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
2
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]
| Participants and Methods | Results | Discussion | Conclusion Introduction
CLINICAL PATHWAY[10]
4
AimsTo 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
| Participants and Methods | Results | Discussion | Conclusion Introduction
USF: Unidade de Saúde FamiliarGPM: Grupo de Patologia Mamaria
5
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
| Participants and Methods | Results | Discussion | Conclusion Introduction
GPM: Grupo de Patologia MamáriaBI-RADS: Breast Imaging Report and Data System
MeSH terms:Breast Neoplasm ; Diagnosis; Referral and Consulting; Practice Guideline; Breast Care
6
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
GPM: Grupo de Patologia MamáriaBI-RADS: Breast Imaging Report and Data System
Delivery of questionnaires
Evaluate the awareness regarding the guidelines
ANALYZE THE REFERRAL
Design of questionnaire
Delivery of questionnaires
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
Distribution of questionnaires
Introduction | | Results | Discussion | Conclusion Participants and Methods
8
Data collectionDevelopment 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]
Distribution of questionnaires
Introduction | | Results | Discussion | Conclusion Participants and Methods
[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
9
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
Introduction | | Results | Discussion | Conclusion Participants and Methods
Data collectionDistribution of questionnaires
10
Variables descriptionDistribution of questionnaires
Introduction | | Results | Discussion | Conclusion Participants and Methods
11
Variables descriptionDistribution of questionnaires
Introduction | | Results | Discussion | Conclusion Participants and Methods
12
Variables description
Introduction | | Results | Discussion | Conclusion Participants and Methods
Distribution of questionnaires
ANALYZE THE REFERRAL
Evaluate the awareness regarding the guidelines
13
Analysis of BI-RADS of women reffered to
GPM
→ transversal and observational study Study Design
Introduction | | Results | Discussion | Conclusion Participants and Methods
GPM: Grupo de Patologia MamáriaBI-RADS: Breast Imaging Report and Data System
Analysis of the BreastCare database
Analysis of BI-RADS of women referred to
GPM
ANALYZE THE REFERRAL
Delivery of questionnaires
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
14
2º GROUP: Women with breast cancer who
participated in the Breast Care of HSJ
Analysis of the BreastCare database
Introduction | | Results | Discussion | Conclusion Participants and Methods
Study Participants
GPM: Grupo de Patologia MamáriaHSJ: Hospital de São João
15
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
Analysis of the BreastCare database
Introduction | | Results | Discussion | Conclusion Participants and Methods
16
Statistical analysis
Introduction | | Results | Discussion | Conclusion Participants and Methods
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.
18 answers maximum score: 18 units – 100%
percentage of the right questions allowed us to conclude about the general efficiency of breast pathology care in our primary health centers.
Distribution of questionnaires
Introduction | | Results | Discussion | Conclusion Participants and Methods
Statistical analysis
18
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%)
Distribution of questionnairesStatistical analysis
Introduction | | Results | Discussion | Conclusion Participants and Methods
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 Distribution of questionnaires
ResultsIntroduction | Participants and Methods | | Discussion | Conclusion
GP: General PractitionersCS: Centro de SaúdeACES: Agrupamento de Centros de Saúde
20
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
21
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%
22
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
23
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
24
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
25
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”
26
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
27
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
28
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
29
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
30
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
GP: General Practitioners
32
Inadequate rerouting frequency(CI 95%): [64.5%; 75.6%]
percentage of incorrect referrals to the hospital
Discussion
DiscussionIntroduction | Participants and Methods | Results | | Conclusion
• 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
33
“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
DiscussionIntroduction | Participants and Methods | Results | | Conclusion
[17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005; 293: 1245-1254
GP: General Practisioners
34
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
DiscussionIntroduction | Participants and Methods | Results | | Conclusion
35
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
36
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
37
AddendumWEBSITE
Introduction | Participants and Methods | Results | Discussion | Conclusion
38
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
Introduction | Participants and Methods | Results | Discussion | Conclusion
39
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
Introduction | Participants and Methods | Results | Discussion | Conclusion