controversial topics in surgery

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1 doi / X The Royal College of Surgeons of England Tom Dehn, Series Editor E: controversial topics in surgery Who should run breast clinics, surgeons or radiologists? Demand management remains a difficult problem to resolve throughout the NHS. Nowhere has this been more so than in symptomatic breast clinics which have witnessed continued increase in referral over many years. These difficulties have been compounded by changes to the role of junior medical staffing, an expectation that the service is consultant based, the demands of the 'two-week wait' rule and the potential need to see all patients within this time-frame. These two papers provide local evidence that it is possible to run symptomatic breast clinics either by surgeons or, in part, by radiologists. Certainly, it is an advantage to have available full radiological support in the clinic to aid not only with imaging but also to perform directed biopsy. The key question is whether surgeons can adopt these skills especially in the presence of a well-staffed radiology department keen to maintain this role. Surgeons should be aware that, if they do not embrace these diagnostic techniques, radiology departments may make major inroads into symptomatic breast clinics and that their role in this specialty may become attenuated to that of surgical technicians. Michael J Greenall Department of Surgery, John Radcliffe Hospital, Oxford, UK A case for the radiologist DA GODDARD Breast Unit, Royal United Hospital, Bath UK CORRESPONDENCE TO: Dorothy Goddard, Consultant in Diagnostic Breast Imaging, Royal United Hospital NHS Trust, Combe Park, Bath BA1 3NG, UK T: +44 (0) ; F: +44 (0) ; E: Dorothy.Goddard@ruh-bath.swest.nhs.uk There continues to be an increasing number of referrals to the symptomatic breast clinic with high expectations for rapid specialist assessment. Government waiting-time targets for diagnosis and treatment have increased the pressure on breast services, with an expected 2-week wait for all referrals by late The model of service delivery must meet the increased demand for symptomatic assessment within cancer waiting times, whilst maintaining a high quality which is standards-based and quality assured, efficient and affordable. The NHS Breast Screening Programme (NHSBSP) in conjunction with the Association of Breast Surgery at the British Association of Surgical Oncology (BASO) and the Royal College of Radiologists (RCR) Breast Group have been the main drivers of service improvements for the diagnosis and management of breast disease and have established national guidelines and standards of care. 1 3 The RCR Breast Group Symptomatic Clinic Survey in revealed a considerable variation in practice amongst symptomatic breast clinics in the UK with 95% of clinics completing diagnostic work-up within 14 days for urgent referrals, but an average waiting time of more than 6 weeks for non-urgent referrals with consequent delays in diagnosis and treatment for a number of patients with breast cancer. Most symptomatic breast clinics are surgically led but, in 34%, radiology work-up is carried out prior to clinical consultation with a surgeon. Osborn et al. 5 found the accuracy of an open-access breast radiology service provided by a specialist radiologist, equivalent to traditional, rapidaccess breast clinics. The symptomatic breast clinic at the Royal United Hospital in Bath is radiology-led with breast imaging prior to surgical consultation for a significant number of patients. This article outlines how this works, why it works and the advantages of a radiology-led service. How it works The Bath breast unit provides a symptomatic service with approximately 3500 new referrals and 300 symptomatic cancers per year. Clinical and imaging assessment, with core biopsy as required, is provided in a variety of ways Ann R Coll Surg Engl 2008; 90:

2 A B Figure 1 (A) One-stop patients (n = 195) receiving imaging-first (over 9 weeks). Most Normals and Cysts were discharged; the remainder were referred to the surgical clinic where 25% were confirmed as malignant disease. (B) Non-urgent (n = 147) imaging-first cases (over 9 weeks). Most Normals and Cysts were discharged; the remainder were referred to the surgical clinic where 2% were confirmed as malignant disease. depending on the mode and clinical details of the referral, by the multidisciplinary team using skill-mix and diagnosis based on triple modality assessment. Since 2000, all referrals have been directed to the breast unit. Urgent referrals are booked directly to the one-stop clinics within 2 weeks. Non-urgent referrals are triaged by the lead specialist radiologist to a one-stop or routine breast clinic, or directly to imaging: women aged below 35 years have ultrasound whereas women aged 35 years and over have mammography with ultrasound, if