Over 50,000 people are diagnosed with breast cancer each year in the UK and approximately two thirds of these are identified through the referral of symptomatic patients to specialist breast units from primary care.1,2

Generally speaking, primary care practitioners (PCPs), which includes GPs, nurse practitioners (NPs) and others, do not have access to specialist breast investigations and use history and examination alone for assessment. Patients who are deemed to have a 3% or greater risk of breast cancer are referred via the “two-week wait” (2WW) pathway.3 Patients deemed to have a less than 3% risk of cancer are referred through the “choose and book” (C&B) route.3 Whilst this model is suited to discriminate cancer from non-cancer, it is less suited to patients with benign disease and puts pressure on secondary care resources.4 Furthermore, this model places an additional step between cancer patients and their diagnosis.

Changing to a system where patients self-refer would arguably work in the best interest of patients, primary care services and secondary care units, and allow for more cost-effective allocation of resources.5 However, there is currently no data which would support this. This study aims to evaluate the primary care breast workload in the Plymouth catchment area, obtain PCPs’ opinions on the current referral pathway, explore whether PCPs feel change is warranted, and investigate what affect, if any, the Covid-19 pandemic has had on referral rates.

Methods

The study team consisted of a breast surgeon, a specialty trainee in general surgery and two GPs. An 18-question survey was designed on SurveyMonkey.com. The survey was aimed at all PCPs in the catchment area of the Primrose Breast Care Centre, University Hospitals Plymouth NHS Trust (UK) and was intended to take the participant no longer than four minutes to complete. 14 questions were multiple choice and compulsory; three of these multiple-choice questions had a follow-on free text box where participants could provide further information if they wished.

Three questions asked for a free-text response only; these were optional. One question asked participants to provide a contact email if they wanted to be involved in a future project; this was also optional.

Questions aimed to collect the following data: role and gender of participant, confidence of participant when consulting patients with a breast-related issue (one to five scale), details of participant’s breast workload, details of how breast care in the community has been affected by Covid-19, participant’s estimate of how many breast cancers they diagnose in a typical year, participant’s level of satisfaction with the current breast referral pathway (one to five scale), and participant’s opinions on a potential change to patient self-referral.

The SurveyMonkey.com link was sent out to PCPs in the Plymouth catchment area on 07/09/2020 via two electronic newsletters. Responses were collected on 26/10/20. All responses were fully anonymised. The study was approved by a local institutional review board and followed local protocols. This study adhered to the Declaration of Helsinki.

Data are presented as frequency counts and associated percentages, median, mode as appropriate. Comparisons were made using the Mann Whitney U test and the Chi-squared test. Spearman’s Rank test was used to investigate correlation. A p-value of less than 0.05 was considered statistically significant. Statistical analyses were performed using MedCalc® Statistical Software version 19.5.3 (MedCalc Software Ltd, Ostend, Belgium; https://www.medcalc.org; 2020).

Results

During the study period, 79 responses were received. Results are summarised in Table 1. When asked to provide their level of satisfaction with the current breast-referral pathway using a one (very unsatisfied) to five (very satisfied) scale, the median score was 4 (mode: 5).

No significant difference was observed between male and female participants (P = 0.18). 59 participants (74.7%) felt a change to a system where patients were able to self-refer would be in the best interest of primary care services and patients. Just seven participants (8.9%) said they felt such a change would not benefit primary care services and only six (7.6%) felt this would not benefit patients.

 

Table 1: Summary of results

What is your role?

GP

72 (91.4%)

Nurse practitioner

6 (7.6%)

GP registrar

1 (1.3%)

What is your gender?

Male

28 (35.4%)

Female

50 (63.3%)

Not disclosed

1 (1.3%)

How confident do you feel when assessing a patient with a breast-related complaint? (Sliding scale)

 

 

1, Not confident at all

1 (1.3%)

2

0 (0.0%)

3, Reasonably

42 (53.2%)

4

30 (38.0%)

5, Extremely

6 (7.6%)

What percentage of your consultations are with a female patient? Please estimate.

Median (range)

63% (25 – 96%)

In what percentage of your consultations does the patient present with a breast-related complaint? Please estimate.

Median (range)

7% (1 –  43%)

Before Covid-19, what percentage of your patients with a breast-related complaint did you refer on to secondary care? Please estimate.

Median (range)

60% (5 –  97%)

Since Covid-19, what percentage of your patients with a breast-related complaint do you refer to secondary care? Please estimate.

