Breast Cancer 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
E-mail: turma14med@gmail.com
Adviser: Rosa Oliveira; Class Number 14
ABSTRACT:
Introduction: In breast cancer, the 5th cause of death worldwide, prevention and early diagnosis play
an essential role in diminishing mortality. Therefore, evaluating the patients’ pathway, the general
practitioners (GPs) knowledge of guidelines and their use of systems as BI-RADS is important to
assure an effective treatment and improve health care and its costs.
Aims: Investigate the referral of patients to Grupo de Patologia Mamária (GPM) of Hospital de São
João, and GPs’ knowledge of guidelines and best medicine evidence concerning diagnosis of breast
pathology.
Study Design: Transversal and observational study. A questionnaire was delivered to GPs to
evaluate their efficacy at identifying patients with breast cancer comparing their awareness of the
pathway with the BI-RADS score. It also was analyzed the statistics gathered from the BreastCare
database. The statistical study included frequencies and percentages, means and standard deviation,
as well as binomial tests and intervals of 95% confidence.
Results: All of the respondents considered mammography as the standard test for screening
pathology. All of the GPs know BI-RADS classification but only 76.5% of them know the
“Recomendações Nacionais para o Diagnóstico e Cancro da Mama” (p=0,049). More than 50% (95%
CI) of the GPs are familiared with these guidelines. 70% of women arrived to the GPM incorrectly
rerouted (53.1% of them were referred as BI-RADS Stage 2).
Discussion/Conclusion: More than half of the GPs are following the guidelines and are aware of
“Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama” and BI-RADS
classification. However, the massive rerouting of BI-RADS Stage 2 proves that women are being bad
rerouted and resources are being spent inadequately. There are some limitations in this study such
as the high number of missing values on BreastCare database. Further studies will be required in
order to complete and improve these results.
KEY-WORDS: Breast Neoplasm [MeSH Term]; Diagnosis [MeSH Term]; Referral and Consulting
[MeSH Term]; Practice Guideline [MeSH Term]; Breast Care
Page 1 of 15
INTRODUCTION
Cancer is the second leading cause of death in developed countries and about 12.5% of all
deaths in the world are caused by it.
[1,2]
Breast cancer is the second most common type of cancer in
the world and is the most prevalent worldwide among women ranking in 5 th as cause of death
[3].
Worldwide, it is estimated that more than one million women are diagnosed with breast cancer every
year, and more than 410000 will die
[4].
In Portuguese population, around 4500 new cases of breast
cancer occur each year [5].
Since the early 90’s, it has been observed in Europe an estimated annual percent change of 2% in the breast mortality cancer due, in part, to the progress in early diagnosis and effective
treatments
[6].
Screening and early diagnosis are the most effective ways to prevent cancer,
guaranteeing an early and successful treatment.
In order to assure a common network of actualized knowledge, doctors have compiled
national guidelines, a guide to the best practice which provides information on which decisions can
be made.
[7]
They intend to assist doctors and women in decision-making as well as educate all
people involved in the care of women with breast cancer.[8]
Studies have shown that primary care providers are crucial to providing high quality health
care
[9].
Physician awareness to guidelines may be limited by the physician’s disagreement with a
specific guideline or the concept of guidelines in general or even the inability to reconcile patient
preferences with the guideline recommendations
[10].
There are no references in literature concerning
numbers related to primary care physicians in what concerns following national guidelines for breast
cancer diagnosis. However, a recent 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
[11].
In Portugal, primary health care units are the first institution of the National Health Care
System providing diagnosis and medical assistance to women who suspect to have breast pathology,
rerouting them to the appropriate hospital if needed
[12].
The exam for breast cancer screening is the
mammography, which can detect small breast tumors, (less likely to metastasize) allowing the patient
to be treated with a non-invasive method.[13]
Considering the diagnosis and referral of women who suspect to have breast cancer, doctors
use another tool besides the guidelines, the Breast Imaging Report and Data System (BI-RADS), a
report which includes the description of all mammographic images of each breast, with a conclusion
which should include the BI-RADS categories, from 0 to 6. It has a proper lexicon defining several
mammographic features (images of masses and lesions for instance), which contributes to the
standardization of the radiological language and to a more objectively compared report (in
Page 2 of 15
comparison to a radiologist’s), justifying why the BI-RADS is so largely used in countries where
breast cancer screening is implemented [14].
