Family history: a comprehensive genetic risk assessment method for the chronic conditions of adulthood

Motivation for health screening: evaluation of social influence among Mexican-American adults

BACKGROUND

Americans of Mexican origin are at high risk for developing cardiovascular disease.

PURPOSE

This study aimed to evaluate the associations between the presence of social network members who encourage screening and individuals' motivation to undergo three types of health screening: blood cholesterol, blood pressure, and blood glucose. The distinct roles of encouragers from different generations (older, same, and younger) were evaluated.

METHODS

Adults of Mexican origin (N=452) aged 20-75 years from 162 households in Houston TX were included in this cross-sectional study by completing surveys in 2008 regarding their intentions to screen, health behaviors, illness beliefs, social networks, and family health history in either English or Spanish. Data were analyzed in 2009.

RESULTS

About one third of the participants reported having at least one same-generation network member who encouraged screening; smaller proportions reported having at least one older- (17% to 19%) and one younger-generation (11% to 12%) encourager. The presence of at least one older-generation encourager was associated with higher levels of intention to screen for all three screenings controlling for sociodemographic characteristics and illness beliefs. Having at least one same-generation encourager was associated with higher levels of intention to screen for blood cholesterol.

CONCLUSIONS

Social influence may play an important role in motivating individuals to engage in screenings. Network-based intervention involving older individuals to provide encouragement to younger network members should be explored as a means to increase motivation to screen among this population.

Obtaining the family history for common, multifactorial diseases by family physicians. A descriptive systematic review

OBJECTIVE

To summarize the knowledge on the use of comprehensive family history taking for common, multifactorial diseases in primary health care.

DESIGN AND DATA SOURCES

Systematic review of MEDLINE (1966-2008), EMBASE (1986-2008) and Cochrane Library.

METHODS

Search terms reflected 'primary care', 'family history' and 'genetics'. Included were original studies, published in the English language, from a primary care setting, investigating family history taking for multifactorial disorders. Methodological criteria (design, size, response rate) were not used to exclude papers. Out of 116 potentially eligible papers, 27 papers were selected: nine studies on opinions, eight studies on actual practice, seven studies on family history tools, and three studies on the patient perspective. Two authors independently extracted the data, and consequently discussed and summarized them. Given the heterogeneity of the studies, outcomes were presented in a qualitative way.

RESULTS

Among family physicians, the general opinion was that taking a family history is the task of the primary care physician. However, observational studies of consultations and analyses of medical records showed wide variability and low regular updating. There are no family history tools yet, that are sufficiently feasible and reproducible. Patients and doctors may perceive a positive family history differently, which may cause miscommunication.

CONCLUSION

There is a need for research into feasible and high quality tools for detailed family history taking for multifactorial disorders.

Familial melanoma: a meta-analysis and estimates of attributable fraction

Melanoma commonly clusters in families, and the recent identification of numerous genotypes predicting higher risks of melanoma has led to the widespread perception that this cancer is predominantly a genetic disease. We conducted a systematic review of the literature and meta-analysis to quantify the contribution of familial factors to melanoma, estimated by the population attributable fraction (PAF). Eligible studies were those that permitted quantitative assessment of the association between histologically confirmed melanoma and family history of the disease; we identified 22 such studies using citation databases, followed by manual review of retrieved references. We calculated summary RRs using weighted averages of the log RR, taking into account random effects, and used these to estimate the PAF. Overall, family history was associated with a significant 2-fold increased risk of melanoma (odds ratio, 2.06; 95% confidence interval, 1.72-2.45); however, there was significant heterogeneity (P = 0.01). The pooled estimate for population-based studies (n = 11) was 2.03 (1.70-2.43), and 2.51 (1.55-4.07) for clinic/hospital-based studies (n = 11), both with significant heterogeneity (P = 0.049 and P = 0.013, respectively). Two studies used record linkage to verify family history in relatives; the pooled risk estimate from these two studies was 2.52 (2.11-3.00) with no evidence of heterogeneity (P = 0.258). Estimates of PAF associated with a positive family history ranged from 0.007 for Northern Europe to 0.064 for Australia (0.040 for all regions combined). Our findings suggest that only a small percentage of melanoma cases (always <7%) are attributable to familial risk; the majority of melanomas are presumably attributable to other factors.

A family history of diabetes mellitus is associated with poor glycemic control and increased metabolic risks among people with diabetes: data from the National Health and Nutrition Examination Survey 1999-2004

BACKGROUND

Several lines of evidence from studies involving both general and non-diabetic populations have shown that a family history of diabetes was associated with an increased risk for cardiovascular diseases and metabolic alterations. However, little is known about the relationship of a family history of diabetes to glycemic control and metabolic risks among people with diabetes.

METHODS

We conducted a cross-section study of 946 diabetic adults from the National Health and Nutrition Examination Survey between 1999 and 2004. Familial risk of diabetes was classified as average, moderate, or high. Logistic regression analyses were conducted to determine the association between familial risk of diabetes and poor glycemic control, as defined by A1C > or = 8%. According to stratified levels of familial risk of diabetes, adjusted means of various metabolic risks, including A1C, BMI, lipid profiles, and C-reactive protein, were obtained by using multiple linear regression.

RESULTS

Independent of basic demographics, health-related behaviors, use of anti-diabetic medications, diabetes duration, cardiovascular co-morbidities, and various metabolic risks, the odds ratio of poor glycemic control comparing participants with a high familial risk of diabetes to those with an average risk was 1.91 (95% confidence interval 1.02-3.58). In the multivariate analysis, the adjusted means of A1C in participants with high, moderate, and averaged familial risk of diabetes were 7.75%, 7.45%, and 7.25%, respectively (p for trend 0.036). Participants with a high familial risk of diabetes also had higher triglycerides and body mass index (p for trend 0.042 and 0.02, respectively).

