Cancers found at breast screening: is the radiologist giving the surgeon all the information he needs in the referral letter?

Introduction

In our breast unit cancers detected at screening are assessed by the radiologist. A standard referral letter is then written to the breast surgeon, copied to the GP. This letter, in addition to being of use to the surgeon, is also a helpful record for the radiologist when the patient returns for localisation. It also may contain useful medical and social information. An audit of the referral letters was undertaken by the surgeons and radiologists to see if all the required information was present and if the surgeon required further details.

Methods

Thirty referral letters were audited for the standard information, including mammographic and ultrasound findings. In addition information not routinely given but wanted by the surgeon was documented.

Results

Sixteen of the letters did not have complete information. In ten of the letters the quadrant was not stated, in four axillary status was not documented and in four precise dimensions were not given. For 11 of the patients additional health or social information was provided, which the surgeons found useful. Supplementary information not given in the standard letter but wanted by the surgeon included lesion depth and distance from muscle and nipple.

Conclusion

The referral letters are important and a set format will encourage all the information to be included. We have changed our letter template accordingly and will re-audit.