key: cord-0851460-ultwibnv
authors: Cathcart, Paul; Clayton, Gill; Smith, Simon; Dua, Sascha; Gandamihardja, Tasha
title: Virtual clinic triage of breast referrals during the COVID-19 pandemic: retrospective outcome analysis
date: 2021-12-07
journal: Br J Surg
DOI: 10.1093/bjs/znab424
sha: 1a4099b0f8051a2fae7e5a6c1fc5d0877e5610de
doc_id: 851460
cord_uid: ultwibnv

nan

One-stop clinics for breast triple assessment have been adopted widely in the UK and provide an accurate assessment of symptomatic patients. Before the COVID-19 pandemic, most patients were reviewed in such clinics, with a select number identified by senior breast care nurses for a nurse-led pain clinic. Several cancer services worldwide have implemented telephone triage 1,2 , risk calculators 3 , and virtual meetings 4 in an attempt to optimize the diagnostic pathway and minimize hospital footfall during the pandemic. In February 2021, National Health Service (NHS) England 5 provided updated pan-specialty guidance for urgent cancer diagnostics, highlighting the use of breast virtual clinic triage consultations to determine whether a clinical assessment is required.

All breast referrals to the authors' hospital were telephone triaged by consultant surgeons before offering a one-stop appointment during the initial phases of the pandemic. As referral volume increased, experienced breast care nurses screened the referral letters to identify high-risk patients, with the remainder being telephoned by a consultant. Patients were either discharged with advice, deferred to a further telephone consultation or delayed appointment, or seen in the one-stop clinic.

Data on 624 patients referred between 1 June and 31 July 2020 were assessed retrospectively. The male to female ratio was 43 : 581, and the overall mean age was 48 (range 6-96) years ( Fig.  1) . Most patients presented with a lump, and 80 per cent of cancers were identified in patients presenting with a breast lump.

The referral letter triage by breast care nurses overall identified a large proportion of cancers (67.5 per cent), which was particularly apparent towards the latter stage of the study when breast care nurse triage was fully functional (94.7 per cent of cancers detected over 4 weeks). Moreover, 27 patients were managed remotely by the breast care nurse team for breast pain alone, with one re-presentation for persistent symptoms. The majority of patients triaged by breast care nurses were women (male to female ratio 2 : 223), and the mean age was 55 (14-90) years. Most presented with a breast lump (152 of 225), of whom 22 (14.4 per cent) were found to have a cancer. Most patients after one-stop consultation had normal or physiological clinical findings (116), or palpable benign changes/lumps (55). Compared with consultant-led telephone clinics, breast care nurse triage of referral letters identified patients requiring urgent attention or a one-stop appointment on average 8 days earlier as the telephone consultations required dedicated clinics and patient availability.

Consultant telephone triage led to direct discharge of 143 patients (37.3 per cent of those telephoned) but with a notable reattendance rate of 16 per cent, all with the same symptoms requiring clinical assessment and subsequent discharge. Over half of patients telephoned (54.9 per cent) were directed to a one-stop clinic, with most describing a breast lump. Nine cancers presented with a lump and two with nipple hardening/blood-stained nipple discharge, whereas most other patients had a normal/benign clinical examination. Three women reattended the clinic after full assessment, one of whom had a new clinical and radiological cancerous lump 4.5 months after the initial consultation.

A total of 37 patients (male to female ratio 5 : 32) were deferred, with no reattenders noted during the study interval. Deferral was useful only for select patients such as the frail, as most other deferrals were ultimately reviewed in the one-stop clinic.

In the present cohort, telephone triage helped to reduce hospital footfall without any missed cancers. A large number of patients telephoned, however, still required one-stop assessment, increasing the overall departmental workload with a high reattendance rate. Telephoning patients requires dedicated clinic time, letter dictation, and associated administration time. Nurseled triage has a high cancer detection rate and a shorter decisionto-clinic time than telephone triage. Virtual breast pain clinics were safe and offer an alternative management option; however, they should be used selectively and with appropriate safety netting and written advice. One-stop clinic n = 1 Fig. 1 Overall patient referrals and management pathway for study period June-July 2020 DNA, did not attend.

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