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
Academic Year: 2010/2011
Adviser: Rosa Oliveira
Introdução à Medicina
Class 14
Introduction
| Participants and Methods | Results | Discussion | Conclusion
BREAST CANCER
Chart 1: Cancer incidence statistics in
Portuguese women (2003)
[1]
Mortality is
decreasing[2]
 Early diagnosis
 Effective treatments[2]
[1] Pinheiro PS, 2003
[2] Coughlin SS, 2009
[3] Who, 2010; [4] Ferlay, 2010; [5] Davis, 2010; [6] Kerr F, 2006
2
Introduction
| Participants and Methods | Results | Discussion | Conclusion
CLINICAL PATHWAY[10]
GUIDELINES[7,8]
PRIMARY HEALTH
CARE CENTERS
Consulting
Woman who
suspects to
have breast
pathology
a) Imagiologic exams
requested
BI-RADS[9]
Specialized breast
pathology unit
b) Follow the patient for
observation
[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 Don’t Physicians Follow Clinical Practice Guidelines?”
3
Introduction
| Participants and Methods | Results | Discussion | Conclusion
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
USF: Unidade de Saúde Familiar
GPM: Grupo de Patologia Mamaria
4
Introduction
| Participants and Methods | Results | Discussion | Conclusion
Research Questions
• Do general practitioners know any GUIDELINES
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 BI-RADS classification?
MeSH terms:
Breast Neoplasm ; Diagnosis; Referral and Consulting; Practice Guideline
GPM: Grupo de Patologia Mamária
BI-RADS: Breast Imaging Report and Data System
5
Introduction |
Participants and Methods
Study Design
| Results | Discussion | Conclusion
→ transversal and observational study
Design of questionnaire
Analysis of the BreastCare database
Delivery of questionnaires
Analysis of BI-RADS of
women referred to
GPM
Evaluate the awareness
regarding the guidelines
ANALYZE THE REFERRAL
GPM: Grupo de Patologia Mamária
BI-RADS: Breast Imaging Report and Data System
6
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Study Participants
Delivery of questionnaires
1st GROUP: General
Practitioners from primary
health care institutions in the
metropolitan area of Oporto
 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
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Data collection
Delivery of questionnaires
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]
[11] Guidance on Cancer Services: Improving Outcomes in Breast [14] Early and locally advanced breast cancer. Diagnosis and
Cancer, 2002
treatment, 2009
[12] Referral guidelines for suspected cancer in adults and
[15] Recomendações Nacionais para o Tratamento e Diagnóstico
children, 2005
de Cancro da Mama, 2009
8
[13] Referral guidelines for suspected cancer, 2005
[16] Health Care Guideline: Diagnosis of Breast Disease, 2010
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Data collection
Delivery of questionnaires
Questionnaire
Discussion with Dr. Fernando Osório
Compile data in a database
Some modifications on the questionnaire
Delivery to the doctors of
primary care units
Pilot test to 2 general practitioners
9
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Variables description
Delivery of questionnaires
10
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Variables description
Delivery of questionnaires
11
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Variables description
Delivery of questionnaires
12
Introduction |
Participants and Methods
Study Design
| Results | Discussion | Conclusion
→ transversal and observational study
Design of questionnaire
Analysis of the BreastCare database
Delivery of questionnaires
Analysis of BI-RADS of
women referred
reffered to
GPM
Evaluate the awareness
regarding the guidelines
ANALYZE THE REFERRAL
GPM: Grupo de Patologia Mamária
BI-RADS: Breast Imaging Report and Data System
13
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Study Participants
Analysis of the BreastCare database
2º GROUP: Women with
breast cancer who
participated in the Breast
Care of HSJ
 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
GPM: Grupo de Patologia Mamária
HSJ: Hospital de São João
14
Introduction |
Participants and Methods
Variable description
| Results | Discussion | Conclusion
Analysis of the BreastCare database
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
15
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Statistical analysis
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.
16
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Statistical analysis
Delivery of questionnaires
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.