they have not had a mammogram within 12 months. The patients sent directly to imaging have mammography (with specialist radiographers performing additional views as required) and ultrasound examination with clinical assessment by the radiologist and all necessary biopsies performed under image guidance. Patients having a biopsy return to the breast surgical clinic for surgical assessment and results within 1 week. Symptomatic simple cysts are aspirated to extinction under ultrasound guidance and the patients discharged. Patients with normal radiology but symptoms and/or signs of concern are referred to the breast surgical clinic but those with normal radiology and clinical assessment are discharged with information leaflets as appropriate and an invitation to return if there are further problems or concerns. The one-stop clinics have operated on an imaging-first basis since 2000, initially with all patients also seeing the specialist surgeon at the same visit with the radiology results available prior to surgical assessment. With pressure on the clinics from an increasing demand, selectively more patients are discharged directly from imaging with clinical assessment performed by the radiologist, using the same protocols as outlined above, working alongside the surgeons in the same clinic. The non-urgent referrals that may not require imaging (for example, those with breast pain) are seen first in the breast surgical clinic. If clinically suspicious, imaging is performed at the same visit. If routine imaging is requested, the surgeon indicates on the request form whether or not surgical follow-up is required if the imaging is normal/benign, so avoiding unnecessary follow-ups. All patients having a biopsy are discussed at the weekly multidisciplinary meeting and all radiological assessments and interventions are audited with annual review. 188 Ann R Coll Surg Engl 2008; 90:

3 Table 1 Numbers of referrals, percentage having imaging-first and waiting times Total Urgent Non-urgent Non-urgent Percentage Maximum referrals (n) one-stop imaging-first clinic first with imaging-first waiting time (a) (b) (a+b/total) (days) April % 56 January % 42 March % 21 April % 14 Why it works This unit has a strong multidisciplinary team and a close working relationship between surgeons and radiologists, which is essential for the successful working of this model of service delivery. The specialist radiologist working within the multidisciplinary team triages referrals to imaging-first according to agreed protocols with recommendations for the most appropriate imaging modality. Breast specialist radiologists are already performing both clinical and radiological assessment within the NHSB- SP and can provide a similar complimentary service to their surgical colleagues within the symptomatic clinics. Advantages Discharge of patients following imaging-first increases capacity within the surgical breast clinics. A recent audit over a 9-week period in 2007 compared the outcome of patients having imaging-first as urgent referrals within the one-stop clinic with non-urgent referrals triaged to imaging-first. In both groups, the majority of patients had benign disease with almost 49% of urgent referrals (seen in the one-stop clinic) and 69% of non-urgent cases discharged following imaging. Of the urgent referrals, 25% had confirmed malignant disease compared with 2% of the non-urgent group (Fig. 1A,B). Imaging-first reduces the time to diagnosis by removing the first step from the conventional pathway with surgical assessment prior to imaging. Even in the one-stop clinic, many of the patients having a biopsy return the following week for their surgical assessment together with the biopsy results. In April 2006, 39% of referrals had imaging-first with the longest waiting time for the surgical clinic or radiological assessment at 56 days. In April 2007, when 70% of referrals had imaging-first, the longest waiting time was 14 days (Table 1). Discussion There has been incremental improvement in waiting times as the proportion of referrals having imaging-first has increased, following expansion in the use of skill-mix and the training of a breast clinician. All models of symptomatic breast assessment must acknowledge the importance of increasingly sophisticated, high-quality imaging and image-guided biopsy techniques and the most efficient use of resources requires triage to the most appropriate pathway, such as imaging-first for those who will certainly require imaging in addition to clinical assessment (for example, over 35 years with a discreet lump) or surgical clinic first for those who may require imaging (for example, breast pain). Any triage requires clear clinical protocols as agreed by the multidisciplinary team, the service delivered according to national standards and quality assured, to ensure patients undergo the appropriate investigation with