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Goh NM, Simonca C, Verroiotou M, Jenkins S. A Study Evaluating the Accuracy of Triage for Breast Referrals During the Covid-19 Pandemic in a Tertiary Hospital. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:409-414. [PMID: 37638330 PMCID: PMC10457637 DOI: 10.1089/whr.2023.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/29/2023]
Abstract
Objective To evaluate the accuracy of breast referral triage during Covid-19. Design Retrospective case study. Setting 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. Participants All referrals received, triaged, and seen (n = 870) in the unit, identified by referral records. Main Outcome Measures 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. Results 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). Conclusion Triage accuracy is sufficiently robust to diagnose cancer promptly, which should reassure clinicians and decision makers within the cancer networks.
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Affiliation(s)
- Ngee-Ming Goh
- Primrose Breast Unit, University Hospitals Plymouth NHS Trust, Derriford, Plymouth, United Kingdom
| | - Claudiu Simonca
- The Breast Care Unit, Medway Maritime Hospital, Gillingham, United Kingdom
| | - Maria Verroiotou
- Primrose Breast Unit, University Hospitals Plymouth NHS Trust, Derriford, Plymouth, United Kingdom
| | - Stephane Jenkins
- Primrose Breast Unit, University Hospitals Plymouth NHS Trust, Derriford, Plymouth, United Kingdom
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Smith AF, Frempong SN, Sharma N, Neal RD, Hick L, Shinkins B. An exploratory assessment of the impact of a novel risk assessment test on breast cancer clinic waiting times and workflow: a discrete event simulation model. BMC Health Serv Res 2022; 22:1301. [PMID: 36309678 PMCID: PMC9617530 DOI: 10.1186/s12913-022-08665-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Breast cancer clinics across the UK have long been struggling to cope with high demand. Novel risk prediction tools – such as the PinPoint test – could help to reduce unnecessary clinic referrals. Using early data on the expected accuracy of the test, we explore the potential impact of PinPoint on: (a) the percentage of patients meeting the two-week referral target, and (b) the number of clinic ‘overspill’ appointments generated (i.e. patients having to return to the clinic to complete their required investigations). Methods A simulation model was built to reflect the annual flow of patients through a single UK clinic. Due to current uncertainty around the exact impact of PinPoint testing on standard care, two primary scenarios were assessed. Scenario 1 assumed complete GP adherence to testing, with only non-referred cancerous cases returning for delayed referral. Scenario 2 assumed GPs would overrule 20% of low-risk results, and that 10% of non-referred non-cancerous cases would also return for delayed referral. A range of sensitivity analyses were conducted to explore the impact of key uncertainties on the model results. Service reconfiguration scenarios, removing individual weekly clinics from the clinic schedule, were also explored. Results Under standard care, 66.3% (95% CI: 66.0 to 66.5) of patients met the referral target, with 1,685 (1,648 to 1,722) overspill appointments. Under both PinPoint scenarios, > 98% of patients met the referral target, with overspill appointments reduced to between 727 (707 to 746) [Scenario 1] and 886 (861 to 911) [Scenario 2]. The reduced clinic demand was sufficient to allow removal of one weekly low-capacity clinic [N = 10], and the results were robust to sensitivity analyses. Conclusion The findings from this early analysis indicate that risk prediction tools could have the potential to alleviate pressure on cancer clinics, and are expected to have increased utility in the wake of heightened pressures resulting from the COVID-19 pandemic. Further research is required to validate these findings with real world evidence; evaluate the broader clinical and economic impact of the test; and to determine outcomes and risks for patients deemed to be low-risk on the PinPoint test and therefore not initially referred. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08665-0.
