Download April 2014 - Devon Sessional GPs

Minutes of the Exeter Sessional GPs Group
Darts Farm – 1 April 2014
The meeting was kindly sponsored by:
Linda Loveless
Pfizer
Jan Sparrow
Boehringer Ingelheim
Tracie Symonds
Bayer
Attendance:
25 members
Welcome:
Kathryn Shore opened the meeting and thanked the reps. Anna Beazley asked for a
show of hands as to how many of those present would be interested in a resuscitation
training session if the cost was around £50 per person (to cover a room hire and the
trainer’s fee). Only three people were interested so unless more express an interest
then this will not be viable.
Clinical meeting
Kathryn welcomed the speaker Dr Di Cameron, who was a GP at Exwick branch of St
Thomas for fourteen years before leaving general practice to work as breast physician
at RDE.
Breast Update - Dr Di Cameron – Breast physician RDE
Breast Team set up:
 Four surgeons – some with plastic surgery training
 Oncoplastic fellow
 Breast physician
 Seven breast care nurses
 Radiologists
 Also involved are many others including oncology, lymphoedema nurse,
physiotherapists.
Three gateways:
 Screening – half of breast cancer this route
 From secondary or tertiary care – e.g. genetics
 GP referrals
Cancer service is the bulk of the work
All patients are seen within two weeks, whether referred through the two week wait
pathway or not
Ratio of benign to malignant is rising and currently approximately 12:1
At the same time number of cancers treated is rising - 450 per year until 2011 but 600
per year in 2012 and 2013.
Hence workload is INCREASING.
Why more?
 Screening commencement age reduced from 50 to 47
 Over 70s being encouraged to continue with screening
 Incidence of breast cancer increasing – risk for women over lifetime is now
between 1:8 and 1:7
 It is a high profile illness
It is necessary to optimise resources – there is increased workload with no real
increase in resources. Ideally there would be a one stop clinic with clinical
examination, imaging and results all in one clinic on the same day. However
resources are not sufficient to do this for everyone so it is necessary to change
expectation. Some conditions only require reassurance.
Increase in breast cancer numbers due to:
 Increase in screen detected tumours
 Increase in real incidence – lifestyle reasons – increased weight of women and
increase in binge alcohol drinking
 Increasing age of population
Things not to miss:
 65% of breast cancer present as a lump
 Distortion of breast or nipple are common presentations
 Lobular breast cancer can be mammo occult
 Normal mammogram does not rule out breast cancer – refer if in doubt
 Inflammatory breast cancer – involves skin of whole breast with erythema but
unlike mastitis it is painless – important to refer
Nipple discharge – 5% of referrals and 95% are benign:
Benign:
 Induced
 Multiple ducts
 One or both breasts
 60% of non-lactating females have physiological discharge
Malignant:
 Spontaneous
 From one duct
 Blood stained or blood on testing – but <10% with blood are malignant
Nipple inversion:
 Benign – central, symmetrical, transverse slit
 Malignant – involes whole nipple, nipple distorted
Paget’s and eczema:
Pagets – eczemoid change of nipple with malignancy in breast, 1-2% of breast cancer,
starts on nipple, treated in same way as other breast cancers.
Eczema – starts on areola and rarely spreads to nipple, treat by removing aggravating
factors and apply topical steroid.
Periductal mastitis:
 Periareolar inflammation / abscess
 Age 18-48
 Purulent nipple discharge
 Usually anaerobes
 Associated with smoking
 Antibiotics – co-amoxiclav, erythromycin or metronidazole
 Surgery if not resolving
Duct ectasia:
 Slit like retraction
 Cheesy / toothpaste like discharge
 Age 42-85
 Usually sterile
Breast pain:
 Common reason for referral
 Rule out cancer
 Reassurance alone leads to resolution in 86% of mild and 52% of severe
mastalgia
 NBSP survey showed 69% of women had pain at some time and 3% sought
treatment for the pain
 Positive association with caffeine, smoking, stress
 Improves with the pill
 70% cyclical (late luteal), 20% non-cyclical and 10% extra mammary
 Ask women to lie in lateral position so breast falls away and can palpate for
chest wall tenderness – can manage with topical NSAID or inject local
anaesthetic with steroid
Mondors disease:
 Superficial phlebitis of lateral thoracic vein
 History of trauma or inflammation
 Palpable cord or linear skin dimpling present
 Use NSAID
Cyclical pain:
 Positive association with dietary fat
 Evening primrose oil has no effect – although some women swear by it
 Danazol is effective in 93% but has side effects
 Tamoxifen 10mg for 3 months then alternate days for 3 months is useful but
“off licence” for benign disease
 Alternative treatments – e.g. red clover
 Without a lump is rarely malignant so best to reassure without imaging –
sometimes expectations of women mean mammogram needed
Family history and NICE 2013:
 GP referral into family history clinics – a 4-5 month wait
 Guidelines for GP referral are unchanged since 2006
 It takes time to ask all the questions
 Refer if any uncertainties
 If patients do not fit criteria, they can be reassured their risk is near population
risk
 The unit is developing a pro forma questionnaire to let patients record their
family history
Initial assessment in primary care for people without a personal history of breast
cancer:
 When a person with no personal history of breast cancer presents with breast
symptoms or has concerns as relative has breast cancer, take a first and second
degree family history to assess risk, as this allows appropriate classification
and care.
 Attempt to gather information that is as accurate as possible on age of
diagnosis of any cancer in relatives, site of tumours, multiple cancers
(including bilateral disease) or Jewish ancestry.
 Offer referral to secondary care for breast cancer risk estimation if the patient
meets any of the following criteria:
1. One first degree female relative with breast cancer at < 40 yrs
2. One first degree male relative with breast cancer at any age
3. One first degree relative with bilateral breast cancer and the first cancer was
diagnosed at age <50
4. Two first degree or one first degree plus one second degree relative with
breast cancer at any age
5. One first degree or second degree relative with breast cancer at any age plus
one first degree or second degree relative with ovarian cancer at any age (one
of these should be a first degree relative)
6. Three first degree or second degree relatives on the same side of the family
with breast cancer at any age
7. If more than one relative is involved, they should be on the same side of the
family.
 Women who do not meet these criteria can be reassured that they are at near
population risk of getting breast cancer and do not require referral for specific
breast cancer risk estimation.
Housekeeping
Kathryn thanked Dr Cameron and reminded members to sign the attendance register.
Future ESGPG Meetings
6th May 2014 – Colorectal update, Miss Trish Boorman, Consultant Colorectal
Surgeon
3rd June 2014 – Functional Illness and Medically Unexplained Symptoms, Dr Jo
Bromley, Consultant Psychiatrist
1st July 2014 – Gastroenterology update, Dr Shyam Prassad, Consultant
Gastroenterologist
5th August 2014 - SUMMER SOCIAL EVENT – Details to follow
2nd September 2014 – The Movement Disorders Clinic Dr Sarah Jackson
7th October 2014 - Hospice Update Dr Becky Baines
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Megan James (chairman)
Dr Laura Davies (website co-ordinator)
Dr Lynne Reid (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
Dr Sarah Hemingway (funding co-ordinator)
Dr Anna Beazley (treasurer)
Dr Kathryn Shore (minutes’ secretary)
Dr Clair Homeyard (social secretary)
Dr Megan James (LMC link)
[email protected]
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