CONCLUSION

Diabetic adults with a higher familial risk of diabetes have a worse glycemic control, higher BMI, and higher triglycerides. Obtaining family history of the disease is crucial in identifying and targeting high risk diabetic patients who may require more stringent lifestyle changes as well as pharmaceutical intervention.

Educating underserved Latino communities about family health history using lay health advisors

BACKGROUND

Family health history (FHH) is a tool used to inform individuals about inherited disease risk. Due to their disproportionate morbidity and mortality from some common chronic diseases, U.S. Latinos are an important audience for FHH information. This study examined the effects of a culturally-tailored intervention led by lay health advisors (LHAs) in delivering information about FHH on participants' intentions, self-efficacy, and conceptual knowledge.

METHODS

474 Spanish-speaking Latino participants were enrolled in the study. Individuals in the intervention group participated in a single group educational session using discussion and interactive activities to build skills for discussing FHH with one's family members and doctor, while individuals in the comparison group had a brochure read aloud to them. Pre- and post-test questionnaires were verbally administered.

RESULTS

Primary dependent variables were intentions and self-efficacy to discuss FHH with family members and doctors; these increased in both groups. Multivariate analyses demonstrated that the intervention led to a significantly greater increase in self-efficacy to discuss FHH with family members (p = 0.03). LHA participants were also more than twice as likely (OR = 2.6, 95% CI = 1.3-5.0) to correctly understand the purpose of a FHH and found FHH information more useful (p < 0.0001).

CONCLUSIONS

A communication intervention delivered by LHAs shows promise as an effective means of educating underserved Spanish-speaking Latinos about the importance of FHH for disease prevention. Such community-based approaches can help to close knowledge and skills gaps about FHH and increase confidence in using this information to improve the health of those most at risk.

Primary care providers' responses to patient-generated family history

Family health history is one of the best predictors of an individual's risk for common disease, yet it is underutilized in routine care. Although the Surgeon General has recommended consumers record their family health history and share it with their health care provider, providers' perceptions of patient-generated family histories are unknown. To learn more about providers' experience with and perceptions about patient-generated family histories, we mailed surveys to 301 providers and had a response rate of 24% (n = 68). Seventy-three percent felt a patient-generated computer pedigree would improve their ability to assess risk as compared to their current methods. Seventy percent felt a patient-generated computer pedigree would either have no effect on or would increase the number of patients that could be seen in a day. Results suggest that providers appreciate the potential benefits of patient-generated family histories. Genetic counselors and nurses are in a prime position to promote and facilitate the use of patient-generated family health histories in routine care.

Decisions to seek healthcare based on family health history among urban Appalachian women

Family health history (FHH) is a valuable health promotion tool that can be used to assess disease risk and make lifestyle and screening recommendations. However, few FHH resources exist for medically underserved populations such as the urban Appalachian community in Cincinnati Ohio. Women of Appalachian heritage with less than a college education who did and did not participate in a prior FHH education session were interviewed by phone in a semi-structured format. Interviewees were asked to discuss their understanding of FHH and the role FHH played in seeking (or not seeking) medical care. Analysis of their discussion identified four overarching themes as well as a model identifying conditions that facilitated or impeded the choice to seek medical care based on FHH. Findings from this study may be used to develop targeted FHH educational interventions in the urban Appalachian and other communities.

Racial differences in the interaction between family history and risk factors associated with diabetes in the National Health and Nutritional Examination Survey, 1999-2004

PURPOSE

We sought to determine whether the association between family history, a surrogate for genetic predisposition, and diabetes was modified by any known diabetes risk factors and if these relationships were constant across different ethnic groups.

METHODS

We examined 10,899 adults from the National Health and Nutrition Examination Survey (1999 -2004) to identify interactions between family history and clinical, demographic, and lifestyle variables for the outcome of diabetes using logistic regression analysis in racial/ethnic subgroups.

RESULTS

There was significant heterogeneity by race/ethnicity in the interaction between covariates and family history in relation to diabetes. In black (P = 0.0001) and Hispanic (P = 0.013), but not white (P = 0.75) subgroups, high-familial risk was a strong risk factor for diabetes among lean individuals but less so among overweight or obese subjects.Among blacks, high-familial risk conferred a 20-fold increased odds of diabetes among lean subjects and only a sixfold increased odds among obese individuals.

CONCLUSIONS

These findings suggest possible race/ethnic-specific differences in gene by environment interaction and identify body mass index as an important effect modifier of familial risk in diabetes in non-white populations. These findings may help guide future genetic studies and improve the utility of family history as a public health screening tool.

The association between family history of asthma and the prevalence of asthma among US adults: National Health and Nutrition Examination Survey, 1999-2004

PURPOSE

To assess the overall prevalence of asthma and the association between family history of asthma and the prevalence of asthma among US adults.

METHODS

We analyzed National Health and Nutrition Examination Survey data from 1999 to 2004 for 15,008 respondents aged 20 years or older with no history of emphysema. We divided respondents into three familial risk groups (high, moderate, and average) on the basis of the number and closeness of relatives, that they reported as having asthma and then assessed the asthma prevalence in each. We also assessed associations between asthma prevalence and age, sex, race/ethnicity, income, body mass index, smoking status, household smoking exposure, and physical activity.

RESULTS

By our definitions, 2.3% of respondents were at high, 13.0% at moderate, and 84.7% at average familial risk for asthma. The crude prevalence of self-reported lifetime asthma was 11.5% (95% confidence interval [CI]: 10.7-12.3%) among all respondents, and 37.6% (95% CI: 30.4-45.4%), 20.4% (95% CI: 18.2-22.7%), and 9.4% (95% CI: 8.7-10.2%) among those at high, moderate, and average familial risk, respectively. Among all risk factors we looked at, family history had the strongest association with lifetime asthma prevalence, and the association remained significant after adjustments for other risk factors. Compared with average familial risk, the adjusted odds ratios for lifetime asthma were 2.4 (95% CI: 2.0 -2.8) for moderate and 4.8 (95% CI: 3.5-6.7) for high familial risk.

