Breast Referrals Research Articles

Community breast pain clinics can provide safe, quality care for women presenting with breast pain.

Breast pain is not typically a symptom of breast cancer, yet nationally 20% of 2-week wait (2WW) breast referrals are breast pain alone. The East Midlands Breast Pain Pathway improves patient experience and frees capacity in secondary care diagnostic breast clinics, managing women with breast pain only in a community setting. We report the results of implementation of community breast pain clinics (CBPCs) at sites in Derbyshire (catchment population ~1 million), with 12 months follow-up data. 1036 patients were seen at CBPCs between June 2021 and February 2023. The median patient age was 49 (range 16-88) years. 993 patients (95.8%) were discharged from the clinic with breast pain management advice. 43 (4.2%) patients were referred for further assessment at a 2WW breast diagnostic clinic. Objective family history risk assessment identified 124 patients (12.3%) above population risk of breast cancer, who were offered referral to familial cancer services for ongoing management. Seven patients were diagnosed with breast cancer at or within 12 months of CBPC attendance. Five patients were diagnosed through attending the CBPC, one patient was subsequently referred to 2WW clinic with a new symptom and had a mammographically occult tumour and one was diagnosed following a subsequent routine breast screening invitation. Two of the five patients had a personal history of breast cancer which was a stated exclusion criterion for the CBPC. Breast cancer incidence in women with breast pain only and fulfilling CBPC referral criteria was 4.8/1000, confirming that this population is at low risk of developing breast cancer.Patient service satisfaction was high with 99% (n=1022) 'extremely likely or likely' to recommend the service. The results confirm the pathway is the first to demonstrate women can be safely managed with breast pain alone in a community setting with high levels of patient satisfaction.

Evaluation of a pilot of a community virtual triage for breast symptoms outside of usual primary or secondary care pathways.

Both primary and secondary care services in the NHS have been overwhelmed with an increase in referrals on the suspected cancer pathways. The years 2020/2021 saw 551,770 symptomatic breast referrals made in England alone. The Wessex Rapid investigations service in conjunction with the local district general hospital and primary care networks instigated a virtual triage for new breast symptoms. Over the course of a year, 664 people were assessed by either telephone or video using specially trained nurses. Appointments were given within 1-2 working days. The service was highly valued by patients and general practitioners. We were unable to confirm a reduction in referral to secondary care as the evaluation occurred during a postpandemic peak in referrals. We found that 10% of patients with new breast symptoms can safely self-manage. This percentage varied with the experience of the triage clinician. A specialist community face-to-face service could reduce further the need for full secondary care evaluation. Better integration and use of information technology systems would improve the service. The rapid responsiveness and length of consultations is valued by patients. Representation with the same symptoms was rare. This pathway utilises staff outside of the usual primary and secondary care providers and thus reduces the pressure on stretched systems.

A Retrospective Audit of the Triage Process Introduced for Breast Referrals Received During the Covid-19 Pandemic

PurposeDue to restrictions on breast clinic appointments during the Covid-19 pandemic, a triage process was introduced for new patient referrals. The robustness of this process was examined by analysing the incidence of cancer diagnosis and wait times to treatment. MethodsPatients were triaged by secondary care consultant surgeons to an urgent appointment if they had high-risk symptoms based on prespecified guidelines eg, a lump or previous cancer. Those with non-urgent symptoms were seen on a deferred basis. A retrospective audit of patients referred between March 23 and July 20, 2020 was performed, to investigate incidence of cancer, concordance of primary and secondary care diagnosis, and the wait times to first appointment. ResultsMost patients with breast-related symptoms received a face-to-face appointment (69%) with a Primary Care Physician (PCP) or Nurse Practitioner (NP), with 544 (31%) having a telephone PCP/NP appointment. Of 2023 patients, 1461 were triaged by the receiving breast unit to an urgent appointment, 461 to a deferred appointment and 101 to a breast pain telephone clinic. A diagnosis of breast cancer was made in 111/1461 (7.6%), 5/461 (1.1%) and 0% in these triaged groups respectively, and the median wait time to first appointment was 14 days (range 1-94), 32 days (range 6-114) and 21 days (range 10-52, P < .001). ConclusionThe one-stop triage process was safe, with statistically fewer cancer diagnoses in patients allocated a deferred appointment, at a rate similar to that seen in a screening population.

Evaluating a novel patient pathway to manage symptomatic breast referrals (the blue flag clinic): a longitudinal observational study.

