer for specialist management despite non-suspicious findings on initial investigations, a referral letter along with the report of any tests performed is forwarded by facsimile to the study centre. The information is processed by administrative staff in consultation with a medical officer and the patient is triaged to the appropriate clinic within the centre. This study explores the reasons why patients are referred to a specialised breast clinic despite the ‘low-risk’ findings, and describes the outcomes following assessment. Understanding these referrals may help to target education programs for GPs (and other health professionals) and patients and to better support GPs in dealing with the spectrum of non-malignant breast disease. It may also assist in focusing the resources of specialised breast units to the management of malignant disease and benign breast conditions requiring surgery by reducing referrals for other conditions.
Materials and methods Two hundred and ten consecutive new patient referrals to the low-risk clinic were identified from the clinic database. This represented all new referrals to the clinic over a period of 15 months from July 2003. The medical records were reviewed by one of the authors (MB) and data were collected to include patient demographics, the classification of the referring doctor (GP or specialist), the main reason for referral, the assessment diagnosis, and the outcome following the first consultation (followup or management recommendations.) Clinical information was determined by reviewing the referral letter, the standardised breast assessment form completed by the consulting doctor for every new patient (available from authors), the progress notes, and the results of any investigations performed. The data were analysed to determine the number and percentage of the total in each category.
Results Of the 210 patients in the study, all but 1 were women and 95% were referred by GPs. Eighty per cent of the referrals from specialists were from a
M.E. Brennan, N. Houssami clinical geneticist in an affiliated familial cancer clinic. The patients ranged in age from 12 to 87 years with an average age of 42. The most common reasons for referral, final diagnoses and management/follow-up recommendations are shown in Table 1. Almost all patients had benign findings, with only three patients (1.4%) being found to have a malignancy. All three patients found to have breast cancer on our assessment were symptomatic. They were aged 43, 60 and 69 years. Two women presented with a lump, and the third presented with lumpy breasts and was found to have a dominant area of clinical thickening on examination. All of these patients had false negative breast imaging in the 6 months prior to presentation. In one patient, mammography had been performed, in one ultrasound had been performed and the third patient had both forms of imaging. In all of these cases repeat breast imaging at presentation showed suspicious or malignant findings. Histopathology following excision showed high grade ductal carcinoma in situ in one case and invasive ductal carcinoma in the other two cases, one of which had a single metastatic lymph node in the axilla.
Discussion The main reason for referral was breast lump. This is a common and appropriate reason for referral, and it implies that GPs are aware that the ‘triple test’1 is required to assess women with breast problems even if imaging does not indicate a suspicious finding. Other symptoms that prompted referrals include mastalgia, nodularity and nipple symptoms. Our data also show that only about a third of subjects were found to have a definite palpable abnormality on examination at the study centre (either a benign or malignant lesion or an area of focal nodularity). GPs are therefore largely referring women with symptoms, but not necessarily referring according to whether a palpable finding is present on clinical assessment. Even in the subgroup of subjects who were referred for assessment of a ‘breast lump’ only 68% were considered to have a definite palpable lesion. This is an important issue to explore further in qualitative studies to understand whether GPs referred the subjects because they considered the symptoms significant enough (regardless of clinical examination), whether they were uncertain regarding the findings of clinical examination, or whether other patient-related factors influenced the decision to refer.
