1. Breast cancer clinical pathway: are doctors aware? Ana Filipa Amador | Ana Rita Comba | Bárbara Castro | Beatriz Ferreira | Daniela Casanova | Duarte Alves | Filipe Machado | Helena Corado | Inês Silva | Lídia Ribeiro | Tiago Sousa Introdução à Medicina Class 14 Adviser: Rosa Oliveira Academic Year: 2010/2011

2. 2 BREAST CANCER [1] Pinheiro PS, 2003 [2] Coughlin SS, 2009 [3] Who, 2010; [4] Ferlay, 2010; [5] Davis, 2010; [6] Kerr F, 2006 Chart 1: Cancer incidence statistics in Portuguese women (2003) Mortality is decreasing [2] Early diagnosis Effective treatments [2] | Participants and Methods | Results | Discussion | Conclusion Introduction [1]

3. 3 [7] Macedo A, 2010; [8] Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, 2009 [9] Not All Doctors Follow Cancer Screening Guidelines, Study Finds, 2010 [10] Cabana, Why Dont Physicians Follow Clinical Practice Guidelines? Woman who suspects to have breast pathology PRIMARY HEALTH CARE CENTERS Consulting a)Imagiologic exams requested b)Follow the patient for observation Specialized breast pathology unit GUIDELINES [7,8] BI-RADS [9] | Participants and Methods | Results | Discussion | Conclusion Introduction CLINICAL PATHWAY [10]

4. 4 Aims To evaluate the effectiveness of the clinical pathway regarding women suspected to have breast cancer: from primary health care centers to a specialized breast pathology center. USF GPM | Participants and Methods | Results | Discussion | Conclusion Introduction USF: Unidade de Saúde Familiar GPM: Grupo de Patologia Mamaria

5. 5 Research Questions Do general practitioners know any and best medicine evidence concerning diagnosis of breast pathology? If so, do they follow them? Are patients correctly rerouted to the GPM taking into account their classification? GUIDELINES BI-RADS | Participants and Methods | Results | Discussion | Conclusion Introduction GPM: Grupo de Patologia Mamária BI-RADS: Breast Imaging Report and Data System MeSH terms: Breast Neoplasm ; Diagnosis; Referral and Consulting; Practice Guideline

6. 6 Analysis of the BreastCare database Evaluate the awareness regarding the guidelines Analysis of BI-RADS of women referred to GPM transversal and observational study Study Design Introduction | | Results | Discussion | Conclusion Participants and Methods ANALYZE THE REFERRAL GPM: Grupo de Patologia Mamária BI-RADS: Breast Imaging Report and Data System Delivery of questionnaires Evaluate the awareness regarding the guidelines ANALYZE THE REFERRAL Design of questionnaire Delivery of questionnaires Design of questionnaire

7. General practitioners of primary health care centers from Grande Porto Inclusion Criteria: General practitioners of the primary health care. Exclusion Criteria: No exclusion criteria were considered. 7 Study Participants 1 st GROUP: General Practitioners from primary health care institutions in the metropolitan area of Oporto Delivery of questionnaires Introduction | | Results | Discussion | Conclusion Participants and Methods

8. 8 Data collection Development of the survey Patologia mamária nos cuidados de saúde primários based on: Guideline of August 2002 [11] Guideline of July 2005 [12] Guideline of June 2005 [13] Guideline of February 2009 [14] Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, ACS, Setembro 2009 [15] Guideline of January 2010 [16] Delivery of questionnaires Introduction | | Results | Discussion | Conclusion Participants and Methods [11] Guidance on Cancer Services: Improving Outcomes in Breast Cancer, 2002 [12] Referral guidelines for suspected cancer in adults and children, 2005 [13] Referral guidelines for suspected cancer, 2005 [14] Early and locally advanced breast cancer. Diagnosis and treatment, 2009 [15] Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, 2009 [16] Health Care Guideline: Diagnosis of Breast Disease, 2010

9. 9 Discussion with Dr. Fernando Osório Questionnaire Some modifications on the questionnaire Pilot test to 2 general practitioners Compile data in a database Delivery to the doctors of primary care units Introduction | | Results | Discussion | Conclusion Participants and Methods Data collection Delivery of questionnaires