Median (range)

60% (1 –  100%)

If you were to estimate, how many new breast cancers do you diagnose in a typical year?

 

*24 participants estimated that they diagnosed two cancers per year

Median (range)

 

2 (0 – 10)

Mode

2

What is you level of satisfaction with the current referral pathway? (Sliding scale)

 

1, Very unsatisfied

0 (0.0%)

2

3 (3.8%)

3, Indifferent

9 (11.4%)

4

33 (41.8%)

5, Very satisfied

34 (43.0%)

Since Covid-19, the decision to refer a patient (in the majority of cases) is following which type of consultation?

Telephone

70 (88.6%)

Face-to-face

6 (7.6%)

Other

3 (3.8%)

Do you feel a change to patient self-referral would work in the best interest of primary care services?

Yes

59 (74.7%)

No

7 (8.9%)

I don’t know

13 (16.5%)

Do you feel a change to patient self-referral would work in the best interest of patients?

Yes

59 (74.7%)

No

6 (7.6%)

I don’t know

14 (17.7%)

 

 

 

Table 2 illustrates PCP’s opinions on a potential change to patient self-referral. Whilst the quantitative data suggested PCPs were overwhelmingly in support of a change to patient self-referral, the qualitative data helped put this into perspective. Common themes in support included: reduced primary care workload, improved efficiency, more convenient for patients, reduced anxiety for patients, and reduced time to cancer diagnosis. Common themes in opposition to patient self-referral included: secondary care units being overwhelmed, increased time to cancer diagnosis for high risk patients, and de-skilling of PCPs.

 

Table 2: PCP's comments on patient self-referral to secondary care breast services* 

*Grammatical and typographical errors have been corrected. All additional responses to question thirteen and fourteen have been included.

 

Comments in support of patient self-referral

 

“Generally, if there is a palpable breast lump noted by the patient they will automatically be referred anyway.”

“Quicker easier access.”

“Cuts out an unnecessary rate limiting step - the GP.”

“Essentially anyone with a breast lump I refer whether I can feel it or not. It’s only breast pain alone that I may try and treat first.”

“(Self-referral would) remove delay to diagnosis.”

“Often there is a high degree of anxiety that is not helped by a negative exam by GP.”

“It skips the step of waiting for a GP call-back and then waiting for a face-to-face appointment…”

“We (GPs) would have less work, freeing up time.”

“In my experience, every woman who says they can feel a lump has a lump. Guidelines advise referral, so I refer them. I don't think seeing a GP in order to get the referral adds anything.”

“Self-referral would be a massive improvement.”

“A breast lump will end up being referred anyway so it takes time to first triage them, then examine them, then do the 2WW paperwork.”

“Anything that speeds up the time from finding a lump to diagnosis is good for patients.”

 

 

Comments in opposition of patient self-referral

 

“Potential for lots being sent back to primary care with uncertain outcomes creating discontinuity and confusion for those without serious pathology. Currently I think most women are willing to present to primary care - and we should be examining.”

“It would overwhelm the system so that patients who need the service wouldn't be able to access it.  You would see a lot of the worried well.”

“Self-referral may result in a longer wait. If we see these patients the same day, we may be able to provide reassurance if referral is not needed.”

“This may delay access for high risk patients”.

“(This would)… increase waiting times for those who could only be managed in secondary care.”

“For some highly anxious patients ease of access may be a hindrance.”

“(Secondary care is) likely to get swamped. This could lead to delay seeing serious pathology.”

“I have been a patient as well as a referring GP. I still felt I needed to talk to my GP to decide if I needed to go to breast clinic again.”

“We (GPs) would de-skill”.

“Not all (patients) are referred. (Self-referral would) result in an increase in workload with, I suspect, no increase in diagnostic yield of important new pathology.”

“Women worry a lot about breast symptoms. Seeing an additional practitioner (GP) is always helpful for patient education.”

“(I) worry that clearly benign mastalgia and issues in young women would overwhelm secondary care.”

“Reduce barriers for patients and lead to earlier diagnosis. Reduction in patient anxiety.”

“Breast patients are a small component of the workload and usually straightforward from a primary care point of view.”

“You would be overwhelmed as GPs screen out a lot of benign stuff.”

“(Self-referral would result in) deskilling of clinicians.”

 

 

Mixed comments

 

“It may generate a lot of work for hospitals but could be an excellent service for women. GPs would become deskilled.”