The referral system implemented by the Portuguese National Health Service is determinant to
save time and improve prognosis and survival of the patients
[15].
Aiming to support the clinical
activities of the breast pathology unit, the Serviço de Bioestatística e Informática Médica (SBIM) of
the Faculdade de Medicina da Universidade do Porto (FMUP), in collaboration with the Breast Center
of Hospital de São João (HSJ), developed an informatics application named BreastCare. It provides
to health care professionals technological means to support provision care, register symptoms,
morphology and site of injury, as well as data concerning complementary means of diagnosis and
group consultations. The history of database creation describes a prospective collection procedure,
elapsed during a period of 26 months in Grupo de Patologia Mamária (UPM) of HSJ. This database
includes women with breast pathologies who were admitted to the UPM and rerouted from primary
health care centers [16].
Because the medical decisions of the primary care physicians are so determinant to the
subsequent medical pathway of the patients and there are remaining doubts about the efficiency of
diagnosis and referral of women with breast cancer to a specialist, the present study intends to
evaluate the effectiveness of the clinical pathway of women suspected to have breast cancer from
primary health care centers to a specialized breast pathology center.
Aims and Research questions
The aim of this project is to investigate the referral of patients defined as women having
suspicious breast abnormalities followed by GPM of HSJ, as well as assessing the quality of
rerouting and the information of general practitioners (GPs) concerning the national guidelines for
adequate referral of breast pathology patients.
•
Do primary care physicians know the guidelines and best medicine evidence concerning
diagnosis of breast pathology?
•
•
If so, do they follow them?
Are patients correctly rerouted to the GPM according to their BI-RADS classification?
Answering these questions allow us to conclude about the effectiveness of the rerouting from
primary health care units to GPM.
We also collected medical terms associated with breast cancer and organized them into a
glossary so that patients and medical professionals can access it, which is available online.
Page 3 of 15
PARTICIPANTS AND METHODS
There are two target populations in this study: GPs of the primary health care units of the
metropolitan area of Oporto and women with breast pathology accompanied in the GPM of HSJ.
The application of questionnaires to the GPs, concerning the rerouting of breast care patients
to the hospitals, allowed to evaluate their awareness regarding the guidelines that should be followed
when a breast cancer patient is diagnosed, in order to have a suitable referral. The sample was
randomly chosen from a group of GPs of primary health care units of S. Pedro da Cova (Famalicão),
S. Mamede Infesta, Rio Tinto, Valongo, Leça da Palmeira, Sra. da Hora, Santo André do Corvo Canidelo. No exclusion criteria were considered and the only criterion for inclusion was being general
clinical primary health care centers’ doctors. The primary health care units were chosen according to
the residence of each one of the students involved in this study.
At the same time, through the BreastCare database, we compared the BI-RADS score of
rerouted patients to the UPM with the standards of well-rerouting (BI-RADS≥4). This statistical
analysis clarifies if the referral done in primary health care units and UPM are being well conducted.
Study Design
A transversal and observational study of patients clinical charts, selected according to criteria
of inclusion and exclusion in two groups.
Data Collection Methods
A structured questionnaire, named “Clinical Pathway: are doctors aware?” (Appendix 1), was
developed to establish current clinical practice in primary health care units, with regard to breast
cancer diagnosis
and compliance with breast cancer guidelines. Once there are no national
guidelines, we based our questionnaire on Guideline of January 2010 (Institute for Clinical Systems
Improvement), Guideline of June 2005 (National Institute for Clinical Excellence – concerning cancer
in general), Guideline of February 2009 (National Institute for Clinical Excellence – specific for breast
cancer), Guideline of July 2005 (National Colaborating Centre for Primary Care), Guideline of August
2002 (National Institute for Clinical Excellence – outcomes in breast cancer) and “Recomendações
Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, ACS, Setembro 2009”. It must be
taken in consideration that, even similar, there are always dissimilarities between different guidelines,
which may influence the results of our survey once each primary health care unit or physician may be
following a different guideline. To minimize these differences, we included general procedures and
algorithms in our survey.
