Referral patterns, clinical examination and the two-week-rule for breast cancer: a cohort study

Current NHS guidelines require patients with suspected breast cancer to be seen urgently at a specialist breast clinic. The aim of this study was to assess referral patterns and clinical findings of patients referred to a specialist breast clinic.

A prospective database was maintained for consecutive patients referred. Symptoms and clinical findings in primary and secondary care were recorded. Correlation with final diagnoses was made. Tertiary referral patients were excluded.

1098 patients attended a specialist breast clinic over six months. 588 (54%) were referred as urgent, 285 (26%) routinely and 225 (20%) were unspecified. 492 (45%) patients were referred with the incorrect referral priority. 42 patients were unexamined in primary care. Examination findings in primary and secondary care correlated in only 487 (46%) patients. Examination in primary care when compared with secondary care was highly sensitive for detecting breast lumps, but specificity was low. 86 patients (8%) were diagnosed with breast cancer, 72 (84%) were referred urgently, 6 (7%) routinely and 8 (9%) as unspecified priority. Regardless of the clinical expertise of the referrer, sensitivity and specificity of the two-week guidelines for cancer are low.

Examination findings in primary and secondary care correlate in only 46% of referrals. Additionally, 55% of referrals were of the correct priority. The two-week rule guidelines have poor sensitivity and specificity for cancer. The safest and fairest policy would be to abandon the concept of urgent referral criteria and see all patients in a timely fashion. Alternatively, simplifying the referral criteria would improve sensitivity and specificity for cancer without leading to increased waiting times.