Breast cancer clinical pathway : are doctors aware?

1. 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 Academic Year: 2010/2011 Adviser: Rosa Oliveira Introdução à Medicina Class 14

2. | Participants and Methods | Results | Discussion | Conclusion Introduction BREAST CANCER Chart 1: Cancer incidence statistics in Portuguese women (2003) [1] Mortality is decreasing[2] ?  Early diagnosis  Effective treatments[2] [1] PinheiroPS, 2003 [2] Coughlin SS, 2009 [3] Who, 2010; [4] Ferlay, 2010; [5] Davis, 2010; [6] Kerr F, 2006

3. | Participants and Methods | Results | Discussion | Conclusion Introduction CLINICAL PATHWAY[10] GUIDELINES[7,8] BI-RADS[9] PRIMARY HEALTH CARE CENTERS Specialized breast pathology unit • Consulting • Imagiologic exams requested • Follow the patient for observation Woman who suspects to have breast pathology • [7] Macedo A, 2010; [8] “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”, 2009 • [9] “NotAllDoctorsFollowCancerScreeningGuidelines, StudyFinds”, 2010 • [10] Cabana,“Why Don’t Physicians Follow Clinical Practice Guidelines?”

4. | Participants and Methods | Results | Discussion | Conclusion Introduction • Aims To 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 • USF: Unidade de Saúde Familiar • GPM: Grupo de Patologia Mamaria

5. | Participants and Methods | Results | Discussion | Conclusion Introduction • 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 • MeSH terms: Breast Neoplasm ; Diagnosis; Referral and Consulting; Practice Guideline; Breast Care • GPM: Grupo de Patologia Mamária • BI-RADS: BreastImagingReportand Data System

6. Introduction | | Results | Discussion | Conclusion Participants and Methods • Study Design → transversal and observational study Design ofquestionnaire Design ofquestionnaire Analysis of the BreastCare database Delivery ofquestionnaires Delivery ofquestionnaires Analysis of BI-RADS of women referred to GPM Evaluate the awareness regarding the guidelines Evaluate the awareness regarding the guidelines ANALYZE THE REFERRAL ANALYZE THE REFERRAL • GPM: Grupo de Patologia Mamária • BI-RADS: BreastImagingReportand Data System

7. Introduction | | Results | Discussion | Conclusion Participants and Methods • Study Participants Distribution ofquestionnaires 1st GROUP: General Practitioners from primary health care institutions in the metropolitan area of Oporto •  General practitionersof primary health care centers from Grande Porto • InclusionCriteria: General practitioners of the primary health care. • Exclusion Criteria: No exclusion criteria were considered.

8. Introduction | | Results | Discussion | Conclusion Participants and Methods • Data collection Distribution ofquestionnaires Development of the survey“Patologia mamária nos cuidados de saúde primários” basedon: • Guideline of August 2002[11] • Guideline of July 2005[12] • Guideline of June 2005[13] • Guideline of February 2009[14] • “RecomendaçõesNacionaispara o Tratamento e Diagnóstico de Cancro da Mama”, ACS, Setembro2009[15] • Guideline of January 2010[16] • [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. Introduction | | Results | Discussion | Conclusion Participants and Methods • Data collection Distribution ofquestionnaires Questionnaire DiscussionwithDr. Fernando Osório Compile data in a database Delivery to thedoctorsofprimarycareunits Some modificationsonthequestionnaire Pilottest to 2 general practitioners

10. Introduction | | Results | Discussion | Conclusion Participants and Methods • Variables description Distribution ofquestionnaires

11. Introduction | | Results | Discussion | Conclusion Participants and Methods • Variables description Distribution ofquestionnaires

12. Introduction | | Results | Discussion | Conclusion Participants and Methods • Variables description Distribution ofquestionnaires

13. Introduction | | Results | Discussion | Conclusion Participants and Methods • Study Design → transversal and observational study Design ofquestionnaire Analysis of the BreastCare database Analysis of the BreastCare database Delivery ofquestionnaires Analysisof BI-RADS ofwomenreffered to GPM Analysisof BI-RADS ofwomenreferred to GPM Evaluate the awareness regarding the guidelines ANALYZE THE REFERRAL ANALYZE THE REFERRAL • GPM: Grupo de Patologia Mamária • BI-RADS: BreastImagingReportand Data System

14. Introduction | | Results | Discussion | Conclusion Participants and Methods • Study Participants Analysis 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 2º GROUP: Women with breast cancer who participated in the Breast Care of HSJ InclusionCriteria: All women followed in the GPM. Exclusion Criteria: Patients whose data of diagnosis is incomplete • GPM: Grupo de Patologia Mamária • HSJ: Hospital de São João

15. Introduction | | Results | Discussion | Conclusion Participants and Methods • Variable description Analysis of the BreastCare database • Only some of the collected data was used: • Gold-standard classification (BI-RADS) • Proves the adequacy of rerouting • Only 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 Mamária • 2. HJS: Hospital de São João

16. Introduction | | Results | Discussion | Conclusion Participants and Methods • Statistical analysis 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.

