Assessing the appropriateness of urgent GP referrals to breast clinics in the West Kent region - Correspondence

Abstract

Dear Editor With approximately 50,000 [1] new breast cancer cases in the UK every year, it is the most common cancer in the UK; making up 15% of all new cancer cases. A full-time GP is likely to diagnose 1–2 new breast cancer cases each year. Therefore, it is essential that primary care referrals are appropriately streamlined to minimise the number of inappropriate referrals whilst maximizing the number of appropriate suspected breast cancer referrals. Based on the consideration of this balance, the guideline development group (GDG) guidelines recommend a set of referral symptoms with a positive predictive value of 3% or more. The GDG agreed that the threshold provided enabled accurate and timely management of those with breast cancer whilst minimising risk to those without. For example, evidence suggested that breast cancer in people below 30 years of age is extremely rare and as a result, the GDG recommendation [2] highlighted that if a person is ‘aged 30 and over and has an unexplained breast lump with or without pain’ this should prompt a suspected cancer pathway referral. Despite these guidelines [3], there have been several GP referrals that stray beyond the evidence based two-week-wait proforma. Inappropriate referrals risk reducing capacity within breast clinics and increasing overall waiting time for those eventually diagnosed with breast cancer. We present our findings following the retrospective analysis of primary care referrals to the two-week-wait breast clinic service at Maidstone hospital. The sample size included 100 patients referred within a period of four weeks; patient notes were reviewed following breast clinic attendance. A total of 27 patients referred via the urgent two-week-wait pathway were not in accordance with parameters set by NICE and were therefore, inappropriate referrals. Eighteen (18%) of the total referrals sent showed discordance between the clinical information initially provided and clinical examination findings apparent in breast clinics (see Fig. 1); 9 referrals sent were inappropriate (underage patients) due to discrepancies between the West Kent suspected cancer referral form parameters and the GDG recommendations.Fig. 1.: Comparison of inappropriate referrals sent against total number of referrals.These data demonstrate a discordance between the reasons identified for urgent GP referrals to the two-week-wait breast clinics and guidelines provided by the GDG. The impact is increased workload on breast surgeons and breast services in secondary care. Interestingly, 33% of inappropriate referrals identified were due to discrepancies between the referral form provided by West Kent and NICE guidelines. Evidently, the referral form included the option to select ‘any age’; this accounts for 9% of patients who were ‘underage’ according to the current guidelines. It is therefore important that the West Kent suspected cancer referral form is regularly reviewed and updated in accordance with current guidelines. Most inappropriate referrals received (67%) were a result of incorrect clinical descriptors. Notably, the data showed that some patients were referred due to ‘an unexplained breast lump’ when the actual complaint was revealed to be breast pain. This highlights the importance of providing primary care services with further clarity regarding the most current two-week-wait criteria, as well as stricter inclusion and exclusion referral criteria. Provenance and peer review Not commissioned, internally peer-reviewed. Ethical approval Not required. Sources of funding None. Author contribution All authors contributed to the study design, data analysis and writing of the paper. Registration Unique Identifying number (UIN) 1. Name of the registry: 2. Unique Identifying number or registration ID: 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Guarantor Mr Mohsin Dani (Consultant Breast & Oncoplastic Surgeon, MTW NHS Trust) Declaration of competing interest None.