Referral Pathways: Waiting. Waiting. Waiting…


A referral pathway is the path a patient has to walk, step by step, in the process of moving through breast cancer. It is intended to ensure that the outcomes of diagnosis and treatment are as proactive and positive an experience for the patient as possible. The referral pathway is also set in place to secure service equality at all levels.

PUBLIC SECTOR: In the public sector this normally means that a patient will start their journey at a primary health care facility in the community from where the patient is referred (via a letter of referral) by a health professional for follow-up to a Secondary Hospital. Once a diagnois is made by doing a mammogram, ultrasound and a biopsy, a patient will then be referred to a  Tertiary Hospital where the ‘staging’ of the illness will be done via additional tests such as a lung X-ray, liver scan and  bone density test. These tests will help develop the appropriate treatment plan if applicable.

STATE SECTOR: Things are, however, different in South Africa’s state sector where the same process as above can literally take entire months to be processes. Result? By the time the patient reaches the tertiary hospital, the illness has progressed to a later stage.

referral pathways breast cancer advocates for breast cancer


We are privileged to have a few truly effective walk-in breast clinics in our country – such as the ones at Cape Town’s Groote Schuur Hospital and at Johannesburg General Hospital where patients can go straight to the specialised breast clinic, where all the above-outlined steps are done in a very efficient manner. We need many more of these cancer screening clinics that will expedite prompt diagnosis and work-up to ensure that effective treatment is provided — sooner rather than too late!


“Stage at Breast Cancer Diagnosis & Distance from Diagnostic Hospital in a Periurban Setting: a South African Public Hospital Case Series of Over 1000 Women.” ~ via the National Centre for Biotechnology Information


Compared to the state sector, the private sector’s referral pathway is markedly simpler and shorter, making access to breast cancer diagnosis and treatment easier and more efficient. Your journey could look like this:



Day -4 Referred by GP
Day 0 Seen in clinic. Assessment by surgical team, X-Ray and histopathologist
Day 1 The Multi Disciplinary Team (MDT) co-ordinator collates the information on all patients who have abnormal results from the clinic – then guides and drives the rest of the pathway communication regularly with the patient and the rest of the team
Day 3-7 Discussion at the MDT meeting: the whole team meets to discuss the results for patients and concur on a patient treatment plan. (Treatment plans vary from patient to patient.)
Day 9+ Pre-operative assessment with pre-assessment nurse and the breast care nurse if mastectomy is necessary.

Pre-planning for radiotherapy if adjuvant therapy is applicable

Pre-planning with oncologist for chemotherapy if adjuvant therapy is applicable

Day 14 Surgery/chemo therapy/radiation therapy starts and continues as required for breast cancer standardised treatment guidelines.
Day 15+ Discharge if operated
Day 17+ Re-discussion at MDT meeting to plan further treatment if necessary after surgery
Day 18 – 21+ Seen at clinic with final and full results of surgery
Next Phase Start of further therapy

Hormone therapy



Follow-up with Oncologist Usually 6 – 12 months for up to 5 years



In the absence of a breast health policy in South Africa, the time linked to a referral pathway is dependant on where you live, how soon you can be referred to the facility which will then confirm the diagnosis and the actual waiting times between screening, diagnosis and ultimately, treatment.


The driving aim of a BREAST HEALTH POLICY is to ensure that each and every single person in our country has equitable and accessible access to effective and efficient breast health services.  This is a basic health right! It is a right we all havedeserve and must insist on as South African citizens and human beings!

Make the difference only YOU can make by Liking our Facebook page or joining this critical conversation on Twitter! Share our FB posts and email off our blog articles to those you know care! This is how you can stand with us to adamantly ensure this policy is drafted and implemented timeously to save the lives of thousands of women in South Africa!


We Need Trained Health Professionals!

Mammography, ultrasounds, genetic testing… Lifestyles of the rich and the famous? Well, at least that is how many people living in South Africa feel.

