Transcript Two week rule for breast

Tracey Irvine
Consultant Oncoplastic Surgeon
Clinical Director Breast Unit
Overview
 Current pathways
 The reality
 The future
 Room for improvement
 Other referrals
Current pathways
 1995 Guidelines for urgent breast referral introduced
 2000 DOH rolled out to other tumour sites
 2005 Taken under auspices of NICE
 2007 Concerns – majority diagnosed outside TWR
 2010 Breast becomes two weeks for all (excludes
cosmetic and family history)
TWR guidelines
RSCH breast referral form
WE AIM TO SEE ALL SYMPTOMATIC PATIENTS WITHIN 2 WEEK
Family History assessments and Cosmetic referrals will be seen routinely.
Patient Name:
DOB:
Address:
GP Name:
Surgery Address:
Mobile/Home preferred number for
appointment:
Telephone:
NHS No:
RSCH breast referral form
R
L
Thickening
Lump
Skin change
Nipple change
Discharge
Blood stained
Pain
Other information………………………………………………………………………………..
Previous Mammogram
Yes No
Where?................. When? …………………
Signature of referring doctor:…………………………………//……...Date:…………………
RSCH referral form
 Fax to:
 Email to:
01483 406632
[email protected]
 Post to: Breast Unit, OPD 13, RSCH, Egerton
Road, Guildford GU27XX
The reality – all referrals
2010
2011
2012
2013
2014
908
820
796
1877
2539
Referrals per 17.5
week
15.8
15.3
36.1
48.8
Cancers
85
99
71
139
160
Conversion
rate
9.4
12.1
8.9
7.4
6.3
Referrals
TWR vs. Symptomatic
2010
2011
2012
2013
2014
Referrals
382/526
369/451
353/443
709/1168
1010/1527
Referrals per
week
7.3/10.1
7.1/8.7
6.8/8.5
13.6/22.5
19.4/29.4
Cancers
69/16
68/31
48/23
84/55
94/66
Conversion
rate %
18.1/3
18.4/6.9
13.6/5.2
11.8/4.7
9.3/4.3
Remember…
 The bean counters are only asked to count cancers
 Any discrete lump at any age should have a diagnosis
even if benign
 There are many breast problems that benefit from a
breast specialist opinion
 We are here to help!
What is my reality?
The future - NICE guidance
 Bring down threshold to 3%
 Looked at evidence – PPV of various symptoms
 Guidelines same for women and men
 Same for patients with a previous history of breast
cancer
 They think this will reduce referrals……
NICE guidance
 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. [new 2015]
 PPV approx 10% (approaching 50 % in over 70s)
NICE guidance
 Refer people using a suspected cancer pathway referral
(for an appointment within 2 weeks) for breast cancer
if they are aged 50 and over with any of the following
symptoms in 1 nipple only:
 discharge or
 retraction or
 other changes of concern. [new 2015]
 PPV 2-5%, over 10% in over 70s
NICE guidance
 Consider a suspected cancer pathway referral (for an
appointment within 2 weeks) for breast cancer in
people aged 30 and over with an unexplained lump in
the axilla. [new 2015]
 PPV felt to be over 3% by the panel
No breast pain?
 A lump in the breast is painless
 We will still find cancer in these patients –
opportunistic screening – PPV <2%
 Reassure, reassure, reassure
 Bra fitting, topical anti-inflammatory gel
No skin changes?
 Felt to be a soft symptom, not clear in the studies
 Better guide in combination with a lump
 If in doubt - refer
Room for improvement - admin
 DNA rate up to 6% - mostly new patients
Patient contact number!!!!!!!!
 NHS number
 Holidays
Please note….
 TWR is two weeks from date of receipt of referral
 You cannot refer TWR to Jarvis – they will be bounced
 You cannot refer directly to breast imaging – they will
be bounced
 We will see young girls but not young boys (paeds)
Please note…
 Referral for mammographic follow up is not a TWR!
 Ultrasound is not a screening tool
 If they were assessed at the Jarvis 6 months ago – send
them back…and vice versa
 If they are about to go on holiday do not send as TWR
 Please book the students as C&B
What is unlikely to be cancer
 17 year olds with breast pain – or with anything….
 Nipple eczema – please complete the course of topical
treatment – not if over 70
 Implants changing shape – or causing anxiety…
 Sebaceous cysts
Paget’s
Other referrals – family history
 Dedicated weekly CNS run family history clinic
 One FDR under 40, 2 close family members (one FDR)
any age, one breast and ovarian cancer
 Ashkenazi Jewish or Polish* ancestry (*and family
history)
Family history screening
 We will arrange this if the patients come through the
family history clinic here
 Jarvis will arrange this if the patients come through the
family history clinic there
 BRCA patients – we will look after them – screening
with mammogram and MRI through Jarvis
Breast abscesses
 Lactating breast abscesses – all sensitive S Aureus
 Non lactating – mostly S Aureus, smokers – broader
spectrum
 Breast feed – support – Kate Rosati
 Refer early to us!
Cosmetic
 Not two week referrals
 Consider private centre
 BMI < 26, non smoker, over 19, Bra fitting
 Funding – BBR – 500g tissue each side (surgeon),
documented evidence back pain and failure of
treatment
The boys
 300 male breast cancers per year
 Young boys do not get breast cancer
 Treatment with hormonal therapy only in early
glandular changes
 No funding for surgery
Missed referrals
 Delay in diagnosis commonest cause of non cosmetic
litigation
 Failure to refer – repeated presentations
 Failure to do true triple assessment
 Inflammatory breast cancers
Other patients
 Previous cancers – usually call BCNs
 Topical oestrogen is fine – low systemic absorption
 Advice – happy to help
 But how we can really improve…..
Metastatic patients – first 6
months
5
5
4
4
3
3
2
2
1
1
0
A&E
Routine follow Expedited
up (eg, raised follow up via
markers)
BCN
GP referral
Other medical
team
Contacts – please call!!
 Breast office email: [email protected]
 Breast Office fax – 01483 406632
 My PA – Connie – 01483 402743, [email protected]
 BCNs – Primary – 01483 406624, Secondary – 01483
406844
Summary
 You already do a good job
 Breast symptoms are non specific
 NICE wants you to refer more – not less
 Refer the over 70s
 Think metastatic
 Call us if in doubt...
 If you do one thing – get a contact number for the
patient