Referrals
Rapid access breast clinics
Referral to breast unit
Referral to breast nurse
Referral to district nurse
Referral to hospice
Referral for palliative management
Referral for psychological support
Referral to specialist care nurse
Referral to specialist surgeon
Triple assesment
Rapid access breast clinics
Triple assessment can be provided at a single visit. There is a debate about whether the results should be communicated to the patient immediately. A definitive benign result would allow the patient to be reassured and discharged, however, it may not be appropriate to give a malignant result to a patient who has come alone. Other advantages of obtaining results at the first visit include the ability to repeat a test if inconclusive or to proceed to the next level of investigation, i.e. stereo guided cytology or core biopsy.
Referral to breast unit
It is now recognised that the outcome of patients with breast cancer is greatly improved if they are treated by centres of excellence, who are staffed by skilled professionals with expertise in the management of the disease.
These Breast Units are being established nationally, although some have been in existence for a length of time.
Most GPs should be aware of their local hospital services and be prepared to refer for specialist needs.
The Government White Paper entitled "The new NHS - Modern, Dependable" guaranteed that everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding that they need to be seen urgently and requesting an appointment.
This is known as the 'Two Week Standard'.
Referral to breast nurse
Breast nurses are usually based in, and attached to, Breast Units. They usually play a large role in the discussion of treatment, counselling and support of the patient.
It is common practice for any patient undergoing treatment for possible breast cancer to be referred to a breast nurse by the surgeon involved.
Referral to district nurse
District nurses are an essential part of the Primary Health Care Team. They are often involved early on in the treatment of patients with a diagnosis of malignancy.
District nurses may deal with a patient in the post -operative stage if a wound requires dressing or stitches require removing, and can be involved in administering depot preparations.
Once initial recovery has been achieved the District Nurse may not be involved with the patient until the terminal stage, when further nursing and support of the family is required.
Often practices will have a policy for discussing terminal patients with the Primary Health Care Team in order to establish a management plan for the care of the patient.
Referral to hospice
The use of hospices is very individual, for both the patient and the GP.
Many patients are aware of the existence of hospices and are familiar with their role in the care and support of the dying patient and their families.
This may cause anxiety for the patient and their families, usually generated by misinformation and/or fear.
It is important for the GP and the Macmillan nurse to give the patient as much information as is regarded necessary, in order for the patient and their family to make a valid judgement as to whether the hospice services are appropriate for them.
Often hospices have a day-care facility, which enables the patient and their family to become familiar with the surroundings and the staff of the hospice.
Respite care for pain control is another facility which may be available.
A hospice may also be a source of information concerning the treatment of the dying patient. The GP may wish to discuss the management of pain etc. with the medical officer of the hospice for a patient they are caring for at home.
Appropriate admission to the hospice is a difficult issue as timing is very important. Often respite care can be offered by the hospice, which gives the patient and their family a chance to familiarise themselves with the hospice or cope with a crisis.
However, more usually a patient is admitted to the hospice at the end stages of their disease. This may be in the patient's best interests but their family may require careful counselling afterwards in order to overcome any feelings of guilt or inadequacy.
Referral for palliative management
Palliative management or the relief of symptoms related to recurrence of disease can be managed by several individuals.
Historically, palliative management has been undertaken by GPs and possibly the oncologist, but more recently Palliative Medicine has become a speciality in its own right.
Patients are usually referred by the GP or from the Breast Unit in which they are being treated, to a specialist palliative care team, which may be based in the hospital, in the community or in the hospice.
Patients may be referred for specialist day care facility or for complex problem solving.
Referral for psychological support
The mental wellbeing and psychological support of patients with malignant disease is very important throughout the course of the disease.
Patients with a positive mental approach to their disease tend to have a better outcome.
Patients with a recent diagnosis or who are living with a diagnosis of malignancy can often suffer with anxiety and/or depression.
Some patients find counselling helpful either at their own surgery, if available, or provided by the Breast Care nurse.
Careful pre-treatment counselling and discussion can often avoid unnecessary emotional trauma later. Some patients find local or national support groups helpful.
In some cases, where simple counselling or medication, such as anxiolytics or antidepressants, have not helped, referral to psychological or psychiatric services may be appropriate.
Body image, libido and sexuality are specific areas which can be seriously affected by a diagnosis of malignancy and subsequent medical and surgical treatments.
It is important to raise these issues with patients as many find these problems difficult to discuss. There are many publications and counselling services available from several national organisations which will give patients useful information.
Referral to specialist care nurse
Macmillan* nurses are trained to support and counsel patients, and their families, who have been diagnosed as having cancer.
Each GP will have a Macmillan nurse attached to their practice and most hospitals will have the availability of a Macmillan nurse.
It is usual for the nurse to be involved with the patient following initial diagnosis, in order to build a rapport with and gain the confidence of the patient and their family.
Macmillan nurses usually view the care of patients with malignant disease holistically and have the experience to give practical, helpful advice to patients. Often, they help the patient and their family come to terms with a diagnosis and make the necessary decisions concerning treatment regimes, side effects of drugs and ultimately terminal care.
*In different parts of the Country these nurses may be variously referred to as Cancer Care Nurses, Care of the Dying Nurses, Marie Curie Nurses or St David's Nurses.
Referral to specialist surgeon
When a patient has been clinically assessed and a decision has been taken that they require further investigation, it is very important that patients are referred to specialist breast teams.
Women treated by specialist surgeons have been shown to have increased survival. When attending a breast cancer unit, women are more likely to be asked to participate in research and clinical trials.
It may be necessary for some patients to have a tertiary referral to a regional cancer centre, which may be outside the local area, for complex chemotherapy or radiotherapy.
Conditions which require referral are:-
- Any new discrete lump with or without pain
- New lump in pre-existing nodularity
- Asymmetrical nodularity persisting after menstruation
- Abscess-persistent or non-responding
- Cyst refilling or recurrent
- Intractable pain (refer to Breast pain rationale)
- Unilateral persistent pain in post-menopausal women
- Nipple discharge in women >50years of age
- Nipple discharge in women
- Nipple retraction, distortion or eczema
- Change in skin contour.
Triple assesment
The Triple assessment is a diagnostic procedure used for symptomatic women and women recalled for assessment following screening.
All women with a discrete lump referred to a specialist surgeon will undergo Triple assessment.
The procedure consists of examination by a breast surgeon, mammography and/or ultrasound, and fine needle aspiration or core-cut biopsy
| Triple assessment | ||
| Clinical | Imaging | Pathology |
| Age examination (Family history) |
Ultrasound | Fine needle aspiration |
| Mammography | Core-cut biopsy | |
| Confident diagnosis in 95% cases |
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