The winning project in the breast referrals category in the 2004 Guidelines in Practice Awards has improved appropriate referrals to diagnostic services and enabled rapid feedback to GPs



Breast cancer is the most common cancer in women, and the incidence is rising. In Scotland, it accounted for 27% of newly diagnosed cancers in women in 2001.1

In our area, NHS Ayrshire and Arran, as in other parts of the country, local data have shown a significant increase in referrals to diagnostic breast services, with little or no increase in numbers of cancers diagnosed. 2,3 Waiting times for a clinic appointment for all patients, including those who have a positive diagnosis, have increased.

Other factors affecting waiting times include the European Working Times Directive relating to doctors in training, implementation of which has resulted in shorter clinics.

We set up a steering group composed of community- and hospital-based doctors and nursing staff as well as a patient representative. The group’s main aims were two-fold: to ensure that referrals were appropriate, and to inform the GP as soon as possible when a patient is diagnosed with breast cancer. We also wanted to provide feedback for GPs when the patient could have been managed, at least initially, in primary care rather than being referred.

A programme facilitator was appointed with funding from the New Opportunities Fund.

Improving referrals

An initial audit was carried out in 2002. This showed that 15% of women were waiting for longer than 28 days (Table 1, below); NHS Quality Improvement Scotland (NHS QIS) sets a target of 70% of patients seen within 28 days.4 Some 19% of referrals were for patients who could have been managed in primary care.

The steering group developed local guidance based on SIGN Guideline 29, Breast Cancer in Women.5 The local guidance described indications for referral (Box 1, below) as well as signs and symptoms that might be managed more appropriately in primary care (Box 2, below).

Table 1: Patients seen at breast clinics and time-scales
  Audit 1 (Jul-Aug 2002) Audit 2 (Sept-Oct 2003) Audit 3 (Sept-Oct 2004)

Achieved (No.)
Achieved (No.)
Achieved (No.)

Seen within 28 daysa,b

[Seen within 14 daysa

Patients who could have been managed in primary care

Total patients seen at breast clinics during period






85% (197)

31% (71)

19% (45)







88% (350)

63% (249)

13% (52)







66% (156)

26% (61)]

16% (38)


a From date of GP referral letter; b NHS QIS target


Box 1: Recommendations for referral to breast clinic


  • Any new discrete lump
  • New lump in pre-existing nodularity
  • Asymmetrical nodularity that persists at review after menstruation
  • Abscess or breast inflammation that does not settle after one course of antibiotics
  • Cyst persistently refilling or recurrent cyst (if the patient has recurrent multiple cysts and the GP has the necessary skills, aspiration is acceptable)


  • Unilateral persistent pain in post-menopausal women
  • If associated with a lump
  • Intractable pain that interferes with a patient’s lifestyle or sleep and which has failed to respond to reassurance, simple measures such as wearing a well supporting bra, and common drugs

Nipple symptoms

  • In women under age 50, discharge that is: bloodstained; or bilateral discharge sufficient to stain clothes; or persistent single duct discharge
  • In all women aged 50 and over
  • New nipple retraction
  • Nipple eczema (if not present elsewhere)

Skin changes

  • Skin tethering
  • Fixation
  • Ulceration
  • Abscess or breast inflammation if not settled after one course of antibiotics
  • Abscess in patient aged over 40, even after settled (refer for mammogram)


Box 2: Breast symptoms and signs that can be managed in primary care


  • Tender, lumpy breasts in women aged under 35
  • In older women, symmetrical nodularity if no localised abnormality
  • Tender, developing breasts in young people


  • In women aged under 50 (eliminate caffeinated drinks and suggest proprietary source of gamma linolenic acid)
  • Minor and moderate degrees of breast pain in women who do not have a discrete palpable lesion

Nipple symptoms

  • In women aged under 50, nipple discharge from more than one duct, intermittent and not bloodstained
  • Longstanding nipple retraction
  • Nipple eczema if present elsewhere treat with topical steroids)

Skin changes

  • Obvious simple skin lesions e.g. sebaceous cysts
  • Abscess (try one course of antibiotics)*
  • Inflammation (try one course of antibiotics)*

* If abscess or inflammation does not settle, refer

GPs in all 61 practices in Ayrshire and Arran participated in the project, referring patients to one of two one-stop breast clinics held in local hospitals.

