I enjoyed reading John Donald's clear and succinct account of how breast cancer should be managed using the best evidence available ('Guideline will help GPs provide holistic care to breast cancer patients' Guidelines in Practice February 2006).1

It brings into sharp focus the need to screen women with breast cancer for psychosocial problems and the provision of cognitive behavioural therapy for those with anxiety and depressive disorders (Grade A).

As with NICE guidelines on the management of depression,2 non-pharmacological approaches to psychological problems will need to be matched by significant investment in primary care.

The evidence for the other recommendations is less robust. However, health authorities will need to put in place systems to ensure that women who fail to attend 3-yearly mammography are identified in order that they can be encouraged to attend (Grade C).

Good communication between hospitals and primary care teams, including information for GPs and their patients (Grade C), is a 'given' and underpins the Gold Standards Framework. This may also help GPs achieve QOF targets.

The effect of delays of 3 months or more on survival is likely to remain contentious, regardless of the evidence (Grade C). GPs should continue to enable women to be seen as promptly as possible to prevent unnecessary distress for their patients.

Dr Jill Murie, GP

  1. Scottish Intercollegiate Guidelines Network (SIGN 84). Management of breast cancer in women. Edinburgh: SIGN, 2005.
  2. National Institute for Health and Care Excellence. Depression: management of depression in primary and secondary care. London: NICE, 2004.


I found the three articles discussing cancer care in the February issue of Guidelines in Practice very helpful.1,2,3

I believe there is a strong case for looking at pooled budgets between health and social services, to enable healthcare professionals with the appropriate background to provide the psychological and practical support needed.

Carers' assessments are at present undertaken only by social services, and I would argue that these assessments could be carried out by a health worker at the same time as offering psychological, palliative and healthcare support.

Partnership working has become a buzz theme but we need to see it working out in practice.

We still work in our own particular silos despite legislative changes.

Alison Wall, HV/PEC nurse & child protection lead
Watford and Three Rivers PCT

  1. Donald J. Guideline will help GPs provide holistic care to breast cancer patients. Guidelines in Practice 2006; 9(2): 13-21.
  2. Murie J. Cancer indicators pave the way to improved GP care. Guidelines in Practice 2006; 9(2): 23-30.
  3. SIGN notes for discussion with patients and carers. 25. Management of breast cancer in women.Guidelines in Practice 2006;9(2): 38-40.

Guidelines in Practice, April 2006, Volume 9(4)
© 2005 MGP Ltd
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