A study led by the University of Cambridge and the Institute of Cancer Research, London, has found that 95% of women under 50 in England who later develop breast cancer are not identified by the guidelines that family doctors use when deciding whether to refer patients for further checks. The findings, released on 4 August, have prompted calls for the National Institute for Health and Care Excellence (Nice) to review the criteria that underpin GP referrals.
The Nice criteria are intended to help GPs judge which women may be at increased risk and should be offered specialist breast cancer risk assessment and care. According to the research, the current guidance fails to pick up almost all women in this age group who go on to receive a breast cancer diagnosis within the next ten years. Only around 5% of those later diagnosed with the disease would have been identified under the existing rules.
The researchers said this meant the vast majority of younger women who develop breast cancer were not being referred for early tests or preventive treatment at a stage when intervention might have made a significant difference. The findings suggest that the problem lies in the design of the referral rules rather than in the decisions made by GPs, who are expected to apply the guidance as set out by Nice.
In England, GPs are the gatekeepers to most specialist services, and for younger women a referral for breast cancer assessment is usually the only route into more detailed checks. The research is therefore likely to renew discussion about whether the official guidance has kept pace with scientific understanding of the disease and which women are most likely to be affected.
As part of their analysis, the researchers examined the health records of women under 50 who developed breast cancer over a ten-year period and compared that group with the predictions generated by the Nice criteria. The comparison showed a substantial mismatch between the number of women the rules would have flagged for referral and the number who actually went on to receive a diagnosis.
The findings are particularly significant because breast cancer is a disease where timing matters. Detecting a tumour early is widely recognised as one of the most effective ways of improving outcomes, and the authors argue that the failure to identify younger women in time could damage their treatment options. The study suggests that many younger women are currently missing that opportunity because they are not identified as being at risk early enough.
The study will add weight to calls for Nice to examine whether its guidance reflects the most up-to-date evidence on breast cancer risk. Authors of the research argue that refining the criteria could improve the chances of identifying younger women who need specialist care, and that a formal review is needed to prevent similar gaps from continuing. The research is likely to be central to that review as clinicians and policymakers assess whether the current system of GP referrals in England is fit for purpose.