CONCLUSION

Our findings showed that a family history of asthma is an important risk factor for asthma and that familial risk assessments can help identify people at highest risk for developing asthma. Additional research is needed to assess how health care professionals can use family history information in the early detection and management of asthma.

Musings on genome medicine: the value of family history

Will the routine availability of genome sequence information on individuals render family history information obsolete? I argue that it will not, both because the taking of a family history has other uses for the health professional, and because genome sequence data on their own omit the effects of numerous factors important for modifying risks of disease. These include information derived from factors downstream of genetic variants and from upstream epigenetic effects. Further difficulties arise with uncertainties relating to gene-gene and gene-environment interactions, which may take decades to resolve if their resolution is even possible.

Detecting undiagnosed type 2 diabetes: family history as a risk factor and screening tool

A family history of diabetes is a major risk factor for the disease. As such, it is often included in a variety of tools designed to detect either people at risk of diabetes or people with undiagnosed diabetes. One of the reasons to screen for diabetes is that it has a prolonged asymptomatic phase, which includes impaired fasting glucose, impaired glucose tolerance, and the early stages of diabetes. In terms of prevalence, diabetes is a major public health problem. Evidence shows that the detection of impaired glucose metabolism in its early stages (prediabetes) could lead to the delay or prevention of the disease and its complications. However, the issue of using family history to screen for diabetes must be discussed within the context of screening for diabetes in general. Screening for a disease among asymptomatic people must meet a series of stringent requirements to ensure the best possible outcomes. Screening for diabetes meets most of these requirements but the ones it does not meet are still important. Therefore, based on systematically collected evidence or simply by consensus among scientists, influential organizations recommend screening only among high-risk individuals. As a result, researchers have developed a variety of simple tools to identify high-risk individuals for diabetes in populations. Family history is included as a key variable in the vast majority of them. This article is a brief overview of the reasons to screen for diabetes in general, the tools available for conducting this screening, and the role of family history in these tools.

Familial risk for common diseases in primary care: the Family Healthware Impact Trial

CONTEXT

Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice.

BACKGROUND

Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool.

DESIGN

In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey.

SETTING/PARTICIPANTS

Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices.

MAIN OUTCOME MEASURES

The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population.

RESULTS

From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (p<or=0.02) more likely to have a strong family history for CHD, stroke, and diabetes. Older participants were significantly (p<or=0.02) more likely to report a strong family history for CHD and stroke as well as colorectal and breast cancer.

CONCLUSIONS

This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population.

TRIAL REGISTRATION

NCT00164658.

Perceptions of familial risk in those seeking a genetic risk assessment for Alzheimer's disease

Perceived risk is a complex concept that influences the genetic counseling process and can affect client coping and behavior. Although the association between family history and risk perception is well recognized in the literature, no studies have explored this relationship specifically in those seeking genetic susceptibility testing for a common chronic condition. REVEAL is a randomized trial assessing the impact of APOE disclosure and genetic risk assessment for Alzheimer's disease (AD). Using baseline REVEAL data, we hypothesized that there would be a significant association between the degree of AD family history and risk perception of AD, and that this relationship would be stronger in those who believed that genetics is a very important AD risk factor. In our sample of 293 participants, we found that a higher self-perceived risk of AD was associated with strength of family history of AD (p < 0.001), belief in genetics as an important AD risk factor (p < 0.001), being female (p < 0.001) and being Caucasian (p = 0.02). These results are the first to demonstrate the association between family history and risk perception in persons volunteering for genetic susceptibility testing for a common complex disease.

Interviews with primary care physicians regarding taking and interpreting the cancer family history

BACKGROUND

The cancer family history can be used to stratify risk and guide management regarding screening and prevention of cancer.

OBJECTIVE

The current study was designed to gain understanding of specific barriers to obtaining and using the cancer family history for the primary care physician.

METHODS

Interviews were conducted with structured samples of specialists in family medicine, general internal medicine and gynaecology in three settings in two north-eastern states. A medical anthropologist conducted interviews based on a topical outline; transcripts were systematically analyzed by a research team to identify major themes expressed by participants.

RESULTS

Among 40 urban, suburban and rural physicians interviewed, 40% were women and medical school graduation years ranged from 1963 to 2000. These physicians regarded cancer family history as important, but process and content were not standardized. Major barriers to more focused use of this information included limitations of patients' family history knowledge; time needed to clarify and interpret this information and the lack of clear and accessible guidelines to assist in collection, interpretation and management decisions for average, moderate and higher risk patients. Language and cultural barriers made it more difficult to collect family histories in some populations.

CONCLUSIONS

Barriers to effective application of cancer family history information included limitations of patients' family history information; lack of methods to systematically and efficiently focus on the most useful information and lack of accessible guidance for risk stratification and management. Results suggest a need for support addressing these concerns to better utilize several readily available cancer risk management opportunities.

A pilot study of a family history risk assessment tool for cardiovascular disease

This study evaluated the effectiveness of using a family history questionnaire to ascertain patients and families at-risk for inherited cardiovascular disease. A questionnaire composed of 21 questions was developed based on the experience of a cardiovascular genetic counselor. This questionnaire was administered to 39 patients at a University-based cardiology practice reflecting general and specialized aspects of cardiovascular medicine. Using the number and degree of relatedness of relatives reported and limited age of onset information participants were ranked into three familial risk categories. Thirty-nine patients participated in this pilot study. Of the 39 patients, six Mendelian diseases were identified. All individuals surveyed in this study were found to be at high and/or moderate risk for at least one disease based on the family history questionnaire. Twenty-five out of 39 participants (64.1%) were found to be at high risk for at least one cardiovascular disease, and thirty-three out of 39 participants (84.6%) were found to be at moderate risk for at least one disease. A family history of arrhythmia disorders, hypertension, hyperlipidemia, coronary artery disease and diabetes were more likely to be associated with a personal history in family histories of both moderate and high risk. Family history questionnaires in cardiology clinics can be a cost-effective tool for identifying patients and families who are in the greatest need of genetic evaluation and genetic counseling services.