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Ramzi S, Cant PJ. Comparison of the urgent referral for suspected breast cancer process with patient age and a predictive multivariable model. BJS Open 2020; 5:6044706. [PMID: 33688948 PMCID: PMC7944494 DOI: 10.1093/bjsopen/zraa023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022] Open
Abstract
Background The urgent 2-week wait referral for suspected breast cancer system (U2WW) in the UK prioritizes primary care referrals to one-stop breast clinics as ‘urgent’ or ‘choose and book’ (C&B). The aim of this study was to evaluate the accuracy of U2WW in discriminating cancer versus no cancer, and to consider alternative criteria. Methods Clinical features elicited in primary care and demographics of consecutive female patients in a specialist breast clinic were collated at the time of consultation from May 2008 to July 2017. U2WW was compared with patient age alone and a multivariable model in terms of accuracy and net cost for eight underlying cost–benefit assumptions. Results There were 7915 eligible referrals: 4877 urgent (61.6 per cent) and 3038 C&B (38.4 per cent) referrals. Breast cancer was diagnosed in 546 patients (6.9 per cent): 491 (10.1 per cent) in urgent and 55 (1.8 per cent) in C&B referrals (P < 0.001). The multivariable model summated the significant variables: age (odds ratio (OR) 1.07, 95 per cent c.i. 1.07 to 1.08), tumour (OR 4.85, 3.62 to 6.52), observed change (OR 1.73, 1.34 to 2.23), pain (OR 0.46, 0.35 to 0.61) and gravidity (OR 0.72, 0.54 to 0.95). The area under the curve was 0.651 for U2WW, 0.784 for age alone, and 0.824 for the multivariable model (P <0.001 for all comparisons). Considering the cost assumptions, age alone and the multivariable model were either more accurate than U2WW, or as accurate but less costly. Conclusion The U2WW is surpassed by patient age as a single referral criterion. A multivariable model based on demographics and simple clinical features outperformed both. The continued use of the U2WW needs to be reconsidered.
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Affiliation(s)
- S Ramzi
- Primrose Breast Care Centre, Derriford Hospital, University Hospitals Plymouth NHS Trust, UK
| | - P J Cant
- Primrose Breast Care Centre, Derriford Hospital, University Hospitals Plymouth NHS Trust, UK
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Karimian F, Keramati MR, Abbaszadeh-kasbi A. Patient Complaints in Benign vs. Malignant Breast Disease. Indian J Surg Oncol 2017; 8:298-303. [DOI: 10.1007/s13193-017-0626-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/13/2017] [Indexed: 10/20/2022] Open
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Galvin R, Joyce D, Downey E, Boland F, Fahey T, Hill AK. Development and validation of a clinical prediction rule to identify suspected breast cancer: a prospective cohort study. BMC Cancer 2014; 14:743. [PMID: 25277332 PMCID: PMC4197234 DOI: 10.1186/1471-2407-14-743] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/26/2014] [Indexed: 12/25/2022] Open
Abstract
Background The number of primary care referrals of women with breast symptoms to symptomatic breast units (SBUs) has increased exponentially in the past decade in Ireland. The aim of this study is to develop and validate a clinical prediction rule (CPR) to identify women with breast cancer so that a more evidence based approach to referral from primary care to these SBUs can be developed. Methods We analysed routine data from a prospective cohort of consecutive women reviewed at a SBU with breast symptoms. The dataset was split into a derivation and validation cohort. Regression analysis was used to derive a CPR from the patient’s history and clinical findings. Validation of the CPR consisted of estimating the number of breast cancers predicted to occur compared with the actual number of observed breast cancers across deciles of risk. Results A total of 6,590 patients were included in the derivation study and 4.9% were diagnosed with breast cancer. Independent clinical predictors for breast cancer were: increasing age by year (adjusted odds ratio 1.08, 95% CI 1.07-1.09); presence of a lump (5.63, 95% CI 4.2-7.56); nipple change (2.77, 95% CI 1.68-4.58) and nipple discharge (2.09, 95% CI 1.1-3.97). Validation of the rule (n = 911) demonstrated that the probability of breast cancer was higher with an increasing number of these independent variables. The Hosmer-Lemeshow goodness of fit showed no overall significant difference between the expected and the observed numbers of breast cancer (χ2HL: 6.74, p-value: 0.56). Conclusions This study derived and validated a CPR for breast cancer in women attending an Irish national SBU. We found that increasing age, presence of a lump, nipple discharge and nipple change are all associated with increased risk of breast cancer. Further validation of the rule is necessary as well as an assessment of its impact on referral practice.
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Affiliation(s)
- Rose Galvin
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, 123 St, Stephen's Green, Dublin 2, Republic of Ireland.