no delay in the diagnosis of breast cancer. Many symptomatic patients in Bath have both mammography and ultrasound examination with a combined false-negative rate of 1 2%. To date, all of the patients with false-negative breast imaging were also assessed by the surgeons in the clinic and there have been no missed cancers within the group discharged following imaging and clinical assessments by the radiologists (subject to on-going audit). Conclusions It is an efficient use of resources to provide breast imaging and image-guided biopsy where required, prior to surgical assessment and logical for those clinics adopting the imaging-first model to be radiology-led. Whether the clinics are run by surgeons or radiologists will be determined by local manpower and expertise but there is a case for the symptomatic assessment to be radiology-led with imaging-first as appropriate, especially for those most likely to have breast cancer. Ann R Coll Surg Engl 2008; 90:

4 References 1. Wilson R, Liston J, Cooke J, Duncan K, Given-Wilson R et al. Clinical Guidelines for Breast Cancer Screening Assessment, 2nd edn. Sheffield: NHS- BSP Publication No 49, The Association of Breast Surgery (BASO, the Royal College of Surgeons of England). Guidelines for the management of symptomatic breast disease. Eur J Surg Oncol 2005; 31 (Suppl 1): Royal College of Radiologists. Guidance on Screening and Symptomatic Imaging, 2nd edn. London: Royal College of Radiologists, Purushothaman H, Michell M. RCR Breast Group Symptomatic Clinic Survey. London: On behalf of the Royal College of Radiologists Breast Group, Osborn GD, Gahir JK, Preece K, Vaughan-Williams E, Gower-Thomas K. Is general practitioner access to breast imaging safe? Clin Radiol 2006; 61: Surgeons should lead breast clinics SIMON CAWTHORN Breast Care Centre, Frenchay Hospital, Bristol, UK CORRESPONDENCE TO Simon Cawthorn, Consultant Breast Surgeon, Breast Care Centre, Frenchay Hospital, Beckspool Road, Bristol BS16 1LE, UK E: simon.cawthorn@nbt.nhs.uk All patients referred to breast clinics should be examined by specialists who are trained to perform the triple assessment of the patients breasts, and who work in multidisciplinary teams. This assessment involves clinical examination, imaging with either or both breast ultrasonography and mammography, plus biopsies where appropriate, and whenever possible under ultrasonography control with core needle. These are the gold standards which reduce the risk of a missed diagnosis with a preoperative diagnosis rate of approaching 99%. The team in the clinic should provide the diagnostic package at one visit, with results available with minimal delay and, whenever possible, on the same day with full psychological support in order to reduce the impact of a cancer diagnosis. 1 The Frenchay Breast Care Centre serves a population of 500,000 in Bristol and North East Somerset. All new patients are seen and examined by hand and ultrasonography by the same individual, either surgeon or breast physician, and then undergo mammography when appropriate. All lesions that require biopsy are done by the same specialist who saw the patient on arrival in the clinic, under ultrasonography control using core biopsy for histology or fine needle. The competencies to perform the three aspects of the triple assessment have been identified. The surgeon is taught breast examination as part of the core training. The UK Department of Health Skills for Health project has set out the core knowledge for breast examination together with the assessment process to establish competency to allow training of all healthcare professionals; 2 the Royal College of Radiologists has done the same for breast sonography and ultrasound-guided biopsies. 3 The four core members of our team (three surgeons and one breast clinician) have satisfactorily achieved these standards in breast ultrasonography, both for diagnosis and ultrasound-guided interventions, and we now provide a bi-annual 2-day course for surgeons to help others do the same. To date, 90 consultant and training surgeons have attended these courses since they were started in There is, therefore, no reason why the patient cannot have the triple assessment done by the same practitioner. The background of that individual can be a doctor (surgeon or radiologist), a nurse or radiographer. So why should a surgeon bother to train to do ultrasonography? I did it to relieve the strain on my radiological colleague at her suggestion! I believe that the aim of the breast clinic is to provide holistic care, and the best way to do that is to start by having the same specialist do all three aspects of the assessment. This reduces the risk of poor communication, and enhances the patient experience by reducing delays, uncertainty and improving the quality of the experience care designed to suit the patient, not the system. It has enabled me to develop the use of vacuum-assisted devices (mammotome) under ultrasonography control to remove benign lumps. 