1. Breast cancer pathway update – Primary care pathways event
Julia Massey
Consultant Oncoplastic Breast Surgeon

2. Proposed changes to follow up of breast cancer patients in Yorkshire and Humber
Breast cancer outcomes are improving 5YS>80%
Long term survivors may suffer adverse effects from diagnosis and treatments
Routine follow up does not confer survival benefit despite widespread current practice
Current CRH pathway:
DCIS – 5 years imaging follow up only
Invasive cancer – 5 years imaging follow up and clinical follow up at 2 and 5 years (unless on trial)

3. Proposed risk stratified clinical follow up – low risk group
Group stratified as unlikely to benefit from clinical follow up
Includes:
NPI <3.4 ER neg or NPI <4.4 ER pos
DCIS
Oncotype DX low recurrence score
Low life expectancy due to other co-morbidities

4. Proposed risk stratified clinical follow up – low risk group
Schedule of clinical follow up:
Will all have End of Treatment Appointment:
to ensure suitable for discharge
provide plan (endocrine, bisphosphonates DEXA etc)
holistic needs assessment
Will have ‘open access’ for 5 years (discussed later)
Schedule of imaging follow up
Annually for 5 years or until enter NHSBSP
> 5 years
GP to manage endocrine treatment (with treatment plan provided)
Self referral via GP if symptomatic
Extended imaging via NHSBSP

5. Proposed risk stratified clinical follow up – high risk group (‘standard follow up group’)
Includes:
All chemotherapy and biological therapy and ALND
Young patients with possible fertility issues
Struggling psychologically
Learning difficulties
Non-compliance with standard treatment
Ongoing side effects from breast cancer treatment
Schedule of clinical follow up
Appointments at 3 and 5 years post diagnosis
Imaging follow up as for low risk group
>5 years:
as for low risk group

6. Potential issue- ‘open access’
Aim is to move away from current model of patients seeing GP for advice first
‘Open access’ to service instead
Will patients do this?
How should they access service?
How many should we plan for?
How do we get paid if discharged?

7. Potential solutions Will patients do this?
Patient education
? Part of EOT treatment plan
How should they access service?
Will need triage according to problem so will need to be clinical eg routine follow up/lymphoedema clinic/reconstruction clinic
? Breast care nurses
? Macmillan Care worker
How many should we plan for?
Hopefully there will be more capacity as fewer routine follow ups
Audit (see next slide)
How do we get paid?

8. Changes to pathway for patients within 5 years of diagnosis presenting with new symptoms on same side
Currently advised to see GP for referral to Fast track as fastest way to be seen
Auditing numbers currently – seem to be lower than though (7 in three months)
Need to be seen in 2 weeks
Options:
Specific new clinic
Reserved slots on Fast track clinic

9. Recent issues with breast screening invitations: what went wrong
Women aged 70 up to 71 years of age who should have automatically received an invitation were put into the age extension randomisation a year early
A proportion were randomised out and therefore not sent a letter of invitation
Some of these will have self referred and been screened
This has been happening since 2010 when age extension started but only picked up now

10. Recent issues with breast screening invitations: what happens next?
PHE will send a list of ladies who are now under the age of 72 who missed their final screen and they need to be screened in the next 6 months
They don't need to do anything, they will be sent a letter informing of the situation and invited for a mammogram
There is a national helpline for anyone concerned to ring
Ladies who are currently older than 72 will be sent a letter informing them they were missed and they can ring and book a mammogram if they wish
If we identify interval cancers that occurred because of a missed screen then duty of candour will apply

11. Recent issues with breast screening invitations: what impact do we expect locally?
We think around 500 ladies will be affected
Over next 6 months this will equal:
12 extra assessments clinics
2 extra cancer diagnoses
Unknown quantity are those over 72 who won’t be automatically recalled