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Diagnostic performance of urgent referrals for suspected gynaecological malignancies. Arch Gynecol Obstet 2011; 284:1495-500. [PMID: 21331542 DOI: 10.1007/s00404-011-1854-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The objective of this study was to investigate the outcome of the urgent referrals with suspected gynaecological malignancy. METHODS Retrospective analysis of the data of the urgent referrals for suspected gynaecological cancers over a 12-month period at a gynaecological oncology cancer centre in the UK. RESULTS A total of 233 patients (70.61%) were referred with suspected endometrial pathology, 59 patients (17.88%) with suspected ovarian, 25 patients (7.58%) with suspected cervical and 13 patients (3.94%) with suspected vulval malignancy. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulval malignancy was 11.6, 23.7, 12.0 and 15.4%, respectively. Amongst the indications for referral for suspected endometrial cancer, presence of postmenopausal vaginal bleeding had the higher odds for cancer (odds = 0.13; 95% CI 0.08-0.21). The odds for cancer for women referred with a pelvic mass was 0.17 (95% CI, 0.07-0.42) and for women referred with abdominal bloating was 0.66 (95% CI, 0.18-2.36). All the cases of malignancy were diagnosed in women referred with suspicious appearance of the cervix on clinical examination. The odds for cancer was 0.50 if the indication for referral was vulval itching. The majority of cases of gynaecological cancers during the study period were diagnosed following routine referrals. CONCLUSION The overall predictive value of two-week wait referrals for suspected gynaecological malignancies is low. Refinement of the current referral guidelines is required with particular emphasis in the premenopausal women where the diagnostic performance of the urgent referrals is significantly poorer.
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Abstract
Much investment has been put into facilities for early cancer diagnosis. It is difficult to know how successful this investment has been. New facilities for rapid investigation in the UK have not reduced mortality, and may cause delays in diagnosis of patients with low-risk, or atypical, symptoms. In part, the failure of new facilities to translate into mortality benefits can be explained by five misconceptions. These are described, along with suggested research and organisational remedies. The first misconception is that cancer is diagnosed in hospitals. Consequently, secondary care data have been used to drive primary care decisions. Second, GPs are thought to be poor at cancer diagnosis, yet the type of education on offer to improve this may not be what is needed. Third, symptomatic cancer diagnosis has been downgraded in importance with the introduction of screening, yet screening identifies only a small minority of cancers. Fourth, pressure is put on GPs to make referrals for those with an individual high risk of cancer - disenfranchising those with 'low-risk but not no-risk' symptoms. Finally, considerable nihilism exists about the value of early diagnosis, despite considerable observational evidence that earlier diagnosis of symptomatic cancer is beneficial.
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Potter S, Govindarajulu S, Shere M, Braddon F, Turner J, Sahu AK, Cawthorn SJ. Does limiting long-term follow-up for breast cancer allow all referrals to be seen in 2 weeks? Ann R Coll Surg Engl 2008; 90:381-5. [PMID: 18634731 DOI: 10.1308/003588408x301181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The UK National Institute for Health and Clinical Excellence (NICE) recommends that breast cancer follow-up should be limited to 2-3 years stating this will 'release resources' making it 'possible for all women with breast symptoms to be seen within 2 weeks'. In 2000, breast cancer follow-up services in North Bristol were redesigned to reflect evidence-based best practice. The aim of this paper is to assess the impact of this policy on numbers of follow-ups, clinic capacity and waiting times. PATIENTS AND METHODS Data regarding the numbers of new and follow-up patients seen in breast clinic between January 2000 and December 2005 were collected from the hospital Patient Administration System. New patients were categorised as either 'routine' or 'urgent' according to '2-week wait' rule guidelines. Median waiting times were calculated for each group and nominal appointment times assigned in an attempt to assess the effect of any changes on clinic capacity. RESULTS The number of follow-ups decreased by 33% as a result of the new policy. Numbers of referrals over the same period, however, increased by 14%. Routine referrals declined, but there was a 27% increase in '2-week wait' patients. Waiting times for routine appointments initially decreased in response to reduced follow-up, but then rose as the number of '2-week wait' referrals increased. CONCLUSIONS Reducing long-term follow-up is a simple and effective method of increasing clinic capacity but its effects are inadequate and transient in the face of increasing service demand. Additional innovative and creative strategies will be required if all breast patients are to be seen within 2 weeks.
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Affiliation(s)
- S Potter
- Breast Care Centre, Frenchay Hospital, Bristol, UK.
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Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Sahu AK, Cawthorn SJ. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007; 335:288. [PMID: 17631514 PMCID: PMC1941875 DOI: 10.1136/bmj.39258.688553.55] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the long term impact of the two week wait rule for breast cancer on referral patterns, cancer diagnoses, and waiting times. DESIGN Prospective cohort study. SETTING A specialist breast clinic in a teaching hospital in Bristol. PARTICIPANTS All patients referred to breast clinic from primary care between 1999 and 2005. MAIN OUTCOME MEASURES Number, route, and outcome of referrals from primary care and waiting times for urgent and routine appointments. RESULTS The annual number of referrals increased by 9% over the seven years from 3499 in 1999 to 3821 in 2005. Routine referrals decreased by 24% (from 1748 to 1331), but two week wait referrals increased by 42% (from 1751 to 2490) during this time. The percentage of patients diagnosed with cancer in the two week wait group decreased from 12.8% (224/1751) in 1999 to 7.7% (191/2490) in 2005 (P<0.001), while the number of cancers detected in the "routine" group increased from 2.5% (43/1748) to 5.3% (70/1331) (P<0.001) over the same period. About 27% (70/261) of people with cancer are currently referred in the non-urgent group. Waiting times for routine referrals have increased with time. CONCLUSION The two week wait rule for breast cancer is failing patients. The number of cancers detected in the two week wait population is decreasing, and an unacceptable proportion is now being referred via the routine route. If breast cancer services are to be improved, the two week wait rule should be reviewed urgently.
