Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 68, Num. 3, 2006, pp. 142-145

Indian Journal of Surgery, Vol. 68, No. 3, May-June, 2006, pp. 142-145

Review Article

Fast access breast clinic

Jothi R. Murugesan, David Valerio, Sheena Bradley*

Departments of General Surgery and *Radiology, Grantham and District Hospital, United Kingdom
Correspondence Address:Jothi R. Murugesan, Department of General Surgery, Grantham and District Hospital, 101, Manthorpe Road, Grantham, Lincolnshire, NG31 8DG, United Kingdom. E-mail: docmjr@rediffmail.com

Code Number: is06040

Abstract

Keywords: Breast cancer, breast clinic, symptomatic

Introduction

Working pattern of fast access breast clinic

The clinic environment
Adequate consulting and examination rooms should be available to allow patient privacy, allow efficient working practice and enable discussion with breast care nurses. A hospital should seek to function as a cancer unit only if the volume of work related to each cancer site is sufficient to maintain such expertise.[2]

Core team members
The core team members include a surgeon with an interest in breast disease, a radiologist, a radiographer, a pathologist, laboratory support staff, a breast care nurse, clinic staff and administrative staff.

Surgeon
In general, surgeons who specialize in a particular anatomical area should carry out the surgical management of that cancer. Retrospective data from the UK suggest that a minimum caseload of at least 30 newly diagnosed breast cancer cases per consultant per year is required to optimize patient outcomes.[3] Excessive surgical caseload is also likely to be detrimental. Initial investigations are usually requested by the surgeons.

Radiologist
The radiologist should decide on the most appropriate imaging investigations, report significant abnormalities with a characterization of the level of suspicion for cancer of these abnormalities and should also include recommendations for further imaging or guided biopsy.[2]

Pathologist
The pathologist should have special expertise in breast pathology and cytology, with designated time for breast work. Cytology and core biopsy standards should be strictly adhered to and a formal report for diagnostic pathology should be available within five working days.[2]

Breast care nurse
A Breast care nurse should provide care in keeping with the set national breast screening standards and keep up to date, the knowledge of breast disease. There must be an agreed programme of continuing education and they should be involved in the education of other nursing staff on breast disease, both in the hospital setting and elsewhere. Ideally a breast unit should have at least two breast care nurses and it is essential that they attend the multidisciplinary breast meeting regularly. The breast care nurse should be present, particularly at the time of diagnosis and when options for treatment are discussed. All patients diagnosed with breast cancer should have access to a breast care nurse and must be given the opportunity to see them pre-operatively and after discussion of histological findings.[4]

Other team members
In addition to the medical staff and breast care nurses, other staff members also fulfill important roles. Trained reception staff must be present to assist people on arrival at the clinic and adequate portering staff for specimen transfer should be available. Adequate clerical support is essential to maintain good communication with patients, GP′s and other members of the breast team. Provision of a complete, accurate and timely data requires a properly trained data manager.[2]

Primary care
GP′s are given referral guidelines for suspected breast cancer by the NHS. The present guidelines adequately cover referral for the diagnosis of malignant breast disease to a specialist.[5] The GP referrals are faxed to a dedicated collection point, usually a university hospital, whence they are distributed to the hospital, the patient can access easily. Telephonic communications are associated with faster median access times when compared to those that are mailed.[6] There is a "two week" target wait from urgent GP referral to first outpatient appointment for all patients with suspected cancer.[7] Some of the non-urgent referrals are sent as letters, which reach the desired hospital directly. The decision on the urgency of referral should be in the hands of the relevant specialist who individually can decide the best way to run their FABC′s.[8] The patients are sent an appointment and an information leaflet regarding FABC. Once the patient arrives at the clinic, the breast care nurse explains the procedures and also helps the patients to fill a form with questions related to risk factors for breast cancer.

All patients over 35 years are subjected to mammography, before consultation. The radiologist and the surgeon interpret the mammogram, after which patient is thoroughly examined. Any clinical abnormality is always checked with ultrasound. If need arises, a fine needle aspiration cytology (FNAC) is done. A patient′s permission should always be sought before any invasive procedure is performed. The surgeon should mark the specimen prior to delivery to the pathologist and make a decision, whether normal cytology is acceptable or not. Core biopsy is performed if solid lesions are found and this can provide information on the presence or absence of invasive tumour, allow provisional assessment of tumour type and grade and enable tumour receptor analysis. However there is now a trend towards use of core biopsy rather than FNAC for all patients presenting with radiologically suspicious palpable lumps.[9]

When the results are ready, they are sent to the breast care nurse, who informs the patients when benign cytology is reported on FNAC and also arranges for a repeat FNAC, if suspicious or inadequate cytology is reported. Written information about the diagnosis is also sent to their address. If a core biopsy is performed, the surgeon gives the reports. The days between clinic visits can allow formal assessment and discussion of suspected cancer diagnoses in the multidisciplinary meeting, prior to a second clinic visit where the patient is informed of the diagnosis and the appropriate treatment options. To inform a patient of a benign diagnosis after full investigation at a first clinic visit is beneficial but it is less certain whether a similar benefit is obtained in patients with breast cancer. The multidisciplinary meeting should take place on a weekly basis to consider the clinical, radiological and pathological results of new patients, those with recurrent disease and those who had recent surgery and a record of the meeting, including the attendance, should be kept and the conclusions documented in the patients′notes.[4] The rules require the treatment to be started within 31 days of diagnosing breast cancer and within 62 days of referral.[10] The department of health in the UK has a "cancer plan", which states that its government believes the ultimate goal should be to offer patients a maximum one-month wait from an urgent referral for suspected cancer to the beginning of treatment.[11]

Screening clinics
A screening test is designed to identify subjects who are at sufficient risk of a specific disorder to benefit from further investigation or preventive action, among those who have not sought medical attention on account of symptoms of that disorder.