ARTICLE IN PRESS Image-detected ‘probably benign’ breast lesions
685
Table 1 Reasons for referral, final diagnoses and management recommendations in consecutive women referred to a low-risk (probably benign) clinic (N ¼ 210). Reason for referral
Number (%)
Breast lump
79 (37.6)
Incidental imaging abnormality Mastalgia
54 (25.7)
Impalpable benign imaging abnormality No abnormality
Lumpy breasts or focal nodularity Nipple discharge or nipple change
20 (9.6) 10 (4.8)
Palpable benign lesion Localised nodularity Other
High risk of cancer/strong family history Other
10 (4.8)
Malignant lesion
Total
29 (13.7)
Final diagnosis
Number (%) 86 (41.0)
50 (23.8) 48 (22.8)
3 (1.4)
18 (8.6) 5 (2.4)
8 (3.8)
210 (100)
Total
The second most common reason for referral was the presence of an image-detected abnormality as an incidental finding on breast imaging (‘screendetected’) and unrelated to the clinical findings or symptom.2 Our data show that a significant proportion (about 26%) of women was referred primarily because of a benign image-detected finding. This raises an issue which has not been previously identified in published work: outside the context of screening services, a substantial number of women are being referred from primary care to specialist breast clinics for management of benign image or screen-detected lesions. This not only indicates an area of need for GP support but warrants further research to ascertain the underlying reasons for these referrals. While this may be related to primary care physician knowledge, other factors may also contribute. For example ambiguous or inconclusive imaging reports or patient anxiety caused by an imaging abnormality may also prompt referral. As this was an exploratory study, our audit did not identify whether these imagedetected lesions were detected with mammography or sonography or both, but it is possible that these are largely sonographically detected lesions related to the increasing role of ultrasound in breast diagnosis.3,4 The most common management recommendations following the first consultation were early clinical and/or imaging review and percutaneous biopsy with only 12% able to be discharged following the first visit. A large proportion of
210 (100)
Management
Number (%)
Early clinical and/ or imaging review (0–6 months) Percutaneous biopsy Discharged/ no follow-up required Imaging work-up
71 (33.8)
Recommended for surgical opinion or surgery Clinical and/or imaging review 12+ months Clinical and/or imaging review 7–11 months
14 (6.7)
Total
64 (30.5) 26 (12.4) 21 (10.0)
10 (4.7)
4 (1.9)
210 (100)
patients therefore required further work-up or monitoring. It is unclear from this early study how the incidental imaging lesions are being managed in the study centre following referral. It is likely that some clinicians are recommending needle biopsy (with a plan to dismiss should a benign result be obtained) while others are recommending imaging surveillance of the lesion instead. Such variations in practice have been described in the management of screen-detected probably benign findings.5
Conclusion This study has explored the reasons why patients are being referred to a specialist breast centre despite clinical and imaging findings that indicate a low probability of malignancy. Concern about the presence of a breast lump was, not unexpectedly, the main reason for referral. However, we have identified the second most common reason for referral as an image-detected (incidental) benign abnormality. The reasons prompting such referrals are unclear and warrant further evaluation, and would be relevant to health systems where GPs (family physicians) have primary responsibility for investigating women with breast symptoms. Factors that may contribute include uncertainty on the part of the referring doctor as to how these lesions should be managed, unclear or non-definitive radiology reports, patient anxiety, and potential
ARTICLE IN PRESS 686 medicolegal concerns (delays in breast cancer diagnosis are a major reason for medicolegal action in Australia and North America). While much has been written about screen-detected lesions (both cancers and false positives) in the breast cancer screening setting there is very little documentation of the prevalence and impact of image-detected ‘probably benign’ lesions outside of the population screening setting. There is also little to no information on the quality of breast imaging reporting in the diagnostic setting. The cost of work-up of these incidental lesions, including specialist referral, opportunity cost and psychological impact are areas that require further research. This work also highlights the need for evidence-based protocols, both for primary care and in dedicated breast services, to assist in the management of benign (or probably benign) imaging lesions identified incidentally in the course of breast diagnosis.
M.E. Brennan, N. Houssami
Acknowledgement The NSW Breast Cancer Institute receives funding from the NSW Department of Health.
References 1. Irwig L, Macaskill P, Houssami N. Evidence relevant to the investigation of breast symptoms: the triple test. Breast 2002;11:215–20. 2. http://www.bci.org.au/medical/leura%5Fabstracts2000/ abstracts21to25.htm 3. Houssami N, Brennan M, French J, et al. Breast imaging in general practice. Aust Fam Phys 2005;34:467–73. 4. Irwig L, Houssami N, van Vliet C. New technologies in screening for breast cancer: a systematic review of their accuracy. Br J Cancer 2004;90:2118–22. 5. Sickles EA. Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up protocol? Radiology 1999;213:11–4.
THE BREAST www.elsevier.com/locate/breast
SHORT REPORT
Image-detected ‘probably benign’ breast lesions: A significant reason for referral from primary care M.E. Brennana,, N. Houssamia,b a
NSW Breast Cancer Institute, Westmead Hospital, PO Box 143, Westmead NSW 2145, Sydney, Australia Screening and Test Evaluation Program, School of Public Health, The University of Sydney, Australia
b
Received 2 September 2005; received in revised form 10 November 2005; accepted 8 December 2005
KEYWORDS Benign breast disease; Imaging; Diagnosis; Primary care
Summary In Australia, and many health care provider systems, primary care physicians are the first to see women with breast symptoms and are responsible for making decisions on whether to investigate and when to refer to specialist teams. We present an audit of new patient referrals from primary care triaged to a ‘lowrisk’ (low likelihood of cancer) clinic on the basis of benign findings. The most common reason for referral was ‘breast lump’ (38%) followed by ‘image-detected’ abnormality (26%.) We have identified that (outside of population screening services) many women are being referred from primary care to specialist clinics for management of screen-detected lesions considered benign on imaging. Further research is needed to identify the reasons for such referrals and to develop appropriate educational strategies and clinical policy, both for the primary care and the specialist breast practitioner. & 2005 Elsevier Ltd. All rights reserved.
