In-hospital delay in the diagnosis of breast cancer.

BACKGROUND: There is evidence that delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic. METHODS: The interval between first breast clinic visit and a definitive diagnosis was recorded in all patients with invasive breast cancer between 1988 and 1997. In all patients with a delay of 3 months or more, the case notes were reviewed for evidence of a triple assessment (clinical examination, imaging and needle biopsy). The principal cause of delay was identified. RESULTS: Of 1004 patients with invasive breast cancer, there was a delay in diagnosis of 3 months or more in 42 patients between 1988 and 1997, an incidence of 4.2 per cent. The median delay was 6 months and the median age at diagnosis was 53 (range 27-89) years. Triple assessment was undertaken in 30 patients; ten did not have a needle biopsy performed and three patients had no mammography. The principal cause of delay was: false-negative or inadequate fine-needle aspiration cytology (FNAC) in 19 patients, failure of follow-up in eight, clinical signs did not impress in five, FNAC not carried out in four, false-negative mammogram in three, failure of needle localization in two and one patient did not accept clinical advice. The annual incidence of delay in diagnosis did not change significantly over the 10-year interval. CONCLUSION: Triple assessment is not sufficiently sensitive to detect every breast cancer and a small incidence of diagnostic delay is therefore inevitable with current techniques.

Does open-access mammography and ultrasound delay the diagnosis of breast cancer?

There is a consensus that open-access breast imaging for general practitioners is inappropriate since the process omits an expert clinical examination and fine needle aspiration cytology. However, it was decided to test this hypothesis by comparing the outcome of breast referrals in a district with both an open-access imaging and a one-stop clinic. The time from referral to definitive diagnosis in all women with breast cancer was compared over a 12 month period in 1996. Of 1049 women referred for open-access imaging 20 (2%) were found to have breast cancer compared with 91 (9%) of 995 women referred to the one-stop breast clinic. There was a longer interval before the diagnosis of breast cancer was made in cases referred for open-access imaging compared with cases referred to the one-stop breast clinic (mean 63 vs 35 days). However, if patients with advanced disease are excluded the mean interval was 63 vs 44 days. The mean tumour size of breast cancers in cases referred to open-access imaging was smaller (1.5 vs 2.3 cm), there were fewer grade 3 tumours (10% vs 39%), and there was a lower rate of axillary lymph node metastases (20% vs 32%) compared with cases referred to the one-stop breast clinic. The longer interval for the open-access patients was largely due to administrative delay and the 3 patients with a delay of more than 3 months had all had a triple assessment which was false negative. This study does not support the hypothesis that open-access mammography is unsafe and should be withdrawn.