Breast Cancer

1
Breast Cancer

• Most common cancer in women in UK
• 40,000 new cases in England per year
• Lifetime risk of around 11
• Breast cancer survival rates are high
• 93 at 1 year
• 76 at 5 years

2
How do women get diagnosed with breast cancer?

• Referral to breast unit
• by different routes
• Diagnosis
• by breast surgeons in special breast units
• by triple assessment
• Examination
• Radiology
• Pathology

3
Referral routes to breast clinic

• GP referral
• Routine
• Urgent
• Screening service
• Outpatient referral
• Inpatient referral
• Emergency admission

Breast clinic
4
Referral routes to breast clinicGP referrals
Urgent GP referral Routine GP referral Screening
service referral Outpatient referral Inpatient
referral Emergency admission
40 per week
Around 2000 cases of which about 200 breast
cancers
Breast clinic
5
Referral routes to breast clinicERA
Urgent GP referral Routine GP referral Screening
service referral Outpatient referral Inpatient
referral Emergency admission
ERA
Breast clinic
6
GP referral decisions
Assess the patient- refer or not
Assess urgency
Choose referral method
New patient breast lump/ symptom Recurrence of
breast lump/symptom Family history of breast
cancer
2 week urgent referral pro-forma General
referral pro-forma GP letter Electronic referral
Urgent or Routine
7
Breast unit actions

• Referral received by breast unit
• Check urgency
• Book appointment
• Patient
• Start care spell record

8
Breast Unit- what information do they need ?

• Assess urgency
• Booking
• Patient
• GP
• Start care spell record

• Clinical data to assess urgency
• Patient information
• GP information
• Data for audit

9
GUYS Breast Unit

• Tertiary referral centre
• Two new patient clinics per week
• See all new referrals, not just from GPs

10
GP referral method to Guys Breast Unit

• 2 week referral pro-forma
• General breast clinic referral pro-forma
• Computerised referral
• GP letter/ letters from OPD

11
Data content of referrals
12
Pro-forma and letter referralsUrgent referrals
Urgent referral faxed
2 week office
Book urgent appointment
Paper pro-formas GP letter
Phone/ Letter to patient
13
Pro-forma and letter referralsRoutine referrals
2 week office
Book urgent appointment
Paper pro-formas GP letter
Phone/ Letter to patient
Assess urgency
Routine referral faxed
Referrals office
Book routine appointment
14
Computerised referralsUrgent referral
Phone/ Letter to patient
Decision support on urgency of the referral,
booking in GP office with the patient (via
intranet onto PAS)
New booked appointments viewed at Guys booking
office. Non-urgent referrals checked by Prof
Computerised referral
15
How can we assess the Gold Standard for GP
referral to Breast Clinics

• Appropriateness of GP referral when assessed
  against the NHS Guidelines
• Correct identification and referral of urgent
  cases
• Proportion of breast cancer rates in non urgent
  referrals

16
Is the Gold Standard being met for referral to
Guys breast unit?

• 5 different methods of referral to breast unit by
  GPs
• Different data provided by different referrals
• Therefore
• Difficult to assess the urgency of referrals to
  the breast clinic
• Evidence of problem
• 7 out of 25 GP referrals did not comply with the
  NHS guideline

17
Is the Gold Standard for GP referral to Breast
Clinics being met nationally ?

• Surveys of consultants working in breast
  clinics reveal that about a quarter of all GP
  referrals fall outside published guidelines- but
  also a third of women who do have cancer are not
  referred urgently. Careful adherence to NHS
  guidelines could substantially reduce the rate of
  inappropriate referral without increasing the
  risk of missing cases of breast cancer
• NICE Improving Outcomes in Breast Cancer
  Aug 2002