Some people do not even know what a mammogram is. But is this important? Should every woman be going for screening? Why is it that in a country where imaging and treatment is available do women still present with late stage cancer?

The answer is that basic breast self-examinations (carried out by oneself) and clinical breast examinations (performed by a trained health care professional) are not actually being carried out. Yes, mammograms are relevant in certain cases, as are ultrasounds, genetic testing and various other tests and screening – but in our country it is not the answer for the millions of women that have no easy access or funding to go for these tests. Breast self-examination and clinical breast examinations are the number one “tests” that need to be carried out.

It is vitally important that if a woman finds a new lump in her breast, that she goes for a clinical breast examination. Many women in South Africa do not have access to health care facilities like hospitals as the hospitals are often very far from where the people live (and therefore expensive to travel to)  and are also often back-logged with patients. The first point of care for the majority of women in South Africa would be a clinic where a primary health care nurse would assess them.

Breast Course for Nurses - Dr Jenny Edge

The Breast Course for Nurses – one of the partner organisations that make up the Advocates for Breast Cancer –  aims to equip primary health care nurses with the knowledge to perform clinical breast examinations and to know the differences between the normal changes to the breast and changes that need to be referred. The Breast Course for Nurses was started by Dr Jenny Edge, a general surgeon from Cape Town with a special interest in breast conditions. Dr Jenny Edge and Professor David Woods, a retired neonatologist (of the PEP foundation), wrote the Breast Care book which the course is based on. (Click here to equip yourself with a copy!)

To date, courses have been completed in Cape Town, Johannesburg and Durban with courses currently running in Cape Town and Port Elizabeth. We are so excited to see what an impact this course is making! Look at the photos taken at the courses across the country here.

The Breast Course for Nurses focuses on the following topics:

  • the normal breast
  • clinical assessment of the breast
  • special investigations of the breast
  • benign changes of the breast
  • cancer of the breast
  • treatment of breast cancer
  • side effects of breast cancer treatment
  • palliative care
  • community outreach programmes

The course starts with a one day session where the first two  modules of the book are discussed. It then consists of six  months of distance learning with multiple choice questions (MCQ’s) for each module that need to be completed. The course then ends with a two day residential course where the remaining modules are discussed, wound care and palliative care are addressed and networking takes place. Practical sessions about biopsy techniques and lymphoedema therapy are carried out.

Although the core content of the course remains the same, both the input and practical sessions differ regionally depending on the needs of the nurses. The emphasis of the course is on learning rather than teaching and is primarily aimed at equipping nurses with the skills and knowledge to manage women with breast problems.

The World Health Organisation predicts that the mortality due to non-communicable diseases in the developing world will increase by 17% in the next 10 years. This will have a major impact on an already overburdened system.

Primary health care nurses will remain the first point of contact for many women as time goes on. The Breast Course for Nurses aims to educate these primary health care nurses so the correct clinical examinations can be carried out and an efficient referral system can be implemented.

breast course

Conquer Cancer with Coordinated Care!

What does it mean to ‘coordinate care’?

Until about 15 years ago, there was a very strict division between the GP and the specialist. It was a division that the patients recognised; you knew that if you wanted to see a specialist, you would need to be referred by your GP. Now that strict division seems to have fallen away. As more people gain access to the internet, many start “diagnosing” their own conditions and deciding for themselves when specialist help is needed.

A system of proper coordination of healthcare will ensure the best possible outcome for the patients and the healthcare providers (doctors, nurses and specialists) — all helping to manage costs.

Nowhere is this more needed than in the area of chronic diseases, of which breast cancer is one. Research by the World Health Organisation (WHO) suggests that the global burden of chronic disease will boom from 27% of the total cost of healthcare to 43% in the next two decades!

The WHO points out that positive outcomes for chronic conditions are achieved only when patients and families, community partners, and health care teams are informed, motivated, prepared, and working together.

Advocates for Breast Cancer is lobbying for an effective and appropriate referral system for breast health. This referral system could take the form of five steps in the management of breast cancer:

Coordinated Cancer Care