Breast cancer clinical pathway: are doctors aware? Ana Filipa Amador | Ana Rita Comba | Bárbara Castro | Beatriz Ferreira | Daniela Casanova | Duarte Alves

Breast cancer clinical pathway:

are doctors aware?Ana Filipa Amador | Ana Rita Comba | Bárbara Castro | Beatriz Ferreira | Daniela Casanova | Duarte Alves | Filipe Machado | Helena Corado | Inês Silva | Lídia Ribeiro | Tiago Sousa

Introdução à Medicina Class 14Adviser: Rosa Oliveira

Academic Year: 2010/2011

http://www.med.up.pt/

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BREAST CANCER

[1] Pinheiro PS, 2003

[2] Coughlin SS, 2009

[3] Who, 2010; [4] Ferlay, 2010; [5] Davis, 2010; [6] Kerr F, 2006

Chart 1: Cancer incidence statistics in Portuguese women (2003)

Mortality is decreasing[2]

Early diagnosis Effective treatments[2]

| Participants and Methods | Results | Discussion | Conclusion Introduction

[1]

?

3[7] Macedo A, 2010; [8] “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”, 2009 [9] “Not All Doctors Follow Cancer Screening Guidelines, Study Finds”, 2010[10] Cabana, “Why Don’t Physicians Follow Clinical Practice Guidelines?”

Woman who suspects to have breast pathology

PRIMARY HEALTH CARE CENTERS

Consulting

a) Imagiologic exams requested

b) Follow the patient for observation

Specialized breast pathology unit

GUIDELINES[7,8]

BI-RADS[9]


CLINICAL PATHWAY[10]

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Aims

To evaluate the effectiveness of the clinical pathway regarding

women suspected to have breast cancer: from primary health care

centers to a specialized breast pathology center.

USF

GPM


USF: Unidade de Saúde FamiliarGPM: Grupo de Patologia Mamaria

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Research Questions

• Do general practitioners know any and best

medicine evidence concerning diagnosis of breast pathology?

• If so, do they follow them?

• Are patients correctly rerouted to the GPM taking into account their classification?

GUIDELINES

BI-RADS


GPM: Grupo de Patologia MamáriaBI-RADS: Breast Imaging Report and Data System

MeSH terms:Breast Neoplasm ; Diagnosis; Referral and Consulting; Practice Guideline

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Analysis of the BreastCare database

Evaluate the awareness regarding the guidelines

Analysis of BI-RADS of women referred to

GPM

→ transversal and observational study Study Design

Introduction | | Results | Discussion | Conclusion Participants and Methods

ANALYZE THE REFERRAL


Delivery of questionnaires



Design of questionnaire


Design of questionnaire

General practitioners of primary health care centers from Grande Porto

Inclusion Criteria: General practitioners of the primary health care.

Exclusion Criteria: No exclusion criteria were considered.

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Study Participants

1st GROUP: General Practitioners from primary

health care institutions in the metropolitan area of Oporto

1st GROUP: General Practitioners from primary

health care institutions in the metropolitan area of Oporto



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Data collection

Development of the survey “Patologia mamária nos cuidados de

saúde primários” based on:

• Guideline of August 2002[11]

• Guideline of July 2005[12]

• Guideline of June 2005[13]

• Guideline of February 2009[14]

• “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da

Mama”, ACS, Setembro 2009[15]

• Guideline of January 2010[16]



[11] Guidance on Cancer Services: Improving Outcomes in Breast Cancer, 2002[12] Referral guidelines for suspected cancer in adults and children, 2005[13] Referral guidelines for suspected cancer, 2005

[14] Early and locally advanced breast cancer. Diagnosis and

treatment, 2009[15] Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama, 2009[16] Health Care Guideline: Diagnosis of Breast Disease, 2010

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Discussion with Dr. Fernando Osório

Questionnaire

Some modifications on the questionnaire

Pilot test to 2 general practitioners

Compile data in a database

Delivery to the doctors of primary care units


Data collectionDelivery of questionnaires

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Variables descriptionDelivery of questionnaires


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Variables descriptionDelivery of questionnaires


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Variables description





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Analysis of BI-RADS of women reffered to

GPM

→ transversal and observational study Study Design




Analysis of BI-RADS of women referred to

GPM



Design of questionnaireAnalysis of the BreastCare database

Data was acquired from a database previously created in the context of the BreastCare project

Prospective data was collected in GPM from HSJ – Oporto

Inclusion Criteria: All women followed in the GPM.

Exclusion Criteria: Patients whose data of diagnosis is incomplete

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2º GROUP: Women with breast cancer who

participated in the Breast Care of HSJ

2º GROUP: Women with breast cancer who

participated in the Breast Care of HSJ



Study Participants

GPM: Grupo de Patologia MamáriaHSJ: Hospital de São João

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Variable description

Only some of the collected data was used: • Gold-standard classification (BI-RADS)

Proves the adequacy of reroutingOnly BI-RADS ≥ 4 should be referred to a specialized unit

• Age at the arrival to GPM

• Age at the first diagnosis

• Use of echography and mammography requested by the primary health care centers

1. GPM: Grupo de Patologia Mamária2. HJS: Hospital de São João



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Statistical analysis


Frequencies and percentages: used to display responses to individual

questions, such as gender.

