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The right referral for breast conditions

In the first of two articles, breast cancer specialist Professor Ian Fentiman suggests how GPs can achieve a tricky balance when referring to breast clinics

In the first of two articles, breast cancer specialist Professor Ian Fentiman suggests how GPs can achieve a tricky balance when referring to breast clinics

For the GP confronted with a patient complaining of a breast problem, the aim should be to perform triage: identify those who need hospital referral, reassure some without further investigation and for a third group, arrange subsequent reassessment. This apparently simple task can be difficult to achieve.

Partly as a result of Government edicts, and also after reports of heavy payouts for litigation for delay in diagnosis of breast cancer, a minority of GPs refer all patients with breast problems to a clinic, sometimes without an examination. This is bad medicine: it causes significant patient distress and has financial costs for both the individual and the NHS, specifically the PCT. At present, fewer than half the patients with symptomatic cancers are referred as urgent cases, so diagnosis is delayed by misclassification.

How common are breast symptoms?

In a series of over 20,000 primary care consultations, reported by the Women's Concerns Study Group, breast symptoms were mentioned in 6% and concerns about breast cancer risk discussed in a further 4%. With one in 10 of consultations with female patients involving a breast concern, this is a significant proportion of GPs' workload.

The medicolegal position

The key legal test of breach of duty in medicolegal cases is the Bolam principle – has the doctor acted in accordance with the practice accepted as proper by a responsible group in the profession skilled in that particular art? The most common ways in which this is breached in patients with breast symptoms are either a failure to carry out a clinical examination, or to record that it has been performed. Although the principles of history taking and clinical examination are instilled at medical school, the passage of time and constant pressure of overfilled surgeries can erode these building blocks of a successful consultation.

Delaying referral

Another concern is that any delay will lead to a significant worsening of outcome for a patient with breast cancer. This is biologically implausible. Even among younger women, some of whom will have rapidly proliferating cancers, the tumour volume doubling time will usually be in excess of 60 days.

Although some studies have indicated that a three-month delay has an impact on prognosis, most medicolegal cases decided in favour of the complainant have involved a delay in excess of six months.

This means that a decision to evaluate a premenopausal woman with an equivocal finding ‘is it a lump, or lumpiness?' two weeks later in a different phase of her menstrual cycle will be regarded as a completely appropriate form of management.

In the context of an organ subject to the effects of hormones, both endogenous and exogenous, and that frequently changes in response to hormones, a delay of two weeks will save many patients from what turns out to be an unnecessary hospital visit. At the same time for those in whom an abnormality persists or enlarges, the delay will not affect the outcome if a malignancy is diagnosed.

Effective examination

Ensuring that patients with true breast abnormalities are referred is the other part of GPs' tricky balancing act.

To maximise the chance of finding breast abnormalities, the patient should be examined lying on a couch with the head elevated to 45% in a warm, well-lit room. The patient should be asked to place her finger on the lump and then requested to raise her arms to determine whether there is any dimpling at that site.

Because the greatest amount of breast tissue is located in the upper outer quadrant, most lumps will lie there. Sometimes the examiner will be unable to feel any lump while the patient is lying on her back and by subsequently asking her to turn half towards or away, so the upper outer quadrant can be more easily palpated and small lumps then become more obvious.

It is the failure to carry out this key part of breast examination that has helped some lawyers educate their children privately.

What should be done if a breast lump is found?

Age is a powerful indicator of the likely diagnosis. Any woman aged over 50 with a lump is likely to have breast cancer and requires urgent referral. In those unusual individuals taking HRT at that age some may have cysts rather than cancer but still need rapid evaluation.

A lump in a woman under 25 is most likely to be a fibroadenoma, unless she is lactating when it may be a galactocoele. Although a clinical diagnosis of fibroadenoma is reasonable, it is mandatory that this is confirmed by triple assessment (specialist examination, ultrasound and fine needle aspiration cytology) – but this does not have to happen urgently.

It is in the 25-50 age group that there is the greatest uncertainty about the likely cause of a breast lump and these patients make up most breast clinic referrals. In most cases, the lump is localised nodularity that has often resolved by the time the patient attends the hospital. Unless the patient has a lump with signs of attachment (skin dimpling with or without moving the lump), a two-week delay followed by reassessment will free some from an unnecessary hospital visit.

It is essential that any abnormality is recorded, preferably on a simple diagram with dimensions so that if the second examination is carried out by a different GP they will be able to determine whether the clinical signs have changed in the abnormality. Persistence or increase in size of the lump should provoke hospital referral.

Professor Ian Fentiman is professor of surgical oncology at Guy's, King's and St Thomas' School of Medicine, London

delay in breast referral

Although some studies have indicated that a three-month delay has an impact on prognosis, most medicolegal cases decided in favour of the complainant have involved a delay in excess of six months.

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