The family history: reemergence of an established tool

Genetics has transformed the use of family history information and has led to the reemergence of the detailed genetic family history. It is critical that public and professional educational efforts to increase family history awareness and working knowledge are prioritized. Patient maintenance of the pedigree provides increased patient awareness and facilitates some of the limitations associated with conventional medical history ascertainment, ultimately improving health care and research. The increasing use of genetic screening promises to cultivate a paradigm shift in medical treatment emphasizing primary prevention and early intervention. Appreciation of the family history is necessary to make this important advance.

Family history of cancer in Brazil: is it being used?

In developing countries, low budgets make the issue of integrating genetics into clinical practice a challenge, a situation in which the use of family history (FH) becomes important for patient care, as it is a low cost strategy and a risk assessment tool. The purpose of this study was to review medical records of patients with colorectal cancer (CRC) seen in a public University Hospital and evaluate how often FH of cancer is registered. Initially we searched a database for patients who were seen in our hospital between 2002 and 2004 with the diagnosis of CRC. We found 415 patients, 104 of whom were excluded. A total of 311 charts were reviewed and classified into 3 groups. Group A: no FH documented; group B: FH was documented, but FH of cancer was not collected; and group C: FH of cancer was documented. We also investigated what type of information was recorded, in order to verify if important elements were assessed. Ninety-eight charts (31.5%) were classified in group A, 20 (6.5%) in group B, and 193 (62%) in group C. In addition, we observed that important information regarding affected relatives was not collected in most of the charts. In conclusion, we found that although FH of cancer was recorded in 62% of charts of patients with CRC, information that could be relevant for risk assessment and management of at-risk families was missing. Our findings expose an important problem in health education that could reflect negatively in the quality of medical assistance to individuals at risk for familial cancer.

Cholesteryl ester transfer protein B1B1 genotype is associated with a parental history of cardiovascular diseases in Taiwanese people

OBJECTIVE

To investigate the association between family history of cardiovascular disease (CVD) and cholesteryl ester transfer protein (CETP) TaqIB polymorphism in Taiwanese subjects.

SUBJECTS AND METHODS

In this cross-sectional study, 240 subjects (115 men and 125 women) were divided into two groups based on whether or not they had a parental history of CVD. Polymerase chain reaction/restriction fragment length polymorphism was used to analyze the genotype of the subjects for the TaqIB polymorphism of CETP in intron 1.

RESULTS

The frequency of the B1B1 genotype was significantly higher in Taiwanese subjects with a family history of CVD than in those without it (31.2 vs. 18.8%, odds ratio = 1.97, 95% confidence interval = 1.084-3.579, p = 0.035). Siblings with the B1B1 genotype had lower levels of serum high-density lipoprotein cholesterol (HDL-C) than siblings with either B1B2 (46.7 +/- 11.0 vs. 52.5 +/- 11.1 mg/dl, p = 0.034) or B2B2 genotypes (46.7 +/- 11.0 vs. 55.2 +/- 9.6 mg/dl, p = 0.01).

CONCLUSION

CETP TaqIB polymorphism is associated with plasma HDL-C levels. The CETP B1B1 genotype may influence the susceptibility to CVD in Taiwan.

Genetics education for health professionals: a context

Education of health professionals about genetics is essential to the integration of genetics into mainstream health care, but there are a number of associated challenges. By virtue of their training, genetic counselors are well suited to address many of those challenges and to assume a variety of roles related to genetics education for health professionals. This paper provides a brief overview of the status of genetics education for non-genetics health professionals and reviews the context in which educational efforts are likely to occur.

Family history and prevalence of diabetes in the U.S. population: the 6-year results from the National Health and Nutrition Examination Survey (1999-2004)

OBJECTIVE

We sought to test the association between stratified levels of familial risk of diabetes and the prevalence of the disease in the U.S. population.

RESEARCH DESIGN AND METHODS

This study includes 16,388 adults interviewed for the National Health and Nutrition Examination Survey between 1999 and 2004. Fasting glucose was available for a subsample of 6,004 participants. Familial risk of diabetes was classified as average, moderate, or high. The prevalence and the odds of having diabetes were estimated for each risk class after accounting for other risk factors.

RESULTS

Overall, 69.8% of the U.S. adults were in the average, 22.7% in the moderate, and 7.5% in the high familial risk for diabetes. The crude prevalence of diabetes for each risk class was 5.9, 14.8, and 30%, respectively. The graded association between familial risk and prevalence of diabetes remained even after accounting for sex, race/ethnicity, age, BMI, hypertension, income, and education. Versus people in the average risk class, independently of other risk factors considered, the odds of having diabetes for people in the moderate and high familial risk categories were, respectively, 2.3 and 5.5 times higher.

CONCLUSIONS

In the U.S. population, family history of diabetes has a significant, independent, and graded association with the prevalence of diabetes. This association not only highlights the importance of shared genes and environment in diabetes but also opens the possibility of formally adding family history to public health strategies aimed at detecting and preventing the disease.

Utility of family history reports of major birth defects as a public health strategy

A major birth defect is an abnormality that can affect the structure or function of an organ. In the United States, major birth defects are the leading cause of infant mortality and contribute substantially to childhood disability and morbidity. Globally, these conditions lead to the death of millions of infants and children annually. Patients with 1 or more affected family members may be at increased risk for having a child with a major birth defect; thus, accurate knowledge of these conditions among family members of their patients gives the clinician the ability to provide improved risk assessment and reproductive planning. Such knowledge can also serve as motivation for patients to adhere to healthy behaviors such as folic acid use or smoking cessation. To evaluate the utility of collecting family history reports of major birth defects as a public health strategy, 6 key criteria were examined by reviewing the relevant published literature. Overall, the review showed that major birth defects satisfied several of the criteria. Additional research is needed, however, regarding the awareness of parent reports of the occurrence of these conditions among relatives and how knowledge of birth defect diagnoses and related risk factors are transmitted among relatives. Such research needs to encompass not only immediate family members but also other first-degree and second-degree relatives. In summary, routine collection of family history reports of birth defects in pediatric practice holds promise as a public health strategy to reduce the burden of morbidity, mortality, and disability associated with major birth defects.

