The Health Service Circular 1998/242 states that a patient with suspected breast cancer should be seen by a specialist within 2 weeks of their GP requesting an urgent appointment.1 The introduction of the 2-week wait has raised the question of how appropriate it is for GPs, and not the breast surgeon, to determine urgency, as misclassification might cause treatment delay.
Mayday University Hospital serves a population of approximately 330 000. After discussion with local GPs, it was agreed that urgent suspected cancer referrals should be faxed on a printed pro forma (based upon the published Guidelines for general practitioners for referral of patients with breast problems2). The GP may contact the breast unit by any other method to request a non-urgent appointment.
Between 1 January and 31 December 2002, the breast clinic received 2112 referrals; 2059 were GP referrals and 46 originated from the NHS breast screening programme. A total of 172 (8.1%) patients were subsequently diagnosed as having breast cancer. Three of these were from seven internal referrals. Three patients with known cancer were referred for follow-up. Of the remaining 166 patients, 95 (56.9%) were urgent referrals, 34 (20.5%) were non-urgent referrals, and 37 (22.2%) were referrals from the national breast screening programme.
Considering further the 1 in 5 breast cancer diagnoses made at Mayday University Hospital in patients referred non-urgently, the average age of these women was 52.5 years (range = 28–93 years). Twenty-nine (85.3%) were aged 40 years or above. Of these patients, 56% (19 of 34) were considered by a specialist to show features either suspicious of malignancy or frankly malignant on initial clinical examination. One case appears to have been a clerical error of misclassification by the GP. Over a year, 18 patients (0.9% of a total of 2059 GP referrals) were wrongly classified, to their detriment, based on GP clinical examination.
Although a significant proportion of breast cancer patients stem from non-urgent referrals, false-negative examinations by GPs are not a statistically important cause of delay for patients subsequently shown to have breast cancer.
- © British Journal of General Practice, 2004.