Gibraltar: versatility and flexibility in cancer care: The healthcare system in this British overseas territory is based on the NHS, but there are differences in nursing care

As a nurse working in Gibraltar, I am often struck by just how many differences exist in nursing care developments there compared with mainland UK. Gibraltar, a British overseas territory, enjoys a unique position at the south western tip of Europe. Healthcare services are provided by the Gibraltar Health Authority to the approximately 34,000 residents and about a further 10,000 cross-frontier workers. The healthcare model is closely based on the NHS.

The impact of breast care nurse triage of referrals to one-stop clinic on detection of breast cancer

Introduction: To minimise footfall during COVID pandemic, breast care nurse (BCN) led triage of the referral letters was used in our department. Based on the referral history, the nurse would triage patients to be seen in the one-stop clinic, consultant telephone consultation or telephone BCN-led pain clinic. The study aimed to assess the effect of BCN-led triage on detection of cancer and number of patients seen in the clinic. Methods: A retrospective observational analysis was conducted for all referrals to one-stop clinic at breast unit in Broomfield Hospital from 1st-30th July 2020. Results: Of the total number of patients (n=225) triaged by the BCN, majority were females (M:F 2:223) having a mean age of 55.1 years (14-90). Most patients presented with a breast lump (152/225). 12% (n=27/225) of the patients were diagnosed with cancer. The average number of cancers identified per week were 4.4 (3-6) with the BCN identifying 67.5% (n=27/40) of them. The mean time to referral to initial decision was 2.6 days (0-14) with BCN-led triage compared to routine referral route (10.7 days [1-23]). 27 patients (12%) were triaged to telephone breast pain clinic. 1 patient re-attended the clinic after being discharged from pain clinic with persistent pain but not diagnosed with cancer. Conclusion: BCN-led triage had a higher rate of breast cancer detection and less time taken from referral to decision for breast patients. The BCN-led pain clinic reduced the number of patients seen in the one-stop clinic without missing any cancer diagnosis.

Changes in breast cancer presentation during Covid-19: Experience in an Urban Academic Center

Background: The COVID-19 pandemic strained healthcare systems worldwide, delaying breast cancer screening and surgery. In 2019, approximately 80% of breast cancers in the U.S. were diagnosed on screening examinations, with 76.4% of eligible Medicare patients undergoing screening at least every two years. Since the start of the pandemic, many women have been reluctant to seek elective screening mammography, even with the lifting of "lock-down". We describe the effect of the COVID-19 pandemic on breast cancer presentation at an academic medical center in a city hit hard by the pandemic. Materials and Methods: The institutional IRB-approved Breast Cancer Registry Database was queried for patients enrolled during two time periods, those undergoing first surgical procedure before the start of the pandemic (4/1/2019-3/31/2020) to those the year after the pandemic started (4/1/2020-3/31/2021). Elective cancer surgery was paused for 3 weeks, ending 4/20/2020, and access to routine breast care was limited for 3 months. Variables included age, method of detection, palpability, histologic subtype and staging, neoadjuvant systemic therapy, cancer specific treatments, and radiation uptake. Results: 349 patients were in the 2019 cohort;246 in the 2020 cohort. No differences in baseline characteristics, including age at presentation, nodal status, or operation type. Fewer cancers were detected on routine mammography post-COVID vs. pre-COVID. Increase in detection of breast cancer through self-Sexams in 2020 was seen compared to 2019. Palpability on presentation also increased. More patients were treated with neo-adjuvant therapy chemotherapy, and 36 of 45 (80%) eligible early-stage breast cancer patients accepted neoadjuvant hormonal therapy during the period that elective cancer surgery was on hold. Patients received radiation therapy less frequently during the pandemic. The proportion of patients diagnosed with invasive ductal cancers was higher in the 2020 cohort and the proportion of patients diagnosed with ductal carcinoma in situ (DCIS) and for invasive lobular cancers (ILC) was lower. Conclusions: Patients at an academic New York City medical center presented with more palpable and invasive breast cancers during the COVID-19 pandemic compared to the preceding year, and fewer patients with DCIS and ILC, cancers typically detected following screening mammography. While stage migration with an increase in diagnosis of late stage cancers has been described, in our population the stage shift occurred in early stage breast cancer, with decreases in DCIS and increases in Stages I-II, with the higher stages III-IV essentially unchanged. This reflects the effect of delay in our previously highly-screened population, with an average screening delay of 3 + months, and many patients missing their yearly screening altogether. While many medical interactions during COVID-19 were via telemedicine, radiation therapy requires daily office visits, and fear of exposure contributed to the lower rate of radiation. Given the increase in invasiveness and stage of breast cancers diagnosed during the COVID-19 pandemic, this study emphasizes the importance of screening for diagnosis and treatment of breast cancer, even in the face of a concurrent health crisis.