Family history in pediatric primary care

The family history is a critical element in pediatric medicine and represents the gateway to the molecular age of medicine for both pediatric clinicians and their patients. The pediatric clinician has several opportunities to obtain a family history and multiple clinical and educational uses for that information. Available methods include paper and digital forms, classical pedigrees, online programs, and focused family history at the time of a new diagnosis or problem. Numerous barriers impede the application of family history information to primary pediatric practice. The most common barrier is the limited amount of time the typical primary care encounter allows for its collection. The family history can be used in many facets of pediatric practice: (1) as a diagnostic tool and guide to testing and evaluation; (2) to identify patterns of inheritance; and (3) as a patient-education tool. The most exciting future use of family history is as a tool for public health and preventive medicine. More accurately identifying children at risk for common chronic conditions such as diabetes, asthma, and cardiovascular disease could change the primary care clinician's approach to pediatric medicine.

Is family history a useful tool for detecting children at risk for diabetes and cardiovascular diseases? A public health perspective

Several studies indicate that the risk for type 2 diabetes or cardiovascular disease is detectable in childhood, although these disorders may not emerge until adulthood. In addition, type 2 diabetes and cardiovascular disease seem to share risk factors, including obesity and dyslipidemia, and might even share etiology, which has important implications for screening and prevention strategies for both diseases. Primary prevention, in particular, has gained importance because the results of major randomized, controlled trials strongly suggest that, at least in high-risk adult groups, type 2 diabetes can be prevented or delayed. Furthermore, some intervention studies indicate that the risk factors for diabetes and cardiovascular disease can be reduced in children. A simple way to detect risk for either diabetes or cardiovascular disease is to examine the family history. Numerous studies have shown that adults who have 1 or more first- or second-degree relatives affected with diabetes or cardiovascular disease are at high risk of having or developing these diseases. Currently, there are no overall screening strategies recommended for either diabetes or cardiovascular disease among children and adolescents. The evidence is strong, however, that youth with a positive family history already show signs of increased risk for these conditions. Family history can be part of the approach to screening for children at risk of diabetes and cardiovascular disease and should be part of prevention campaigns aimed at reducing the burden of these diseases and their risk factors in children.

The comprehensiveness of family cancer history assessments in primary care

BACKGROUND

Accurate family history information is required for adequate breast and colorectal cancer risk assessments. Few studies have examined the comprehensiveness of the family medical history interview in primary care.

METHODS

We compared family cancer history information collected through a self-completed survey with that documented within medical charts for 310 patients.

RESULTS

Forty-three percent (18/42) of individuals at increased risk for breast or colorectal cancer based on their family history had documentation of this risk within their chart. Age of cancer diagnosis was recorded for 40% (50/124) of affected relatives identified by chart review compared with 81% (203/252) identified through the survey (p < 0.0001).

CONCLUSIONS

Over half of the individuals at increased risk for breast or colorectal cancer based on their family history did not have documentation of this risk within their medical record, and the age of relatives at diagnosis was frequently missing.

The use of family health histories to address health disparities in an African American community

African Americans continue to suffer from health disparities. The Center for Minority Health (CMH) within the University of Pittsburgh has the mission to eliminate racial and ethnic health disparities. CMH has designed and implemented the Family Health History (FHH) Initiative. The FHH Initiative places genetic-counseling graduate students in the African American community to provide risk assessments and emphasize the importance of family history as it pertains to disease prevention. The FHH Initiative also allows participants to enroll into the Minority Research Recruitment Database (MRRD). This enables CMH to alert individuals to available research participation opportunities. In the first year of this program, 225 African Americans completed their family health histories. More than 60% of individuals enrolled in the MRRD. The authors report their initial successes and challenges of an initiative that incorporates awareness of family history information, proper screening guidelines, behavior-modification recommendations, and support for participation in clinical research.

Risk Communication During Screening for Genomic Breast Cancer Susceptibility

Screening for genomic predisposition to diseases of adulthood is emerging in standard medical practice. Breast cancer predisposition testing provides a useful example for understanding the potential implications of risk-related screening in practice. Risk is an important and complex psychological construct that is understood differently both between scientific disciplines and between medical and lay persons. The process of establishing thresholds for classifying whether one's risk reaches levels warranting departure from standard preventive strategies is an important predictor of both physician feedback and patient interpretation of their risk. Messages about genomic breast cancer risk arising during the pedigree screening context are conveyed via explicit and implicit modes of communication. Best practices for communicating about genomic risk and the implications for health disparities related to screening for genomic susceptibility remain unknown. More work is urgently needed given the societal forces that are catalyzing population-based screening for genomic predisposition into the routine practice of preventive medicine.

Evaluation of family history as a risk factor and screening tool for detecting undiagnosed diabetes in a nationally representative survey population

PURPOSE

We examined the utility of a three-level familial risk stratification system as a screening tool for diabetes in a nationally representative sample of the U.S. adult population.

METHODS

National Health and Nutrition Examination Survey data were used to assess the prevalence and distribution of familial risk for diabetes, the association between three levels of familial risk and undiagnosed diabetes, and the use of familial risk as a screening tool for diabetes, alone and in combination with body mass index and age.

RESULTS

The prevalence of undiagnosed diabetes was 3% and increased with increasing familial risk (average = 2%, moderate = 4%, high = 10%). High familial risk was significantly associated with undiagnosed diabetes (adjusted odds ratio = 4.6; 95% confidence interval: 1.9-11.3). The use of a three-tiered familial risk stratification for diabetes screening yielded higher specificity (94%) and positive predictive value (9.9%) for high familial risk than body mass index > or = 25 (specificity = 38%, positive predictive value = 4.2%). High familial risk and body mass index > or = 25 combined had higher specificity (97%) and positive predictive value (13.4%); the addition of age > or = 45 years further improved positive predictive value (21.0%) without reducing specificity.