10. 10 Variables description Delivery of questionnaires Introduction | | Results | Discussion | Conclusion Participants and Methods

11. 11 Variables description Delivery of questionnaires Introduction | | Results | Discussion | Conclusion Participants and Methods

12. 12 Variables description Introduction | | Results | Discussion | Conclusion Participants and Methods Delivery of questionnaires

13. ANALYZE THE REFERRAL Evaluate the awareness regarding the guidelines 13 Analysis of BI-RADS of women reffered to GPM transversal and observational study Study Design Introduction | | Results | Discussion | Conclusion Participants and Methods GPM: Grupo de Patologia Mamária BI-RADS: Breast Imaging Report and Data System Analysis of the BreastCare database Analysis of BI-RADS of women referred to GPM ANALYZE THE REFERRAL Delivery of questionnaires Design of questionnaire Analysis of the BreastCare database

14. Data was acquired from a database previously created in the context of the BreastCare project Prospective data was collected in GPM from HSJ – Oporto Inclusion Criteria: All women followed in the GPM. Exclusion Criteria: Patients whose data of diagnosis is incomplete 14 2º GROUP: Women with breast cancer who participated in the Breast Care of HSJ Analysis of the BreastCare database Introduction | | Results | Discussion | Conclusion Participants and Methods Study Participants GPM: Grupo de Patologia Mamária HSJ: Hospital de São João

15. 15 Variable description Only some of the collected data was used: Gold-standard classification (BI-RADS) Proves the adequacy of rerouting Only BI-RADS 4 should be referred to a specialized unit Age at the arrival to GPM Age at the first diagnosis Use of echography and mammography requested by the primary health care centers 1. GPM: Grupo de Patologia Mamária 2. HJS: Hospital de São João Analysis of the BreastCare database Introduction | | Results | Discussion | Conclusion Participants and Methods

16. 16 Statistical analysis Introduction | | Results | Discussion | Conclusion Participants and Methods Frequencies and percentages: used to display responses to individual questions, such as gender. Means and standard deviation: used for the characterization of continuous variables such as age of women with breast pathology at the arrival to the GPM. Medians, inter-quartile ranges and 90% confidence intervals: score of correct answers, knowledge of referral recommendations.

17. 17 Score of part I + part II Yes and No answers To each correct answer is attributed a value of 1; Incorrect questions were recoded as 0. 12 answers maximum score: 12 units – 100% percentage of the right questions allowed us to conclude about the general efficiency of breast pathology care in our primary health centers. Delivery of questionnaires Introduction | | Results | Discussion | Conclusion Participants and Methods Statistical analysis

18. 18 Knowledge of the "Recomendações Nacionais para Diagnóstico e Tratamento do Cancro da Mama Binomial tests: to assess if at least 50% of doctors of the considered population are familiar with the national guidelines (CI of 95%) Delivery of questionnaires Statistical analysis Introduction | | Results | Discussion | Conclusion Participants and Methods Significance level: 0.05 CI: Confidence Intervals

19. Table 1: GPs from health centers 19 19 GPs from health centers. Response percent: 34.6% Delivered in person 55 questionnaires Request to ACES Results, Tables and Graphics Delivery of questionnaires Results Introduction | Participants and Methods | | Discussion | Conclusion GP: General Practitioners CS: Centro de Saúde ACES: Agrupamento de Centros de Saúde

20. 20 Characterization of the sample: 14 of the GP were female (ratio men : women = 0.34) GP mean age (SD) = 45.1(10.8) years Mean experience time (SD) = 18.4 (12.1) years Results, Tables and Graphics Table 4: Age Table 3: Clinical experience Delivery of questionnaires Results Introduction | Participants and Methods | | Discussion | Conclusion Table 2: Gender of GP GP: General Practitioners SD: Standard Desviation

21. 21 84.2% (n=16) of the GP frequently deal with breast pathology Table 5: Do GP deal with breast pathology? Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires GP: General Practitioners

22. n% Morphologic changes1894,7% Size changes1368,4% Both1368,4% 22 68.4% consider both morphologic and size changes the most important factors in the assessment of the severity of the breast lesion. All the GPs (n=19) considered mammography as the standard test for breast pathology screening. Table 6: What is the most important factor in the assessment of the severity of the breast lesion? Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires GP: General Practitioners

