Comparison of the urgent referral for suspected breast cancer process with patient age and a predictive multivariable model.

BACKGROUND: The urgent 2-week wait referral for suspected breast cancer system (U2WW) in the UK prioritizes primary care referrals to one-stop breast clinics as 'urgent' or 'choose and book' (C&B). The aim of this study was to evaluate the accuracy of U2WW in discriminating cancer versus no cancer, and to consider alternative criteria. METHODS: Clinical features elicited in primary care and demographics of consecutive female patients in a specialist breast clinic were collated at the time of consultation from May 2008 to July 2017. U2WW was compared with patient age alone and a multivariable model in terms of accuracy and net cost for eight underlying cost-benefit assumptions. RESULTS: There were 7915 eligible referrals: 4877 urgent (61.6 per cent) and 3038 C&B (38.4 per cent) referrals. Breast cancer was diagnosed in 546 patients (6.9 per cent): 491 (10.1 per cent) in urgent and 55 (1.8 per cent) in C&B referrals (P < 0.001). The multivariable model summated the significant variables: age (odds ratio (OR) 1.07, 95 per cent c.i. 1.07 to 1.08), tumour (OR 4.85, 3.62 to 6.52), observed change (OR 1.73, 1.34 to 2.23), pain (OR 0.46, 0.35 to 0.61) and gravidity (OR 0.72, 0.54 to 0.95). The area under the curve was 0.651 for U2WW, 0.784 for age alone, and 0.824 for the multivariable model (P <0.001 for all comparisons). Considering the cost assumptions, age alone and the multivariable model were either more accurate than U2WW, or as accurate but less costly. CONCLUSION: The U2WW is surpassed by patient age as a single referral criterion. A multivariable model based on demographics and simple clinical features outperformed both. The continued use of the U2WW needs to be reconsidered.

Factors that influence volume and duration of wound drainage after mastectomy and level III axillary node clearance.

Factors influencing drainage after operations for breast cancer remain controversial. The total volume and duration of drainage was prospectively measured in 252 women undergoing mastectomy and level III axillary clearance, and compared to patient, operative and tumour factors, using multivariate analysis. The total drainage and duration, respectively, correlated with the weight of the patient (r=0.39, P<0.01; r=0.29, P<0.01) and breast weight (r=0.37, P<0.01; r=0.29, P<0.01), and was predicted by the volume on the first postoperative day (r=0.58, P<0.01; r=0.50, P<0.01). There was no correlation with age, blood loss, length of operation, tumour size, number of axillary nodes retrieved, or whether nodes were involved by cancer. The volume and duration of drainage appear thus to be simply a function of the area of tissue planes opened.

Impact of the '2 week wait' directive for suspected cancer on service provision in a symptomatic breast clinic.

BACKGROUND: The '2 week wait' directive (Health Service Circular (HSC) 1998/242) guaranteeing that 'everyone with suspected breast cancer will be able to see a specialist within two weeks of their general practitioner (GP) deciding they need to be seen urgently' is a unique audited approach to access for the British National Health Service, the effects of which have been assessed in a non-academic symptomatic breast clinic. METHODS: New GP referrals (n = 607) were reviewed prospectively in two comparable 3-month intervals, beginning 1 April 1998 and 1 April 1999, to determine the probability of a breast cancer diagnosis from the referral letter and the effects of the directive on waiting times for appointments and utilization of clinics. RESULTS: The urgency of referral was not specified in 53 per cent of GP referrals. For the 'urgent' cases (25 per cent of all new referrals) the probability of a final diagnosis of breast cancer was 0.19. The breast specialists prospectively achieved a rate of 0.26 from 99 per cent of the same referral letters. 'Urgent' referrals did not wait significantly longer in 1999 (median 9 versus 10 days) but waiting times for new appointments overall increased (13 versus 16 days; P < 0.01), and this was greatest for 'routine' [14] versus 21 days; P < 0.001). These changes were caused by an increase in the number of clinic appointments, due to significant increases in median number of visits to diagnosis or discharge and clinic non-attendance in 1999, resulting in overbooking. Telephonic communications were associated with faster median access times (fax 8 days; telephone 2 days), relative to mailed [19] days) (P < 0.01). CONCLUSION: Breast specialists were better overall at assessing the probability of a breast cancer diagnosis. The waiting time for 'urgent' appointments was unchanged following HSC 1998/242, but there was an increased wait for other patients, especially those assessed as having a lower probability of cancer.

Synchronous contralateral adrenal metastasis from renal cell carcinoma: a 7 year survival following resection.

Solitary contralateral adrenal metastasis from a renal cell carcinoma is distinctly unusual but aggressive surgical resection alone can produce long-term survival.

Non-operative management of breast masses diagnosed as fibroadenoma.