A novel referral pathway for exhibited breast symptom (EBS) referrals to manage increasing referrals of urgent suspected cancer (USC) was implemented in our trust. We report on the safety and effect on compliance with the 2-week-wait rule (2WW). A single-centre longitudinal observational study included all patients referred to a UK breast unit during 13 May 2019 to 27 March 2020 (period 1) and 8 February 2021 to 31 January 2022 (period 2). USC referrals were assessed in a one-stop clinic (red flag clinic [RFC]); EBS referrals were assessed in a new clinic in which clinical evaluation was performed and imaging occurred subsequently (blue flag clinic [BFC]). Patients were followed up to determine the symptomatic interval cancer rate. There were 9,695 referrals; 1,655 referrals (17%) were assessed in the BFC after 63 exclusions. Some 95.9% of patients had a benign clinical examination (P1/P2), 80.1% had imaging (mammogram or ultrasound) and 4% had a tissue biopsy. In total, 16/1,655 (0.97%) BFC patients and 510/7,977 (8.2%) RFC patients were diagnosed with breast cancer (breast cancer detection rate). Some 1,631 patients (with 1,639 referrals) were discharged and followed up for a median of 17 months (interquartile range 12-32) with one subsequent cancer diagnosis (symptomatic interval cancer rate, 0.06%). Implementation of the BFC pathway increased 3-month average trust performance of USC referrals with 2WW standard from 8.5% to 98.7% (period 1) and from 30% to 66% (period 2). The BFC pathway for EBS patients is safe and implementation led to improvement against the 2WW target for USC referrals, ensuring resources are prioritised to patients with the highest likelihood of breast cancer.

A Study Evaluating the Accuracy of Triage for Breast Referrals During the Covid-19 Pandemic in a Tertiary Hospital.

To evaluate the accuracy of breast referral triage during Covid-19. Retrospective case study. Primrose Breast Unit, Derriford Hospital, Plymouth. From March 17th to June 30th to encompass the height of the pandemic and the early enforced changes to practice. All referrals received, triaged, and seen (n = 870) in the unit, identified by referral records. The primary outcome measure of a positive disease state was of a histological diagnosis of cancer, with the absence of a cancer diagnosis representing a negative disease state. Accuracy has been determined by sensitivity and specificity calculations; thus defined by correctly triaging cancers to face-to-face clinics and benign cases to telephone or video clinics. Sixty-eight cancers (7.8% of referrals) were detected after initial triage and consultation, of which 51 (sensitivity = 75%) were triaged to one-stop-clinic; positive predictive value was 18.89%. Eight hundred two (specificity = 72.69%) of benign cases were triaged to phone or video clinic initially; negative predictive value was 97.15%. Comparing the study's incidence of cancer (7.8%) to the preceding year's (2019) of 6.8% with Yate's correction shows no significant difference (p < 0.05). Triage accuracy is sufficiently robust to diagnose cancer promptly, which should reassure clinicians and decision makers within the cancer networks.

Male breast referrals and gynaecomastia blood tests - A closed loop audit against ABS guidance

Male breast referrals and gynaecomastia blood tests - A closed loop audit against ABS guidance

Evaluating the blue flag clinic - A novel patient pathway to manage symptomatic breast referrals

Evaluating the blue flag clinic - A novel patient pathway to manage symptomatic breast referrals

Blue flag clinics – a Quality Improvement project to reduce referral pressure on breast surgery 2 week wait service

Introduction: The breast cancer urgent suspected cancer referral pathway is under unprecedented pressures. A Quality Improvement project implemented a new triaging criterion of 2 pathways; red flag (suspected breast cancer referral; same day triple assessment within 2 weeks) and blue flag (symptomatic breast referral; clinical assessment within 2 weeks and uncoupled imaging if required). This evaluation assesses whether the blue flag clinic reduces imaging and its safety.

287 Retrospective Review of a Single Surgeon 5-Year Experience of Paediatric Breast Reconstruction - Challenges, Experience, and the Increasing Role of Lipofilling

Abstract Aim This case series reviews the presentation, clinical and surgical management of paediatric breast cases undertaken by a single surgeon. The series demonstrates the powerful role of lipomodelling when used with breast reshaping techniques to achieve good outcomes and avoid the need to commit young patients to breast implants. Method Retrospective analysis of paediatric breast referrals to a single surgeon at a regional plastic surgery breast reconstruction unit over a 5-year period. Results In a 5-year period, 15 cases which presented in childhood to a tertiary paediatric centre were referred on to our regional plastic surgery breast reconstruction unit. Two patients underwent correction of breast hypoplasia secondary to Poland's syndrome. Nine patients presented for breast asymmetry with associated tuberous deformity. One patient had maldevelopment of a breast secondary to a burn's contracture. Two patients presented with gigantomastia and one patient with juvenile fibroadenomas. Conclusions Paediatric breast abnormalities represent a small but important caseload for a breast reconstructive surgeon. This case series demonstrates the need for careful assessment and an individualised surgical plan for each patient. The surgical plan must achieve a satisfactory outcome whilst minimising the need for further procedures as the patient grows. It is the senior surgeon's preference to avoid breast implant-based reconstruction where possible. In all but one case lipomodelling combined with reshaping of the native tissue was used to good effect.