23. 23 Considering the referral to the GPM, 26.3% (n=14) of GPs would incorrectly keep a patient with modifications of a previously studied breast lesion under their own responsibility. 89.5% (n=17) would maintain a patient with a simple cyst in their own consult for further study instead of referring the patient to another area of expertise or for unnecessary exams. Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires GPM: Grupo de Patologia Mamária GP: General Practitioners

24. 24 Table 7: Are there gathered the basic condicions to deal with breast pathology in Portugal? Table 8: Is it necessary to make changes? 63.2% of the GP considered that there are gathered the basic conditions for the primary health care physicians to deal with breast pathology in Portugal Only 47.4% think that is necessary to make changes in the health system. Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires GP: General Practitioners

25. 25 Chart 2: Are they gathered the basic condicions to deal with breast pathology in Portugal? Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires BI-RADS: Breast Imaging Report and Data System RNDTCM: Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama

26. 26 Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics Delivery of questionnaires BI-RADS: Breast Imaging Report and Data System RNDTCM: Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama Score of questionnaire: Mean = 75.4% 95% CI = [69,1%; 81,7%] Knowledge of National Guideline (RNDTCM): 95% CI = [54%; 99%] Binomial Test - More than 50% of GPs are aware of the national guidelines.

27. Analysis of the BreastCare database 27 1151 women Mean age (SD): 49.6 years (15.0). Breast cancer was first diagnosed at an average age (SD) of 48.9 years (12.9). At the arrival to the GPM, 99.9% (n=335) of the eligible women had done a mammography All who replied had done an echography Table 9: Mean age at the moment of arrival to GPM Table 10: When breast cancer was first diagnosed Table 11: Registration of mammography Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics SD: Standard Deviations GPM: Grupo de Patogia Mamária

28. 28 According to the BI-RADS classification, 70% of the women arrived to the GPM classified as Stage 3 or less. Incorrect rerouting frequency (%) (95%CI) (BI-RADS<4) : [64.5%; 75.5%] Analysis of the BreastCare database Results Introduction | Participants and Methods | | Discussion | Conclusion Results, Tables and Graphics BI-RADS: Breast Imaging Report and Data System GPM: Grupo de Patogia Mamária CI: Confidence Intervale

29. 29 High percentage of GPs are aware of: Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, ACES, Setembro 2009 BI-RADS classification system Discussion Introduction | Participants and Methods | Results || Conclusion Do general practitioners know any and best medicine evidence concerning diagnosis of breast pathology? GUIDELINES BI-RADS: Breast Imaging Report and Data System ACES: Agrupamento de Centros de Saúde GP: General Practitioners

30. 30 Discussion Introduction | Participants and Methods | Results || Conclusion If so, do they follow them? BI-RADS: Breast Imaging Report and Data System CI: Confidence Intervale Score of questionnaire: Frequency (95% CI): 75% [69%; 81%]

31. 31 More than 50% of the GPs ARE following the guidelines Contradicts the literature: This outcome may point to a better referral of the women with breast pathology in Portugal and, consequently, contribute to a more precise diagnose and treatment. A study from the National Cancer Institute states that only 20% of primary care physicians in the US follow guidelines for colorectal cancer screening and diagnosis. Discussion Introduction | Participants and Methods | Results || Conclusion [18] Cabana, Michael D., Rand, Cynthia S. et al. Why Dont Physicians Follow Clinical Practice Guidelines? JAMA, October 20, 199 – Vol. 282, no.15 GP: General Practitioners

32. 32 Inadequate rerouting frequency (CI 95%): [64.5%; 75.6%] percentage of incorrect referrals to the hospital Discussion Introduction | Participants and Methods | Results || Conclusion Are patients correctly rerouted to the GPM taking into account their classification? BI-RADS According to the BI-RADS classification, 70% of the women arrived to the GPM in a Stage 3 or less. BI-RADS: Breast Imaging Report and Data System CI: Confidence Intervals GPM: Grupo de Patologia Mamária