Page 4 of 15
The parts of the questionnaire intended to assess the knowledge of guidelines and procedures
through multiple choice questions [(i) and (ii)], understand the primary care physicians’ ideas
concerning primary health care in breast pathology (iii) and describe the population of the study (iv).
A breast cancer specialist (BCS) of the UPM, Dr. Fernando Osório, reviewed the initial draft, which
was substantially longer than the final questionnaire. The revised final questionnaire was delivered to
three GP, so a pilot test could be performed. With their opinions, little changes were necessary,but
final corrections were made.
The questionnaires were delivered to GPs of primary healh care units in order to assess their
knlowledgement on national guidelines for rerouting breast cancer patients. The response was
anonimous and delivered to the primary mentioned health care units (preferably in person to the GP,
in order to encourage a strong response to a detailed survey). The Agrupamento de Centros de
Saúde (ACES) was also contacted for the purpose of improving the approach of the GP and ensuring
an easier collaboration. However, our request for support had no response neither information to the
respective health centers.
The population was initially divided according the place of residence of each one involved in
the study analysis. Then, from each group of population, physicians from the considered primary
health care centers were randomly chosen. Therefore, this is a stratified random sample.
Secondly, we analyzed the BreastCare database in order to understand if the rerouting was
well conducted and to characterize the population and initial approach of women who arrive to the
UPM.
Variables Description
In the first part of the questionnaire we focused on questions that allow us to understand how
deep is the knowledge of the medical professional regarding terminology related to the breast cancer
pathology. We wanted to know how much are they familiarized with the “Recomendações Nacionais
para o Tratamento e Diagnóstico do Cancro da Mama”, according to Alto Comissariado da Saúde
(September 2009) and with the BI-RADS classification.
In the second part, we inquired more specifically related to their practice, trying to understand
how they act in real life situations and the importance they give to factors like the method of
screening and the reevaluation of the severity of an injury. These last variables depend on what kind
of education they had and the preparation for these kinds of situations.
Once these two parts of the questionnaire are completed, we are able to evaluate the doctor’s
knowledge of guidelines concerning breast cancer rerouting and if guidelines are indeed followed.
Page 5 of 15
In the third part, we have done questions with a more partial and subjective method, to know
their point of view on actual situation regarding breast cancer awareness and health polices and what
they would do to improve it.
The fourth part includes certain demographic questions - age, gender, time of medical practice
and place of work, and experience in following women with breast cancer (all of them are
independent variables). With these, we are able to perform a sample characterization.
In the last part, beyond the questions of characterization there is also an open question, so
that the doctors can add information that they consider relevant.
Regarding the BreastCare database, only some of the collected data will be used. The age of
the women, the use of mammography and echography for the diagnosis of breast cancer, will enable
us to describe the average population which is rerouted to GPM and what initial approach is used by
both GPs and BCS.
The BI-RADS classification of women who are included in the database will allow us to
conclude if their rerouting is being well conducted: according to specialists, only BI-RADS 4 or
superior should be referred to a specialist unit concerning breast cancer.
Statistical Analysis
Frequencies and percentages were used to display responses to individual questions, such as
gender while means and standard deviation were used to characterize continuous variables such as
time of follow up of patients with breast pathology. Medians, inter-quartile ranges and 95%
confidence intervals of the follow-up durations for each continuous variable were, also, displayed.
A score of the questionnaires (using a percentage of the right answers) allowed us to conclude
about the general efficiency of breast pathology care in our primary health care centers. It was
created two types of scores for this propose: one related to the answers about the referral of patients
and the other related to the answers about the GPs’ knowledge of “Recomendações Nacionais para
o Diagnóstico e Tratamento do Cancro da Mama” and BI-RADS classification.
