GPs refer too many for breast lumps

Prof Tom Keane says the symptomatic breast cancer service is getting too many unnecessary referrals. Gary Culliton reports

The Head of the Cancer Control Programme, Prof Tom Keane, appeared before the Oireachtas Health Committee last week to give the committee a briefing on the current situation with cancer care in Ireland.
According to Prof Keane, far more women than expected are presenting at cancer centres who do not have the disease: at some centres as many as 29 patients are being seen for every one diagnosis of breast cancer.
One in ten
At the time of the report by Prof Niall O’Higgins some years ago, the best risk estimate available was that for every ten women referred to symptomatic breast clinics, one would have breast cancer. The national average has increased to 15 women seen for every one case of breast cancer diagnosed. “Breast awareness is good but it is simply not appropriate for 22-year-old women to have annual mammograms. It is actually dangerous,” Prof Keane told the Committee.
“We have seen a massive increase in the number of what one might term ‘worried women’ or ‘worried GPs’.”
The number of women being referred to symptomatic breast services has increased by 50 per cent during the past two years, Prof Keane said. This has placed a significant strain on the system.
No possibility
“In the most extreme cases, we have tried to feed directly back to GPs who are inappropriately referring young women with breast pain, where there is no possibility of it being due to cancer,” Prof Keane told the committee. “We have made HIQA aware that this is an issue that needs to be addressed in terms of the standards. In other words, can we create a different pathway for these low-risk women who are no more at risk than women going into BreastCheck?”
Two groups are now attending clinics, according to Prof Keane, the first of which comprises those who form part of the original high-risk population of women with breast lumps. These women still have a one-in-ten chance of having breast cancer.
The second group – which constitutes 60 per cent to 70 per cent of the total number of women referred – comprises women whose risk of breast cancer is ten times lower than their counterparts in the high-risk group. Those in the low risk group — who are referred to as routine referrals — have the same risk of breast cancer as women who would be referred to a screening service.
“This is a massive change which we did not anticipate. It probably reflects the anxiety of women and GPs,” Prof Keane said. “This development is not something the service was originally designed to support.”
As of September, 95 per cent of urgent cases are being seen within the two-week target. The figure in respect of lower risk women being seen is 82 per cent. There is a concern that the continued growth in the number of non-urgent patients could put pressure on clinics, when it comes to managing the urgent patient population, Prof Keane said.
It is possible for a woman going through her GP to get a mammogram within 12 weeks. Under BreastCheck, she would be on a two-year cycle. “An issue arises with regard to the target population and whether the symptomatic breast service is meeting its original mandate. That mandate has expanded,” Prof Keane told the committee.
The National Cancer Control Programme is halfway through a plan to establish rapid access clinics for the diagnosis of lung and prostate cancer. The rapid access clinics are intended to provide GPs with the opportunity to refer patients who present with certain high-risk features directly to cancer centres for diagnosis. Four such centres will be open by the end of the year, and the other four will open in the first six months of next year. In parts of the country, particularly the west, access to diagnosis for prostate cancer is far below what it needs to be, Prof Keane said.
A new radiation oncology centre — which will be operated on the St James’s Hospital site by the Cancer Control Programme — will open in November of 2010. Four radiotherapy machines will be commissioned on the site.
Behind schedule
The Beaumont site is six to eight weeks behind schedule, but it should be up and running by the beginning of 2011. This is associated with the first phase of the transfer of the workload from St Luke’s Hospital.
Rectal cancer surgery and pancreatic surgery are the next two surgeries to be centralised. Prof Keane had hoped to move rectal cancer surgery into just four hospitals.
The Irish Society of Colo-proctology suggested it would be more reasonable to accommodate such surgery in eight hospitals and that plan is to proceed next year, in two phases. The plan is to centralise all pancreatic cancer surgery, which arguably is the most challenging of all cancer surgeries, in St Vincent’s Hospital in Dublin.
There is a single brain tumour surgery programme between Cork University Hospital (CUH) and Beaumont, and later this month interviews will take place to appoint a lead neurosurgeon for the brain tumour programme nationally.
That appointment will be split between CUH and Beaumont Hospital.
Prof Keane appeared before the committee for approximately 45 minutes.