Triaging referral to a specialist breast clinic

BACKGROUND: The aim of this study was to determine the effectiveness of a triage system in predicting patients with malignancy among those referred to a specialist breast clinic. METHODS: A retrospective study of all referrals seen at the specialist breast clinic from January 2002 to June 2002 was conducted. The triage system allocated an urgent appointment if (i) urgent referral was requested by the referring physicians or (ii) 'non-urgent referral' was made and any one of the following 'high-risk' criteria were present: aged more than 50 years when presenting with breast lump, lump larger than 3 cm, bloody nipple discharge or physical signs suggestive of malignancy. Routine appointment was given if these conditions were not met. The outcomes of individual groups were assessed. RESULTS: Three hundred and sixty-three referrals were analysed and 44 cancers (13.2%) were diagnosed. The mean waiting time for urgent and routine appointments was 19 and 154 days, respectively. There were 108 urgent referrals and 21 (19.4%) cancers were diagnosed. Ninety-two patients were given an urgent appointment because of the presence of high-risk criteria, and 21 cancers were detected (22.8%). After the two-stage triage, breast cancer was subsequently diagnosed in only 2 out of the remaining 163 patients (1.2%) given a routine appointment. CONCLUSION: Most of the patients with cancer (96%) were given an urgent appointment through the triage system. In addition to the assessment by referring physicians, certain high-risk criteria are helpful to select patients who should be seen urgently.     

Audit of patient's waiting time to see their family doctor prior to referral to a fast-access breast clinic in the era of a guaranteed 2-week wait

PURPOSE: A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley. METHODS: Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18-84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology. RESULTS: Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the '2-week wait' period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days. CONCLUSION: A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.     

Impact of the '2 week wait' directive for suspected cancer on service provision in a symptomatic breast clinic

BACKGROUND: The '2 week wait' directive (Health Service Circular (HSC) 1998/242) guaranteeing that 'everyone with suspected breast cancer will be able to see a specialist within two weeks of their general practitioner (GP) deciding they need to be seen urgently' is a unique audited approach to access for the British National Health Service, the effects of which have been assessed in a non-academic symptomatic breast clinic. METHODS: New GP referrals (n = 607) were reviewed prospectively in two comparable 3-month intervals, beginning 1 April 1998 and 1 April 1999, to determine the probability of a breast cancer diagnosis from the referral letter and the effects of the directive on waiting times for appointments and utilization of clinics. RESULTS: The urgency of referral was not specified in 53 per cent of GP referrals. For the 'urgent' cases (25 per cent of all new referrals) the probability of a final diagnosis of breast cancer was 0.19. The breast specialists prospectively achieved a rate of 0.26 from 99 per cent of the same referral letters. 'Urgent' referrals did not wait significantly longer in 1999 (median 9 versus 10 days) but waiting times for new appointments overall increased (13 versus 16 days; P < 0.01), and this was greatest for 'routine' [14] versus 21 days; P < 0.001). These changes were caused by an increase in the number of clinic appointments, due to significant increases in median number of visits to diagnosis or discharge and clinic non-attendance in 1999, resulting in overbooking. Telephonic communications were associated with faster median access times (fax 8 days; telephone 2 days), relative to mailed [19] days) (P < 0.01). CONCLUSION: Breast specialists were better overall at assessing the probability of a breast cancer diagnosis. The waiting time for 'urgent' appointments was unchanged following HSC 1998/242, but there was an increased wait for other patients, especially those assessed as having a lower probability of cancer.     

Positive impact of a breast-health triaging system on breast-care access and physician satisfaction

OBJECTIVE: Minority patients are at risk for delayed breast cancer treatment. Using nonsurgical breast specialists could improve access but requires appropriate referral to ensure prompt cancer care. Our objective was to evaluate a referral triage system in a combined medical/surgical breast health program (BHP). METHODS: A triage system based on imaging findings, examination, and patient age was instituted. An advanced practice nurse managed referrals and a prospective database. Referring providers were surveyed after 2 years. RESULTS: From 2003 to 2006, 4,840 referrals were made to surgeons (57%) and nonsurgeons (43%). Breast cancers were found in 8.5% of patients. Referral error occurred in 4 cancer patients (.1%). BHP-referred patients had significantly shorter times to surgical appointment (10 days) than non-BHP referrals (45 days). A referring provider survey indicated 96% satisfaction. CONCLUSIONS: A breast-care triage system expedited cancer care resulting in physician satisfaction and increased referrals.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

The impact of the two-week wait rule on the diagnosis and management of bladder cancer in a single UK institution

INTRODUCTION

The objective of this study was to investigate the impact of the 2-week wait rule on patient waiting times for the diagnosis and treatment of bladder cancer.

PATIENTS AND METHODS

Data reporting the waiting times from diagnosis to treatment for 100 consecutive patients newly diagnosed with bladder cancer immediately before and after the implementation of the 2-week wait rule were compared. The data were collected both prospectively and retrospectively from cancer multidisciplinary team meeting files and patient records. Various steps of the patient pathway were analysed including waiting times from referral to consultation as well as time to investigation and first treatment. Data were also analysed based upon tumour stage/grade and whether referrals were made on an urgent or routine basis.

RESULTS

One hundred newly diagnosed patients with bladder cancer in each group covered a period of 4–5 years (1997–2001 and 2001–2006). Following the introduction of the 2-week wait rule, there was a 47.6% reduction in the time from referral to first consultation with a specialist (42 days vs 22 days; P < 0.001). The time between first investigation and treatment has not reduced significantly. We also found that, despite the introduction of the 2-week wait rule, only 42% of the patients were diagnosed with bladder cancer using this pathway. Patients referred as ‘routine’ waited longer to be seen in hospital although there was no significant delay in receiving treatment.

CONCLUSIONS

The introduction of the 2-week wait rule has significantly reduced the time patients with bladder cancer wait for their first consultation with a specialist. However, there is no significant change in the time between first consultation and treatment.     

Audit of referral practice to a fast-access breast clinic before the guaranteed 2-week wait

Currently in the fast-access breast clinic at Eastbourne District General Hospital, the specialist determines the level of urgency of a referral. With the new '2-week wait' imposed by the Government since 1 April 1999, the determination of urgency has transferred to the general practitioner. Therefore, we decided to audit the current situation to see whether the guidelines were adequate for this change of emphasis. A total of 100 consecutive patients referred to the fast-access breast clinic were evaluated to assess the quality of referrals and the effectiveness of the clinic. Only 80% of the referrals adhered to the guidelines; 73% of the referrals were deemed by the specialist to be urgent and seen within the 2-week time period. All patients who were subsequently diagnosed as having breast cancer were seen within 2 weeks. The audit indicates that further specific changes could be made to the guidelines to improve the referral practice.     

Immediate cytodiagnosis and imaging in the clinical management of discrete benign breast lesions.

Benign breast disease accounts for the majority of referrals to a specialist breast clinic. Delayed investigation prolongs patient anxiety and increases outpatient waiting lists. Few centres offer the triple test of clinical examination, fine needle aspiration cytology (FNAC) and breast imaging by mammography and/or ultrasonography at initial presentation. We have analysed the practicality of such a service during the 12 months following its introduction in our district general hospital. We studied the cohort of 178 patients who presented with a discrete breast lump which was subsequently shown to be benign. A triple test was performed in 72% of all patients. In 100 patients (56%) this was performed at initial assessment. Of these, 87 had clinically benign disease confirmed by FNAC and breast imaging and they were informed of the results within 3 h. A triple assessment during the initial consultation allows the majority of patients with discrete benign breast disease to be given immediate reassurance.     

Implications of sub-specialisation on the waiting times of general surgical clinics.

INTRODUCTION: Controversy around sub-specialisation in a district general hospital (DGH) has been ongoing for years. AIM: To study the effect of colorectal sub-specialisation on general surgical cases. METHODS: A retrospective audit between October 2002 and September 2003, including all referrals to the outpatient clinics of a single consultant surgeon in a DGH. RESULTS: 1,055 patients were seen in outpatient clinics, of which 53% (563) were seen in rapid access colorectal clinics. Overall, 87% (914) of patients were diagnosed to have colorectal pathology. The majority of the colorectal cases were referred using the designated referral forms. There were 427 urgent, 162 soon and 325 routine referrals with colorectal pathology, and 35 urgent, 22 soon and 84 routine referrals with non-colorectal pathology. Median waiting times for urgent, soon and routine referrals were 12, 61 and 91 days, respectively, for patients with colorectal pathology, in comparison with 44, 75 and 397 days for non-colorectal pathology. CONCLUSION: This audit confirms that colorectal sub-specialisation has resulted in a significant delay in the management of patients with non-colorectal diseases. This has major implications within a DGH setting.     

Quality assurance in a multidisciplinary symptomatic breast assessment clinic

Background : Although quality assurance guidelines for surgeons have been issued and adopted for use in population‐based breast screening programs in Australia, similar guidelines are unavailable for women referred with symptomatic breast problems. Methods : Six hundred and ninety‐six women who attended the Royal Adelaide Hospital Women’s Health Centre between February and November 1998 for investigation and management of a new breast‐related complaint were prospectively evaluated. Investigation strategies and outcomes of the initial consultation were determined and the results compared with the performance quality standards for symptomatic breast disease according to the British Association of Surgical Oncology (BASO) Breast Surgeons’ Group. Results : A breast lump was the presenting symptom in 45%, while breast pain was present in 26%. Ninety per cent of women referred with breast symptoms were given a definitive benign or malignant diagnosis at the initial clinic visit. Although the median time delay between the date of general practitioner referral and breast clinic appointments for all patients was ≤ 7 days, the time delay for ‘urgent’ cases was not met according to BASO performance indicators. All other Royal Adelaide Hospital Breast Clinic audit data were within the range suggested by BASO performance indicators for new consultations in a symptomatic breast assessment clinic. Conclusions : A multidisciplinary breast clinic in a public hospital setting is able to provide clinical services to symptomatic women, with the majority of patients obtaining a confident diagnosis at the first presentation. Performance indicators for symptomatic breast disease are useful in identifying inadequacies at the clerical or clinical level which, following the implementation of subsequent changes, may lead to improvement in patient outcomes.     

Managing aesthetic referrals in NHS Scotland: Outcomes from 1122 patients in the East of Scotland

The Adult Exceptional Aesthetic Referral Protocol (AEARP) encompasses a series of aesthetic procedures which, as they do not treat an underlying disease process, are not routinely available within the National Health Service. Provision of these services can only be provided on an exceptional basis.In this prospective study, we evaluated the referral process and outcomes of 1122 patients referred under the AEARP over a 3.5-year period. Referrals were screened by a vetting panel comprising of a plastic surgeon, clinical nurse specialist, and clinical psychologist. Following initial vetting, supported patients underwent psychological assessment. Patients supported by psychology were assessed in clinic, and if deemed clinically suitable, were offered surgery.Overall, 20% (225/1122) of referrals were supported for surgery. Following primary vetting, 57% (640/1,122) of referrals were supported, 40% (197/492) of referrals to clinical psychology were supported, and 65% (225/345) of the remaining cases referred for consultation were supported for surgery. Unsupported referrals included those not fulfilling the referral guidelines or those with contraindications.The AEARP is simple and effective to implement, and has been instrumental in streamlining the referral-to-outcome process in a centralised, transparent, and fair manner. It reduces a potential high number of clinic appointments where patients do not meet the aesthetic criteria and/or fail to attend – thereby helping to streamline other surgical pathways by improving clinic efficiency. Moreover, it aids referring clinicians and patient education around aesthetic issues including a holistic approach. Wide adoption of such standards may reduce waiting times, facilitate cost savings, and ultimately enhance patient outcomes.     

Reducing surgical outpatient waiting is not the solution to meeting the 2005 colorectal cancer target

OBJECTIVES: The majority of colorectal cancers (CRC) are not diagnosed through the Rapid access route (RAR) and follow-ups (FU) may prolong outpatient-waiting time for new referrals. The aim of this study was to assess the relative contributions of an efficient colorectal clinic and a stringent colonoscopy booking system on the total journey time for CRC. PATIENTS AND METHODS: We reduced the number of follow-up appointments with the introduction of 'Paper clinics'. The composition of the new clinic was determined by the known cancer yield through RAR and non-RAR route. A prospective analysis of clinics and CRC journey times was undertaken from November 2003 for 13 months, with the new outpatient clinic template introduced in December 2003. This coincided with a stringent policy on referral pattern for colonoscopy. RESULTS: In our hospital, only 4% of RAR yield CRC. Seventy-five percent of our CRC are referred through the non-RAR route. Eighty-one percent of follow-ups in a 'paper clinic' were discharged. A flexible template for the outpatient clinics, introduced a corresponding reduction in follow-up and increased urgent and routine slots. There was a progressive drop in the follow-up to new ratio and the waiting times for routine and urgent category decreased from a median of 15.9 and 3.4 weeks to 6.7 and 0.7 weeks, respectively (P < 0.001). Average waiting times for all categories fell from 13.35 weeks in November 2003 to 3.5 weeks in December 2004, while the number of patients waiting less than 4 weeks rose from 46% to 71%. This was associated with reduction in total journey times from 93 days to 62 days (P < 0.05). DNA rates remained unaffected. CONCLUSION: Modifying outpatient clinic composition with 'paper clinics' reduces the waiting time for all referrals to a surgical clinic with a modest effect on CRC clinic waiting time. Reduction in the total waiting time to first treatment (for CRC) is due to reducing the demand on colonoscopy in favour of barium enema. Redirecting the flow of patients towards barium enema is perhaps one way of improving the existing CRC journey time to first treatment, within existing resources. Achieving the 62 day target for cancer journey time will be difficult unless traditional surgical clinic habits are challenged.     