Means and standard deviation: used for the characterization of continuous

variables such as age of women with breast pathology at the arrival to the GPM.

Medians, inter-quartile ranges and 90% confidence intervals: score of

correct answers, knowledge of referral recommendations.

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Score of part I + part II

“Yes” and “No” answers

To each correct answer is attributed a value of 1; Incorrect questions were recoded as 0.

12 answers maximum score: 12 units – 100%

percentage of the right questions allowed us to conclude about the general efficiency of breast pathology care in our primary health centers.



Statistical analysis

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Knowledge of the "Recomendações Nacionais para Diagnóstico e

Tratamento do Cancro da Mama”

Binomial tests: to assess if at least 50% of doctors of the considered

population are familiar with the national guidelines

(CI of 95%)

Delivery of questionnairesStatistical analysis


Significance level: 0.05

CI: Confidence Intervals

Table 1: GPs from health centers

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19 GPs from health centers.

Response percent: 34.6%

• Delivered in person 55

questionnaires

• Request to ACES

Results, Tables and Graphics Delivery of questionnaires

ResultsIntroduction | Participants and Methods | | Discussion | Conclusion

GP: General PractitionersCS: Centro de SaúdeACES: Agrupamento de Centros de Saúde

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Characterization of the sample:

14 of the GP were female

(ratio men : women = 0.34)

GP mean age (SD) = 45.1(10.8) years

Mean experience time (SD) = 18.4 (12.1) years

Results, Tables and Graphics

Table 4: Age

Table 3: Clinical experience



Table 2: Gender of GP

GP: General PractitionersSD: Standard Desviation

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84.2% (n=16) of the GP frequently deal with breast pathology

Table 5: Do GP deal with breast pathology?



GP: General Practitioners

n %

Morphologic changes 18 94,7%

Size changes 13 68,4%

Both 13 68,4%

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68.4% consider both morphologic and size changes the most important factors in

the assessment of the severity of the breast lesion.

All the GPs (n=19) considered mammography as the standard test for breast

pathology screening.

Table 6: What is the most important factor in the assessment of the severity of the breast lesion?




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Considering the referral to the GPM, 26.3% (n=14) of GPs would incorrectly keep a

patient with modifications of a previously studied breast lesion under their own

responsibility.

89.5% (n=17) would maintain a patient with a simple cyst in their own consult for

further study instead of referring the patient to another area of expertise or for unnecessary

exams.



GPM: Grupo de Patologia MamáriaGP: General Practitioners

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Table 7: Are there gathered the basic condicions to deal with breast pathology in Portugal?

Table 8: Is it necessary to make changes?

63.2% of the GP considered that there are gathered the basic conditions for the

primary health care physicians to deal with breast pathology in Portugal

Only 47.4% think that is necessary to make changes in the health system.




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Chart 2: Are they gathered the basic condicions to deal with breast pathology in Portugal?



BI-RADS: Breast Imaging Report and Data System RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”

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BI-RADS: Breast Imaging Report and Data System RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”

Score of questionnaire:

Mean = 75.4%

95% CI = [69,1%; 81,7%]

Knowledge of National Guideline (RNDTCM):

95% CI = [54%; 99%]

Binomial Test - More than 50% of GPs are aware of the national guidelines.


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1151 women

Mean age (SD): 49.6 years (15.0).

Breast cancer was first diagnosed at an average age (SD) of 48.9 years (12.9).

At the arrival to the GPM, 99.9% (n=335) of the eligible women had done a mammography

All who replied had done an echography

Table 9: Mean age at the moment of arrival to GPM

Table 10: When breast cancer was first diagnosed

Table 11: Registration of mammography



SD: Standard DeviationsGPM: Grupo de Patogia Mamária

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According to the BI-RADS classification, 70% of the women arrived to the GPM classified as Stage 3 or less.

Incorrect rerouting frequency (%) (95%CI)

(BI-RADS<4):

[64.5%; 75.5%]




BI-RADS: Breast Imaging Report and Data System GPM: Grupo de Patogia MamáriaCI: Confidence Intervale

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High percentage of GPs are aware of:

“Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da

Mama”, ACES, Setembro 2009

BI-RADS classification system

Discussion

DiscussionIntroduction | Participants and Methods | Results | | Conclusion

• Do general practitioners know any and best medicine evidence concerning diagnosis of breast pathology?

GUIDELINES

BI-RADS: Breast Imaging Report and Data System ACES: Agrupamento de Centros de SaúdeGP: General Practitioners

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Discussion


• If so, do they follow them?

BI-RADS: Breast Imaging Report and Data System CI: Confidence Intervale

Score of questionnaire:

• Frequency (95% CI): 75%• [69%; 81%]

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More than 50% of the GPs ARE following the guidelines

Contradicts the literature:

This outcome may point to a better referral of the women with breast pathology

in Portugal and, consequently, contribute to a more precise diagnose and

treatment.