17
Introduction |
Participants and Methods
| Results | Discussion | Conclusion
Statistical analysis
Delivery of questionnaires
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%)
Significance level: 0.05
CI: Confidence Intervals
18
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
 19 GPs from health centers.
Response percent: 34.6%
• Delivered in person 55
questionnaires
• Request to ACES
GP: General Practitioners
CS: Centro de Saúde
ACES: Agrupamento de Centros de Saúde
Table 1: GPs from health centers
19
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
Characterization of the sample:
 14 of the GP were female
(ratio men : women = 0.34)
Table 2: Gender of GP
 GP mean age (SD) = 45.1(10.8) years
Table 4: Age
 Mean experience time (SD) = 18.4 (12.1) years
GP: General Practitioners
SD: Standard Desviation
Table 3: Clinical experience
20
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
 84.2% (n=16) of the GP frequently deal with breast pathology
Table 5: Do GP deal with breast pathology?
21
GP: General Practitioners
Introduction | Participants and Methods |
| Discussion | Conclusion
Results
Results, Tables and Graphics
Delivery of questionnaires
 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.
n
%
Morphologic changes
18
94,7%
Size changes
13
68,4%
Both
13
68,4%
Table 6: What is the most important factor in the assessment of the severity of the breast lesion?
22
GP: General Practitioners
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
 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.
GPM: Grupo de Patologia Mamária
GP: General Practitioners
23
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
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.
GP: General Practitioners
24
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
Chart 2: Are they
gathered the basic
condicions to deal
with breast
pathology in
Portugal?
BI-RADS: Breast Imaging Report and Data System
RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”
25
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Delivery of questionnaires
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.
BI-RADS: Breast Imaging Report and Data System
RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”
26
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Analysis of the BreastCare database
 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).
Table 9: Mean age at the moment of
arrival to GPM
Table 11: Registration of mammography
 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
SD: Standard Deviations
GPM: Grupo de Patogia Mamária
Table 10: When breast cancer was first
diagnosed
27
Introduction | Participants and Methods |
Results
| Discussion | Conclusion
Results, Tables and Graphics
Analysis of the BreastCare database
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%]
BI-RADS: Breast Imaging Report and Data System
GPM: Grupo de Patogia Mamária
CI: Confidence Intervale
28
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
Discussion
• Do general practitioners know any GUIDELINES and best
medicine evidence concerning diagnosis of breast pathology?
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
BI-RADS: Breast Imaging Report and Data System
ACES: Agrupamento de Centros de Saúde
GP: General Practitioners
29
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
Discussion
• If so, do they follow them?
 Score of questionnaire:
•
•
Frequency (95% CI): 75%
[69%; 81%]
BI-RADS: Breast Imaging Report and Data System
CI: Confidence Intervale
30
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
Discussion
More than 50% of the GPs ARE following the guidelines
 Contradicts the literature:
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.
 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.
GP: General Practitioners
[18] Cabana, Michael D., Rand, Cynthia S. et al. “Why Don’t Physicians Follow Clinical Practice Guidelines?” JAMA,
October 20, 199 – Vol. 282, no.15
31
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
Discussion
• Are patients correctly rerouted to the GPM taking into account
their BI-RADS classification?
According to the BI-RADS classification,
70% of the women arrived to the
GPM in a Stage 3 or less.
Inadequate rerouting frequency
(CI 95%): [64.5%; 75.6%]
 percentage of incorrect referrals to
the hospital
BI-RADS: Breast Imaging Report and Data System
CI: Confidence Intervals
GPM: Grupo de Patologia Mamária
32
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
Discussion
 “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]
GP: General Practisioners
[17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005; 293: 1245-1254
33
Introduction | Participants and Methods | Results |
Discussion
| Conclusion
LIMITATIONS
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.
34
Introduction | Participants and Methods | Results | Discussion |
Conclusion
Conclusion
 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.
BI-RADS: Breast Imaging Report and Data System
GP: General Practisioners
35
Introduction | Participants and Methods | Results | Discussion | Conclusion
Addendum
FLYER
• Delivered at Hospital São João (HSJ) on 30th October
(Dia Nacional da
Prevenção do Cancro da Mama);
• Informative flyer for patients and visitors of HSJ.
36
Introduction | Participants and Methods | Results | Discussion | Conclusion
Addendum
WEBSITE
37
Introduction | Participants and Methods | Results | Discussion | Conclusion
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
38
Introduction | Participants and Methods | Results | Discussion | Conclusion
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 Don’t 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
39