The NHS Executive has set a two-week target for outpatient waiting times for women with suspected breast cancer, and data on this has had to be collected since 1 April.1,2 We audited our outpatient breast clinic waiting times and subsequent management over athree-month period before implementing these targets to determine whether the guidelines were already being met and how easy it was to collect relevant data.
Twenty-six specialist dedicated breast clinics were audited over the period 1 January-31 March and 499 new patients were seen and categorised into four groups (see table). Of the 499, 380 were symptomatic. Those under 35 years old were placed in a separate category because it is widely agreed they do not benefit from routine mammographic examination. Patients were identified from clinic lists, and their demographic details completed after the letter to the referral source, usually a general practitioner, had been dictated. This took about 10 hours a week of research co-ordinator's time for the three-month period. A network was constructed to ensure that no patient's data was lost.
The breast unit at North Tees General Hospital has had an agreed referral form available for many years, but it was used for relatively few referrals. Only 32 patients (from the relevant symptomatic 380 combined one-stop and under-35-year-old patients) were referred with a suspicion of having a breast cancer and described as being urgent by the referring GP, as suggested by the NHS circular.1
The breast clinics had at least one consultant present, together with two specialist registrars, two to three senior house officers, one staff- grade surgeon and a consultant oncologist.
All patients referred from the breast screening unit and all but two of the symptomatic patients were seen within two weeks of the receipt of the referral letter. Both of the latter were marked urgent; one waited 15 days and the other 20 days (mainly related to the three Christmas bank holidays before their appointment in January). Neitherwas subsequently found to have a breast cancer.
Of the 32 designated urgent, seven were found to have a cancer (22 per cent), but of the symptomatic patients overall 36 (9.5 per cent) had a breast cancer. Only one cancer was found in the under-35s (less than 1 per cent).
Two hundred and twelve symptomatic women (56 per cent) were discharged after their visit (mostly with a diagnosis of benign breast disease or after cyst aspiration) and 109 (29 per cent) had fine-needle cytology with 36 (9.5 per cent) being positive for cancer.
With two possibly excusable exceptions, the breast clinics in this trust were already achieving a two-week target for breast referral before thehealth service circular.
Over a quarter of these symptomatic women were under 35 years old and only one was found to have a breast cancer, possibly justifying the decision for one-stop triple assessment (clinical examination, mammography and cytology) in women aged over 35.
The British Association of Surgical Oncology guidelines recommend that 40 new referrals to a breast unit be seen each week, and it is estimated that 25 per cent of surgical outpatients work is dedicated to breast diseases (commensurate with the numbers seen in this trust).3,4
This can be done only at some cost as it involves large numbers of junior staff with limited teaching time and needs the resources of breast care and outpatient nurses as well as radiological and pathology services for one-stop processing.
It is an administrative challenge to ensure that reporting can be achieved within the confines of clinic time. If core biopsy diagnosis were introduced it would not be possible.
Once diagnosed, symptomatic patients with breast cancer wait a comparable median eight to nine days for definitive surgery, which equals the NHS breast screening programme for qualityof care.
1 Breast cancer waiting times - achieving the two-week target. HSC 1998/242.
2 Collection of information on waiting times for suspected breast cancer patients in 1999/2000. HSC 1999/084.
3 The British Association of Surgical Oncology breastspeciality group. Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom (1998 revision). Eur J Surg Oncol 1998; 24 (6): 464-76.
4 Dawson C, Lancashire M, Reece Smith H et al. Breast disease and the general surgeon (part one): referral of patients with breast problems. Ann Roy Coll Surg Eng 1993; 75 (2): 79-86.
Jean Patton is research co-ordinator, Francesca Leaper is assistant director, clinical support, Anthony Peel is consultant surgeon, Colm Hennessy is consultant surgeon and David Leaper is professor of surgery, North TeesGeneral Hospital.
First-time appointments, breast clinics 1 Jan-31 Mar 1999
One-stop symptomatic(triple assessment) 271
Breast screening referrals 51
Other (mainly family history and cosmetic surgery referrals) 68