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GPs should not refer breast pain patients for cancer investigation, say researchers


No link between breast pain and breast cancer, finds large study


GPs can feel ‘reassured’ that they do not need to refer women with breast pain alone for cancer investigation, researchers have said.

A large study, carried out by researchers from Manchester University NHS Foundation Trust, University of Manchester and the University of Exeter, found ‘no association’ between breast pain and breast cancer.

It concluded that referral of women only suffering from breast pain is ‘not cost-effective and may cause delay for women with higher-risk symptoms’.

And researchers said the results should ‘prompt a review of health policy for the care of women with breast pain alone’.

The analysis, of 10,830 symptomatic women referred to a breast cancer diagnostic clinic over a year, found that only 0.4% of the women with symptoms of breast pain actually had breast cancer.

Of the 10,830 women, 18% had breast pain, 62% had lumps, 4% had nipple symptoms and 15% had other symptoms. 

The paper, published in the British Journal of General Practice (BJGP), said: ‘Of the 1,972 women with breast pain, breast cancer incidence was 0.4% compared with ~5% in each of the three other clinical groups.

‘Using “breast lump” as reference, the odds ratio of women referred with breast pain having breast cancer was 0.05 (95% confidence interval = 0.02 to 0.09, P<0.001).’

There has been almost a 100% increase in referrals over the past 10 years, the researchers noted, with recent audits showing that women referred with breast pain account for more than 20% of attendees to breast outpatient services.

The researchers commented: ‘Breast pain is common and is not a presenting symptom of breast cancer. Women and GP should be reassured of this finding, there is no need for routine referral of women with breast pain to a cancer diagnostic clinic.’

Exeter GP and professor of primary care diagnostics at the University of Exeter Professor Willie Hamilton told Pulse the study suggests there is ‘little to be gained by putting these women through all the testing for cancer’ but that it ‘does not mean’ referral is ‘necessarily wrong’.

He said: ‘If the woman is fearful their mastalgia augurs cancer, GPs have now a solid basis for reassurance (assuming there’s no accompanying high-risk features). Referral may still be helpful as mastalgia can be a ghastly complaint, and specialist input may help.’

Professor Hamilton said this ‘suggests the optimum specialist pathway is a clinic for mastalgia, quite separate from the cancer pathway.’

East London GP and researcher at King’s College London Dr Thomas Round told Pulse GPs may want to use advice and guidance, as well as patient contact to go through self-examination and ‘safety net for worrying clinical features like breast lumps, which would require an urgent referral’.

And RCGP vice chair Dr Gary Howsam said the study results should ‘reassure patients suffering solely with breast pain, that it is unlikely to be a sign of cancer’.

He said: ‘Medical research, such as this, is vital to improving the timeliness and accuracy of cancer diagnosis. 

‘As such, it’s important that this research is considered when clinical guidelines are developed or updated, so that GPs are confident they are making decisions about whether a referral is required, based on the latest evidence.

‘Overall, GPs are doing a good job at identifying cancers and referring appropriately with around 75% of cancers being diagnosed after just one or two GP consultations – what would help further is better access to diagnostics in the community, and the appropriate staff and training to use them.’

It comes as a trust recently reported 40-day indicative waits for urgent breast cancer referrals.

And the Government suggested patients who think they may have cancer could self-refer for investigation without the need for a GP referral.

NICE guidance for breast cancer diagnosis

1.4 Breast cancer

1.4.1 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

  • aged 30 and over and have an unexplained breast lump with or without pain or

  • aged 50 and over with any of the following symptoms in one nipple only:

     

    • discharge

    • retraction

     

  • other changes of concern. [2015]

1.4.2Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

  • with skin changes that suggest breast cancer or

  • aged 30 and over with an unexplained lump in the axilla. [2015]

1.4.3Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain. See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice. [2015]

Source: NICE

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READERS' COMMENTS [8]

The Prime Minister 22 February, 2022 9:35 am

Will the researchers support GPs in GMC hearings? I don’t think so. Many so called researchers have a very poor understanding of real life presentations. If I had always followed algorithms Various patients would have lost out over the years.

Charles McEvoy 22 February, 2022 11:19 am

18% of women had breast pain. Thats nearly 2,000 women frightened they had cancer when they presented. All of these had a reason why their GP felt they could not, or should not, reassure and send away. 0.4% of these women actually had cancer. Small number? 8 patients. Maybe not cost effective, but that is 8 early diagnoses that would not otherwise have been made, and 8 potentially huge legal payouts avoided, and 16 families whose lives have not been ruined – 8 women and 8 GPs who have not had to face any of this trauma. And 2,000 women reassured; women who would doubtless have re-presented at their GP multiple times, the cost of which is never, ever included in these hospital/NHS-centric analyses, because GP appointments remain essentially free to the NHS.

Michael Staite 22 February, 2022 12:27 pm

So, at same time as “Patients could self-refer for cancer investigations, suggests Government consultation”, we are told not to refer. Interesting.

Patrufini Duffy 22 February, 2022 3:25 pm

Sajid wants 10 million people to come forward. Let them come. It’s free. Who cares about guidelines anymore? Just get them in and off your case. Isn’t that the NHS message, “patient choice agenda”. And “right to complain”. Funny that researchers can’t get struck off, they just blurt stuff out, but don’t need to deal with the drivel.

Slobber Dog 22 February, 2022 4:40 pm

‘GPs can feel reassured’ , (which is doubtful), but will the patient ?

Thomas Robinson 23 February, 2022 8:53 am

“This concern is reinforced in secondary care by breast clinicians requesting investigations such as mammography on women presenting with breast pain alone,”

So the lady has a one in 250 chance.

This is a RCGP ! paper, but no mention of asking whether she wants a referral.

The specialist who will be called as an expert witness, would scan, but the idea is the GP, should not refer in the first place, because the expert will scan, and the researchers who never see the patient feel this is wasteful.

Thomas Robinson 23 February, 2022 12:06 pm

“Of women attending the current authors’ breast clinic with breast pain alone, 83% underwent imaging investigations in accordance with national guidance”

Forgive me editor but I think your title, article and interpretation, of this paper is fundamentally incorrect.

I propose the authors are suggesting national guidance should be changed, not that GP’s themselves should change their practice, which would according to the above statement, be in contravention of national guidelines and the authors own current practice.

Nadia Lone 23 February, 2022 12:43 pm

In Primary Care we already keep many patients out of hospital. If we do refer for breast pain it’s usually because we are concerned and need some extra advice and reassurance and often it is because the patient is very concerned or we have already followed them up in the community, surely that’s what specialists are helpful for?……if there anything else we should do in 10 minutes….a solution for world peace???