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Primary Care Physicians, Advocates and Referrals

Women who have yearly physical examinations typically have a clinical breast exam at that time. Often, the primary care physician is the one to detect the mass on physical exam or is the one to order a mammogram when a woman is concerned about an area they found during self-examination. The primary care physician must be able to perform a breast examination and correlate those with a patient’s risk factors for breast cancer. 1

Primary care physicians, also called general practitioners or family physicians, are often the ones to initiate the process that leads to a diagnosis. They often have a number of additional resources that can readily be accessed, including specific medical tests, further examinations or referral to specialists. 2

There are several pitfalls primary care physicians may face that can lead to a failure in making a diagnosis of breast cancer. According to a presentation provided for primary care physicians by the American Cancer Society, the major pitfalls include:

  • Inability to detect a lump or mass in the breast during a physical examination
  • Lump detected by physical examination but absent on a mammogram
  • Lump not detected by physical examination but present on a mammogram
  • Lump detected on a scheduled mammogram with no follow up for a physical examination
  • Failure to provide referral options for a patient with a positive physical examination and mammogram
  • Incorrect screening exam or failure to follow accepted screening guidelines 3

Primary care physicians are less comfortable when dealing with young females or men that may have breast cancer, than when they are working with older women. This may result in fewer diagnoses being made at early stages in these two sub-populations.

Referrals to a Specialist

The decision to refer a patient to a specialist is typically done while consulting with the patient. In general, the majority of breast cancer patients are initially referred to a surgeon or an oncologist. Of those who saw a surgeon prior to an oncologist, the surgeon referred the patient to an oncologist over 87% of the time.

The same study, which interviewed 170 surgeons who covered 244 cases of breast cancer, found that surgeons tend to make fewer referrals to an oncologist when the patient was node negative, unemployed, or elderly. Patients who had a great prognosis often preferred not to see an oncologist at all and were subsequently not offered a referral. 4

Other factors may also play into which patients are offered a referral and which patients actually seek care from a specialist. Some research focuses on socioeconomic status as a risk factor, in that those with a lower status are less likely to obtain a referral. Highest level of education may also be a factor in the ability of the patient to understand the benefit of seeing an oncologist. Furthermore, there could simply be a lack of communication and advocacy for the patient, causing patients to be lost to follow-up. 5

Patients As Self-Advocates

Breast cancer patients have the ability to be a self-advocate, asking for referrals to oncologists, second opinions and to see pain management specialists when needed. Breast cancer treatment regimens and technology have changed over the past decade and what is offered at one facility may not be offered at another. Without the courage to speak-up and ask for a referral, there may be treatment options that the patient does not know about and may make a difference in their particular case.

Patients who are uncomfortable speaking-up as their own advocate may be able to take advantage of patient advocates offered by some institutions. These individuals may work directly in the hospital or clinic and are often social workers, mental health professionals or simply volunteers. Ask if a patient advocate is available or contact a local breast cancer survivor group/educational agency to see if they can provide resources for an advocate nearest you.

Recommendations for or Referral to a Clinical Trial

Doctors can recommend patients or refer patients with an unresectable or otherwise untreatable breast cancer to clinical trials that are using experimental cancer drugs or treatments. Clinical trials are often at very low or no cost to the patient. Interestingly, patients that were actively involved in making decisions about their treatment were eight times more likely to be referred to a clinical trial and participate in research than those that were not. In addition, research also found that the key factors impacting a patient’s decision to join a clinical trial were the surgeon’s or oncologist’s explanation of the trial process and their perceived confidence about the treatments being tested.6

References

1 Avery, D. M. (2010). A Family Physician’s Role in the Prevention, Diagnosis, and Management of Breast Cancer. American Journal of Clinical Medicine , 76-79.

2 Hjortdahl, P., & Borchgrevink, C. F. (1991). Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. 1181-4.

3 Screening & Diagnosis of Breast Cancer For Primary Care Physicians. (n.d.). Retrieved from National Cancer Institute: rtips.cancer.gov/rtips/viewProduct.do?viewMode=product&productId=11995

4 Siminoff, L., Zhang, A., & al, e. (2000). Referral of breast cancer patients to medical oncologists after initial surgical management. Med Care , 696-704.

5 Dunlop, S., Coyte, P., & McIsaac, W. (2000). ocio-economic status and the utilisation of physicians’ services: Results from the Canadian National Population Health Survey. Soc Sci Med , 123-133.

6 Siminoff, L., Zhang, A., Colabianchi, N., et al. (2000). Factors That Predict the Referral of Breast Cancer Patients Onto Clinical Trials by Their Surgeons and Medical Oncologists . Journal Of Clinical Oncology , 1203-1211.

This article was originally published on July 27,2012 and last revision and update of it was 9/2/2015.