One stop breast clinics—victims of their own success?A prospective audit of referrals to a specialist breast clinic

doi:10.1053/ejso.1999.0920

European Journal of Surgical Oncology (EJSO)

Volume 26, Issue 5, August 2000, Pages 452-454

https://doi.org/10.1053/ejso.1999.0920 Get rights and content

Abstract

Aims: We aimed to assess the number of unnecessary referrals to a specialist breast clinic, with special reference to urgent referrals, and to compare referrals with published guidelines for referral to these clinics.Methods: We carried out a prospective audit of new patient referrals from primary care to a specialist breast clinic. We assessed the total number of referrals, proportion of urgent and non-urgent referrals, proportion of unnecessary referrals according to published guidelines, waiting times for outpatient appointments and outcomes for these patients. Results: Of the total of 321 referrals, 35% were urgent. Twenty-eight per cent of urgent referrals and 37% of non-urgent were inappropriate according to published guidelines. Ten per cent of referrals had breast cancer while 90% had benign disease or no pathology. Conclusions: There is a proliferation of guidelines (NHS, SIGN, BASO, Patients» Charter) for the organization of specialist breast clinics with the aim of providing rapid diagnosis for patients with malignant disease, or reassurance for symptomatic patients that they do not have breast cancer. However increasing numbers of patients are being referred to these clinics with minimal or no pathology, and this is not acknowledged by these guidelines. In this prospective study of referrals from primary care to a specialist breast clinic, one-third of referrals were inappropriate and this inevitably reduced the efficiency of the service provided for patients with significant symptoms.

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Cited by (34)

