11 Do Breast Surgeons Play an Important Role in a Clinic for Benign Breast Disease?
Jessica Rahme, BAppSc, MPhys, BMBS1; Melanie Johnston, Jocelyn Lippey, Grace Chew, Michael Issac, Wanda Stelmach
1Northern Hospital, Melbourne, Australia.
Background
“Benign breast disease” is an umbrella term encompassing all breast symptoms, imaging, and pathology that are unrelated to breast cancer. Breast symptoms that lead patients to present to health care services include breast tenderness, mastalgia, self-detected lumps, nipple discharge, and skin changes.1 Most women will experience benign breast disease at some point in their lives.2 The majority of breast-related presentations to primary care and breast clinics are ultimately diagnosed as benign breast disease, rather than breast cancer.3,4 It is inefficient and expensive for surgeons to deliver breast care in nonoperative, benign patients,5 and it negatively affects available time and resources for patients with cancer.
Benign breast disease can often be managed by general practitioners (GPs). One study determined that 47% of patients referred to a breast clinic did not need surgical management and could have been managed by a GP.6 Several guidelines have been developed for the primary care management of benign breast disease, which contain helpful algorithms for the management of various breast presentations to aid GPs in the diagnosis and management of benign breast disease.7 However, a retrospective review of GP referrals to a breast clinic found that 29% of patients with benign breast disease would not have been referred to a breast surgeon if the GP had followed the relevant guidelines.8 GPs report reluctance to use the guidelines, believing that there is a lack of consideration for patient anxiety and psychosocial factors in referral criteria.9
Patients referred to breast clinics often do not require specialist input from breast surgeons, with only 16% requiring admission for surgery10 and only 9% receiving a diagnosis of cancer.4 This study aimed to determine the role of surgeons in the outpatient management of benign breast disease, with a view to developing an optimized triage pathway to reduce the burden of these patients on the clinic.
Materials and Methods
A retrospective audit was conducted of female patients without known cancer referred from GPs to the clinic from January 1, 2016, through June 30, 2020. The Northern Hospital is a secondary health service in Epping, a district in north Melbourne. The breast clinic is staffed by 6 specialist breast surgeons, as well as a surgical fellow, registrar, and 2 surgical interns. Patients were included in the study if they were new referrals to the breast clinic from GPs. Patients were excluded from the study if they were male, had a past history of or current known breast cancer, were referred internally, were being treated for skin lesions of the breast (ie, sebaceous or epidermoid cysts), or were being treated in another breast clinic. Data were collected from electronic and scanned medical records; they included patient demographics, reported family history of breast cancer, reasons for referral, and management in the outpatient setting. A descriptive analysis of categorical and continuous data was conducted (SPSS; IBM).
Results
The study included 300 patients, representing 73% of the total number of referrals. Twelve percent of patients were excluded due to past or current breast cancer.
The most common reasons for referral were abnormal imaging findings (78%), breast lump (63%), and mastalgia (51%). Forty-nine percent of patients had an abnormal clinical breast examination at the first appointment. Eighty-five percent of patients required a follow-up appointment. In terms of further imaging completed, 69% of patients had an ultrasound and 24% of patients had a mammogram. Forty-four percent of patients underwent biopsy. Ten percent of patients were admitted for surgery. Patients waited a median of 52 days for their first appointment from date of referral, a median of 39 days from first appointment to diagnostic biopsy, then a median of 101 days from first appointment to surgery.
Patients who were referred because of mastalgia were less likely to have an abnormal clinical breast examination (P = .014) than those who were referred because of a condition other than mastalgia. Patients who were referred because of a lump were more likely to undergo core needle biopsy (P = .015) than those who were referred because of a condition other than a lump. Patients who were referred because of mastalgia were 2.9 times (1.2-6.7) less likely to undergo surgery (P = .016). Patients who had examinations by the surgeon that revealed abnormalities were 3.5 times (1.5-8.7) more likely to undergo surgery (P = .005).
Conclusions
A large proportion of the workload at The Northern Hospital Breast Clinic was patients with benign disease. These patients experience long wait times before being seen in the clinic and are often booked for follow-up appointments after the first consultation. We found that only 44% of patients underwent a biopsy, which is low considering that 63% of patients were referred for a lump and 78% were referred for abnormal imaging. Only 10% of the cohort underwent surgery. As expected, abnormal clinical breast examination at the first appointment was predictive of the need for surgery. Patients with mastalgia were significantly less likely to have an abnormal clinical breast examination and significantly less likely to undergo surgery.
Surgeons are needed for the management of some patients with benign breast disease but the triage pathway could be optimized. We propose that patients are seen by specialist breast surgeons at their first appointment to undergo a clinical breast examination. Patients with a normal examination can be seen by breast care nurses or breast physicians for any subsequent follow-up management. This would free surgeons to more quickly see patients requiring their expertise and ongoing care, such as patients with an abnormal clinical breast examination and patients with breast cancer. Future studies are required to determine the feasibility, acceptability, and efficiency of this new model of care.
References:
1. Vaidyanathan L, Barnard K, Elnicki DM. Benign breast disease: when to treat, when to reassure, when to refer. Cleve Clin J Med. 2002;69(5):425-432. doi:10.3949/ccjm.69.5.425
2. Courtillot C, Plu-Bureau G, Binart N, et al. Benign breast diseases. J Mammary Gland Biol Neoplasia. 2005;10(4):325-335. doi:10.1007/s10911-006-9006-4
3. Barton MB, Elmore JG, Fletcher SW. Breast symptoms among women enrolled in a health maintenance organization: frequency, evaluation, and outcome. Ann Intern Med. 1999;130(8):651-657. doi:10.7326/0003-4819-130-8-199904200-00005
4. Seltzer MH. Breast complaints, biopsies, and cancer correlated with age in 10,000 consecutive new surgical referrals. Breast J. 2004;10(2):111-117. doi:10.1111/j.1075-122x.2004.21284.x
5. Blackmore et al. 2014
6. Laver RC, Reed MW, Harrison BJ, Newton PD. The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services. Ann R Coll Surg Engl. 1999;81(4):242-247.
7. Practice bulletin no. 164: Diagnosis and Management of Benign Breast Disorders. Obstet Gynecol. 2016;127(6):e141-e156. doi:10.1097/AOG.0000000000001482
8. Cochrane RA, Singhal H, Monypenny IJ, Webster DJ, Lyons K, Mansel RE. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. Eur J Surg Oncol. 1997;23(3):198-201. doi:10.1016/s0748-7983(97)92220-4
9. BRIDGE Study Group. Responses of primary health care professionals to UK national guidelines on the management and referral of women with breast conditions. J Eval Clin Pract. 2002;8(3):319-325. doi:10.1046/j.1365-2753.2002.00335.x
10. Dawson C, Lancashire MJ, Reece-Smith H, Faber RG. Breast disease and the general surgeon. I. referral of patients with breast problems. Ann R Coll Surg Engi. 1993;75(2):79-82.