In the UK, the NHS breast screening programme provides free breast screening every three years for all women in the UK aged 50 and over. Women aged between 50 and 70 are now routinely invited. Because the programme is a rolling one, which invites women from GP practices in turn, not every woman will receive an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday. Once women reach the upper age limit for routine invitations for breast screening, they are encouraged to make their own appointment.[12]

With the present socio-economic state, mammographic screening may neither be feasible nor very efficacious in the relatively younger population of India. Hence our best bet to partially offset the rising tide of breast cancer is through public awareness for adoption of healthier life style, diet, exercise, promoting breast feeding, breast awareness, self or physician breast examination and high risk or opportunistic screening using appropriate technology.

Family history clinics
Approximately 10 to 15 percent of all breast cancers are thought to be familial and about one third of these cases are due to an inherited mutation in a BRCA1 or BRCA2 breast cancer- susceptibility gene. The patient′s decision to undergo genetic screening is complicated by the technical difficulty of the test and substantial cost. However, family history remains the best tool for planning breast cancer surveillance. As experience with BRCA1 and 2 mutations increases, the role of genetic screening may be clarified for both society at large and the medical community.

Breast cancer statistics in India

The Indian health system

Indian national cancer control programme (NCCP) was initiated in 1975 and then revised in 1984 and 1994.[15] The national cancer registry programme (NCRP), initiated by Indian Council of Medical Research in 1982, despite some deficiencies in coverage and accuracy, gives us reasonable estimate of the cancer burden in selected urban and rural areas of the country. Very few countries outside the western world have such information on the cross section of their population. Through its programmes and findings, the NCCP has sensitized and aided not only the health planners but has also made oncologists, whose focus is generally on treatment, more aware of the need for prevention and rehabilitation. The International agency for research on cancer (IARC) has also played a major role in the implementation of breast cancer screening programme in various parts of India.

Modification of symptomatic breast clinics in the UK, according to the availability of resources would be appropriate for use in India. Setting up a dedicated diagnostic service, which can offer triple assessment in a single visit, is likely to involve capital and human resource costs. This is likely to be offset by a reduction in unnecessary surgery, improved outcomes, fewer return visits by patients and the use of more cost-effective treatment. Further, provision of ultrasound machines to improve diagnostic accuracy has capital cost implications. However, if a comprehensive programme of guidance setting national standards for effective cancer services is established, it would provide assurance for patients and the public. Increased use of educational material for the patients and special breast referral forms for GPs could further increase the benefits by reducing inappropriate referrals.

The efficacy of organized early detection programmes based on breast self-examination and/or clinical breast examination remains inconclusive and controversial. Studies comparing the combined effects of mammography and clinical breast examination with the effects of mammography alone as a population-based screening tool have shown no difference in the number of deaths from breast cancer in the two groups after more than 15 years of follow-up.[16],[17],[18],[19],[20],[21] Thus, there is no evidence of any additional benefit of clinical breast examination for women who are already attending for regular screening mammography. For women who are not participating in regular mammographic screening, regular clinical breast examination may offer some benefit.

Community-based cluster randomised controlled trial, as proposed by the IARC, working in collaboration with the Regional Cancer Centre, Trivandrum and the Kerala state health services, India, could help evaluate the effectiveness of a package of interventions consisting of health education, opportunities for clinical early diagnosis, provision of readily accessible diagnosis and treatment services and hence improved outcome of breast cancer. Such studies would also help to to assess the role of clinical early diagnosis of breast cancer in low-resource settings.[22]

Discussion

FABC is basically a specialist led service. The benefit of specialist led care is consistent for all age groups irrespective of the size of the breast lump, axillary node status or the socioeconomic category.[23]

Triple assessment is highly precise in the diagnosis of breast masses and patients in whom all three-examination results are benign can be safely observed, obviating the need for an open biopsy.[24] However, the likelihood that conservative therapy will be appropriate is reduced when the hospital delay in the diagnosis of breast cancer is more than 240 days.[25] "Diagnostic delay index (DDI)" is defined as the time between the medical system′s awareness of a diagnostic need and the completion of the diagnostic process. With respect to breast cancer, it includes the time awaiting breast clinic consultation and the diagnostic events experienced. Delays of 3-6 months between the onset of symptoms and the start of treatment are associated with lower survival. These effects cannot be accounted for by lead-time bias.[26] Efforts should be made to keep delays by patients and providers to a minimum. Inappropriate referrals on the other hand tend to reduce the efficacy of the service.[27] The Breast cancer referral guidelines seem to have been efficient in plummeting the higher level of inappropriate referrals in younger patients at less risk of carcinoma.[28]

Hence, the one-stop clinic allows optimum patient management, minimises anxiety associated with symptomatic breast disease and maximises utilisation of hospital outpatient resources.[29]

Conclusion

Acknowledgements

References

Copyright 2006 - Indian Journal of Surgery