With relative frequencies of the knowledge of the "Recomendações Nacionais para
Diagnóstico e Tratamento do Cancro da Mama" we will be able to assess the doctor’s knowledge of
the national guidelines, using binomial tests (considering several cut-off points such as 0.50, 0.60,
0.70 and 0.80).
The characterization of the GPM’s population was also described using means (for the
continuous variables like age and age of diagnosis) and frequencies for the qualitative variables (like
the preforming of complementary exams).
PASW Statistics 19.0 was used for the statistical analysis, and 0.05 was set as significance
level.
Page 6 of 15
RESULTS
In the study, 19 of the 55 delivered surveys were answered (response rate = 34.6%). 14 of the
GPs were female (ratio men: women was 0.34). GPs mean age (SD) years was 45.1(10.8) (referring
to the 1st January of 2011) and mean experience time (SD) years was 18.4 (12.1).
16 (84.2%) of the GPs frequently deal with breast pathology, 2 (10.5%) don’t and 1 (5.3%)
didn’t answer. In average, 94.8 patients with breast pathology (± 107.7) are followed per GP, every
year.
Each primary health center had the median response of 3 GPs (minimum: 1; maximum: 5).
All of the respondents (n=19) considered mammography as the standard test for screening of
breast pathology.
Concerning
the
most
important
factors in the assessment of the severity of
the breast lesion, 13 (68.4%) of the GPs
considered both morphologic changes and
size changes as the main factors while 5
(26.3%)
only
considered
Table 1 – Important factors in the assessment of breast lesion.
%
n
Morphologic changes
18
94.7%
Size changes
13
68.4%
Both
13
68.4%
morphologic
changes (Table 1).
When questioned about the clinical procedure to be taken by a patient with a simple cyst, 17
(89,5%) of the GPs affirmed to maintain the patient in their own consult for further study instead of
referring her to another area of expertise or unnecessary exams.
Considering the referral to the BCS, 5 (26.3%) of the GPs would incorrectly keep a patient with
modifications of a previously studied breast lesion under their own responsibility. The situation which
is most easily identified as likely to be solved with the exclusive intervention of the GP is “women with
non-disabling breast ache and without clinical or imaging lesions” (18 – 94.7% – of the GPs
considered themselves capable to treat these patients on their own).
According to the analisys of the third part of the survey, 63.2% of the GPs considered that
there are gathered the basic conditions for the primary health care physicians to deal with breast
pathology in Portugal and only 47.4% think that is necessary to make changes in the health system,
concerning the referral of women with breast pathology from the primary health care centers to the
hospitals.
Using the binomial test, we can state (with a 95% confidence) that more than 50% of the GPs
know the “Recomendações Nacionais para o Diagnóstico e Cancro da Mama” (p=0.049). The
interval (with 95% confidence) which represents the percentage of GPs who are familiared with these
guidelines is located between 54% and 99%.
Page 7 of 15
All of the GPs are aware of BI-RADS classification system but only 13 (66.7%) of them would
correctly reroute a woman scored with a stage 3 (Graph 1).
Graph 1 - Percentage of GPs who are aware of BIRADS and RNDTCM
100%
80%
60%
100,0%
40%
76,5%
66,7%
20%
* “Recomendações Nacionais
0%
Knowledge of
RADS
BI-
Knowledge of
RNDTCM*
Correct referral of
BI-RADS 3
para o Tratamento e Diagnóstico
de Cancro da Mama”
The mean (SD) of percentage of correct answers of the questionnaires in total was 75.4%
(11.9). We can affirm (95% CI) that GPs who answered this questionnaire would have a result
between 69.1% and 81.7% (for a more detailed analysis of the percentage of right answers to each
question of the questionnaire, see Appendix 2).