Online application for self-referral of the patients with breast symptoms
2021, Annals of Medicine and Surgery
Citation Excerpt :
Rates of referrals from GPs remain high despite the introduction of the “two week wait” initiative in 1999, with the aim to aid GPs to stratify urgent and non-urgent referrals to ensure patients with suspected cancer symptoms are seen within two weeks. One study concluded that one third of referrals to ‘one stop breast clinics’ were inappropriate and therefore put unnecessary strain on the service [4]. To enable suspected breast cancer patients to be seen in the quickest possible time and avoid overwhelming urgent services further initiatives must be taken.
The study aimed to devise a self-referral mobile/web application for patients with new breast symptoms, giving them an outcome, thus bypassing the need for primary care consultation.
The online application was designed on the automated algorithm based on evidence-based guidelines for referral to breast onco-plastic units. A retrospective questionnaire-based anonymous survey was carried out at the breast unit in Southend University Hospital (January 2019 to March 2020). The outcome of the patients was recorded, the same data was entered in the software and its outcome was compared with their clinic outcome to assess and validate the software. Chi-square and t-test were used in formulating results.
Data was collected for 366 patients who were referred urgently to the clinic. Only 50.5% (n = 186) were appropriately referred, with the main complaint being breast lump (94.1%). 39.6% of referred patients did not require a secondary care referral. Sensitivity and specificity for identifying patients requiring urgent referral was 100% and 98%, respectively.
A significant number of urgent referrals to breast units do not require urgent specialist referral, and this results in a big strain on the hospital service. The discussed self-referral pathway is a promising alternative with the potential to reduce workload in primary and secondary care and improve patient satisfaction.
The need for triple assessment and predictors for diagnosis of breast cancer in patients <40 years of age
2018, Clinical Radiology
Citation Excerpt :
As none of the patients with breast cancer had a high-risk family history in this cohort, it was not possible to include it in the regression analysis. One-stop breast clinics have now been established for >20 years and are the standard of care in management of breast-related symptoms with high cost-efficiency and patient satisfaction.3,4,9–18 The vast majority of patients referred to the one-stop breast clinic under the current referral guidelines are young, with a low-risk family history and benign clinical examination.
To assess the safety of selective use of triple assessment with omission of radiological assessment proposed in patients <40-years old.
Data were collected retrospectively for all patients seen in the one-stop breast clinic between January 2014 and August 2015. Demographics, symptoms, diagnostics, and treatment details were recorded. Subgroup and logistic regression analysis was performed to identify predictors for breast cancer.
Of the 3,305 patients included, 95.6% (n=3,161) were first-time referrals. 57.6% (n=1,903) had a breast lump, and 4% (n=133) had a high-risk family history; 75.6% (n=2,499) underwent imaging and 16.7% (n=552) underwent a biopsy. The median age was 29 years (interquartile range [IQR]=25–34). Breast cancer was diagnosed in 29 cases (0.88%) and 3.2% (n=105) had surgery. Median referral-to-diagnosis time was 13 days (IQR=9–14) and referral-to-surgery time was 44 days (IQR=34–95). Patients with breast cancer were significantly older (33 versus 28 years, p=0.016). All patients were first-time referrals. Most patients had a breast lump with low suspicion on clinical examination and breast cancer identified on imaging. Time-to-diagnosis (12 versus 14 days, p=0.017) and time-to-surgery (37 versus 67 days, p=0.012) was significantly shorter in the breast cancer group. Comparative older age (odds ratio [OR]=1.08, 95% confidence interval [CI]: 1.01–1.15) and breast lump (OR=11.43,95% CI: 2.72–48.07) were the only significant predictors of cancer on uni/multivariate regression.
Triple assessment is also the best practice for all patients in the younger age group. This cohort should not be treated any differently regarding one-stop clinic infrastructure as the cancers detected were not clinically malignant. Missed cancers in this age group would have significant personal, clinical, and legal consequences.
Value of a short-term imaging follow-up after a benign result in a one-stop breast unit: Is it still useful?
2017, European Journal of Cancer
Citation Excerpt :
Some studies raised the notion that one-stop breast unit populations might represent a group with a higher risk of breast cancer than the screening population [29]. A global cancer rate of 35% (3815/10,833) was diagnosed in our one-stop breast unit in the study period, much higher than that of other studies, with 6.3% for Cochrane et al. [30], 6.4% for Mehrotra et al. [28], 10% for Patel et al. [31] and 14.7% for Biggs and Ravichandran [29]. Thus, the patient population seen at our one-stop breast unit may not be comparable with general patient population referred in breast imaging centres, as our population is likely to be more at risk of cancer.
A short-term radiologic follow-up after a benign breast biopsy or fine needle aspiration (FNA) is recommended in many guidelines. However, the current trend is to reduce imaging investigations, radiation dose and costs. The objectives of this study were to evaluate the cancer detection rate at short-term follow-up and to estimate its cost.
We retrospectively assessed all consecutive patients referred to our ‘one-stop’ breast unit between 2004 and 2012, with a benign histological or cytological result and at least one short-term follow-up within 3–12 months after the initial diagnosis. We evaluated the number of cancers detected, as well as the mean cost to detect each cancer and per patient.
About 1366 patients were eligible for this study. Ten patients were diagnosed with cancers (0.73%) at short-term follow-up; six of 10 were low-grade tumours or ductal carcinoma in situ. The cost for detecting one cancer was 19,043€, with mean cost per patient of 139€.
The cancer detection rate at short-term follow-up after benign biopsy or FNA was low and was similar to that of most national screening programs. The cost of cancer detection appeared high, considering that most cancers were indolent. This suggests that radiologic follow-up could reasonably be carried out at a later point in time.
Breast clinic triage tool: Telephone assessment of new referrals
2012, Breast
Citation Excerpt :
Recently, breast clinic referrals from general practitioners (GPs) have increased, particularly of those with benign disease,1–4 sometimes representing 81–92% of ‘urgent referrals’.1,2
Efficient systems to triage increasing numbers of new referrals to breast clinics are needed, to optimise the management of patients with cancer and benign disease. A tool was developed to triage the urgency of referrals and allocate the most appropriate clinician consultation (surgeon or breast physician (BP)).
259 consecutive new referrals were triaged using the tool. 100% new cancers and 256 (98.8%) referrals overall were triaged to both appropriate category of urgency and the appropriate clinician.
This triage tool provides a simple method for assessing new referrals to a breast clinic and can be easily delivered by trained administrative staff by telephone.
The approach to diagnosis and assessment of breast lumps
2009, Hughes, Mansel & Webster's Benign Disorders and Diseases of the Breast: Third Edition
Positive impact of a breast-health triaging system on breast-care access and physician satisfaction
2007, American Journal of Surgery
Minority patients are at risk for delayed breast cancer treatment. Using nonsurgical breast specialists could improve access but requires appropriate referral to ensure prompt cancer care. Our objective was to evaluate a referral triage system in a combined medical/surgical breast health program (BHP).
A triage system based on imaging findings, examination, and patient age was instituted. An advanced practice nurse managed referrals and a prospective database. Referring providers were surveyed after 2 years.
From 2003 to 2006, 4,840 referrals were made to surgeons (57%) and nonsurgeons (43%). Breast cancers were found in 8.5% of patients. Referral error occurred in 4 cancer patients (.1%). BHP-referred patients had significantly shorter times to surgical appointment (10 days) than non-BHP referrals (45 days). A referring provider survey indicated 96% satisfaction.
A breast-care triage system expedited cancer care resulting in physician satisfaction and increased referrals.

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^f1: Correspondence to: Miss I. Reid, Tel: 0141-2015454; Fax: 0141-2015117; email: [email protected]

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Originalr ArticleOne stop breast clinics—victims of their own success?A prospective audit of referrals to a specialist breast clinic

Abstract

Eur J Surg Oncol

Consultations for breast disease in general practice and hospital referral patterns

Br J Surg

London: HM Stationery Office

The Patients Charter

Originalr Article
One stop breast clinics—victims of their own success?A prospective audit of referrals to a specialist breast clinic