CONCLUSIONS

There was a strong and proportional association between familial risk and undiagnosed diabetes, suggesting that a three-tiered assessment of familial diabetes risk may increase the effectiveness of diabetes screening.

Validation of a Self-Administered, Computerized Tool for Collecting and Displaying the Family History of Cancer

Purpose

A detailed family history is important for cancer risk assessment, but obtaining it is time consuming and infrequently accomplished in practice. The Genetic Risk Easy Assessment Tool (GREAT) conducts a computer-administered family history interview and immediately generates a pedigree diagram in digital form. The purpose of this study was to validate family cancer histories produced by patients using the computer tool in comparison with pedigrees made by genetic counselors.

Methods

Patients scheduled for genetics consultation recorded their family histories using the GREAT, separate from their genetic counseling session. The presence of each relative; presence, type, and age at diagnosis of cancers; and cancer geneticist's risk assessment were compared for 120 pairs of pedigrees produced by counselors versus computer tool.

Results

The automated telephone interview took a mean of 33.5 minutes and was highly acceptable to respondents. Ninety-four percent of first-degree relatives, 67% of second-degree relatives, and 38% of third-degree relatives were identical on paired pedigrees; computer-generated pedigrees included additional relatives. Sixty-three percent of all cancers were identified by both family histories, with 90% agreement on the type of cancer. There was very good agreement (κ = 0.70; correlation = 0.77) between the geneticist's breast cancer risk assessments based on computer versus counselors' pedigrees. In a subsample of 61 users, test-retest reliability for the computer-administered questionnaire was high (φ = 0.94 for cancers in first-degree and φ = 0.91 in second-degree relatives).

Conclusion

The GREAT computer-administered questionnaire provides an acceptable, reliable, and valid way of collecting an unverified but extensive family history of cancer and displaying it as a pedigree, in an entirely automated process.

Self-rated breast cancer risk among women reporting a first-degree family history of breast cancer on office screening questionnaires in routine medical care: the role of physician-delivered risk feedback

PURPOSE

We investigated whether risk-related feedback delivered by one's primary care physician is associated with self-ratings of risk among women found to have a first-degree family history of breast cancer on office screening questionnaires.

METHODS

DESIGN

Mailed survey of women registered with the Cancer Genetics Network having a first-degree family history of breast cancer. Eligibility: Completion of primary care-based family history screening within the past year.

INDEPENDENT VARIABLE

presence of physician feedback about breast cancer risk. Dependent variable: self-rated breast cancer risk. Modifying variable: trust in one's doctor.

RESULTS

Three hundred one women met eligibility criteria (73% minimum response rate); feedback was associated with rating one's risk to be "high" in both crude and multivariate analysis. (ORadj = 2.38; 95% CI = 1.30, 4.38). Higher levels of trust in the physician were associated in a dose-dependent fashion with the strength of association between feedback and self-rating one's risk to be high.

CONCLUSIONS

Physician feedback following the identification of a first-degree family history of breast cancer appears to influence whether or not women categorize themselves to be at high risk and trust is an important modifier of this association.

Familial risk assessment for early-onset coronary heart disease

PURPOSE

We examined the performance of a familial risk assessment method that stratifies risk for early-onset coronary heart disease by considering the number of relatives with coronary disease, degree of relationship, lineage, and age at diagnosis.

METHODS

By using data from the HealthStyles 2003 survey, we assessed the associations between familial risk and early-onset coronary heart disease, diabetes, hypercholesterolemia, hypertension, and obesity. By using area under the curve statistics, we evaluated the discriminatory ability of various risk assessment models.

RESULTS

Of 4,035 respondents, 60% were female and 72% were white, with a mean age of 48.8 years. After adjustment for demographics, strong and moderate risk were significantly associated with approximately a five- and twofold risk of early-onset coronary disease, respectively. After adjustment for demographics and personal history of cardiovascular disease, strong familial risk was also significantly associated with diabetes, hypercholesterolemia, hypertension, and obesity. A risk assessment model that included familial risk, demographics, and personal history of diabetes, hypercholesterolemia, hypertension, and obesity was most optimal with an area under the curve statistic of 87.2%

CONCLUSIONS

Familial risk assessment can stratify risk for early-onset coronary heart disease. Several conditions associated with increased familial risk can be prevented. These results have important implications for risk assessment and risk-reducing interventions.

Impact of patient age on family cancer history

PURPOSE

Younger individuals with relatives diagnosed with cancer are at greater risk for developing certain cancer when compared with older individuals with affected relatives. The purpose of this study was to calculate the age-specific proportion of individuals reporting positive family histories for colon, breast, and prostate cancer.

METHODS

Family cancer history information was reviewed on 32,374 adults interviewed for the 2000 National Health Interview Survey. Family histories were categorized as high risk, with a relative diagnosed before 50 years of age or with multiple affected relatives, or moderate risk, with a single relative diagnosed at age 50 years or older.

RESULTS

For individuals with a family history of colorectal cancer, the odds of having a high-risk pedigree decreased by 1% (95% confidence interval 0%-2%) for every year of age increase. For women reporting a family breast cancer history, the odds of reporting a pedigree with high-risk features decreased by 3% (95% confidence interval 2%-4%) for each year of age increase. Age was not associated with reporting a high-risk pedigree for prostate cancer.

CONCLUSION

For colorectal and breast cancers, younger individuals reporting a family history of these cancers were more likely to report a pedigree with high-risk features than older individuals.

Expanding the definition of a positive family history for early-onset coronary heart disease

PURPOSE

Assessing familial risk for early-onset coronary heart disease (CHD) is typically limited to first-degree relatives with early-onset CHD. To evaluate the impact of additional family history, we examined the associations between various family history definitions and early-onset CHD.