Introduction As the ‘gate keepers’ of the health care system in many parts of the world, such as Australia and North America, primary care (family) physicians or general practitioners (GPs) are the first to see women with breast symptoms. They must decide which patients they will refer for investigation and at what point during investigation and treatment Corresponding author. Tel.: +61 2 9845 6728;
fax: +61 2 9845 7246. E-mail address: [email protected] (M.E. Brennan).
they will refer to specialists. Whereas GPs refer patients whose initial assessment suggests possible breast cancer to specialists, little is known about the management of women with benign findings in the primary care setting. The experience of clinicians working in multidisciplinary breast centres suggests that many patients are also referred when their symptoms and clinical and imaging findings show that malignancy is unlikely. The study centre, a multidisciplinary breast service, has established a ‘low-risk’ breast clinic which supports GPs in the management of women with breast problems that are not considered to be
0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2005.12.002
ARTICLE IN PRESS 684 suspicious (‘probably benign’). The referring doctor performs the initial assessment, which includes clinical breast examination and any other tests deemed necessary by the referring physician (these may include mammography, ultrasound, and sometimes percutaneous needle biopsy). If the responsible (referring) doctor wants to refer for specialist management despite non-suspicious findings on initial investigations, a referral letter along with the report of any tests performed is forwarded by facsimile to the study centre. The information is processed by administrative staff in consultation with a medical officer and the patient is triaged to the appropriate clinic within the centre. This study explores the reasons why patients are referred to a specialised breast clinic despite the ‘low-risk’ findings, and describes the outcomes following assessment. Understanding these referrals may help to target education programs for GPs (and other health professionals) and patients and to better support GPs in dealing with the spectrum of non-malignant breast disease. It may also assist in focusing the resources of specialised breast units to the management of malignant disease and benign breast conditions requiring surgery by reducing referrals for other conditions.
Materials and methods Two hundred and ten consecutive new patient referrals to the low-risk clinic were identified from the clinic database. This represented all new referrals to the clinic over a period of 15 months from July 2003. The medical records were reviewed by one of the authors (MB) and data were collected to include patient demographics, the classification of the referring doctor (GP or specialist), the main reason for referral, the assessment diagnosis, and the outcome following the first consultation (followup or management recommendations.) Clinical information was determined by reviewing the referral letter, the standardised breast assessment form completed by the consulting doctor for every new patient (available from authors), the progress notes, and the results of any investigations performed. The data were analysed to determine the number and percentage of the total in each category.
Results Of the 210 patients in the study, all but 1 were women and 95% were referred by GPs. Eighty per cent of the referrals from specialists were from a
M.E. Brennan, N. Houssami clinical geneticist in an affiliated familial cancer clinic. The patients ranged in age from 12 to 87 years with an average age of 42. The most common reasons for referral, final diagnoses and management/follow-up recommendations are shown in Table 1. Almost all patients had benign findings, with only three patients (1.4%) being found to have a malignancy. All three patients found to have breast cancer on our assessment were symptomatic. They were aged 43, 60 and 69 years. Two women presented with a lump, and the third presented with lumpy breasts and was found to have a dominant area of clinical thickening on examination. All of these patients had false negative breast imaging in the 6 months prior to presentation. In one patient, mammography had been performed, in one ultrasound had been performed and the third patient had both forms of imaging. In all of these cases repeat breast imaging at presentation showed suspicious or malignant findings. Histopathology following excision showed high grade ductal carcinoma in situ in one case and invasive ductal carcinoma in the other two cases, one of which had a single metastatic lymph node in the axilla.
Discussion The main reason for referral was breast lump. This is a common and appropriate reason for referral, and it implies that GPs are aware that the ‘triple test’1 is required to assess women with breast problems even if imaging does not indicate a suspicious finding. Other symptoms that prompted referrals include mastalgia, nodularity and nipple symptoms. Our data also show that only about a third of subjects were found to have a definite palpable abnormality on examination at the study centre (either a benign or malignant lesion or an area of focal nodularity). GPs are therefore largely referring women with symptoms, but not necessarily referring according to whether a palpable finding is present on clinical assessment. Even in the subgroup of subjects who were referred for assessment of a ‘breast lump’ only 68% were considered to have a definite palpable lesion. This is an important issue to explore further in qualitative studies to understand whether GPs referred the subjects because they considered the symptoms significant enough (regardless of clinical examination), whether they were uncertain regarding the findings of clinical examination, or whether other patient-related factors influenced the decision to refer.