According to the BreastCare database, there were 1151 women and the mean age (SD) was
49.6 years (15.0). At the arrival to the GPM, 335 (29.1%) of the women had done a mammography
(0.1% hadn’t and 70.8% didn’t anwser). Considering the ecoghraphy registries, all who replied had
done an echography (n=250), but 901 (78.3%) participants didn’t answer. Breast cancer was first
diagnosed at an average age (SD) of 48.9 years (12.9).
Regarding BI-RADS classification, 70% of the women arrived to the GPM classified as Stage 3
or less (77.4% didn’t anwser), 53.1% of them were referred as BI-RADS Stage 2. Using a 95%
confidence, we are able to state that 64.5% to 75.6% of women are being incorrectly rerouted to the
GPM of HSJ.
DISCUSSION/CONCLUSION
Considering the population who responded to the questionnaire, most of the GPs regularly
deal with women with breast pathology, which may indicate the strong impact of the disease in the
population. On the other hand, this frequent contact with the pathology may also explain the high
percentage of GPs who are aware of the “Recomendações Nacionais para o Tratamento e
Diagnóstico de Cancro da Mama”, ACS, Setembro 2009 and of the BI-RADS classification system.
Every year, 94.8 patients with breast pathology are followed per GP but, once the standard deviation
Page 8 of 15
is particularly high for this parameter (107.7 patients), this data was not considered valid, due to
errors concerning the explanation of the question, the differences between the tasks of the physicians
on the different health care sections and the subjectivity of the numbers (it was an estimation, not
statistically calculated).
All of the GPs considered mammography as the standard test for screening of breast
pathology, which is in agreement with the literature stating that mammography remains the main
screening tool, which has been recommended for many decades [17].
A small percentage of the GPs considered only morphologic changes as the main factor
concerning the assessment of the severity of a breast lesion, while more than half considered both
morphologic changes and size changes as the most important factors which is the correct answer.
This represents the importance of the modifications in breast lesions, which are probably responsible
for most of the rerouting of patients to BCS.
Regarding the high percentage of GPs who affirmed to keep a patient with a simple cyst under
their own consult for further study, instead of referring her to another area of expertise or
unnecessary exams, it could indicate the correct interpretation of a diagnosis, which emphasizes the
importance of the GPs in health care costs once, with a good diagnosis, the patient is rerouted only
when necessary, which saves resources and time.
The GPs’ opinion about the Portuguese health care system, concerning breast pathology, is
reasonably positive, helping us understand that the improvement of breast pathology study should be
more directed to the information and learning of the GPs rather than developing the Serviço Nacional
de Saúde itself and its resources.
The general score of the questionnaire were between 69.1% and 81.7% (95% CI) which
indicate a high percentage of right answers and we can also state that more than half of the GPs are
following the guidelines. This would eventually guarantee an efficient referral to BCS, which would be
ideal to develop the competence of our primary health care facilities.
Regarding the BreastCare database, breast cancer is first diagnosed at an average age of
48.9 years, which is in agreement with the literature, with states that, commonly, breast cancer first
appear in women with 50 years (or more) [18].
Only a few percentage of the women arrived to the GPM with the reccomended diagnostic
tests done, such as mammography and echography, but, since the rate of answer was very low, we
can not consider this data valid.
According to the BI-RADS classification, 70% (confidence interval of 95% to the population [64.5%; 75.6%]) of the women arrived to the GPM in a stage 3 or less wich indicates the percentage
of incorrect referrals to the hospital. However, considering that there was more than 50% of missings,
this percentage may not represent the reality. The bad rerouting is however clear, since more than
Page 9 of 15
half of the women were referred as BI-RADS Stage 2, which is usually described as “benign
finding(s)”.
There are some limitations in this study such as the high number of missing values on
BreastCare database and the low rate of answer in the surveys (34.6%), leading us to conclude that
further studies will be required in order to complete and improve our results. The low fidelity of the
answers (due to acess to the Internet during the filling out of the questionnaires or the fact that the
answers weren’t given in person) is also important to enhance, since it may be easily improved with a
different approach of GPs, guaranteeing a better percentage of response and fidelity to our work.
Investigating using interviews would also be important and would enchance our knowledge on the
actual information of each GP.
