Doctors ‘over-referring’ breast cancer cases, says study

GPs may be causing anxiety, confusion and potential legal issues by over-referring patients to breast cancer clinics, a study suggests.

Most of the “urgent” cases referred by GPs to a Galway cancer clinic were downgraded by the centre to routine, an analysis of over 1,000 referrals found. Where GPs reported a clinical abnormality, in fewer than one-third of cases was this clinical finding confirmed by the breast surgeon.

The study, published in the Irish Journal of Medical Science, says it is unclear whether there are gaps in GPs' training or clinical assessment, or whether referrals are being submitted in a manner designed to secure an early appointment by overstating the clinical findings.

“It may be that GPs feel by indicating a clinical abnormality in their patients [they] will be seen more rapidly within the two-week timeframe for urgent referrals rather than the 12-weeks for routine ones.”

The study warns of a major medico-legal issue where doctors report clinical abnormalities but these are not confirmed at the breast clinic. Given that one in 10 of such women will go on to develop the disease anyway, in cases where a GP overstated a clinical finding, the breast clinic could be placed in the undesirable position of “defending accusations of delayed diagnosis for a clinical finding that never actually existed”.

About 3,000 new cases of female breast cancer are diagnosed each year. The number of new referrals to the State’s eight breast cancer centres has doubled in recent years, yet the number of cancers detected has remained static, according to the study by a team from University Hospital Galway’s department of surgery.

Forty-nine per cent of GP referrals to the hospital’s breast unit were marked urgent, yet after triage by the centre only 22 per cent of referrals were categorised as urgent. In just over half of the referrals, GPs reported a clinical abnormality, yet in only 39 per cent of these cases was this confirmed by the breast unit.

Cancer was detected in 33 of the 1,014 referrals, a detection rate of 3 per cent.

The study says that even in the best centres in the world, there are difficulties in diagnosing breast cancer because of the limitations of the technology available. The development of breast cancer after symptoms have been investigated does not necessarily imply an error or misdiagnosis.

Up to 4.1 per cent of women will coincidentally develop breast cancer in the 10-years after visiting a clinic, even though they didn’t have the disease at their first visit.

The increased level of demand for breast cancer screening has placed pressure on existing services, the authors point out. “The increased referral rates are not matched by increased numbers of cancers detected, suggesting that many worried, well patients who could be managed in primary care are being referred to symptomatic breast clinics.”