METHODS

By using the national HealthStyles 2003 survey data, we assessed associations between self-reported family history and personal history of early-onset CHD (diagnosed at or before age 60 years), adjusting for demographics, hypercholesterolemia, hypertension, and obesity.

RESULTS

Of 4,035 respondents, 60% were female and 72% were white, with a mean age of 48.8 years; 4.4% had early-onset CHD. In addition to having at least one first-degree relative with early-onset CHD, other significant associations included having at least one first-degree relative with late-onset CHD, at least one second-degree relative with early-onset CHD, and two or more affected second-degree relatives regardless of age of onset of CHD. Early-onset stroke in at least one first-degree relative and, in women, having at least one first-degree relative with diabetes were also significantly associated with early-onset CHD.

CONCLUSIONS

Family history beyond early-onset CHD in first-degree relatives is significantly associated with prevalent CHD diagnosed at or before age 60 years.

Ethical issues in genetic testing

Genetic factors contribute to risk for disease. Information clarifying risk in an individual and his/her family members can be identified through clinical screening and genetic testing. In some circumstances, this information can be used in clinical decisions about surveillance and prevention or treatment of disease. However, use of this information is not always a straightforward process. Application of knowledge about risk of genetic disease in provision of primary health care for women requires understanding of new genetic discoveries as well as the ability to participate in resolution of ethical dilemmas that may result when genetic screening and testing are considered. These dilemmas arise not only from the current state of knowledge about genetic risk factors and utility of genetic tests but also result from conflicts that can arise when the needs of the client are not in unison with needs of others within the family or society. Ethical theories and principles provide a framework for resolving ethical dilemmas in maternal screening for genetic conditions during a pregnancy, carrier testing prior to or during a pregnancy, clinical genetic testing, and newborn metabolic screening.

Family history of type 2 diabetes: a population-based screening tool for prevention?

PURPOSE

To evaluate the use of self-reported family medical history as a potential screening tool to identify people at-risk for diabetes.

METHODS

The HealthStyles 2004 mail survey comprises 4345 US adults who completed a questionnaire to ascertain personal and family history of diabetes, perceived risk of diabetes, and practice of risk-reducing behaviors. Using number and type of affected relatives, respondents were ranked into three familial risk levels. Adjusted odds ratios (AORs) were obtained to evaluate associations between familial risk and prevalent diabetes, perceived risk of disease, and risk-reducing behaviors. Validity of family history as a screening tool was examined by calculating sensitivity, specificity, and positive and negative predictive values.

RESULTS

Compared to those of average risk, people with moderate and high familial risk of diabetes were more likely to report a diagnosis of diabetes (AOR: 3.6, 95% CI: 2.8, 4.7; OR: 7.6, 95% CI: 5.9, 9.8, respectively), a higher perceived risk of diabetes (AOR: 4.6, 95% CI: 3.7, 5.7; OR: 8.5, 95% CI: 6.6, 17.7, respectively), and making lifestyle changes to prevent diabetes (AOR: 2.2, 95% CI: 1.8, 2.7; OR: 4.5, 95% CI: 3.6, 5.6, respectively). A positive familial risk of diabetes identified 73% of all respondents with diabetes and correctly predicted prevalent diabetes in 21.5% of respondents.

CONCLUSION

Family history of diabetes is not only a risk factor for the disease but is also positively associated with risk awareness and risk-reducing behaviors. It may provide a useful screening tool for detection and prevention of diabetes.

Association between screening family medical history in general medical care and lower burden of cancer worry among women with a close family history of breast cancer

PURPOSE

Soliciting family medical history (FMH) is the initial step in the process of screening for heritable cancer risk in medical care. We investigate whether recent solicitation of FMH in general medical care is associated with cancer worry among a sample of women having a first-degree relative with a breast cancer diagnosis.

METHODS

Surveys were mailed to women registered with the Cancer Genetics Network having a first-degree relative with a breast cancer diagnosis and a regular source of medical care. The independent measure consisted of two items for solicitation of FMH based on validated measures of clinical interactions with one's physician; the dependent measure was a novel measure of cancer worry based on validated patient-centered measure of distress; and the secondary measures were 6-point scales for perceived likelihood of developing breast cancer and perceived severity of breast cancer as a health outcome.

RESULTS

A total of 353 women responded and met eligibility criteria (76.4% minimum response rate). One fifth reported no cancer worry during the past 4 weeks. After adjustment for age, education, pedigree features, and clustering within families, recent FMH solicitation was associated with lower odds of cancer worry (odds ratio = 0.58; 95% confidence interval = 0.51-0.70). FMH solicitation was associated with lower perceptions of the severity of developing breast cancer but not with the perception of cancer likelihood.

CONCLUSIONS

Our data do not support the hypothesis that FMH solicitation in general medical practice causes cancer worry. In fact, we observed a protective association possibly explained by influences on perceptions of breast cancer severity. Prospective research among less select populations is necessary.

Collecting genetic information in primary care: evaluating a new family history tool

BACKGROUND

The family history is a time-honoured method for identifying genetic predisposition. In specialist practice the standard approach is to draw up a family tree based on a genetic pedigree interview, but this is too time-consuming and focused on single gene disorders to be applicable in primary care.

OBJECTIVES

To assess the ability of a brief self-administered Family History Questionnaire (FHQ), given to patients when they register with a GP, to identify genetic risk.

METHODS

A comparative study. Informants completed an FHQ at registration, and later participated in a genetic pedigree interview. Two clinical geneticists independently scored results obtained with each instrument. Discrepancies were agreed by consensus. The genetic risks identified by the two instruments were compared.

