REFERRALS TO SYMPTOMATIC BREAST CLINICS:NON-COMPLIANCE WITH ESTABLISHED SIGN GUIDELINES

V Shanmugam, C Wilkins, SD Heys, E Smyth, S Chaturvedi

Key words: Scottish Intercollegiate Guidelines Network (SIGN), Breast cancer, Urgent / Non-urgent referrals, Waiting time.

Abstract

Background : Breast cancer is the most common malignancy in women. The Scottish Intercollegiate Guideline Network (SIGN) has published guidelines for referral of patients with breast symptoms to breast specialists. This study has examined GP referrals to a symptomatic breast clinic with respect to their appropriateness in view of the SIGN Guidelines.

Patients and Methods : This is a prospective audit of consecutive cohort of patients referred during a 6-week period. The data regarding reason for referral, clinical examination and investigation results were analysed and then compared with SIGN guidelines.

Results : 318 new patients (median age of 43 years) were referred to one Breast Clinic over a period of 6 weeks. Of these, 49 (15.4%) were "urgent" referrals as designated by the General Practitioner. Mean waiting time for "urgent" referrals was 23 days and for "non-urgent" referrals was 43 days. The benign to malignant ratio was 18.7:1 for all the patients. Although a lump was the commonest presenting symptom (n=192) breast cancer was diagnosed in only 17 (5.3%) patients. There were 46 (14%) referrals where the GPs letter did not meet the guidelines and this was confirmed after examination in the clinic Furthermore, of the remaining patients, the breast surgeon judged after clinical examination of the patient that only 74% of referrals met the SIGN guidelines.

Conclusion : The overall referrals which failed to comply with the guidelines imply that utilisation of clinical resources could be improved if the guidelines are adhered to.

Introduction

Breast cancer is the most common malignancy among women in the UK with an estimated incidence of 40,000 per annum. In addition, 14000 patients die each year 1 as a result. Awareness among the public through the media and Internet 2 has increased the pressure from patients on the primary care practitioners to refer these patients to specialist breast clinics 3 some of whom may not be appropriate. The Scottish Intercollegiate Guidelines Network (SIGN) guidelines in were published in 1998 and provided what were considered to be appropriate criteria for referral by general practitioner 4. The conditions warranting referral to a specialist breast clinic according to SIGN guidelines are outlined in Table 1. In this study we have audited the compliance of all GP referrals to specialist breast unit at Aberdeen Royal Infirmary and compared those to the SIGN Guidelines.

Scottish Intercollegiate Guidelines Network 1998. Breast Cancer in women - a national clinical guideline

Aberdeen Royal Infirmary (ARI) serves a population of approximately 438,996 from the Grampian region. There are usually 6 breast clinics staffed by 3 consultant surgeons and supported by one surgical trainee or a staff grade surgeon.

Each clinic will have up to 16 new patients and a similar number of return patients. The clinic has facility for ultrasound examination and fine needle aspiration cytology with immediate reporting. Patients have mammography carried out prior to the clinic visit with the report available.

Patients and Methods

This was a prospective observational audit of 318 consecutive referrals by general practitioner to a specialist breast clinic over a 6 week period. The GP letters were evaluated and reason for referral were compared with SIGN guidelines. The clinical findings of each patient as documented in the referral letter were compared with breast specialist's finding as documented by their examination in the breast clinic and were also compared with the SIGN guidelines. Finally, the breast specialist's definitive diagnosis for each patient after investigations had been completed was recorded and the prioritisation category of the referral ("urgent" or "non-urgent"), symptoms and patient's age each was recorded separately. Details were entered in a Microsoft Excel database and statistical calculations performed using the SPSS 11.1.5 (for Microsoft Windows XP)

Results

The general practitioners referred a total of 318 consecutive new patients to the specialist breast clinic at Aberdeen Royal Infirmary, over a period of 6 weeks. The mean age of all patients was 46 (range 14 -88) years. A total of 139 patients were between 35 and 49 years of age. 101 patients were 50 years or over and 78 patients were less than 35 years of age.