4 We have also extended the use of this minimally invasive office breast surgery to excision of single-nipple duct discharges 5 and sub-areolar ducts in patients requesting nipple-sparing mastectomy with immediate reconstruction as a pre-operative assessment. 6 Using the mammotome, we have also saved women with chronic lactating breast abscesses too thick for needle aspiration from having incision and drainage 7 as an in-patient. The ultrasonography scanner also travels to the operating theatre to assist the surgeon in locating impalpable cancers. From 1999 to 2005, the number of referrals increased by an apparent 9% (n = 322) from 3499 in 1999 to 3821 in As Figure 1 shows, however, the number of 2-week wait referrals has dramatically changed, increasing by an apparent 190 Ann R Coll Surg Engl 2008; 90:

5 Figure 1 Trends in primary care referrals to the Frenchay Breast Care Centre during % (n = 739) from 1751 in 1999 to 2490 in By contrast, the number of routine referrals has declined over the same period by an estimated 63 referrals per year. This increasing service demand has had an impact on non-urgent cases and the waiting times for routine referrals has increased. The decrease in waiting times during the period seen in Figure 2 reflects an increase in clinic capacity created by the introduction of a new followup policy. After 2003, however, waiting times have steadily increased reflecting the increasing numbers of 2-week wait patients referred. The waiting time at the end of 2005 for a routine referral was 30 days, but in some centres may be significantly longer. 8 This has considerable psychological impact for any Figure 2 Waiting times for routine and 2-week wait appointments at the Frenchay Breast Care Centre during Ann R Coll Surg Engl 2008; 90:

6 patient, regardless of their diagnosis; 9 for the 1 in 4 patients with cancer in this no-urgent group, the additional wait constitutes yet another unacceptable delay for definitive diagnosis and treatment. We have reduced waiting times further by training Extended-role Nurse Specialists to perform triple assessment. A course has been established at the University of the West of England to train specialists from any medical background in triple assessment, including ultrasonography diagnosis and biopsy. The breast follow-up nurse can now examine and perform ultrasonography of the breast. The breast care nurse now sees the elderly patients receiving primary medical therapy, performing clinical assessment and ultrasonography to monitor accurately response or progression. This not only improves the patient experience (same person at each visit who provides emotional support to the patient and family when necessary) but frees up capacity for the assessment of new patients. This has allowed the waiting times to fall to 12 days for the nonurgent patients in 2007, allowing all symptomatic patients to be seen within 2 weeks. All of these innovations have been led by the surgeon trained in ultrasonography who can explore the re-design of the workforce to meet increasing demands ensuring the patient gets the best service from the right person at the right time in the right place. It does not need to be a surgeon, but we are capable and keen to lead the breast clinic service provided we work with the support of the radiologists in our multidisciplinary team. References 1. Harcourt D, Ambler N, Rumsey N, Cawthorn SJ. Evaluation of a one-stop breast lump clinic: a randomised controlled trial. Breast 1998; 7: Royal College of Radiologists. Ultrasound Training for Medical and Surgical Specialties < 3. Department of Health. M1 Assess Individuals with Suspected Breast Disease < 4. National Institute for Health and Clinical Excellence. Interventional Procedures Programme 188. Interventional procedures overview of image-guided vacuum assisted excision biopsy of benign breast lesions < 5. Varey A, Shere M, Cawthorn S. Treatment of loculated lactational breast abscess with a vacuum biopsy system. Br J Surg 2005; 92: Govindarajula S, Narreddy SR, Shere M, Ibrahim N, Sahu A, Cawthorn S. Preoperative mammotome biopsy of ducts beneath the nipple areolar complex. Eur J Surg Oncol 2006;: 32: Govindarajula S, Narreddy SR, Shere M, Ibrahim N, Sahu A, Cawthorn S. Sonographically guided mammotome excision of ducts in the management of single duct discharge. Eur J Surg Oncol 2006; 32: Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R et al. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007; 335: Sauven P. Impact of the 2 week wait on referrals to breast units in the UK. Breast 2002; 11: Griffiths C, Raine C, Sauven P, Mason S. Patients with breast cancer present with identical symptoms in the urgent 2 week wait stream and the routine stream. Eur J Surg Oncol 2006; 32: Ann R Coll Surg Engl 2008; 90: