title: Risk of breast cancer in symptomatic women in primary care: a case-control study using electronic records.
abstract: BACKGROUND
  Breast cancer is the most common cancer in the UK. GPs are encouraged to refer all women whose symptoms may represent cancer, rather than selecting those at highest risk.
  
  
  OBJECTIVE
  To identify and quantify features of breast cancer in primary care.
  
  
  METHODS
  A UK case-control study using the Clinical Practice Research Database (CPRD).
  
  
  METHODS
  Possible features of breast cancer were identified in the year before diagnosis, and odds ratios calculated using conditional logistic regression. Positive predictive values (PPVs) were estimated for consulting women.
  
  
  RESULTS
  A total of 3994 women aged ≥40 years with breast cancer between 2000 and 2009, and 16 873 age-, sex-, and practice-matched controls were studied. Median age at diagnosis was 63 years (interquartile range 55-74 years). Four features were significantly associated with breast cancer: breast lump (odds ratio [OR] 110; 95% confidence interval [CI] = I88 to 150), breast pain (OR = 4.2; 95% CI = 3.0 to 6.0), nipple retraction (OR = 26; 95% CI = 10 to 64), nipple discharge (OR = 19; 95% CI = 8.6 to 41): all P-values <0.01. In the year before diagnosis, 1762 (44%) of cases had a breast lump compared with 132 (0.8%) controls. The PPV of breast cancer with a breast lump was 4.8% in women aged 40-49 years, rising to 48% in women aged >70 years. PPVs were lower in women who also reported breast pain.
  
  
  CONCLUSIONS
  Generally, the figures support current referral practice. However, the low likelihood of cancer for all the non-lump symptoms means that the current guidance recommends investigation for possible cancer at a more liberal risk threshold than for other cancers. Although supported by patients, this may not meet current NHS criteria for cost-benefit.
authors.affiliation: University of Exeter Medical School, Exeter.
authors.forename: Sarah
authors.initials: S
authors.lastname: Walker
authors.affiliation: University of Exeter Medical School, Exeter.
authors.forename: Chris
authors.initials: C
authors.lastname: Hyde
authors.affiliation: University of Exeter Medical School, Exeter.
authors.forename: William
authors.initials: W
authors.lastname: Hamilton
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D016022:Case-Control Studies; D055088:Early Detection of Cancer; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D058006:General Practice; D006801:Humans; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D011320:Primary Health Care; D012017:Referral and Consultation / Q000458:organization & administration*; D018570:Risk Assessment; D006113:United Kingdom / Q000453:epidemiology
keywords: breast cancer; diagnosis; primary health care