NICE guidelines

The National Institute for Health and Care Excellence (NICE) and Healthcare Improvement Scotland (HIS) produce guidelines for GPs to help them decide when specialist referral is appropriate.

According to the NICE 'suspected cancer pathway referral' breast cancer patients should be referred for an appointment within two weeks if they are aged 30 and over and have an unexplained breast lump with or without pain, or if they are aged 50 and over and have symptoms of discharge, retraction or other changes of concern in one nipple only.

Other circumstances where referral should be considered include where there are skin changes that suggest breast cancer or the patient is 30 and over with an unexplained lump in the axilla. Non-urgent referrals should be considered in patients under 30 with an unexplained breast lump with or without pain.

The situation is slightly different in Scotland, where a doctor should offer a specialist referral if a patient is over 35 and has a new breast lump, a swollen lymph node in the axilla or if they are over 35 and have nodularity of the breast that does not resolve following menstruation, if they have a cyst that does not resolve, nipple changes (including blood stained discharge) or an eczema-type rash which does not respond to steroid treatment. Patients should also be referred if they are over 35 and have skin changes on the breast or inflammation in the breast which does not respond to antibiotics.

Risk factor

The risk of developing cancer rises as a patient gets older, with only two out of every 100 women being diagnosed with breast cancer under the age of 35, and four out of every 100 women being diagnosed with breast cancer under 40. As well as age, other risk factors for developing breast cancer include genetics (family history) and certain potentially avoidable lifestyle factors.

Oestrogen exposure is the main potentially avoidable risk factor (oral contraceptives, some forms of hormone replacement therapy, ionising radiation and diethylstilbestrol use in pregnancy), along with other risk factors such as obesity (9% of breast cancers), alcohol use (6%) and certain occupational exposures (5%). Breast feeding and physical activity are protective against breast cancer.

According to Cancer Research UK there were 55,222 new cases of invasive breast cancer in 2014 in the UK and 11,433 deaths. Five year survival is 85% and 10 year survival rates for females with breast cancer in England and Wales in 2010 to 2011 was 78%. It is thought that 27% of cases of breast cancer in the UK are preventable, being linked to major lifestyle and other risk factors.

Summary

Breast cancer is a common disease where patients have a better prognosis if they are referred to specialist services early on, and doctors need to be familiar with the referral guidelines and ensure that they apply these unless there is a good reason not to.

As part of their assessment to see whether a patient fulfils the relevant referral criteria, doctors need to take a full history and make a detailed record of this and their examination findings. This should include any relevant negative responses to questions or relevant negative examination findings.

There were a number of files where relevant information had not been recorded, and therefore it was not clear if this information had been asked. One solution may be for doctors to use a standard template when assessing patients with breast symptoms to ensure they capture all the relevant information required to make an appropriate and timely referral. While the use of a template would not be a substitute for clinical judgement, it may help to ensure that the history and examination are thorough and comprehensive.

Breast cancer advisory complaint analysis

Breast cancer advisory complaint analysis ad 1

Breast cancer advisory complaint analysis