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

OBJECTIVE

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.

BACKGROUND

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

Breast cancer surgery without suction drainage: the impact of adopting a 'no drains' policy on symptomatic seroma formation rates

AIM

To determine the effect of a 'no drains' policy on seroma formation and other complications in women undergoing breast cancer surgery.

MATERIALS AND METHODS

Before May 2010 drains were routinely used in our unit following mastectomy ± axillary surgery and axillary lymph node dissection (ALND) ± wide local excision (WLE). Since then, a 'no drains' policy has been adopted. Data was collected prospectively between 01/12/06 and 30/11/11 to compare symptomatic seroma, wound infection, re-admission and re-operation rates in women treated with a drain and those without.

RESULTS

596 women were included in the study. 247 women underwent modified radical mastectomy (MRM) and ALND (Group 1), 184 MRM ± sentinel lymph node biopsy (SLNB)/axillary node sampling (ANS) (Group 2) and 165 ALND ± WLE (Group 3). In group 1, 149 had a drain, in group 2, 62, and in group 3, 50. Within each group, the presence or absence of a drain did not significantly affect the rate of symptomatic seroma, number of aspirations performed, wound infection rates or the incidence of complications requiring re-admission. Having a drain was associated with lower volumes of seroma aspirated. In all three groups, the presence of a drain was associated with a longer hospital stay (p < 0.001).

CONCLUSION

This study suggests that MRM ± ALND/SLNB/ANS and ALND ± WLE can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a 'no-drains' policy may also contribute to earlier hospital discharge.

Round ligament varicosity: a rare cause of inguinal swelling

We report a case series of three pregnant patients who presented with inguinal mass that were found to be round ligament varicosities. The diagnosis and management of this rare condition are discussed. A review of the literature is presented.

Incidence of Breast Cancer in Patients Undergoing Diagnostic Duct Excision for Pathological Nipple Discharge

BackgroundWomen with pathological nipple discharge (PND), defined as single duct, blood stained or serous discharge, usually undergo diagnostic surgery to exclude breast cancer. The purpose of this study was to ascertain the incidence of breast cancer in women undergoing such surgery in our unit and examine the use of nipple discharge cytology.MethodsPatients who underwent either total duct excision (Hadfield's procedure) or microdochectomy at City Hospital, Birmingham between January 2005 & April 2009 were identified from hospital computer records. In total 139 women were identified but 37 were excluded as they did not have PND and underwent surgery for indications such as recurrent episodes of sepsis due to peri-ductal mastitis, for symptomatic relief of nipple discharge and for correction of nipple inversion.Overall, 102 patients with PND and no other clinical signs of malignancy underwent diagnostic duct surgery. Data collected included patient age, laterality of surgery, radiological imaging undertaken, nipple discharge cytology results and final pathology from the resection specimen.ResultsThe majority of patients (99%) were female. Patient age ranged from 21 – 81 years, with a median of 50 years. Fifty nine patients (57.8%) had surgery for left breast symptoms, 41 (40.2%) for the right side and 2 patients (2%) had bilateral surgery. Most patients had imaging – 50 patients (49.0%) had mammography, 41 (40.2%) had mammography plus ultrasound whilst 7 (6.9%) had ultrasound alone. Only 4 patients (3.9%) had no imaging and all these patients were &lt; 35 years. Imaging did not show any features of breast cancer in any of the patients.Nipple discharge cytology showed benign changes (C1/C2) in 65 patients (63.7%), atypical cells (C3) in 21 patients (20.6%) and suspicious or malignant cells (C4/C5) in 4 patients (3.9%) whilst 12 patients (11.8%) did not have cytology performed. Hadfield's was the most common operation (61.8%) and was performed in an older age group (median age 55yrs) compared to microdochectomy (median age 43 yrs) (p=0.02 Mann-Whitney test).The most frequent primary pathological findings were intraduct papilloma (39.2%) and duct ectasia (38.2%). Other benign changes including fibrocystic disease accounted for 8.9% whilst 14 patients (13.7%) had either invasive or in-situ breast cancer. All patients with suspicious or malignant cytology were found to have an underlying breast cancer, but of note, 13.8% of patients with benign cytology were found to have breast cancer. One male patient who did not have nipple cytology performed was found to have DCIS. Of the 14 patients diagnosed with breast cancer, 8 (57%) had pure ductal carcinoma in situ whilst 6 (43%) had foci of invasive disease in additional to the DCIS.Result of Nipple Discharge Cytology & Final PathologyCytology Resultn=No. Patients with breast cancerNo cytology121 (8.3%)Benign (C1/C2)659 (13.8%)Atypical (C3)210 (0%)Suspicious / Malignant (C4/C5)44 (100%) ConclusionsNipple discharge cytology is unreliable in diagnosing the cause of pathological nipple discharge and its routine use should be reconsidered. All patients with pathological nipple discharge require diagnostic surgery.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6014.