New guidance from SIGN should enable GPs to manage the psychological aspects of the disease as well as providing long-term follow-up, says Dr John Donald

The Scottish Intercollegiate Guidelines Network (SIGN) published Management of breast cancer in women (SIGN 84) in December 2005.1 The new guideline is an updated version of SIGN 29, which was published in October 1998.2

Since publication of the previous guideline, a large number of new studies have been published which update the recommendations made in SIGN 29, not only in the areas of radiotherapy, surgery and chemotherapy, but also on psychological aspects of the disease. Many of the original recommendations are incorporated in the new document and these are clearly marked with a ‘SIGN 29’ symbol which makes it easier to see which of the recommendations are new.

SIGN have graded their recommendations from A to D according to the strength of evidence (Figure 1, below).

Figure 1: Key to evidence statements and grades of recommendations
Reproduced from Management of breast cancer in women by kind permission of SIGN

Thirty per cent of all cancers in women occur in the breast, which makes it the most common female cancer. In Scotland in 2002 more than 3600 women were newly diagnosed with this disease and 80% of those cancers occurred in post-menopausal women.3

GPs are often the first point of contact for women with breast problems and the guideline attempts to give the GP some triggers for prompt referral to a breast clinic. GPs and the primary care team also have a major role to play in the ongoing support of women already diagnosed with breast cancer and a large part of the guideline is devoted to the psychological and stress components of breast cancer.

The guideline refers to further referral guidance which is published by the Scottish Cancer Group4 and this is summarised in the guideline (Figure 2, below).

Figure 2: Scottish Cancer Group referral guide
Reproduced from Management of breast cancer in women by kind permission of SIGN

There are four important recommendations in the first part of the guideline, which relate to diagnosis and are particularly relevant to primary care. The first three are taken from the previous guideline, SIGN 29, and the fourth is a new statement.

Women should be encouraged by the primary care team to participate in the NHS Breast Screening Programme (NHSBSP).5 This programme invites women between the ages of 50 and 70 years for screening every three years.Women aged over 70 years are not currently routinely invited, although they are encouraged to continue their three-yearly attendance.

The guideline, while acknowledging that ‘breast self examination does not reduce morbidity or mortality from breast cancer’, states that ‘since the majority of breast cancers are found by women themselves, self examination optimises the chances of a woman finding a change from normal’. (Grade C)

There is much controversy about the value of breast self-examination but the guideline appears to endorse this procedure as a valuable help in diagnosis.The guideline also encourages women to become aware of the feel and shape of their breasts, so that they are familiar with what is normal for them. (Grade C)

There is an emphasis on good communication between hospital and primary care teams.The GP should be informed about the management plan after the initial hospital visit.This should include information given to the patient and relatives. (Grade C)

No evidence was found that delays of less than 3 months have an effect on survival although there was some evidence that delays in referral of between 3 and 6 months have adverse effects on the patient. This includes delays from first symptoms to treatment and from seeing a professional to treatment. (Grade 2++)

A large part of the guideline is devoted to the psychological issues associated with breast cancer. Women with breast cancer are at high risk of significant levels of anxiety and depression over and above that associated with the diagnosis of a potentially life threatening illness and side-effects of treatment. In one study, up to 45% of women were found to have clinically significant levels of psychological distress.6

The guideline acknowledges that clinical staff often do not recognise psychological problems and even if they do, they may not offer help and support as they see this as being a ‘normal’reaction to the disease. A useful table is included in the guideline (Figure 3, below) that should help primary healthcare professionals identify those most at risk of developing psychological symptoms.

Figure 3: Factors associated with increased risk of psychosocial problems 7
Reproduced from Management of breast cancer in women by kind permission of SIGN

Routine screening of patients with breast cancer by formal evaluation of distress and anxiety using methods such as the Hospital Anxiety and Depression (HAD) scale is thought to be less effective than more informal methods tailored to individual patients.

Before the more formal methods are used, the patients should be individually screened by healthcare professionals using the criteria listed in Figure 3 (above). Then cognitive behavioural therapy, either in groups or individually, should be offered to selected patients with anxiety and depression disorders. (Grade A)

There was good evidence for effective communication being beneficial to patients. Patients’ knowledge and experience during consultations are greatly improved if clinicians have undergone communication skills training and use consultation prompt sheets.The guideline strongly recommends that after important consultations women should be offered audiotapes or follow-up summary leaflets.

The key role of the breast care nurse specialist in providing information and support at every stage of diagnosis and treatment is highlighted. It is emphasised that primary care teams should be aware of the role of these nurses and have their contact details available.

Many of the recommendations in this section of the guideline are derived from a specially commissioned workshop involving a large group of women who all had direct experience of treatment for breast cancer. Five main themes emerged from this meeting:

  • Delivery of information – emphasising the manner in which important information was imparted and the importance of face-to-face delivery of such information
  • Results of investigations – there was no consistent approach to providing information about the triple assessment. A rapid referral from primary to secondary care was considered important for psychological wellbeing
  • Side-effects of treatment – information given was often ad hoc and insufficient. Patients felt that a notebook to record side-effects would be very useful
  • Information for carers – it was considered important that, with the patient’s agreement, family, carers or friends should be involved during consultations
  • Home care/follow-up – women recorded significant variations in their after-care. Some women found their GP and breast care nurse to be a great support while others felt abandoned and isolated.

Many women are unsure of what to expect as they move from primary to secondary to tertiary care. The guideline includes a useful section on questions that breast cancer patients frequently ask (see Notes for discussion with patients and carers).

In the past 8 years since the previous guidelines were published, there have been tremendous advances in knowledge about breast cancer; in fact, it is one of the best researched areas in medicine.There has been an increasing awareness of the physical and psychological impact of this disease and how these aspects can be recognised and treated.

Women with breast cancer,even those with advanced disease, can expect to live a great deal longer than they could 10 years ago and thus primary care teams will have more contact and involvement with patients over a longer period of time. This guideline gives us much additional information on the diagnosis, support and followup of patients with breast cancer.

The full guideline and the quick reference guide can be downloaded from the SIGN website:

  1. Scottish Intercollegiate Guidelines Network (SIGN 84). Management of breast cancer in women. Edinburgh: SIGN, 2005.
  2. Scottish Intercollegiate Guidelines Network (SIGN 29). Breast cancer in women. Edinburgh: SIGN, 1998.
  3. ISD (Information and Statistics Division) Scotland. Breast
  4. Scottish referral guidelines for suspected cancer. Scottish
  5. NHS breast screening programme. Breast Screening: a pocket guide.
  6. Kissane DW, Clark DM, Ikin J et al. Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey. Med J Aust 1998; 169 (4): 192-6.
  7. National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown: National Breast Cancer Centre, 2003.

Guidelines in Practice, February 2006, Volume 9(2)
© 2006 MGP Ltd
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