The role of virtual clinics in the assessment of non-urgent breast referrals: A useful tool in a post pandemic era?

Introduction: During the COVID-19 pandemic virtual clinics (VC) were widely rolled out amongst all specialties, in order to maintain key services, while avoiding unnecessary face-to-face (FTF) contact. We assessed the validity/safety of using a VC to assess non-urgent referrals to the breast service.

Breast pain: Releasing capacity on the 2WW symptomatic service

Introduction: In the UK there are 560,000 symptomatic breast referrals annually, and this is continuing to rise. Approximately 20% of all referrals to one-stop breast clinic in the UK are related to breast pain. We investigated whether a 'Non-urgent Mastalgia Clinic' would be a safe and feasible option to relieve the pressure on the symptomatic service.

Developing an effective triaging algorithm for breast referrals

Background: Nationally, a significant increase in referrals has created unsustainable pressure on breast services. Radiology shortages have compounded this, reducing availability of triple assessment appointments. Despite revising our regional 2WW referral form, increasing primary care education and improving access to online advice and guidance, demand continued to outstrip supply. We developed a triaging algorithm to identify patients at higher risk of breast cancer based on a retrospective analysis of referrals. High risk patients were directed to a one stop hot clinic. The remaining patients attended cold clinic for clinical assessment and delayed imaging was requested as required. All referrals were seen within two weeks and their outcomes analysed.

Assessing the impact of a gynaecomastia assessment and treatment infographic in primary care in Greater Manchester.

Men with gynaecomastia are routinely referred to breast clinics, yet most do not require breast surgical intervention. The aim of this study was to assess the impact of a novel point-of-care gynaecomastia decision infographic in primary care on the assessment, management and referral practices to tertiary breast surgical services. A study was carried out of male patient referrals from primary care in Greater Manchester to a tertiary breast centre between January and March in 2018-2020. Referral patterns were compared before and after the infographic went live in general practices in Greater Manchester in January 2020. Data were collected for gynaecomastia referrals, including aetiology, investigation and management. In total, 394 men were referred to a tertiary breast centre from 163 general practices, of which 271 (68.8%) had a diagnosis of gynaecomastia. Use of the decision infographic by primary healthcare providers was associated with a decrease in male breast referrals with gynaecomastia (79.6% to 62.0%). Fewer gynaecomastia patients were referred with a benign physiological or drug-related cause after implementation of the infographic (52.2% vs 41.8%). Only 10 (3.7%) patients with gynaecomastia underwent breast surgery during the study period. Implementation of a gynaecomastia infographic in primary care in Manchester was associated with a reduction in gynaecomastia referrals to secondary care. We hypothesise that implementation of the infographic into primary care nationally may potentially translate to hundreds of patients receiving more specialty-appropriate referrals, improving overall management of gynaecomastia. Further study is warranted to test this hypothesis.

Virtual clinic triage of breast referrals during the COVID-19 pandemic: retrospective outcome analysis.

Virtual clinic triage of breast referrals during the COVID-19 pandemic: retrospective outcome analysis.

TP8.1.9 Effect of Covid 19 on breast referrals from GP

AimCoronavirus disease 2019 (COVID-19) has put a strain on regular healthcare worldwide. This study shares a DGH experience of effect of covid 19 on breast referrals from GP.MethodsIt is a single centre retrospective comparative study to analyze the effect of Covid 19 on breast referrals during the pandemic.Patients referred under TWR from 15th march to 15th July 2020 were included and a comparison was made with March to July 2019. The primary outcome was number of referrals and number of cancer diagnosis.Secondary outcomes were breach in 62 day pathway.ResultsIn Covid pandemic, 1231 symptomatic patient were referred under TWR, of which 91 (7.4%) were diagnosed with breast cancer. There were 22 (24%) 62 days breaches.Comparing this with similar 4 months in 2019 there were 1826 symptomatic patients referred under TWR of which 131 (7.1%) diagnosed with cancer. There were 34 screen detected cancers as well. There were 28 (21%)62 day breaches.The reduction in GP referral was 32%.ConclusionThere was an overall decrease in number of patients referred from GP but cancer diagnosis remained almost same for symptomatic patients since TWR pathway carried on with telephonic clinics & assessments at nearby closed screening centres.

