Uptake of risk-reducing surgery in BRCA gene carriers in Wales, UK.

Women who inherit a mutated copy of the BRCA gene have a higher lifetime risk of developing breast cancer. No large epidemiological studies exist looking at BRCA mutation carriers in UK populations. All patients with BRCA1/BRCA2 mutation identified between 1995 and 2015 were included. Individuals were identified from a prospectively gathered data base. Genetics case-notes were obtained and retrospective analysis performed. 581 female BRCA mutation carriers were identified with a median age of 34 (18-81) at the time of testing. Of the 301 women who underwent diagnostic testing (symptomatic) 246 had been diagnosed with breast cancer, 89 with ovarian cancer and 37 had both at time of testing. Median age at diagnostic test was 51 (25-81). 33% of women underwent risk-reducing mastectomies (RRM); median age at surgery 45. This compares with 37% of women in this diagnostic group who underwent Risk-reducing bilateral salpingo-oopherectomies (RRBSO) at a median age of 46. Two hundred and eighty women underwent predictive testing (family history, asymptomatic), median age 36 (18-81). 34% of women in this predictive group underwent RRM, median age 37. There was a 29% uptake of RRBSO (median age 44 years). Fifteen women (5%) developed breast cancer after being tested; none of these had undergone RRS. This unique study of all BRCA mutation carriers in Wales shows considerable variation in uptake of RRS. The decision to undergo RRS is complex and involves a number of factors, including a woman's age and life stage. As BRCA testing becomes more frequent and more gene mutation carriers are identified there will be significant implications for service allocation, screening demands, and provision of risk-reducing surgery for this high-risk patient group.

Breast disease diagnostic ability of nurse practitioners and surgeons.

AIM: This paper is a report of a study to compare history-taking and breast and axillary examination skills of nurse practitioners and surgeons. BACKGROUND: In the United Kingdom, patients referred by their general practitioners with suspected breast cancer should be seen within 2 weeks by a specialist. As a result of the European Working Time Directive there has been a reduction in junior doctors' working hours within the European Union. This makes such targets harder to achieve and risks delays in patient assessment and diagnosis. Trained nurse practitioners can perform an important role in assessing new patients in breast clinics to ensure that they are seen expeditiously. Nurse practitioners' competence assessing patients with breast disease needs to be objectively demonstrated. METHODS: Between 1st March 2007 and 31st March 2008 patients referred to a symptomatic breast disease clinic were seen by a single nurse practitioner and a single consultant surgeon. Findings were recorded on a standardised pro forma and compared using one-way analysis of variance. FINDINGS: Assessments were recorded for 128 patients. No abnormality was found in 41% of patients but nine (7%) had breast cancer. There was no evidence of a statistically significant mismatch in scoring between the nurse practitioner and consultant surgeon. Thirty-seven lumps were identified in 35 patients. There was no difference in mammography requests from the nurse practitioner and surgeon. CONCLUSION: The diagnostic accuracy of a nurse practitioner compares favourably with that of a consultant surgeon.

Reviewing interval cancers: time well spent?

OBJECTIVES: To categorize interval cancers, and thus identify false-negatives, following prevalent and incident screens in the Welsh breast screening programme. SETTING: Breast Test Wales (BTW) Llandudno, Cardiff and Swansea breast screening units. METHODS: Five hundred and sixty interval breast cancers identified following negative mammographic screening between 1989 and 1997 were reviewed by eight screening radiologists. The blind review was achieved by mixing the screening films of women who subsequently developed an interval cancer with screen negative films of women who did not develop cancer, in a ratio of 4 to 1. Another radiologist used patients' symptomatic films to record a reference against which the reviewers' reports of the screening films were compared. Interval cancers were categorized as 'true', 'occult', 'false-negative' or 'unclassified' interval cancers or interval cancers with minimal signs, based on the National Health Service breast screening programme (NHSBSP) guidelines. RESULTS: Of the classifiable interval films, 32% were false-negatives, 55% were true intervals and 12% occult. The proportion of false-negatives following incident screens was half that following prevalent screens (P = 0.004). Forty percent of the seed films were recalled by the panel. CONCLUSIONS: Low false-negative interval cancer rates following incident screens (18%) versus prevalent screens (36%) suggest that lower cancer detection rates at incident screens may have resulted from fewer cancers than expected being present, rather than from a failure to detect tumours. The panel method for categorizing interval cancers has significant flaws as the results vary markedly with different protocol and is no more accurate than other, quicker and more timely methods.