There were 49 (15.4%) "urgent" and 269 (84.6%) "non-urgent" referrals. The mean ages for urgent and non-urgent referrals were 57 (range 32-88) and 44 (range 14-84), respectively. The average waiting times for a clinic appointment to be seen by a breast specialist in the "urgent" and "non-urgent" referrals were 17 (range 4-69) and 31 (range 5-134) working days, respectively. This time was taken from the date the referral was received at the hospital to the patient attending. 48 (98%) of "urgent" referrals and 224 (83%) of "non-urgent" referrals met the SIGN guidelines criteria according to the referral letter. However only 41 (83%) of "urgent" and 159 (59%) of "non-urgent" referrals met the guidelines after history and examination had been undertaken by the breast specialist (Figure 1).

Figure 1 Appropriateness of referral in relation to SIGN Guidelines

Overall, 272 (85.5%) patient referrals were consistent with the criteria laid down in the SIGN guideline pertaining to the symptom for which they were referred. However only 200 (63%) of them were found to comply with the SIGN guidelines after a breast specialist had undertaken clinical examination. All GP referral letters and findings for patients diagnosed with cancer were consistent with the SIGN guidelines.

When patient referrals were examined with respect to their age it was found that an increased proportion of patients did not meet the criteria according to the SIGN guidelines. In terms of the symptoms at initial clinical presentation, "breast lump" was the predominant reason for referral followed by "Breast pain" in all those patients whose referrals were consistent with SIGN guidelines. The frequency of presenting symptom in different diagnostic category is given in Figure 2.

Figure 2 Appropriateness of referral according to patient's age

Figure 3 Symptoms at presentation after different diagnoses

The clinical and investigation findings were normal in 110 (34.6%) patients whereas breast cancer was confirmed in 17 (5.3%) patients [9 (18.3%) "urgent" and 8 (3.0%) "non-urgent" referrals]. The mean age of patients with breast cancer was 68 (range 34-88). Benign fibro-cystic change was the commonest non-malignant diagnosis (Figure 1).

Discussion

Malignant breast disease has a major impact on the workload of the clinicians nationwide because of the increasing awareness and a rising incidence of approximately 2% per annum. In the general population the risk of breast cancer is 1 in 625 under 35 years, 1 in 56 at age 50 rising to 1 in 18 by age 65 5. In spite of the existing screening programmes, GPs may be coming under pressure to refer many patients from those who are not included in the National Breast Screening Program. Previously Cochran et al found that 27% of GP referral were inappropriate and that increased to 37% after clinical examination had been undertaken by a breast specialist 6. This is comparable with our study showing 14.5% and 37% before and after clinical examination by a specialist respectively. The difference between the two could be due to the result of cyclical or self-limiting nature of majority of benign breast diseases or due to non-breast symptoms mimicking breast disease. Another reason could be misinterpretation of clinical findings by the GPs due to inadequate experience eg. nodular breast could be perceived as lump or because of the pressure from the patients to be seen by a "specialist breast surgeon. When compared to the findings of the GPs, a significant proportion of patients (n=111) in our study had entirely normal breast on examination by a specialist. It should also be noted that the urgent referrals (98%) were more compliant with the guidelines than non-urgent (83%) ones. A similar study from Patel et al.7 showed even poorer compliance with only 72% and 63% appropriate referrals before and after examination by a breast specialist, respectively. This obviously increases the waiting time for the patients who really need earlier appointment in the specialist clinic.

The overall 5.3% incidence of malignant breast disease in our study is less than the 6.3% (2332 patients) and 8.7% reported by Cochran et al 8 and Roshanlall et al 9 respectively. This again suggests that there were slightly more inappropriate referrals in our centre.

Conclusion

There are still a significant proportion of referrals to a specialist breast clinic (15%) that can be considered inappropriate especially for the younger age group patients even 5 years after the SIGN guidelines for the referrals of patients to a specialist breast clinic. This increases the clinic pressure on the breast specialists and unnecessarily increases the waiting time for the patients where symptoms indicate that they require an early appointment. Our study emphasises the fact that GPs should be encouraged to adhere to the guidelines and it may be appropriate to arrange training at the postgraduate level to increase confidence in diagnosis and management of patients with breast disease. Increased use of educational material for the patients and special breast referral forms for GPs could provide benefits in reducing inappropriate referrals.

Acknowledgments

We would like to thank all the staff at the Aberdeen Royal Infirmary Breast Clinic for their help while this audit was undertaken.

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