Downgrading of referrals to breast cancer patient pathway

Discussion

This retrospective study is a review of external referrals to the breast cancer patient pathway that the radiologists at the Department of Breast Diagnostics, Oslo University Hospital in 2020 chose not to refer to this pathway since they did not meet the national criteria for referral. The study showed that most women were prioritised for investigation within four weeks. Seven women (3 %) were diagnosed with breast cancer. One of these underwent investigation five weeks after receiving a referral, while investigation was initiated for the other six in less than 23 days. This appears to suggest that the downgrading system was clinically justifiable and in line with the recommended deadline.

The literature search we conducted did not identify any previously published work on the downgrading of breast cancer patient pathway referrals.

External patients who are referred to our Department of Breast Diagnostics can be divided into three groups: those who are referred to the patient pathway and are registered in this pathway; those who are referred to the patient pathway but are deprioritised; and those who are referred for investigation outside the patient pathway. Referrals that are registered in the patient pathway also include referrals of suspected changes in a mammogram taken in the public health service's breast cancer screening programme, where a category 4 or 5 result is agreed by consensus, and which are therefore referred to the patient pathway according to the national criteria (Box 1).

Ninety-seven cases of cancer detected in the screening programme in Oslo in 2020 (DCIS and infiltrating cancer) are registered in the Norwegian Cancer Registry's report from 2022 (6). After a new review of the registry data by the first author together with the Mammography Section in the Cancer Registry, the number was adjusted up to 115, of which 40 (35 %) had a category 4 or 5 result (data not shown).

In the Norwegian Patient Registry, an organ-specific cancer diagnosis was registered in 2020 in 45 % (450/1,011) of patients who started the breast cancer patient pathway at Oslo University Hospital (7). Patients referred to the pathway from the breast cancer screening programme, or patients who started the pathway following breast diagnostics, will in most cases be diagnosed with cancer. This is in contrast to women who are referred on the basis of clinical findings. Based on a review of our own activity data, it can be assumed that the proportion of these is around 30–35%; however, new studies are needed to obtain a more reliable estimate of the proportion of breast cancer diagnoses in this group.

This study has nevertheless shown that the proportion of malignant findings in the patient pathway group that was downgraded is very low compared to the group that was not downgraded. This indicates that the downgrading has led to more correct prioritisation of patients who are referred to the specialist health service.

In the Norwegian Directorate of Health's document on the breast cancer patient pathway, a new lump in the breast in women over the age of 50 is to be regarded as suspected malignancy (1), and these referrals were not downgraded by our radiologists. This may explain why only one patient over the age of 50 was diagnosed with breast cancer in the study (3 %, 1/31). Of the other seven, five were aged 40–50 years (9 %, 5/56). This suggests that caution should be exercised when deprioritising this age group for referral to the patient pathway. In the patient group under the age of 35, no one had breast cancer.

Our findings indicate that downgrading women under the age of 35 with new symptoms in the breast without a justified suspicion of breast cancer was the right decision. We believe that it is also correct to downgrade women over 50, provided that the national criteria are met.

Referrals that did not meet the national criteria were not linked to specific districts or GPs. The vast majority of GPs had less than three downgraded referrals each, and 90 % of the referrals were of sufficient quality for the radiologists to perform an appropriate assessment.

The national criteria should make it easier for GPs to filter which patients should be referred to the breast cancer patient pathway and help ensure the correct prioritisation of patients for referral to the specialist health service. We found that many GPs are not familiar with the criteria, but also have the impression that the criteria can be difficult to understand.

SINTEF's final report notes that although GPs are generally satisfied with the patient pathway system, the guidelines for the cancer patient pathway are only one of a multitude of guidelines (3). It also points out that GPs' knowledge of patient pathways and referral criteria varies. We believe that our system of downgrading and providing written feedback to GPs about national criteria will help to improve the communication between the primary care service and the specialist health service. New studies are needed to clarify whether the system will, in the long term, improve referral practices and reduce unnecessary referrals to the breast cancer patient pathway. More research is also needed to understand why GPs' assessments of the patient pathway are sometimes at odds with the specialist health service's admission criteria. Information that could help to inform this work may include the number of patients who are upgraded to the patient pathway and the reason for referral among those who are downgraded and do not have breast cancer.

In order to ensure effective prioritisation of healthcare services, the Norwegian health service is organised according to the principle of the lowest effective care level (8, 9). Good referral practices are a prerequisite for setting the right priorities in the specialist health service. If the GP does not follow the referral criteria for the patient pathway, the doctor assessing the referral has to spend time and resources on reprioritising the referrals. The Office of the Auditor General of Norway has pointed out that poor-quality referrals to the specialist health service lead to unnecessary use of resources in hospitals (9). Closer follow-up of the GPs' referral practices is likely to reduce the number of downgraded referrals because it will ensure that the right decision will be made at the lowest care level.

The patient pathway sets stringent criteria for diagnostics deadlines and puts pressure on resource allocation and private services, as pointed out in the SINTEF report (3). Because the implementation of the patient pathway in Norway was introduced without financial incentives, it can pose a challenge for health trusts' priorities (3, 4). Several health trusts have had to resort to the private sector to circumvent the bottlenecks in the patient pathway, particularly within radiology. Previously calculated estimates of marginal costs linked to the use of private operators at the Department of Breast Diagnostics at Oslo University Hospital in 2015 showed that the unit price for investigation was 44–114 % higher compared to investigation at a hospital (10).

One of the objectives of the patient pathway is to lower the threshold for rapid access to health care. Wrong prioritisation of patients, may be counterproductive and lead to an unwanted increase in demand for healthcare services. If the threshold for rapid access to breast diagnostics is lowered, the signal this sends to the population may increase concerns about cancer. This concern does not correspond to the actual incidence of breast cancer, particularly in younger age groups. Health anxiety may have an adverse effect on the total consumption of health services, and in a Danish study, increased consumption of somatic health services was found in 41–78 % of patients with severe health anxiety (11).

The retrospective design and the fact that radiologists with varied experience and competence independently assessed the referrals were weaknesses of the study. Although the assessments are based on national criteria, we found that this variation can impact on the decision-making process. We observed that radiologists with knowledge of patient pathway indicators and an interest in patient pathways are most likely to adhere to the national guidelines. We also found that capacity has an effect on the number of referrals that are downgraded, and when capacity is low, the national criteria are enforced more strictly.