Changes and disruptions in diagnosis, treatment and follow-up of breast cancer during two periods of the COVID-19 pandemic in Turkey.

OBJECTIVES: COVID-19 disease, which rapidly became a pandemic, led to significant changes in the provision of health services. This included radical changes to the supply and delivery of routine services to release resources for emergency care. During this process, a range of restrictions were imposed including the recommended rules to be followed before, during and after surgery. Health services provided for breast cancer diagnosis, treatment and follow-up have also undergone enforced changes meaning the diagnosis, treatment, and follow-up of patients with priority has come to the fore. In this study, the effect of the COVID-19 pandemic in Turkey, between March 11, 2020 and May 31, 2020 was assessed in comparison to pre-pandemic practice in terms of divided into two periods, and breast cancer diagnosis, treatment, and follow-up. MATERIAL AND METHODS: Surgeons dealing with breast cancer treatment and registered to SENATURK (Turkish Senology Academy) were contacted online. The period was divided into two, between March 11th and April 30th and May 1st to May 31st, 2020. Surgeons were requested to complete two electronic evaluation forms, one for each period, investigating change in practice. Only complete responses for both periods were included in the analysis. RESULTS: There were 93 respondents. Except for less multidisciplinary breast councils, there was no delay in radiological and pathological diagnoses. The number of breast cancer surgeries increased in Period 2, and more COVID-19 positive breast cancer patients were operated in Period 2. Benign breast patients were delayed less frequently in Period 2. In the statistical analysis performed between the two groups, it was found that only a significant difference was in the number of outpatients with benign breasts. CONCLUSION: With sufficient awareness of the risks of COVID-19 and with individual protection, breast cancer treatment was not affected during the assessed period of active pandemic in Turkey.

Primary care practitioners have a high level of satisfaction with the current breast referral pathway but the majority would support a change to patient self-referral

Aim: Currently, patients must consult with a primary care practitioner (PCP) prior to being referred to secondary care breast services. A change to patient self-referral would arguably reduce primary care workload, improve access for patients, and allow breast units to allocate resources more appropriately;no data currently supports this. This study aims to explore PCP's views on breast referral, evaluate the community breast workload, and to investigate the impact of COVID-19 on referral rates. Method: An electronic survey was designed on SurveyMonkey.com which aimed to collect both quantitative and qualitative data. The weblink to the survey was sent out via two electronic newsletters. Participants were asked: their role and gender, their level of confidence surrounding breast care, details surrounding their breast workload, how they felt COVID-19 had affected their referral rates, their level of satisfaction with the current pathway, and their opinions on a potential change to patient self-referral. Results: 79 responses were received. PCPs estimated that 7.0% (median) of their total consultations were regarding a breast-related issue and that COVID-19 had not had a significant impact on the rate of referral to breast units (P=0.75). 84.8% of PCPs were satisfied with the current referral pathway. Whilst 74.5% felt a change to patient self-referral would benefit patients and primary care services, their free text comments highlighted some of their reservations. Conclusions: PCPs have a high level of satisfaction with the current breast referral pathway, but the majority would be open to a change to patient self-referral to specialist breast units.

Breast imaging and cancer diagnosis during the COVID-19 pandemic: recommendations from the Italian College of Breast Radiologists by SIRM.

The Italian College of Breast Radiologists by the Italian Society of Medical Radiology (SIRM) provides recommendations for breast care provision and procedural prioritization during COVID-19 pandemic, being aware that medical decisions must be currently taken balancing patient's individual and community safety: (1) patients having a scheduled or to-be-scheduled appointment for in-depth diagnostic breast imaging or needle biopsy should confirm the appointment or obtain a new one; (2) patients who have suspicious symptoms of breast cancer (in particular: new onset palpable nodule; skin or nipple retraction; orange peel skin; unilateral secretion from the nipple) should request non-deferrable tests at radiology services; (3) asymptomatic women performing annual mammographic follow-up after breast cancer treatment should preferably schedule the appointment within 1 year and 3 months from the previous check, compatibly with the local organizational conditions; (4) asymptomatic women who have not responded to the invitation for screening mammography after the onset of the pandemic or have been informed of the suspension of the screening activity should schedule the check preferably within 3 months from the date of the not performed check, compatibly with local organizational conditions. The Italian College of Breast Radiologists by SIRM recommends precautions to protect both patients and healthcare workers (radiologists, radiographers, nurses, and reception staff) from infection or disease spread on the occasion of breast imaging procedures, particularly mammography, breast ultrasound, breast magnetic resonance imaging, and breast intervention procedures.