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

Referral guidelines for colorectal cancer--do they work?

AIMS AND METHODS: Urgent referral guidelines for patients with suspected colorectal cancer were introduced in 2000. In a district general hospital, we prospectively assessed the effect of these guidelines on the number of urgent referrals received and the number found to have cancer. RESULTS: Over the first year, 180 urgent referrals were received of whom 95 (55%) fitted the guidelines. Of these 95 patients, 24 (25%) had colorectal cancer. Conversely, only 2 of the 85 patients (2%) who did not fit the guidelines had colorectal cancer. During the same time period, a total of 145 new cancers were identified within the district of which 119 (82%) were in patients who had not been urgently referred to out-patients as suspected colorectal cancer. DISCUSSION: The guidelines are effective in that patients who fit them have a significant chance of having colorectal cancer. However, the majority of cancers are identified outside the new system. Efforts to reduce delays in diagnosis need to recognise that many patients do not have features which fit published referral criteria. Improved support for general practitioners and better access to specialist services are required to reduce delays in diagnosis.     

Waiting times for appointments with orthopaedic surgeons in Victoria: 1995-97.

BACKGROUND: A number of different models have been proposed for determining surgical workforce requirements. METHODS: In 1995 the Workforce Subcommittee of the Victorian Regional Branch of the Australian Orthopaedic Association commenced a prospective evaluation of waiting times for both urgent and nonurgent appointments with orthopaedic surgeons in Victoria. RESULTS: The results for the 3 years, 1995-97, show no significant change in the waiting time for nonurgent appointments and no difference between metropolitan and rural areas. The waiting time for an urgent appointment increased from 1995 to 1997 for the state of Victoria and for metropolitan Melbourne but not for rural areas. However, the median waiting time for an urgent appointment did not change. CONCLUSION: Overall the waiting times were found to be satisfactory by previously reported standards.     

WAITING TIMES FOR APPOINTMENTS WITH ORTHOPAEDIC SURGEONS IN VICTORIA: 1995–97

Background : A number of different models have been proposed for determining surgical workforce requirements. Methods : In 1995 the Workforce Subcommittee of the Victorian Regional Branch of the Australian Orthopaedic Association commenced a prospective evaluation of waiting times for both urgent and nonurgent appointments with orthopaedic surgeons in Victoria. Results : The results for the 3 years, 1995–97, show no significant change in the waiting time for nonurgent appointments and no difference between metropolitan and rural areas. The waiting time for an urgent appointment increased from 1995 to 1997 for the state of Victoria and for metropolitan Melbourne but not for rural areas. However, the median waiting time for an urgent appointment did not change. Conclusion : Overall the waiting times were found to be satisfactory by previously reported standards.     

Two-week rule: Has prioritisation of breast referrals by general practitioners improved?

INTRODUCTION: A 9-month audit, soon after the introduction of the 2-week rule in the UK in 1999, showed that a significant number of breast cancer patients were referred as non-urgent by their GPs, when the goal is that all suspected breast cancer patients should be seen by a hospital specialist urgently within 2 weeks of referral. The aim of this study was to determine whether GP grading of referrals into urgent and non-urgent had improved. METHOD: A retrospective review of GP referrals over 8 months, between September 2003 and April 2004, with regard to their urgency, subsequent diagnosis and the use of proformas (standardised referral formats) was carried out. The results were compared to the 1999 audit. RESULTS: Eighty-two of 1178 patients referred by GP had breast cancer, versus 115 of 1176 patients referred in 1999. Sixty-eight per cent (56/82) of breast cancer patients were referred as urgent, compared to 47% (54/115) in 1999 (P=0.005). A proforma was used in 47% (548/1178) of GP referrals while no proforma was used in 1999. Sixty-five of the 82 cancer patients were referred with a proforma and 85% (55/65) were referred as urgent. CONCLUSION: GP prioritisation of referrals has improved since 1999. With the use of proformas a significant number of patients with cancer were referred urgently.     