“Anything that helps reduce workload is welcome, but it’s not all about us (GPs).”

“For breast lump presentation direct access may be helpful, but some patients present with a dermatological issue. The system may be overwhelmed with direct access resulting in a diagnosis delay for others.”

“This would reduce workload for primary care but would de-skill us (GPs) and I think you’d (secondary care) end up with an inappropriate high level of patient contacts.”

“I do see some patients more than once before I refer or not to re-examine their breasts. The anxiety patients feel is considerable and I do feel we have a role in managing some of that. However, for some patients (e.g. with recurrent cysts) then direct access would be preferrable. Likewise, if you (already) have a cancer then a new finding needs direct access...”

“If I feel a discrete lump I don’t feel I have the confidence to do anything other than refer it anyway (although I may be able to tell the patient it is almost certainly benign).”

“I think the majority of patients who are worried about a lump I end up referring to you anyway for both of our reassurances. I think direct access for some specific symptoms would definitely save us time, hopefully it wouldn't increase your workload too much. However, ease of access could be a problem if it leads to patients with more serious pathology being delayed...”

“I’m sure patients would be happy with this service but I’m not sure it sounds the most appropriate use of specialist time.”

 

 

Impact of Covid-19 on breast referral

Participants estimated that, prior to Covid-19, they referred 60.0% of patients who presented with a breast-related issue (median). Participants estimated that, since the Covid-19 outbreak, this figure has remained unchanged (median: 60.0%). PCPs who estimated that they saw a higher proportion of female patients also reported a higher rate of referral to the breast unit both before (Spearman’s rank P = 0.0001), and since (Spearman’s rank P = 0.0001), Covid-19. No correlation was observed between estimated proportion of breast patients seen and referral to secondary care either before (P = 0.32), or since (P = 0.20), Covid-19.

Table 3 illustrates PCP’s comments on how they felt their level of confidence surrounding breast care could be improved. Comments were in relation to access to specialist breast investigations, referral pathways/guidelines, level of experience, further teaching/training, communication with secondary care services, and managing patient expectations and risk.

 

Table 3: PCP’s comments on how their level of confidence surrounding breast care could be improved* 

*Grammatical and typographical errors have been corrected. All responses to question five have been included.

Comments related to specialist breast investigations

“Ease of access to investigations.”

“Clinical examination without access to ultrasound/mammography will miss some serious pathology.”

Comments relating to referral pathways and guidelines

“Better guidance, patient support tools.”

“Not sure. Clear pathway of when not to refer.”

“Clearer guidance about what sorts of cases should be routine referral.”

“More experience needed on pathways and when to refer.”

“Simple guidelines from local breast services re managing simple/common presentations”

Comments relating to level of experience

“See more cases”

“More experience and reflection on referrals.”

“Sitting in on a clinic.”

“I know I probably over-refer likely benign breast lumps, but given no education on breast disease except a week in medical school over 10 years ago…”

Comments related to teaching/further training

“Teaching.”

“Teaching.”

“Further education/training.”

“Further training on benign versus malignant lesions.”

“Up-to-date advice at a CPD meeting regarding examinations and red flags.”

“Educational events from the breast team.  Self-guided review of referrals to breast team.”

“Perhaps a CPD event regarding breast problems e.g. mastalgia and dermatology-related issues.”

“Education/teaching from breast consultants.”

“Online learning. Especially regarding outcomes and pathways for patients referred as 2WW that do not have cancer.”

“Teaching from our local breast team about how they would treat breast conditions.”

Comments relating to communication with secondary care

“Access to specialist advice.”

“Easier access to advice from breast team.”

“Better feedback from breast clinic.”

Comments relating to managing expectations and risk

“Confident medically but patients’ expectations and guidelines encourage referral for nearly every woman presenting with new breast lump.”

“I tend to be more cautious and refer if I have any doubt.”

“Not really. As a GP with over 30 years of experience: benign lesions can be malignant and vice versa!”

“Learn from feedback from patients and results of referrals to secondary care. As a breast cancer survivor of 20 years I have a low threshold for referral even if my instinct is that it is not a cancer.”

“I feel pretty confident with breast symptoms, but it is an area which always causes a high degree of anxiety for patients. I do feel that I use your services quite a bit - I hope appropriately as sometimes patients need this reassurance.”

Other

“Not sure it can be.”

 

 

 

Discussion

Currently, UK secondary care breast units are required to allocate all patients referred from primary care to a clinic which offers “one-stop triple assessment” (clinical history and examination, imaging, and biopsy all in one appointment).6 This is despite the fact that not all patients referred will require access to all of these. Whilst these clinics are appropriate for patients with a suspected cancer, they are arguably not best suited to those who present with benign pathology. The focus of a benign breast disease consultation more often focuses on awareness, education and prevention rather than on investigation. As such, consultations often take more time and are not best-suited to the faster-paced one-stop clinic. Although it remains unproven, we argue that women without cancer who are not offered imaging at the time of their appointment are more likely to return with the same or similar benign symptoms.

A possible reason for this is heightened anxiety which has not been adequately addressed in a short consultation, and the impression that they had been referred by their PCP specifically for breast imaging or further investigation which is not undertaken. A multi-tiered referral system, rather than a “one size fits all” approach, may allow for more appropriate allocation of resources. This, in turn, could reduce patient anxiety, increase patient satisfaction, and lead to improved outcomes.

Currently in the UK, access to breast services is controlled by primary care yet it is the responsibility of secondary care to deliver these services.7 However, breast specialists are arguably better equipped to determine risk, manage access to breast resources, and offer therapies to patients with benign and malignant breast conditions.8 

Prior studies have concluded that the two-week rule guidelines have poor specificity and sensitivity for cancer.9-11 A potential alternative is to give patients control over referral to secondary care breast units and to give the breast specialists a higher level of autonomy to appropriately allocate resources and access to the very resource-dependent one-stop clinics.12 Bypassing primary care would also reduce the burden on primary care services, reduce waiting times, reduce patient anxiety, and eliminate primary care referral biases. On the other hand, this may overwhelm breast services and prove too costly to sustain unless breast units are permitted to vet self-referrals and deviate from the current two-week wait model for low risk patients. This will enable the re-design of breast services to support the adoption of low risk clinics (e.g. breast pain clinics) lead by appropriately trained professionals alongside one-stop triple-assessment clinics which will be reserved for patients deemed high risk.

Since such a change would be very complex and disruptive, this study was intended to gather data to see if PCPs feel a change is indicated and to evaluate the current primary care breast workload to assess whether such a change would be feasible.

Breast cancer consultations

In our study, participants estimated that 63.0% of their consultations were with a female patient. This is in line with Hobbs et al who suggested that approximately 60.0% of GP consultations in England in 2014 were with a female patient.13 In our study, almost all PCPs described themselves as “reasonably confident” to “very confident” when consulting patients with a breast-related issue. Only one PCP described suggested that they were “not confident at all”. Two PCPs commented that they would feel more confident if they had greater access to specialist breast investigations. This is understandable as if a patient feels she has identified a breast lump, reassurance from a PCP without further investigation is unlikely to be a satisfactory outcome for the patient.

Furthermore, PCPs are likely to feel vulnerable to “missing” a cancer diagnosis when relying on history and examination alone. Five PCPs felt they would be more confident if referral guidelines were clearer. These individuals felt it was not always easy to know when a patient should not be referred and hence the default was to refer. Four PCPs suggested that they would be more confident if they were more experienced. Our survey did not ask participants to provide their level of experience. Ten participants commented that teaching or further training would improve their level of confidence. This is a considerable proportion, since the question was not compulsory, and something that could be easily actioned. Putting together a virtual teaching session for PCPs over Zoom or Microsoft Teams would take minimal effort and incur almost no financial cost. Since PCPs have almost no contact with breast teams, except by letter, this would arguably improve PCP’s level of engagement with secondary care services; three PCPs stated that they would feel more confident if advice from secondary care was more accessible. A direct number to a specialist nurse, who would have access to a consultant, is a potential solution.

Five PCPs suggested that, whilst they felt confident in their own skills, managing patient expectations was particularly challenging; especially now that society deems it unacceptable to “miss” any diagnosis. It is understandable that PCPs will defer to referring if they come under any kind of pressure from a patient, even if they do not feel there is a reasonable risk that there is an underlying cancer.

