Professor Robert Mansel (left), Dr Nader Khonji and Mr Dayalan Clarke explain how the revised guidelines aim to allow fast-tracking of patients with suspected cancer


   

The original edition of Guidelines for Referral of Patients with Breast Problems was commissioned by the Advisory Committee on Breast Cancer Screening and published by the NHS Breast Screening Programme in December 1995. More than 100 000 copies have since been requested.

It provided protocols for the referral and management of the most common breast symptoms presented to the GP:

  • Breast lumps
  • Pain
  • Nipple discharge.

A second edition has just been published.1 It contains two important additions:

  • Criteria for categorisation of referrals as 'urgent'
  • General advice for referral and management of patients with a family history of breast cancer. This was omitted from the first edition due to a lack of consensus, which still exists on this topic. However, because of requests from many GPs for guidance in this area, an outline of possible management is given, although Khis will be dictated by discussion between GPs and the local breast unit.
Extract from 'Guidelines for Referral of Patients with Breast Problems', 2nd edition 1999
extract from guideline

 

Ten years ago, one in 10 patients referred to a symptomatic breast clinic were found to have a carcinoma.2 Recent studies show that currently only 1 in 15 referrals are diagnosed with malignancy.3,4

This change is almost certainly due to increased public awareness of breast cancer, resulting from the screening programme and prominent media coverage. The consequent increase in presentation of breast symptoms to GPs has resulted in an increased number of referrals to specialist clinics, which are now under considerable pressure.

The guidelines aim to reduce the number of unnecessary referrals to breast clinics.

The pressure on breast clinics is likely to worsen as a result of the introduction of the '2-week rule' in April 1999. This stems directly from the December 1997 White Paper The New NHS, which states that 'everyone with suspected cancer will be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently'.

For this system to be practicable, it is essential that only patients who are truly at high risk of cancer are referred as urgent.

The genetic aetiology of a proportion of breast cancers has been well publicised. This has resulted in a large number of patients consulting their GP with a family history of the disease.

However, the proportion of breast cancers that are truly genetic is small, probably less than 10%, and referral is only required for a strong family history of the disease. Women at only low risk from their family history are another source of unnecessary referral to the breast specialist.

 

The first edition of the guidelines was written after thorough review of the relevant literature and extensive consultation with breast surgeons and GPs, and so it was mainly a consensus-based document.

For the new edition, feedback from GPs, local authorities and GP training programmes has been taken into account, and literature review of the last 4 years has not shown any evidence to support changing the basic structure of the guidelines.

The usefulness of the guidelines is illustrated by a retrospective study of 2332 referrals in South Wales.3 This showed that if the guidelines had been rigorously applied, 29% of patients with benign breast disease would not have been referred. Mastalgia with no discrete lump accounted for 63% of this group. Of the 147 carcinomas diagnosed, none would have been missed by adhering to the guidelines.

 

It is hoped that the guidelines will reduce the number of inappropriate referrals for benign disease, such as moderate diffuse mastalgia and bilateral symmetrical nodularity, which can be safely managed in the primary care setting.

A recent study5 has shown that this can be achieved by training GPs to incorporate the guidelines into their practice. Eighty-three per cent of GP practices in East Surrey were visited individually and introduced to the guidelines. Subsequently, there was a 70% drop iM the number of inappropriate referrals to local specialist breast clinics.

Patients are often referred as 'urgent', even though their risk of cancer is low. For example, a 20 year old with a discrete lump almost certainly has a fibroadenoma and thus does not warrant urgent referral.

The guidelines therefore give specific advice on which patients should be referred as 'urgent.' This should allow GPs to categorise their referrals more confidently as 'urgent' or 'non-urgent,' and restrict the 'urgent' group to those patients at high risk of cancer.

The guidelines should also allow GPs to reassure patients who have a weak family history of breast cancer, while referring those at significantly increased risk, ideally to a dedicated genetics clinic.

 

If the guidelines are adhered to, inappropriate referrals to specialist breast clinics will be reduced. This decreased workload will allow those patients who do require specialist care to be seen more quickly.

The psychological morbidity experienced by patients and their relatives should be reduced, since a proportion will be reassured by their GP, while the remainder will have a shorter period of anxiety before their consultation.

Reducing the number of patients inappropriately referred as 'urgent' will allow fast-tracking of those patients truly at high risk of cancer. This should allow the '2-week rule' to be met in a larger proportion of cases. Patients with cancer should receive their diagnosis and treatment earlier, which should reduce their psychological morbidity.

Overall, if the guidelines are integrated into GPs' practice, specialist care resources will be used more efficiently, and patient satisfaction should improve markedly.

Guidelines for referral and management of patients with a breast lump1
Guidelines for referral and management of patients with breast pain1
Protocol for treating severe cyclical mastalgia1 (mild/moderate mastalgia requires examination and reassurance)
Guidelines for referral and management of patients with nipple discharge1
  • The second edition of Guidelines for Referral of Patients with Breast Problems is published by the NHS Breast Screening Programme. Copies can be obtained from Dr Joan Austoker, Director of the CRC Primary Care Education Research Group, Department of Primary Health Care, University of Oxford, Institute of Health Sciences, Old Road, Headington, Oxford OX3 7LF.

 

  1. Guidelines for Referral of Patients with Breast Problems. 2nd edn, revised by Dr Joan Austoker and Professor Robert Mansel. Sheffield: NHS Breast Screening Programme, 1999.
  2. Barclay M et al. Patterns of presentation of breast disease over ten years in a specialised clinic. Health Bull 1991: 49: 229-36.
  3. Cochrane RA et al. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. Eur J Surg Oncol 1997: 23: 198-201.
  4. Gui GP et al. Clinical audit of a specialist symptomatic breast clinic. J R Soc Med 1995: 88: 330-3.
  5. Henderson G. The East Surrey breast cancer referral guidelines project. Pulse November 1998.

Guidelines in Practice, June 1999, Volume 2
© 1999 MGP Ltd
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