A study from the National Cancer Institute states that only 20% of primary care physicians in the US follow guidelines for colorectal cancer screening and diagnosis.

Discussion


[18] Cabana, Michael D., Rand, Cynthia S. et al. “Why Don’t Physicians Follow Clinical Practice Guidelines?” JAMA, October 20, 199 – Vol. 282, no.15


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Inadequate rerouting frequency

(CI 95%): [64.5%; 75.6%]

percentage of incorrect referrals to the hospital

Discussion


• Are patients correctly rerouted to the GPM taking into account their classification?BI-RADS

According to the BI-RADS classification,70% of the women arrived to the GPM in a Stage 3 or less.

BI-RADS: Breast Imaging Report and Data System CI: Confidence IntervalsGPM: Grupo de Patologia Mamária

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“100% of the GPs considered mammography as the standard test

for screening of breast pathology”

LITERATURE: Mammography remains the main screening tool,

which has been recommended for many decades[14]

Discussion


[17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005; 293: 1245-1254

GP: General Practisioners

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Inadequacy of guidelines:

• High number of missing values on BreastCare database

• Low rate of answer in the surveys (34.6%)

• Inability to reconcile patient preferences with the guideline

recommendations

• Differences between guidelines

Further studies will be required in order to complete and improve our

results.

LIMITATIONS


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The majority of GPs are aware of the National Guidelines and BI-RADS

classification system, performing, in theory, an adequate rerouting.

However, the massive rerouting of BI-RADS Stage 2 proves that

women are being bad rerouted and resources are being spent

inadequately.

ConclusionIntroduction | Participants and Methods | Results | Discussion |

Conclusion

BI-RADS: Breast Imaging Report and Data System GP: General Practisioners

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Addendum

• Delivered at Hospital São João (HSJ) on 30th October (Dia Nacional da

Prevenção do Cancro da Mama);

• Informative flyer for patients and visitors of HSJ.

FLYER

Introduction | Participants and Methods | Results | Discussion | Conclusion

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AddendumWEBSITE


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Aknowledges

• Dr. Fernando Osório, who has patiently helped us with the medical part related to breast pathologies, such as the technical terms and questionnaires' revision

• Prof Doutor Altamiro Manuel Rodrigues Costa Pereira, for the suggestions along all our presentations and work developed along the year

• Health Care Units, for their readiness for response to our questionnaires

• Grupo de Patologia Mamária, for the help with information concerning the BreastCare database and Breast Cancer treatment in general


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References[1] http://www.who.int/mediacentre/factsheets/fs297/en/index.html [2] http://www.who.int/topics/cancer/en/, (04/11/10)[3] http://www.medicinenet.com/cancer/article.htm, (12/11/10)[4] Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. “Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008.” International Journal of Cancer 127.12 (2010): 2893–2917.[5] Coughlin SS., Ekwueme DU., “Breast cancer as a global health concern”, Cancer Epidemiology, Vol 33, Issue 5, November 2009, Pages 315-318 [6] Macedo A, Monteiro I, Andrade A, Cirricione A, Ray J. “Cost-effectiveness of trastuzumab in the treatment of early stages breast cancer patients, in Portugal.” Acta Médica Portuguesa 23.3 (2010): 475-482.[7] http://www.acs.min-saude.pt/files/2009/09/acs_cancro-mama_low.pdf (13/12/2010)[8] http://www.dgs.pt/default.aspx?cn=55065715AAAAAAAAAAAAAAAA (20/12/2010)[9] Oliveira CF, Rodrigues V, Gervásio H, Pereira JM, Albano J, Amaral N, “Carcinoma in situ and early breast carcinoma. Survey of the Portuguese Senology Society on the diagnostic tools used in Portugal and their evolution between 1985 and 2000.” Eur J Gynaecol Oncol. 2004;25(3):293-8.[10] Morris KT, Pommier RF, Morris A, Schmidt WA, Beagle G, Alexander PW, Toth-Fejel S, Schmidt J, Vetto JT, “Usefulness of the triple test score for palpable breast masses”, Arch Surg. 2001 Sep;136(9):1008-12.[11] http://www.sciencedaily.com/releases/2010/10/101014113839.htm (22/12/2010)[12] Cabana, Michael D., Rand, Cynthia S. et al. “Why Don’t Physicians Follow Clinical Practice Guidelines?” JAMA, October 20, 199 – Vol. 282, no.15[13] Cardarelli, Roberto, DO, MPH. “The role of primary care providers in cancer screening”. Primary Care Research Institute, May 2010[14] Ribeiro, Robespierre Costa. “Clinical guidelines: how to evaluate its quality?”. Rev Bras Clin Med 2010;8(4): 350-5

[15] http://www.encr.com.fr/breast-factsheets.pdf


Documents

Breast cancer clinical pathway: are doctors aware? Ana Filipa Amador | Ana Rita Comba | Bárbara Castro | Beatriz Ferreira | Daniela Casanova | Duarte Alves