Family Practice Vol. 16, No. 4, 333-334
© Oxford University Press 1999
Editorial |
Breast problems in general practice: a time for re-assessment
Professor of Surgical Oncology, Hedley Atkins Breast Unit, Guy's Hospital, London SE1 9RT, UK.
Recent political and public interest has focused on the rapid evaluation of women with breast lumps. Additionally, audit of outcome seeks to improve the prognosis of those with malignancy by involvement of multidisciplinary teams, leading to more effective local and systemic therapies. This ignores the raw material, namely those patients who consult their GPs with breast problems, since if selection for specialist referral is ineffective, one-stop clinics will be overwhelmed with inappropriately worried women, thereby blocking immediate access for those with possible breast cancer. The review of presentation and management of women with breast symptoms seen by GPs in Sheffield provides an opportunity to consider what lessons may be learned or re-learned.1
A cloud of medical litigation overhangs both breast cancer and potential symptoms thereof. As a result, some GPs may respond in a Pavlovian manner and refer all cases. This is expensive, time-consuming and very bad medicine. At present this is responsible for the major overload in all breast clinics. How can patient's best interests be served while protecting overworked GPs from serious threats of litigation? Among the Sheffield GPs, who prospectively recorded all patients with breast symptoms, it was apparent that there was a disparity between the numbers recorded as being sent for a specialist opinion compared with those actually referred. In a review of a sample there was no record in the GP notes for 25% of the women who consulted with a breast problem. This failure of notekeeping could have very serious consequences, provoking an allegation of negligence were there to be a subsequent delay in diagnosis of a breast cancer.
Of the 302 women who complained of breast symptoms at a first consultation during the period of the study, 97 (32%) were referred to hospital. Although the major risk factor for breast cancer is increasing age, no apparent selection for referral was made based on age. Of the symptomatic cases, 6% were aged >65 years and 8% of those referred were in this age group; for those aged 50–64 years, the respective percentages were 21 and 26%. Overall, 65% of those referred were aged <50 years, so that a disproportionate number were from a relatively low-risk group in terms of breast cancer.
The most common complaints were of a breast lump (42%), followed by pain (39%). Of those with lumps, 58% were referred compared with only 17% of the women with breast pain. Interestingly, 40% of those with breast pain were given a prescription. The commonest treatment was gamolenic acid (evening primrose oil), an agent of limited but proven efficacy.2 The next most frequent medication was a course of antibiotics, a management of no value whatsoever in patients with breast pain other than those with a definite abscess, a very rare cause in non-lactating women. Other ineffective treatments included pyridoxine (vitamin B6) and diuretics.
In most breast clinics, no specific treatment is instigated in women breast pain unless it is either moderate or severe and has been present for more than 6 months. The reason for this conservative approach is that the majority of women with breast pain have a self-limiting condition. Nevertheless, the few with severe prolonged pain do merit specific therapy and should be referred for assessment.
The beleaguered GP needs criteria for hospital referral of women with breast symptoms, and appropriate indications are as follows:
- a post-pubertal female with a discrete breast lump;
- a post-pubertal female with a localised area of nodularity;
- a blood-stained or haemoglobin-containing nipple discharge;
- recent nipple inversion or eczema and
- severe breast pain lasting >6 months.
Women with short term tender nodularity or one relative with breast cancer (and no others), do not need to be seen in hospital. Much unnecessary worry can be assuaged by a taking a thorough history, carrying out a careful examination, recording any clinical findings and giving the patient an understandable explanation of her symptoms, most of which will not be the result of underlying serious pathology. This should lead to more appropriate referral of women with breast problems, thereby improving the care of patients and minimizing those misunderstandings which lead to breakdowns in patient–doctor relations.
References
1
Newton P, Hannay DR, Laver R. The presentation and management of female breast symptoms in general practice in Sheffield. Fam Pract (this issue) 1999; 16: 360–365.
2 Goodwin PJ, Neela, M, Boyd NF. Cyclical mastopathy: a critical review of therapy. Br J Surg 1988; 75: 837–844.[Medline]
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