Supporting materials were developed and included:

  • A form with tick box for GPs, to guide referral
  • Patient information about the onestop breast clinics, which was made available to all practices
  • Information for patients on management of simple breast pain
  • Information on criteria for family history referrals.

The guidelines and supporting materials were issued to all GPs, practice nurses and sexual health teams involved in well woman services. To encourage implementation of the guidance, the project facilitator worked closely with surgeons and breast care specialist nurses and promoted the guidance and resources through a series of meetings held in local practices.

Keeping GPs informed

Information about a positive diagnosis is often given to the GP by the consultant over the telephone, but the timing of some clinics can make this difficult. We developed a new form to fax to GPs within 24 hours to inform them of a positive cancer diagnosis (Figure 1, below).

Figure 1: Fax form used to notify GPs of a positive diagnosis of breast cancer

To ensure patient confidentiality, we use the patient’s date of birth and CHI number for identification, and do not record the patient’s name on the form.

Receiving this information at the earliest possible opportunity puts primary care teams in the best position to support women and their families at the time of diagnosis.

We have also developed a feedback form that is sent to individual clinicians in cases where a referral might have been more appropriately managed in primary care.

How successful was the project?

To assess the effectiveness of our project, we carried out a further two audits, in 2003 and 2004, which again looked at the time taken from referral to clinic appointment and the percentage of patients referred who could have been managed in primary care (see Table 1).

The percentage of women who had waited more than 28 days fell from 15% in the first audit to 12% in the second, but had increased to 34% by the third audit. The percentage of patients referred who could have been managed in primary care fell from 19% in the first audit to 13% after introduction of the guidelines. The third audit showed that this figure had increased to 16%.

In the first audit, ‘pain’was found to be one of the main reasons for referral when the patient could have been managed in primary care. We therefore developed guidance for patients on the self-management of breast pain, and distributed it widely to appropriate healthcare professionals, in hard copy and by electronic mail. This resulted in a significant drop in this category of referral.

The feedback form is now used extensively for patients at the time of diagnosis to inform the GP within 24 hours.

Patients’ and healthcare professionals’ views

We canvassed patients’ views on the referral process through questionnaires and interviews. Some 180 patients were given a questionnaire and we received 81 responses, while 23 patients were interviewed. Most comments were positive, and only three were negative, all of which related to the wait from referral to diagnosis.

Patients were asked if their GP had received information about their diagnosis when they next visited the practice.

Forty out of 67 who responded reported that their GP did know of their diagnosis; 16 were unaware if their GP knew and one said her GP did not know.

We also sought the views of GPs and primary care nurses. We found that implementing the guidance had succeeded in raising awareness among GPs of the criteria for referral to the one-stop breast clinics. Of the 118 questionnaires returned, 100 indicated that they were aware of the local guidelines based on SIGN 29; 64 had recently made referrals to the one-stop breast clinic, and 18 had issued a patient information leaflet about the clinic.

It is encouraging that 55% of GPs who responded had received early feedback from the clinic about their patients’ positive diagnoses and almost all felt it was helpful.

The benefits of the project

As a result of the project, referrals to the diagnostic breast clinic are more appropriate. Information about the breast clinic is available for patients and they are better informed about the clinic process. Early notification to the GP, within 24 hours of a breast cancer diagnosis, can enable primary care to provide better support for patients and their families.

Information about breast pain is available for patients, to encourage self-management.

Although the number of women waiting more than 28 days fell initially, it subsequently increased. Waiting times is a complex issue influenced by a variety of factors including the European Working Times Directive.

Rolling out the project

The results of the audits were distributed to primary and secondary care clinicians. They were also presented at a series of local meetings as well as at national meetings and conferences.

The local guidance has recently been reviewed and updated and will be further promoted in local practices. A similar project will be implemented for cancer groups.


  1. Cancer in Scotland summary. Scottish Cancer Registry.ISD, National Services Scotland.
  2. Patel RS, Smith DC, Reid I. One-stop breast clinics – victims of their own success? A prospective audit of referrals to a specialist breast clinic.Eur J Surg Oncol 2000; 26(5): 452-4.
  3. Local clinical effectiveness data.
  4. Clinical Standards Board for Scotland. Clinical Standards: Breast Cancer. Edinburgh: CSBS, 2001.
  5. Scottish Intercollegiate Guidelines Network. Breast cancer in women – a national clinical guideline. Edinburgh: SIGN, 1998.

Guidelines in Practice, May 2005, Volume 8(5)
© 2005 MGP Ltd
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