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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
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?”
[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
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
Results, Tables and Graphics Distribution 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
Distribution of questionnaires
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
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?
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
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?
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
GP: General Practitioners
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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.
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
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.
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
GP: General Practitioners
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Chart 2: Are they gathered the basic condicions to deal with breast pathology in Portugal?
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
BI-RADS: Breast Imaging Report and Data System RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”
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ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics Distribution of questionnaires
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.
Analysis of the BreastCare database
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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
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics
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%]
Analysis of the BreastCare database
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
Results, Tables and Graphics
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
DiscussionIntroduction | Participants and Methods | Results | | Conclusion
• 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
DiscussionIntroduction | Participants and Methods | Results | | Conclusion
[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
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