Implications of a negative bronchoscopy on waiting times to treatment for lung cancer patients: results of a prospective tracking study.

Objective: To ascertain the causes of delays in treatment to all patients presenting to our centre with a working diagnosis of lung cancer. All were entered prospectively into a 'tracking study'. Methods: Of 342 consecutive confirmed cases of newly diagnosed lung cancer presenting between September 2003 and December 2005, 193 were general practitioner referrals and 149 presented through casualty and internal referrals. The former group formed the basis of the study. Of GP referral patients, 92 had a positive diagnostic bronchoscopy (group Bronch+). Their waiting times were compared with 94 others with negative result (group Bronch-). For uniformity of comparison the non-GP referral patients were excluded from this study. Results: There were no significant differences in the age, clinical presentation or clinical staging of the two groups. Bronch+ had higher proportion of male patients (p=0.05). Bronch+ group had higher proportion of small cell and squamous cell carcinoma whereas Bronch- group had higher prevalence of adenocarcinoma (p=0.02). More patients in Bronch- underwent curative (36 vs 18, p=0.01) intent treatment. Though the median intervals (days) between the referral to first chest outpatient appointments were similar between the two groups (1 vs 1, p=0.89), the intervals from out-patient to decision-to-treat (33 vs 57, p=0.001) and decision-to-treat to treatment (8 vs 12, p=0.05) were significantly longer for Bronch- group. Overall the median referral to treatment interval for Bronch- was significantly longer compared to Bronch+ (45 vs 75, p=0.001). Most of these delays occurred in the intervals from outpatient appointments to decision-to-treat. Conclusions: A negative initial bronchoscopy in a suspected lung cancer patient implies a greater potential for excessive delays in diagnosis and treatment in spite of a greater chance of curative treatment. Most of the delay occurs in the interval from the outpatient appointment to decision-to-treat. Patients with negative bronchoscopy require a more concerted effort to achieve a timely diagnosis and treatment.     

A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment

OBJECTIVE: Guidelines for the urgent referral of patients with suspected colorectal cancer were introduced in 2000. They aimed to facilitate the prompt diagnosis and treatment of patients with symptoms suggestive of malignant disease. Recent assessment of these guidelines has suggested that although they identify 9-14% of patients with colorectal cancer, they may be used inappropriately and may lead to delays in treatment for those patients with cancers whose symptoms do not fit the guidelines. We aimed to assess the effect of introducing a single pathway for all referrals irrespective of indicated urgency. METHOD: All referral letters to a single consultant colorectal surgeon over a 6-month period were coded 'urgent' irrespective of the indicated urgency on the original referral letter. Data was collected prospectively on 47 patients diagnosed with colorectal cancer identified over the trial period. Patient demographics, the mode of presentation, urgency of referral and waiting times were documented. RESULTS: Following the introduction of the common urgent referral pathway, no patient waited longer than 62 days from referral to treatment or 31 days from the decision to treat to first treatment, thus meeting government targets introduced in 2005. CONCLUSION: The introduction of the urgent referral guidelines has accelerated the referral pathway for patients with symptoms suggestive of colorectal cancer, although this is at the expense of the majority of patients who present via conventional pathways. The introduction of a common urgent pathway allows prompt diagnosis and treatment and is of particular benefit for the majority of patients not referred via the 2-week standard. Until a more accurate method of identifying the highest risk patients is implemented, we suggest that all patients are seen on an urgent basis.     

The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services

Information was collected about 302 women referred for breast symptoms and seen in surgical outpatient or outreach clinics during one month at two hospitals in Sheffield. Three-quarters of the women (n = 244) were referred to specialist breast clinics, 22% (n = 70) were referred to general surgical clinics and 3% (n = 6) were referred to outreach clinics. The ages of the women ranged from 16 to 85 years with a mean and median age of 45 years. Some 200 women (66%) presented with a lump or lumpiness, 42 women (14%) presented with pain, 29 women (10%) had a skin and/or nipple problem, and the remaining 31 women (10%) were concerned about their family history or reported other symptoms. A total of 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer, 22 were over 40 years of age; 21 women presented with a lump, one presented with pain, and one presented with metastatic disease. The time required to reach a final clinical diagnosis varied from the same day as the clinic visit to 35 weeks, with a median time of 3 weeks. Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. The implications of the findings for the organisation of specialist outpatient clinics are discussed, and a categorisation of women as either urgent or routine cases is suggested.