17. Introduction | | Results | Discussion | Conclusion Participants and Methods • Statistical analysis Distribution ofquestionnaires • 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.

18. Introduction | | Results | Discussion | Conclusion Participants and Methods • Statistical analysis Distribution ofquestionnaires • Knowledge of the "RecomendaçõesNacionaisparaDiagnósticoe 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%) Significance level: 0.05 • CI: ConfidenceIntervals

19. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 19 GPs from health centers. • Response percent: 34.6% • Delivered in person 55 questionnaires • Request to ACES Table 1: GPs from health centers • GP: General Practitioners • CS: Centro de Saúde • ACES: Agrupamento de Centros de Saúde

20. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 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 Table 4: Age Table 3: Clinical experience Table 2: Gender of GP • GP: General Practitioners • SD: Standard Desviation

21. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 84.2% (n=16) of the GP frequently deal with breast pathology Table 5: Do GP deal with breast pathology? • GP: General Practitioners

22. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 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: Whatisthemostimportant factor intheassessmentoftheseverityofthebreastlesion? • GP: General Practitioners

23. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 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. • GPM: Grupo de Patologia Mamária • GP: General Practitioners

24. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires Table 7: Are theregatheredthebasiccondicions to dealwithbreastpathologyin Portugal? • 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. • GP: General Practitioners Table 8: Is it necessary to make changes?

25. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires Chart 2: Are they gathered the basic condicions to deal with breast pathology in Portugal? • BI-RADS: BreastImagingReportand Data System • RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”

26. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Distribution ofquestionnaires • 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. • BI-RADS: BreastImagingReportand Data System • RNDTCM: “Recomendações Nacionais para o Tratamento e Diagnóstico de Cancro da Mama”

27. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Analysis of the BreastCare database • 1151 women • Mean age (SD):49.6 years (15.0). • Breast cancer was first diagnosed atan 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 • SD: Standard Deviations • GPM: Grupo de Patogia Mamária

28. Results Introduction | Participants and Methods | | Discussion | Conclusion • Results, Tables and Graphics Analysis of the BreastCare database • 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%] • BI-RADS: BreastImagingReportand Data System • GPM: Grupo de Patogia Mamária • CI: Confidence Intervale

29. Discussion Introduction | Participants and Methods | Results | | Conclusion • Discussion • Do general practitioners know any and best medicine evidence concerning diagnosis of breast pathology? GUIDELINES • Highpercentage of GPs are aware of: • “RecomendaçõesNacionaispara o Tratamento e Diagnóstico de Cancro da Mama”, ACES, Setembro2009 •  BI-RADS classification system • BI-RADS: BreastImagingReportand Data System • ACES: Agrupamento de Centros de Saúde • GP: General Practitioners

30. Discussion Introduction | Participants and Methods | Results | | Conclusion • Discussion • If so, do they follow them? • Score of questionnaire: • Frequency (95% CI): 75% • [69%; 81%] • BI-RADS: BreastImagingReportand Data System • CI: Confidence Intervale

31. Discussion Introduction | Participants and Methods | Results | | Conclusion • Discussion 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. • GP: General Practitioners [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

32. Discussion Introduction | Participants and Methods | Results | | Conclusion • Discussion • 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. • Inadequate rerouting frequency • (CI 95%): [64.5%; 75.6%] • percentage of incorrect referrals to the hospital • BI-RADS: BreastImagingReportand Data System • CI: ConfidenceIntervals • GPM: Grupo de Patologia Mamária

33. Discussion Introduction | Participants and Methods | Results | | Conclusion • Discussion • “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] • GP: General Practisioners [17] Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA. 2005; 293: 1245-1254

34. Discussion Introduction | Participants and Methods | Results | | Conclusion LIMITATIONS • 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.

35. Conclusion Introduction | Participants and Methods | Results | Discussion | • Conclusion • 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. • BI-RADS: BreastImagingReportand Data System • GP: General Practisioners

36. Introduction | Participants and Methods | Results | Discussion | Conclusion • Addendum FLYER • Deliveredat Hospital São João (HSJ) on 30thOctober (Dia Nacional da Prevenção do Cancro da Mama); • Informativeflyer for patientsandvisitorsof HSJ.

37. Introduction | Participants and Methods | Results | Discussion | Conclusion • Addendum WEBSITE

38. Introduction | Participants and Methods | Results | Discussion | Conclusion • 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 thesuggestionsalongallourpresentationsandworkdevelopedalongtheyear • HealthCareUnits, for theirreadiness for response to ourquestionnaires • Grupo de Patologia Mamária, for thehelpwithinformationconcerningtheBreastCaredatabaseandBreastCancertreatmentin general

39. Introduction | Participants and Methods | Results | Discussion | Conclusion • 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 GynaecolOncol. 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