Search

Breast cancer is the most prevalent malignancy among Dutch women; life prevalence is about 10%. A tumour in the breast of a woman of 35 years or older is always an indication for mammography, while a woman younger than 35 should have an ultrasound investigation. This is also the case if the woman can feel the tumour but the doctor is unable to. In breast pain without palpable abnormalities at physical examination, the risk of breast cancer is a lot lower and diagnostics may not need to be instigated immediately. However, persistent localized pain is an indication for breast imaging. Women with at least a doubled risk of getting breast cancer due to the occurrence of breast cancer in their relatives are recommended to undergo mammography every year from the ages of 40-49 years supplementary to the national screening programme. The Dutch national screening programme invites women aged between 50 and 75 to undergo mammography every two years. Follow-up of women of 60 years and older treated by lumpectomy 5 years or more previously, can be done by the general practitioner.

Revised practice guideline 'Screening and diagnosis of breast cancer' The evidence-based revision of the practice guideline 'Screening and diagnosis of breast cancer' was necessitated by new insights, for instance on the cost-effectiveness of screening modalities other than mammography. Mammography is the only screening modality that is recommended for the general population. In the Netherlands, women from 50-75 years of age are invited for screening. However, in view of the ongoing increase in the incidence of breast cancer and of the image quality advantages of radiological digitalization, a study on the decrease of the lower age limit--preferably 45 years--is recommended. Screening with MRI is indicated for carriers of breast cancer gene mutations. Evaluation of risk factors has resulted in a rearrangement of screening recommendations, based on relative risks (RRs): screening apart from the population screening is only recommended in case the RRis 4 or more and in patients with a positive family history in case of a RR of 2 or more. Additional risks require further genetic evaluation. The 'Breast imaging reporting and data system' (BI-RADS) is now recommended for both screening and diagnostic imaging. Its application has had an impact on the triple diagnostic approach, which has now evolved into a consensus between surgeon, radiologist and pathologist. Axillary ultrasound should be carried out ifa sentinel node procedure is being considered. MRI should be included if the cancer cannot be reliably delineated on mammography or ultrasound. The increased complexity of the diagnostic work-up often means that the final diagnosis is not arrived within one day. Every effort should be made to achieve this goal within 5 working days. Ned Tijdschr Geneeskd. 2008;I52:2336-9

The general practitioner should encourage women aged 50-75 who are eligible for the national screening program for the early detection of breast cancer to participate. When any abnormalities are seen on the mammogram, the general practitioner should refer the woman for further investigations and inform her about the procedure to be followed. In the case of a lump, a mammogram or ultrasound examination of the breasts is indicated, unless the abnormality disappears during a different phase of the woman's menstrual cycle. Local pain and brown or bloody discharge from the nipples also necessitate further investigation. Women with a greater than 20% risk of ever developing breast cancer during their life based on a positive family history for breast cancer have an indication for periodic examination of the breasts and a mammogram before they are 50. If the risk is greater than 30%, consultation with a clinical geneticist can be suggested.

For healthy women, without malignancies in their personal histories, a positive family history for breast cancer is the single indication for individual breast surveillance outside the population screening. Management of women is based on individual risk assessment. A cumulative risk of 20% and more, as a result of a positive family history, will in practice be an indication for breast surveillance. This threshold is not evidence-based yet, nor are data available on the benefits of this surveillance efficacy. When a personal cumulative risk of more than 30% exists to develop breast cancer, a consultation with a clinical geneticist involved in a family cancer clinic should be offered. Surveillance of women with a high-risk cumulative risk should preferably be included in a prospective study design. Only in this way will data about compliance and the estimates of different ways of surveillance become available. There is no convincing evidence that population screening for women aged 40-49 years does lead to important mortality reduction in combination with a good balance between pros and cons for the women involved. Women in the age category 50-75 years, with breast cancer in their personal histories, who are not followed anymore, should be informed by their specialist about participating (again) in the population breast screening. There is no evidence of mortality reduction as a result of breast self-examination nor of palpation performed by a physician. However, awareness of the own body can be useful for early recognition of breast abnormalities; it may reduce the delay between the first recognizable symptom and the subsequently initiated therapy.

Objective: To determine which age-related disorders lend themselves for screening followed by intervention in general practice., Setting: Department of General Practice Medicine, University of Leiden., Design: Descriptive., Methods: This study concerned eight frequent age-related disorders: auditory and visual disorders, cognitive limitations, vertigo, incontinence, prostate symptoms, osteoarthritis and depressive symptoms. Four criteria (diagnostic possibilities, therapeutic possibilities, suitability of general practice for screening and intervention, the benefit of the programme to the elderly) were applied to selected literature (from Medicine and the electronic article files of the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) and of Huisarts en Wetenschap (GP and Science) to find out whether screening followed by intervention appeared useful., Results: With regard to three disorders (auditory and visual disorders and incontinence) it appeared possible to reduce the impairments caused by them, while in osteoarthritis, screening and intervention might lead to better mobility., Conclusion: With reference to recent literature, it appears theoretically possible to reduce the impairments caused by auditory and visual disorders, incontinence and osteoarthritis.

Osteoarthritis is a common disease of the cartilage in a joint for which the general practitioner (GP) is frequently consulted. In this contribution the current policy of GPs is described with respect to patients with peripheral osteoarthritis. For this purpose, the medical records of 196 patients from 14 Dutch general practitioners were studied with regard to the GPs management, and the GPs were interviewed about their management. Also, the burden of osteoarthritis was assessed in terms of quality of life for 198 patients. Moreover, the effects of two nonsteroidal treatments (nabumetone versus piroxicam) were studied in 198 patients. GPs management is heterogeneous. The results of the interviews supported this finding. The quality of life of patients with osteoarthritis was significantly reduced in several areas of daily living. After treatment with nonsteroidals the patients' status improved, according to both the GPs and the patients. The GPs and the patients' perspective on change correlated weakly. In future research, it would be interesting to explore these two perspectives.

A limited analysis of the data of the continuous health enquiry of the Central Statistics Office regarding forms of physical impairment of the non-institutionalized Dutch population and of some data on physical ability of nursing home patients, carried out in 1991 by the Health Care Information Centre Foundation, confirmed the supposition that the risk of unwanted urine loss is substantially higher in patients with disability with respect to locomotion, changing posture, purposeful action, communication and condition. This proved to be the case at all ages, in both sexes, and in those living alone and together with others. Further investigation is necessary to determine the connection of these various forms of impairment with each other and with involuntary urine loss, with a view to promoting efficient diagnostic and therapeutic coping with involuntary urine loss; special attention should be paid to the question to what extent the disorders and limitations contribute to the actual handicap.