33. 33 100% of the GPs considered mammography as the standard test for screening of breast pathology LITERATURE: Mammography remains the main screening tool, which has been recommended for many decades [14] Discussion Introduction | Participants and Methods | Results || Conclusion [17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005; 293: 1245-1254 GP: General Practisioners

34. 34 Inadequacy of guidelines: High number of missing values on BreastCare database Low rate of answer in the surveys (34.6%) Inability to reconcile patient preferences with the guideline recommendations Differences between guidelines Further studies will be required in order to complete and improve our results. LIMITATIONS Discussion Introduction | Participants and Methods | Results || Conclusion

35. 35 The majority of GPs are aware of the National Guidelines and BI-RADS classification system, performing, in theory, an adequate rerouting. However, the massive rerouting of BI-RADS Stage 2 proves that women are being bad rerouted and resources are being spent inadequately. Conclusion Introduction | Participants and Methods | Results | Discussion | Conclusion BI-RADS: Breast Imaging Report and Data System GP: General Practisioners

36. 36 Addendum Delivered at Hospital São João (HSJ) on 30 th October (Dia Nacional da Prevenção do Cancro da Mama); Informative flyer for patients and visitors of HSJ. FLYER Introduction | Participants and Methods | Results | Discussion | Conclusion

37. 37 Addendum WEBSITE Introduction | Participants and Methods | Results | Discussion | Conclusion

38. 38 Aknowledges Dr. Fernando Osório, who has patiently helped us with the medical part related to breast pathologies, such as the technical terms and questionnaires' revision Prof Doutor Altamiro Manuel Rodrigues Costa Pereira, for the suggestions along all our presentations and work developed along the year Health Care Units, for their readiness for response to our questionnaires Grupo de Patologia Mamária, for the help with information concerning the BreastCare database and Breast Cancer treatment in general Introduction | Participants and Methods | Results | Discussion | Conclusion

39. 39 References [1] http://www.who.int/mediacentre/factsheets/fs297/en/index.html [2] http://www.who.int/topics/cancer/en/, (04/11/10) [3] http://www.medicinenet.com/cancer/article.htm, (12/11/10) [4] Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International Journal of Cancer 127.12 (2010): 2893–2917. [5] Coughlin SS., Ekwueme DU., Breast cancer as a global health concern, Cancer Epidemiology, Vol 33, Issue 5, November 2009, Pages 315-318 [6] Macedo A, Monteiro I, Andrade A, Cirricione A, Ray J. Cost-effectiveness of trastuzumab in the treatment of early stages breast cancer patients, in Portugal. Acta Médica Portuguesa 23.3 (2010): 475-482. [7] http://www.acs.min-saude.pt/files/2009/09/acs_cancro-mama_low.pdf (13/12/2010) [8] http://www.dgs.pt/default.aspx?cn=55065715AAAAAAAAAAAAAAAA (20/12/2010) [9] Oliveira CF, Rodrigues V, Gervásio H, Pereira JM, Albano J, Amaral N, Carcinoma in situ and early breast carcinoma. Survey of the Portuguese Senology Society on the diagnostic tools used in Portugal and their evolution between 1985 and 2000. Eur J Gynaecol Oncol. 2004;25(3):293-8. [10] Morris KT, Pommier RF, Morris A, Schmidt WA, Beagle G, Alexander PW, Toth-Fejel S, Schmidt J, Vetto JT, Usefulness of the triple test score for palpable breast masses, Arch Surg. 2001 Sep;136(9):1008-12. [11] http://www.sciencedaily.com/releases/2010/10/101014113839.htm (22/12/2010) [12] Cabana, Michael D., Rand, Cynthia S. et al. Why Dont Physicians Follow Clinical Practice Guidelines? JAMA, October 20, 199 – Vol. 282, no.15 [13] Cardarelli, Roberto, DO, MPH. The role of primary care providers in cancer screening. Primary Care Research Institute, May 2010 [14] Ribeiro, Robespierre Costa. Clinical guidelines: how to evaluate its quality?. Rev Bras Clin Med 2010;8(4): 350-5 [15] http://www.encr.com.fr/breast-factsheets.pdf Introduction | Participants and Methods | Results | Discussion | Conclusion