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Toomey DP, Cahill RA, Birido N, Jeffers M, Loftus B, McInerney D, Rothwell J, Geraghty JG. Rapid assessment breast clinics – Evolution through audit. Eur J Cancer 2006; 42:2961-7. [PMID: 16956758 DOI: 10.1016/j.ejca.2006.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Revised: 06/15/2006] [Accepted: 06/29/2006] [Indexed: 10/24/2022]
Abstract
This observational, cohort study aimed to examine the potential utility of Rapid Assessment Breast Clinics (RABC) beyond cancer detection at presentation. One thousand four hundred and twenty nine women were studied over an 18 month period. 154 (10.7%) had breast cancer - 87.7% of whom were seen expediently with 92.9% being diagnosed at one attendance. One hundred and forty three (10%) of those with a benign diagnosis were found by routine questioning to have significant familial risk separate to their reason for referral. Despite careful triage, considerable contamination of appointment allotment occurred with many who were correctly triaged as non-urgent being seen 'urgently'. One hundred and seventy six attendees (12.3%) had neither the symptom that triggered referral, nor breast lump, nipple discharge nor family history of breast cancer, while 283 (19.8%) had no objective clinical or radiological abnormality. Although RABC reliably categorise malignant versus non-malignant diagnoses despite cluttering by low risk women, a significant proportion of non-cancer patients still require address of future risk rather than reassurance of their present status alone.
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Affiliation(s)
- D P Toomey
- Department of Surgery, Tallaght Breast Unit, Adelaide and Meath Hospitals incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland
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Imkampe A, Bendall S, Chianakwalam C. Two-week rule: has prioritisation of breast referrals by general practitioners improved? Breast 2006; 15:654-8. [PMID: 16580206 DOI: 10.1016/j.breast.2006.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 01/13/2006] [Accepted: 02/13/2006] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION A 9-month audit, soon after the introduction of the 2-week rule in the UK in 1999, showed that a significant number of breast cancer patients were referred as non-urgent by their GPs, when the goal is that all suspected breast cancer patients should be seen by a hospital specialist urgently within 2 weeks of referral. The aim of this study was to determine whether GP grading of referrals into urgent and non-urgent had improved. METHOD A retrospective review of GP referrals over 8 months, between September 2003 and April 2004, with regard to their urgency, subsequent diagnosis and the use of proformas (standardised referral formats) was carried out. The results were compared to the 1999 audit. RESULTS Eighty-two of 1178 patients referred by GP had breast cancer, versus 115 of 1176 patients referred in 1999. Sixty-eight per cent (56/82) of breast cancer patients were referred as urgent, compared to 47% (54/115) in 1999 (P=0.005). A proforma was used in 47% (548/1178) of GP referrals while no proforma was used in 1999. Sixty-five of the 82 cancer patients were referred with a proforma and 85% (55/65) were referred as urgent. CONCLUSION GP prioritisation of referrals has improved since 1999. With the use of proformas a significant number of patients with cancer were referred urgently.
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Affiliation(s)
- A Imkampe
- The Breast Unit, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK.
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Abstract
The 2-week rule, stating that patients with suspected cancer should be seen by a specialist within 2 weeks of referral by their General Practitioner, was introduced in the UK in 2000. Although it has been the subject of much interest in the literature, to date there has been no review of the literature. A thorough literature review was undertaken using the medline database, from January 2000; further references were obtained from the reference lists of relevant papers. Some studies have demonstrated a reduction in the waiting times to see specialists, and in some cases time to treatment, and have commented on the potential psychological benefits to patients. However, concerns have been raised over the often low yield of malignancy and the high proportion of malignancies still being diagnosed outside the 2-week wait system. There is, as yet, no evidence that the initiative impacts on survival.
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Affiliation(s)
- S J Hanna
- Department of General Surgery, Department of Urology, Northampton General Hospital, UK.
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