SP8.1.3 Primary care practitioners have a high level of satisfaction with the current breast referral pathway but the majority would support a change to patient self-referral

AimsCurrently, patients must consult with a primary care practitioner (PCP) prior to being referred to specialist breast services. A change to patient self-referral would arguably reduce primary care workload, improve access for patients, and allow breast units to allocate resources more appropriately; no data currently supports this. This study aims to explore PCP’s views on breast referral, evaluate the community breast workload, and to investigate the impact of COVID-19 on referral rates.MethodsAn electronic survey was sent out to PCPs in South West England via two electronic newsletters. Participants were asked: their role and gender, their level of confidence surrounding breast care, details surrounding their breast workload, how they felt COVID-19 had affected their referral rates, their level of satisfaction with the current pathway, and their opinions on a potential change to patient self-referral.Results79 responses were received. PCPs estimated that 7.0% (median) of their total consultations were regarding a breast-related issue and that COVID-19 had not had a significant impact on the rate of referral to breast units (P = 0.75). 84.8% of PCPs had a high level of satisfaction with the current referral pathway. Whilst 74.5% felt a change to patient self-referral would benefit patients and primary care services, their free text comments highlighted some of their reservations.ConclusionsPCPs have a high level of satisfaction with the current breast referral pathway, but the majority would be open to a change to patient self-referral to specialist breast units.

46 Primary Care Practitioners Have A High Level of Satisfaction with The Current Breast Referral Pathway but The Majority Would Support A Change to Patient Self-Referral

AimCurrently, patients must consult with a primary care practitioner (PCP) prior to being referred to secondary care breast services. A change to patient self-referral would arguably reduce primary care workload, improve access for patients, and allow breast units to allocate resources more appropriately; no data currently supports this. This study aims to explore PCP's views on breast referral, evaluate the community breast workload, and to investigate the impact of COVID-19 on referral rates.MethodAn electronic survey was designed on SurveyMonkey.com which aimed to collect both quantitative and qualitative data. The weblink to the survey was sent out via two electronic newsletters. Participants were asked: their role and gender, their level of confidence surrounding breast care, details surrounding their breast workload, how they felt COVID-19 had affected their referral rates, their level of satisfaction with the current pathway, and their opinions on a potential change to patient self-referral.Results79 responses were received. PCPs estimated that 7.0% (median) of their total consultations were regarding a breast-related issue and that COVID-19 had not had a significant impact on the rate of referral to breast units (P = 0.75). 84.8% of PCPs were satisfied with the current referral pathway. Whilst 74.5% felt a change to patient self-referral would benefit patients and primary care services, their free text comments highlighted some of their reservations.ConclusionsPCPs have a high level of satisfaction with the current breast referral pathway, but the majority would be open to a change to patient self-referral to specialist breast units.

900 Effects Of COVID-19 Pandemic Restrictions on the 2ww Breast Referrals in A UK Specialist Breast Service

Abstract Aim Recommendations were issued to the hospital Trusts to configure service delivery to balance cancer care with patient and hospital staff safety during the COVID-19 pandemic. It was felt the service restrictions might lead to delays in diagnosis and treatment of cancer patients. We conducted an audit to compare 2ww breast referrals in our center between May to July of 2019 and 2020. Method We triaged all referrals to face-face consultation or telephone consultation in our center during the pandemic. Patients with suspicious symptoms were offered face-face consultation after the telephone triage. Results Data analysis showed that the referrals fell by 28.3% (N 1569 versus N 1125). The largest reduction was noted in May (34.4% versus 24.2%). Mean waiting time in 2019 was 19.86 (± 7.14) and 11.43 (± 3.48) in 2020. The proportion of patients referred for suspected breast cancers increased across all age groups in 2020 (range +10.4% to 16.2%). Significantly more breast cancers were diagnosed in 2020 (7.1% versus 5.1%). No breast cancer was diagnosed in under 25 patients. 29.1% of the 522 patients telephoned were discharged, and others were seen in the clinic. Conclusions The COVID-19 infection’s management caused a fall in 2ww referrals and shortened waiting times but increased breast cancer diagnosis. Many 2ww referrals during the COVID-19 infection were unnecessary. The telephone consultation reduced waiting times but may have deferred clinic visitation for most patients.

Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic.

The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management. COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk. Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages. Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer. A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

P083. A retrospective audit of the triage process introduced for breast referrals received during the COVID-19 pandemic

Introduction: Due to restrictions on breast clinic appointments during the COVID-19 pandemic, a triage process was introduced for new patient referrals. The robustness of this process was examined by analysing the incidence of cancer diagnosis and wait times to treatment.