One-stop diagnostic breast clinics: how often are breast cancers missed?

The aim of this study was to estimate the number of patients discharged from a symptomatic breast clinic who subsequently develop breast cancer and to determine how many of these cancers had been ‘missed' at initial assessment. Over a 3-year period, 7004 patients were discharged with a nonmalignant diagnosis. Twenty-nine patients were subsequently diagnosed with breast cancer over the next 36 months. This equates to a symptomatic ‘interval' cancer rate of 4.1 per 1000 women in the 36 months after initial assessment (0.9 per 1000 women within 12 months, 2.6 per 1000 women within 24 months). The lowest sensitivity of initial assessment was seen in patients of 40–49 years of age, and these patients present the greatest imaging and diagnostic challenge. Following multidisciplinary review, a consensus was reached on whether a cancer had been missed or not. No delay occurred in 10 patients (35%) and probably no delay in 7 patients (24%). Possible delay occurred in three patients (10%) and definite delay in diagnosis (i.e., a ‘missed' cancer) occurred in only nine patients (31%). The overall diagnostic accuracy of ‘triple' assessment is 99.6% and the ‘missed' cancer rate is 1.7 per 1000 women discharged

Measuring the accuracy of diagnostic imaging in symptomatic breast patients : team and individual performance

Objective: The combination of mammography and/or ultrasound remains the mainstay in current breast cancer diagnosis. The aims of this study were to evaluate the reliability of standard breast imaging and individual radiologist performance and to explore ways that this can be improved. Methods: A total of 16 603 separate assessment episodes were undertaken on 13 958 patients referred to a specialist symptomatic breast clinic over a 6 year period. Each mammogram and ultrasound was reported prospectively using a five-point reporting scale and compared with final outcome. Results: Mammographic sensitivity, specificity and receiver operating curve (ROC) area were 66.6%, 99.7% and 0.83, respectively. The sensitivity of mammography improved dramatically from 47.6 to 86.7% with increasing age. Overall ultrasound sensitivity, specificity and ROC area was 82.0%, 99.3% and 0.91, respectively. The sensitivity of ultrasound also improved dramatically with increasing age from 66.7 to 97.1%. Breast density also had a profound effect on imaging performance, with mammographic sensitivity falling from 90.1 to 45.9% and ultrasound sensitivity reducing from 95.2 to 72.0% with increasing breast density. Conclusion: The sensitivity ranges widely between radiologists (53.1–74.1% for mammography and 67.1–87.0% for ultrasound). Reporting sensitivity was strongly correlated with radiologist experience. Those radiologists with less experience (and lower sensitivity) were relatively more likely to report a cancer as indeterminate/uncertain. To improve radiology reporting performance, the sensitivity of cancer reporting should be closely monitored; there should be regular feedback from needle biopsy results and discussion of reporting classification with colleagues

The dilemma of Brexit: hard choices in the narrow context of British foreign policy traditions

Brexit threatens to disrupt the fabric of British foreign policy thinking. For decades, policymakers identified membership of the European Community as one of two pillars of British influence (the other being the ‘Special Relationship’ with the United States). Together, they allowed Britain to exercise power on a global as well as regional scale. These assumptions were repeated so often that the UK was regularly criticised for lacking policy imagination and avoiding hard choices when the interests of Europe and the United States conflicted. Brexit presents an unavoidable dilemma for policymakers as they chart a new course for British foreign policy. Interpretivism, as set out by Bevir and Rhodes (2003), offers a route to understanding how actors interpret and respond to such dilemmas, via reference to traditions. This article uses their approach to examine the expression of beliefs about Brexit and British foreign policy. In particular, it focuses on two datasets, one a ‘control sample’ of commentary since 2016, the other, the parliamentary debates on the first EU Withdrawal Bill in December 2018 and January 2019. We find a contrasting willingness to evoke traditions in a substantive fashion to understand and justify political choices. In particular, parliamentarians utilise one particular tradition, pragmatism, to marginalise the expression of abstract belief. In the process, they reduce discussion to a technocratic exercise that is unable to manage the conflicts Brexit has brought about. Meanwhile, those MPs that are most creative in their expression of traditions tend to be from smaller regional parties or on the political periphery. The resulting deadlock is evidence of the importance of traditions to interpreting and managing dilemmas of social change

Place-Based Leadership and Public Service Innovation

This article discusses two matters that are becoming increasingly important in debates about local government: place-based leadership and public service innovation. The troubling international economic outlook means that many local authorities are focusing on 'efficiency savings' and the prevailing mantra in public policy circles is 'do more with less'. This article questions this approach. It aims to contribute to what one chief executive described to us as 'more with more' thinking. This approach strives to release the community and business energies of a locality. If this can be achieved the total resources available to improve the local quality of life can be increased, even if state spending is shrinking. A conceptual framework for studying place-based leadership is presented. This distinguishes three, overlapping realms of leadership in any given locality - political leadership, managerial/professional leadership, and community and business leadership. It is argued that the areas of overlap between these realms can be viewed as innovation zones - spaces in which established approaches can be questioned and new trajectories developed. These zones can, however, also become conflict zones with little learning and exchange taking place. Place-based leadership can influence whether such political spaces are used to promote creative problem solving or whether they become arenas for dispute and friction between sectional perspectives. By drawing on a study of the current Digital+Green initiative in Bristol, UK, the article suggests that an imaginative approach to place-based leadership - one that accepts intelligent risk taking - offers potential for improving the local quality of life as well as strengthening local democracy. © 2013 Copyright Taylor and Francis Group, LLC