Breast cancer diagnosis

The participants estimated that they diagnosed two breast cancers per year (excluding screening patients). This agrees with figures found on the Cancer Research UK website which suggests GPs will typically see “one to two” breast cancers per year.14 

Our results suggest female PCPs are more confident when dealing with breast-related issues when compared with their male colleagues. This is perhaps unsurprising as female PCPs estimate their breast workload to be higher and are therefore likely to be more experienced. However, in our study female PCPs felt they were also more likely to refer breast patients to secondary care. Prior studies have concluded that, if given the option, approximately one third of women with a breast-issue will specifically request a female breast surgeon when presenting for a consultation.15,16 To our knowledge, no high-quality studies have proven that a similar pattern exists in primary care, however, we suspect that this is likely.

Consultations during Covid-19 outbreak

Since the Covid-19 outbreak, a high proportion of PCP consultations are now via telephone or a virtual platform. One would predict that this would result in an increase in the proportion of breast patients being referred to secondary care. However, in our study PCPs felt Covid-19 had not had a significant impact on the referral rate. This may because PCPs are electing to hold virtual/telephone consultations with patients with breast pain or issues with breast implants and then selecting out those with a suspected breast lump to see face-to-face.

From analysis of the quantitative data, it is clear that PCPs are open to a change to patient self-referral. Indeed, almost three quarters suggested this would be beneficial. However, when the qualitative data was analysed it was clear that PCPs had concerns regarding this. Comments in support of change related to reduced workload for PCPs, better access for patients, and reduced time to diagnosis.

A proportion of PCPs expressed their concern at secondary care services being overwhelmed and this actually resulting in increased time to diagnosis for high risk patients. Other concerns highlighted included the de-skilling of PCPs and the fact that increasing access to secondary care may be a hindrance for some anxious patients. To our knowledge, no prior study has investigated PCP’s views on a change to patient self-referral within breast care.

Forty-nine participants (62.0%) stated that they routinely “ReadCode” breast-related consultations and 65  participants (83.5%) said they would endorse their workplace’s participation in a future prospective study which aims to investigate referral patterns. As such, we propose a large prospective study which investigates primary care breast workload and referral patterns.17 This would allow for a more in-depth assessment of whether a change to patient self-referral would be feasible.

Whilst we feel we have come to reasonable conclusions, we accept that our study has limitations. Our conclusions are based on the opinions of PCPs and not hard data. They will therefore have been influenced by strong opinions and will have been subject to recall bias. Multivariable analysis was not planned and therefore the results are subject to confounding by various PCP demographics. This survey was primarily performed to explore the opinions of PCPs and gauge the potential need for a larger, more in-depth, study.

Conclusion

Primary care is the first point of contact for patients with a breast-related issue and PCPs act as the gatekeepers to specialist breast units to allow for appropriate allocation of resources. Breast patients are a particularly anxious cohort and PCPs do not have direct access to specialist breast investigations. The results of this survey suggest PCPs refer the majority of patients they see with a breast-related issue to secondary care. This calls for more in-depth studies to accurately assess the primary care breast workload and to identify predictors of higher referral rates. PCPs highlighted further education and training as a means for improving their level of confidence surrounding breast care. The majority of PCPs surveyed suggested bypassing primary care would work in the best interest of primary care services and breast patients.

 


Thomas Russell, Department of General Surgery, North Devon District Hospital, Raleigh Heights, Barnstaple

Jemma Cooper, Yealm Medical Centre, Market Street, Yealmpton, Plymouth

Mairead McIntyre, NHS Devon Clinical Commissioning Group, County Hall, Topsham Road, Exeter

Saed Ramzi, Primrose Breast Care Centre, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth


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Acknowledgements: We would like to thank the primary care practitioners who took the time to complete the survey and Dr Jonathon Cope for sending the survey out via electronic newsletters. We would also like to thank The Primrose Foundation for financing the SurveyMonkey.com subscription.

Competing interests: Thomas Russell, Jemma Cooper, Mairead McIntyre and Sa’ed Ramzi declare that there are no conflicts of interest.

Ethics approval statement: This study was approved by a local review board and adhered to local policies. This study adhered to the Declaration of Helsinki.

Contributorship statement: Sa’ed Ramzi provided the idea for this project and supervised the project. The study was designed by Thomas Russell, Jemma Cooper, Mairead McIntyre and Sa’ed Ramzi. Data analysis was performed by Thomas Russell and Sa’ed Ramzi. The manuscript was written by Thomas Russell. Jemma Cooper, Mairead McIntyre and Sa’ed Ramzi edited the manuscript. 

Funding statement: The SurveyMonkey.com subscription was kindly paid for by The Primrose Foundation. This study received no additional funding.