ARTICLE IN PRESS Image-detected ‘probably benign’ breast lesions
685
Table 1 Reasons for referral, final diagnoses and management recommendations in consecutive women referred to a low-risk (probably benign) clinic (N ¼ 210). Reason for referral
Number (%)
Breast lump
79 (37.6)
Incidental imaging abnormality Mastalgia
54 (25.7)
Impalpable benign imaging abnormality No abnormality
Lumpy breasts or focal nodularity Nipple discharge or nipple change
20 (9.6) 10 (4.8)
Palpable benign lesion Localised nodularity Other
High risk of cancer/strong family history Other
10 (4.8)
Malignant lesion
Total
29 (13.7)
Final diagnosis
Number (%) 86 (41.0)
50 (23.8) 48 (22.8)
3 (1.4)
18 (8.6) 5 (2.4)
8 (3.8)
210 (100)
Total
The second most common reason for referral was the presence of an image-detected abnormality as an incidental finding on breast imaging (‘screendetected’) and unrelated to the clinical findings or symptom.2 Our data show that a significant proportion (about 26%) of women was referred primarily because of a benign image-detected finding. This raises an issue which has not been previously identified in published work: outside the context of screening services, a substantial number of women are being referred from primary care to specialist breast clinics for management of benign image or screen-detected lesions. This not only indicates an area of need for GP support but warrants further research to ascertain the underlying reasons for these referrals. While this may be related to primary care physician knowledge, other factors may also contribute. For example ambiguous or inconclusive imaging reports or patient anxiety caused by an imaging abnormality may also prompt referral. As this was an exploratory study, our audit did not identify whether these imagedetected lesions were detected with mammography or sonography or both, but it is possible that these are largely sonographically detected lesions related to the increasing role of ultrasound in breast diagnosis.3,4 The most common management recommendations following the first consultation were early clinical and/or imaging review and percutaneous biopsy with only 12% able to be discharged following the first visit. A large proportion of
210 (100)
Management
Number (%)
Early clinical and/ or imaging review (0–6 months) Percutaneous biopsy Discharged/ no follow-up required Imaging work-up
71 (33.8)
Recommended for surgical opinion or surgery Clinical and/or imaging review 12+ months Clinical and/or imaging review 7–11 months
14 (6.7)
Total
64 (30.5) 26 (12.4) 21 (10.0)
10 (4.7)
4 (1.9)
210 (100)
patients therefore required further work-up or monitoring. It is unclear from this early study how the incidental imaging lesions are being managed in the study centre following referral. It is likely that some clinicians are recommending needle biopsy (with a plan to dismiss should a benign result be obtained) while others are recommending imaging surveillance of the lesion instead. Such variations in practice have been described in the management of screen-detected probably benign findings.5
Conclusion This study has explored the reasons why patients are being referred to a specialist breast centre despite clinical and imaging findings that indicate a low probability of malignancy. Concern about the presence of a breast lump was, not unexpectedly, the main reason for referral. However, we have identified the second most common reason for referral as an image-detected (incidental) benign abnormality. The reasons prompting such referrals are unclear and warrant further evaluation, and would be relevant to health systems where GPs (family physicians) have primary responsibility for investigating women with breast symptoms. Factors that may contribute include uncertainty on the part of the referring doctor as to how these lesions should be managed, unclear or non-definitive radiology reports, patient anxiety, and potential
ARTICLE IN PRESS 686 medicolegal concerns (delays in breast cancer diagnosis are a major reason for medicolegal action in Australia and North America). While much has been written about screen-detected lesions (both cancers and false positives) in the breast cancer screening setting there is very little documentation of the prevalence and impact of image-detected ‘probably benign’ lesions outside of the population screening setting. There is also little to no information on the quality of breast imaging reporting in the diagnostic setting. The cost of work-up of these incidental lesions, including specialist referral, opportunity cost and psychological impact are areas that require further research. This work also highlights the need for evidence-based protocols, both for primary care and in dedicated breast services, to assist in the management of benign (or probably benign) imaging lesions identified incidentally in the course of breast diagnosis.
M.E. Brennan, N. Houssami
Acknowledgement The NSW Breast Cancer Institute receives funding from the NSW Department of Health.
References 1. Irwig L, Macaskill P, Houssami N. Evidence relevant to the investigation of breast symptoms: the triple test. Breast 2002;11:215–20. 2. http://www.bci.org.au/medical/leura%5Fabstracts2000/ abstracts21to25.htm 3. Houssami N, Brennan M, French J, et al. Breast imaging in general practice. Aust Fam Phys 2005;34:467–73. 4. Irwig L, Houssami N, van Vliet C. New technologies in screening for breast cancer: a systematic review of their accuracy. Br J Cancer 2004;90:2118–22. 5. Sickles EA. Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up protocol? Radiology 1999;213:11–4.