A 7-9-year study was undertaken in 99 female patients (median age 20 years), 56 of whom had single and 43 multiple fibroadenomas (total 279). Thirty-four women with 58 masses (21 per cent) were lost to follow-up. Twenty-eight women with 73 masses (26 per cent) subsequently underwent excision at a median of 10 (range 3-59) months for single and 38 (1-110) months for multiple fibroadenomas (P = 0.03), with histological confirmation in 71 and other benign disease in two cases. There was resolution of 107 masses (38 per cent of those entered into the study, 72 per cent of those not lost or excised), leaving 41 persisting masses (15 per cent of those entered into the study, 28 per cent of those not lost or excised). The actuarial probability of disappearance was 0.46 at 5 years and 0.69 at 9 years (Kaplan-Meier analysis). There was no difference in the rate of resolution when 56 single lesions were compared with 223 multiple lesions, or when 192 lesions measuring 2 cm or less in diameter were compared with 87 greater than 2 cm. Resolution was significantly more frequent in women aged 20 years or less than in those who were older (P < 0.01). Non-operative management remains a safe approach in selected women and should be followed by resolution of half of fibroadenomas at 5 years.

Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy.

To determine the role of antibiotic prophylaxis for stab wounds of the chest requiring intercostal tube drainage, a double-blind study was conducted comparing cefazolin, given to 57 patients at 500 mg every 8 h for 24 h, with placebo, given to 56. Differences were detected in the rate of thoracotomy for sepsis (antibiotic nil versus placebo 9 per cent, P < 0.05) and in the frequency of sputa positive for pathogens (12 versus 34 per cent respectively, P < 0.05), but the incidence of pyrexia, raised white cell count, positive cultures from pleural drainage or intercostal catheter tips and volume of chest drainage was similar. The mean hospital stay and costs consequent on morbidity were greater in patients receiving placebo, supporting the conclusion that antibiotic prophylaxis is indicated.

Management of traumatic parotid sialoceles and fistulae: a prospective study.

A prospective study of 13 patients with traumatic parotid fistulae or sialoceles showed that 54% resolved on conservative management within a 3 week period. Those that did not were treated by internal surgical drainage with uniform success, although care had to be taken with the catheter placement. No factors predictive of those cases requiring operative drainage other than failure of conservative management were found.

Renal excretion of enteral gastrografin in the absence of free intestinal perforation.

The renal excretion of orally administered water-soluble contrast medium has been described in intestinal perforation (Mori and Barret, 1962). We present a case in which orally administered Diatrizoate methylglucamine (Gastrografin, Schering) was detected in the renal collecting system on computed tomography in a man with an ischaemic segment of small bowel associated with abscess formation but no evidence of intra-peritoneal perforation.

Fibroadenoma.

The common breast fibroadenoma makes up between one-third and one-half of biopsies for benign breast disease. The contemporary view is that it is an abnormality of normal development and involution rather than a neoplasm. Various other benign conditions may be clinically indistinguishable, and histological confirmation was only obtained in 68% of 321 masses thought to be fibroadenomas. Short-term (13-24 mo) follow-up of 201 masses, thought to be fibroadenomas on clinical and cytological grounds, showed resolution in 31% and regression in a further 12%, this behavior being more common with single lesions; a further 32% increased in size. There have been no long-term studies, but it is likely that most regress toward the end of a woman's reproductive years. Aspiration cytology can differentiate malignant from benign disease with great accuracy, but had impaired sensitivity (87%) and specificity (76%) in differentiating fibroadenoma from other benign processes in an analysis of 244 successful aspirates. While these lesions may be safely left in women under 25 years of age, only 19 (27%) of 70 women of this age group chose this option and excision remains the most frequent treatment.

Case for conservative management of selected fibro-adenomas of the breast.

To assess the safety of a conservative approach to fibro-adenoma of the breast we prospectively studied 321 women with this clinical diagnosis, and performed aspiration cytology and excision biopsy. There was histological confirmation of fibro-adenoma in 217 (68 per cent), the remainder having various benign conditions and 4 (1.3 per cent) had carcinoma. Aspiration cytology had a sensitivity of 87 per cent and a specificity of 76 per cent for fibro-adenoma. Three cases of carcinoma were identified cytologically and the fourth was regarded as suspicious. To estimate the risk of missing carcinoma we compared the annual frequency of carcinoma with fibro-adenoma in young women and found a ratio of 1:470 between 15 and 19 years, 1:133 between 20 and 24 years and 1:9 in the 25-29 age group. To assess patients' views on non-operative treatment of benign breast masses we asked 124 women, 10 days postoperatively, whether they preferred a conservative approach for a cytologically benign lump: 26 (21 per cent) opted for conservative management in the future and 8 (7 per cent) would have preferred conservatism rather than their recent excision. A conservative approach is safe for clinically and cytologically benign breast lumps in women under 25 years, but very few will accept it.