RESULTS

326 new registrants completed the FHQ, and 121 also completed the genetic interview. 24% of FHQs and 36% of genetic interviews resulted in a score 'higher than population risk'. There was 77% agreement in the scores obtained with the two instruments, with a moderate kappa of 0.52. (95% CI 0.40-0.64). There was 90% agreement in the scores for a family history of premature coronary heart disease (Kappa 0.67; 95% CI 0.49 to 0.85). The instruments were equally effective in identifying ethnicity-related risk of common recessive disorders.

CONCLUSIONS

The FHQ identified most informants with genetic risks that are appropriately addressed in primary care-those with a family history of premature coronary heart disease, those warranting specialist referral, and those who might appropriately be offered carrier testing. However, it was less effective in identifying those with a possible Mendelian disorder for whom more information was required.

Do we need genomic research for the prevention of common diseases with environmental causes?

Concerns have been raised about the value of genomic research for prevention and public health, especially for complex diseases with risk factors that are amenable to environmental modification. Given that gene-environment interactions underlie almost all human diseases, the public health significance of genomic research on common diseases with modifiable environmental risks is based not necessarily on finding new genetic "causes" but on improving existing approaches to identifying and modifying environmental risk factors to better prevent and treat disease. Such applied genomic research for environmentally caused diseases is important, because 1) it could help stratify disease risks and differentiate interventions for achieving population health benefits; 2) it could help identify new environmental risk factors for disease or help confirm suspected environmental risk factors; and 3) it could aid our understanding of disease occurrence in terms of transmission, natural history, severity, etiologic heterogeneity, and targets for intervention at the population level. While genomics is still in its infancy, opportunities exist for developing, testing, and applying the tools of genomics to clinical and public health research, especially for conditions with known or suspected environmental causes. This research is likely to lead to population-wide health promotion and disease prevention efforts, not only to interventions targeted according to genetic susceptibility.

Family history of heart disease and cardiovascular disease risk-reducing behaviors

BACKGROUND

Family history is an important cardiovascular disease (CVD) risk factor. Preventive behaviors, including lifestyle modifications, can attenuate CVD risk. We studied the association between family history-based heart disease (HD) risk and CVD risk-reducing behaviors.

METHODS

Using data from the 2001 Healthstyles survey, we compared frequencies of CVD risk-reducing behaviors among adults without known CVD in categories defined by family history-based HD risk. We classified respondents' HD risk as average (no first-degree relatives with HD), moderate (one relative), or high (> or = two relatives). Behaviors studied included lifestyle modifications, cholesterol measurement, and aspirin use.

RESULTS

Of 3383 respondents without known CVD, 28% were classified as being at moderate risk and 15% as being at high risk for HD based on family history. Adjusted odds ratios indicated that moderate- and high-risk respondents were more likely to report having cholesterol measured within the previous 5 years (OR = 1.39, 95% Confidence Interval [CI] = 1.16-1.67 and 1.29, 95% CI = 1.01-1.64, respectively), and aspirin use to reduce CVD risk (OR = 1.49, 95% CI = 1.23-1.79 and 1.67, 95% CI = 1.33-2.09, respectively) than average-risk respondents.

CONCLUSION

Almost one half of respondents reported a family history of HD. Aspirin use and cholesterol measurement (i.e., behaviors that health-care providers might suggest) were more likely to be reported by moderate- and high-risk respondents than were lifestyle changes. Family history merits further investigation as a public health tool to identify persons with increased HD risk who might benefit from enhanced prevention strategies.

Race and family history assessment for breast cancer

OBJECTIVE

Studies have demonstrated disparities in breast cancer screening between racial and ethnic groups. Knowledge of a woman's family history of breast cancer is important for initiating early screening interventions. The purpose of this study was to determine whether differences exist in the collection of family history information based on patient race.

DESIGN

Cross-sectional patient telephone interview and medical record review.

SETTING

Eleven primary care practices in the Greater Boston area, all associated with Harvard Medical School teaching hospitals.

PARTICIPANTS

One thousand seven hundred fifty-nine women without a prior history of breast cancer who had been seen at least once by their primary care provider during the prior year.

MEASUREMENTS AND MAIN RESULTS

Data were collected on patients regarding self-reported race, family breast cancer history information, and breast cancer screening interventions. Twenty-six percent (462/1,759) of the sample had documentation within their medical record of a family history for breast cancer. On multivariate analysis, after adjusting for patient age, education, number of continuous years in the provider's practice, language, and presentation with a breast complaint, white women were more likely to be asked about a breast cancer family history when compared to nonwhite women (odds ratio, 1.68; 95% confidence interval, 1.21 to 2.35).

CONCLUSIONS

The majority of women seen by primary care providers do not have documentation of a family breast cancer history assessment within their medical record. White women were more likely to have family breast cancer information documented than nonwhites.

Timeline: Raising the profile of genetics in primary care

Primary care practitioners recognize that genetics is relevant to their daily practice, for example, for detecting and managing the risk of multifactorial disorders and genetic reproductive risks, and, in future, for targeted drug therapy. However, they lack confidence in their ability to apply genetic approaches. In fact, genetics is already ingrained in current practice, and the development of appropriate guidelines and web-based information resources will help practitioners to make personalized genetic risk assessment a part of holistic, patient-oriented primary health care.

Case for blending pedigrees, genograms and ecomaps: Nursing's contribution to the 'big picture'

In the 21st century, knowledge of genetics is closely linked to the ability to provide good care for all patients, not just the few with uncommon genetic diseases. The authors suggest that what is needed in nursing is a comprehensive, three generation pedigree that records a patient's medical, social and environmental history, thereby communicating a 'big picture' scenario for holistic nursing care. The case is made for blending pedigrees, genograms and ecomaps. Such a tool can guide risk factor identification and inform patient and family clinical decisions vis-a-vis care management strategies, psychosocial support and education for reproductive decisions, risk reduction, and the prevention, screening, diagnosis, referral and long-term management of disease. Pedigrees, genograms and ecomaps are defined, and their clinical application and reliability are described. A case example that blends these tools is presented. Ethical, legal, educational and research implications are discussed.