1. Two week rule for breast
Tracey Irvine
Consultant Oncoplastic Surgeon
Clinical Director Breast Unit

2. Overview Current pathways The reality The future Room for improvement
Other referrals

3. Current pathways 1995 Guidelines for urgent breast referral introduced
2000 DOH rolled out to other tumour sites
2005 Taken under auspices of NICE
2007 Concerns – majority diagnosed outside TWR
2010 Breast becomes two weeks for all (excludes cosmetic and family history)

4. TWR guidelines

5. RSCH breast referral form
WE AIM TO SEE ALL SYMPTOMATIC PATIENTS WITHIN 2 WEEK
Family History assessments and Cosmetic referrals will be seen routinely.
Patient Name:      
DOB:      
Address:
     
Mobile/Home preferred number for appointment:      
NHS No:      
GP Name:      
Surgery Address:
Telephone:      

6. RSCH breast referral form
Thickening
Lump
Skin change
Nipple change
Discharge Blood stained
Pain
Other information………………………………………………………………………………..
Previous Mammogram Yes No Where? When? …………………
Signature of referring doctor:…………………………………//……...Date:…………………

7. RSCH referral form Fax to: 01483 406632
to:
Post to: Breast Unit, OPD 13, RSCH, Egerton Road, Guildford GU27XX

8. The reality – all referrals
2010
2011
2012
2013
2014
Referrals
908
820
796
1877
2539
Referrals per week
17.5
15.8
15.3
36.1
48.8
Cancers 85 99 71
139
160
Conversion rate
9.4
12.1
8.9
7.4
6.3

9. TWR vs. Symptomatic 2010 2011 2012 2013 2014 Referrals 382/526 369/451
353/443
709/1168
1010/1527
Referrals per week
7.3/10.1
7.1/8.7
6.8/8.5
13.6/22.5
19.4/29.4
Cancers
69/16
68/31
48/23
84/55
94/66
Conversion rate %
18.1/3
18.4/6.9
13.6/5.2
11.8/4.7
9.3/4.3

10. Remember… The bean counters are only asked to count cancers
Any discrete lump at any age should have a diagnosis even if benign
There are many breast problems that benefit from a breast specialist opinion
We are here to help!

11. What is my reality?

12. The future - NICE guidance
Bring down threshold to 3%
Looked at evidence – PPV of various symptoms
Guidelines same for women and men
Same for patients with a previous history of breast cancer
They think this will reduce referrals……

13. NICE guidance
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are aged 30 and over and have an unexplained breast lump with or without pain. [new 2015]
PPV approx 10% (approaching 50 % in over 70s)

14. NICE guidance
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are aged 50 and over with any of the following symptoms in 1 nipple only:
 discharge or
 retraction or
 other changes of concern. [new 2015]
PPV 2-5%, over 10% in over 70s

15. NICE guidance
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people aged 30 and over with an unexplained lump in the axilla. [new 2015]
PPV felt to be over 3% by the panel

16. No breast pain? A lump in the breast is painless
We will still find cancer in these patients – opportunistic screening – PPV <2%
Reassure, reassure, reassure
Bra fitting, topical anti-inflammatory gel

17. No skin changes? Felt to be a soft symptom, not clear in the studies
Better guide in combination with a lump
If in doubt - refer

18. Room for improvement - admin
DNA rate up to 6% - mostly new patients
Patient contact number!!!!!!!!
NHS number
Holidays

19. Please note…. TWR is two weeks from date of receipt of referral
You cannot refer TWR to Jarvis – they will be bounced
You cannot refer directly to breast imaging – they will be bounced
We will see young girls but not young boys (paeds)

20. Please note… Referral for mammographic follow up is not a TWR!
Ultrasound is not a screening tool
If they were assessed at the Jarvis 6 months ago – send them back…and vice versa
If they are about to go on holiday do not send as TWR
Please book the students as C&B

21. What is unlikely to be cancer
17 year olds with breast pain – or with anything….
Nipple eczema – please complete the course of topical treatment – not if over 70
Implants changing shape – or causing anxiety…
Sebaceous cysts

22. Paget’s

23. Other referrals – family history
Dedicated weekly CNS run family history clinic
One FDR under 40, 2 close family members (one FDR) any age, one breast and ovarian cancer
Ashkenazi Jewish or Polish* ancestry (*and family history)

24. Family history screening
We will arrange this if the patients come through the family history clinic here
Jarvis will arrange this if the patients come through the family history clinic there
BRCA patients – we will look after them – screening with mammogram and MRI through Jarvis

25. Breast abscesses Lactating breast abscesses – all sensitive S Aureus
Non lactating – mostly S Aureus, smokers – broader spectrum
Breast feed – support – Kate Rosati
Refer early to us!

26. Cosmetic Not two week referrals Consider private centre
BMI < 26, non smoker, over 19, Bra fitting
Funding – BBR – 500g tissue each side (surgeon), documented evidence back pain and failure of treatment

27. The boys 300 male breast cancers per year
Young boys do not get breast cancer
Treatment with hormonal therapy only in early glandular changes
No funding for surgery

28. Missed referrals
Delay in diagnosis commonest cause of non cosmetic litigation
Failure to refer – repeated presentations
Failure to do true triple assessment
Inflammatory breast cancers

29. Other patients Previous cancers – usually call BCNs
Topical oestrogen is fine – low systemic absorption
Advice – happy to help
But how we can really improve…..

30. Metastatic patients – first 6 months

31. Contacts – please call!!
Breast office
Breast Office fax –
My PA – Connie – ,
BCNs – Primary – , Secondary –

32. Summary You already do a good job Breast symptoms are non specific
NICE wants you to refer more – not less
Refer the over 70s
Think metastatic
Call us if in doubt...
If you do one thing – get a contact number for the patient