With this study we were able to conclude that, 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 from
GPs to BCS and resources are being spent inadequately, probably due to a lack of information and
communication between the two parts of the patient’s pathway. Improvements targeted to solve this
possible lack would considerably develop the health care in our country, with a consequent progress
in other areas (like incidence of certain diseases and costs in all health departments).
Page 10 of 15
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“Ten
leading
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2011(<http://gamapserver.who.int/gho/interactive_charts/mbd/cod_2008/graph.html>)
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[4] Coughlin SS., Ekwueme DU., “Breast cancer as a global health concern”, Cancer Epidemiology,
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[5]
“Cancro
da
Mama”,
Pt-Comunidades,
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30,
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[6] “Evolução da Mortalidade por Cancro da Mama em Portugal (1955-2002)”, Acta Médica
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[8] “Recomendações Nacionais para o Diagnóstico e Tratamento do Cancro da Mama”, May 29,
2011 (< http://www.acs.min-saude.pt/files/2009/09/acs_cancro-mama_low.pdf>)
[9] Cardarelli R, Kurian AK, Pandya V. “Having a personal healthcare provider and receipt of
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[12] “Guia do Utente do Serviço Nacional de Saúde “, Direcção Geral-Saúde, December 20, 2010
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[16] Grupo de Patologia Mamária do Hospital São João, May 22, 2011 (<http://www.hsjoao.minsaude.pt/gpm/>)
[17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005;
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[18] http://www.mulherportuguesa.com/saude-a-bem-estar/o-cancro-da-mama/1109-cancro-damama-o-que-e (28/05/11)
Page 12 of 15
APPENDIX 1
Page 13 of 15
Page 14 of 15
APPENDIX 2
Table 2 – Score of the questionnaires’ right answers.
N
(%)
95% CI
Todas as pacientes com nódulo na mama devem ser submetidas
a exames imagiológicos?
19
(100)
Está familiarizado (a) com as “Recomendações Nacionais para o
Diagnóstico do Cancro da Mama” do Alto Comissário da Saúde
(Set.2009)? *
17
(75)
Conhece a classificação BI-RADS? *
19
(100)
Considera que uma paciente cuja mamografia é classificada
como BI-RADS 3 deve ser reencaminhada para uma consulta de
especialidade?
18
(69)
[0.43;0.94]
Todas as mulheres com corrimento mamilar (sanguinolento,
unicanalicular e espontâneo) devem ser referenciadas a um
especialista com carácter urgente?
19
(81)
[0,60;1.00]
Mulher pré-menopáusica (ou pós-menopáusica com terapêutica
hormonal de substituição) com modularidade dolorosa simétrica
das mamas sem anomalias localizadas.
19
(81)
[0.60;1.00]
Modificação das características de nódulo existente e sob
vigilância.
19
(69)
[0.43;0.94]
Nódulo dominante, de aparecimento recente, em mulher com
idade superior a 30 anos.
19
(44)
[0.16;0.71]
Mulher com mastalgia não incapacitante e sem lesões clínicas ou
imagiológicas.
19
(94)
[0.80;1.00]
Mulher com menos de 50 anos com escorrência mamilar
pluricanicular ou intermitente, não sanguinolenta e não
incomodativa.
19
(44)
[0.16;0.71]
Qual(ais) o(s) factor(es) que considera importantes na reavaliação
da gravidade de uma lesão?
19
(69)
[0.43;0.94]
Qual o método preferencial de rastreio na detecção imagiológica
do cancro da mama?
19
(100)
Perante uma paciente com nódulo palpável na mama, os
resultados do estudo imagiológico indicam cisto simples. Como
procederia?
19
(88)
[0.51;0.99]
[0.69;1.00]
* Questions concerning the GPs’ knowledge of BI-RADS and “Recomendações Nacionais para o Diagnóstico e
Tratamento do Cancro da Mama”. “Sim” answers scored as “right answers”.
(N) – frequency
(%) – percentage
CI – Confidence Interval
Page 15 of 15