UK researchers have developed an initiative that could help hospitals prevent delays to the two-week cancer target, following the reduction in junior doctors' working hours due to the European Working Time Directive. A specially trained nurse practitioner and consultant breast surgeon who examined 126 women referred to a symptomatic breast disease clinic picked up the same breast abnormalities in 92% of cases.
Women were just as likely to have breast abnormalities picked up by a specially trained nurse practitioner as a consultant breast surgeon, according to research published in the July issue of the Journal of Advanced Nursing.
Researchers at Glamorgan Hospital, Wales, UK, compared the findings of 126 women examined by a nurse practitioner and consultant surgeon referred to a symptomatic breast disease clinic over a 13-month period.
They produced exactly the same results in 92 per cent of cases.
"All the assessments were carried out by the same nurse practitioner and consultant surgeon and there were no statistically significant differences between the two sets of results" says lead author Mr Gary Osborn, a Specialist Registrar in General Surgery at the hospital, which treats nearly 300 women with breast cancer a year.
Key findings of the study included:
- The women referred to the clinic during the study period were aged between 20 and 78 with a median age of 54.
- Two of the 126 women had symptoms in both breasts, which means that 128 assessments were recorded.
- 74 women (59 per cent) had some sort of abnormality.
- 37 discrete lumps were discovered in 35 women, with the consultant surgeon missing two breast cysts and the nurse practitioner missing one. They recorded the same results in 34 of the 37 assessments, giving an agreement rate of 92 per cent.
- Nine of the women had breast cancer. Both assessors gave five of the cancers a score of P4 (suspected malignancy) or P5 (malignant) and four cancers were given a score of P3 (indeterminate lump). A single lump thought to be suspicious (P4) by the surgeon was correctly identified as a breast cyst by the nurse.
- The remaining abnormalities included harmless lumps filled with fluid (cysts), fibrous/glandular tissue (fibroadenomas) or fibrous tissue/blood vessels (papillomas).
- 114 patients had scans -- 31 per cent had mammograms, 26 per cent had ultrasounds and 32 per cent had both.
- There was no difference between the mammography requests ordered by the nurse and surgeon, but when it came to ultrasounds, the nurse ordered three extra scans and the surgeon ordered four extra. One of the extra scans ordered by the nurse identified a cyst and one of the extra scans ordered by the surgeon confirmed a benign lymph node.
"In the UK, patients referred by their family doctor with suspected breast cancer should be seen by a specialist within two weeks" says Mr Osborn.
"The reduction in junior doctors' working hours as a result of the European Working Time Directive makes this target harder to achieve and the risk is that patients may experience delays in assessment and diagnosis.
"This study aimed to test the theory that trained nurse practitioners can perform an important role in assessing new patients in breast cancer clinics to ensure that they are seen as quickly as possible."
The authors argue that the audit carried out at Glamorgan Hospital provides objective evidence that a nurse practitioner can become proficient in evaluating patients with symptomatic breast cancer.
"Our study showed that the diagnostic accuracy shown by the nurse practitioner, together with the scans she requested, compared favourably with the consultant breast surgeon" says Mr Osborn.
The team plan further research, with other members of staff and at other hospitals, to see if the encouraging results are replicated.
"We believe that nurse practitioners can be a valuable asset to the multidisciplinary breast team if they received special training, consultant support and are subject to regular comparative audits" concludes Mr Osborn.
"Their enhanced clinical skills can reduce the impact that working hours legislation is having on the availability of junior medical staff.
"This in turn, can enable us to see more patients in clinics, reduce waiting times and meet Government targets."
- Gary David Osborn, Maria Jones, Kate Gower-Thomas, Eifion Vaughan-Williams. Breast disease diagnostic ability of nurse practitioners and surgeons. Journal of Advanced Nursing, 2010; 66 (7): 1452 DOI: 10.1111/j.1365-2648.2010.05291.x
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