"Are you at risk for hereditary breast cancer?": development of a personal risk assessment tool for hereditary breast and ovarian cancer

Family history tools for primary care: A systematic review

Background

Many medical family history (FH) tools are available for various settings. Although FH tools can be a powerful health screening tool in primary care (PC), they are currently underused.

Objectives

This review explores the FH tools currently available for PC and evaluates their clinical performance.

Methods

Five databases were systematically searched until May 2021. Identified tools were evaluated on the following criteria: time-to-complete, integration with electronic health record (EMR) systems, patient administration, risk-assessment ability, evidence-based management recommendations, analytical and clinical validity and clinical utility.

Results

We identified 26 PC FH tools. Analytical and clinical validity was poorly reported and agreement between FH and gold standard was commonly inadequately reported and assessed. Sensitivity was acceptable; specificity was found in half of the reviewed tools to be poor. Most reviewed tools showed a capacity to successfully identify individuals with increased risk of disease (6.2–84.6% of high and/or moderate or increased risk individuals).

Conclusion

Despite the potential of FH tools to improve risk stratification of patients in PC, clinical performance of current tools remains limited as well as their integration in EMR systems. Twenty-one FH tools are designed to be self-administered by patients.

The iPrevent Online Breast Cancer Risk Assessment and Risk Management Tool: Usability and Acceptability Testing

BACKGROUND

iPrevent estimates breast cancer (BC) risk and provides tailored risk management information.

OBJECTIVE

The objective of this study was to assess the usability and acceptability of the iPrevent prototype.

METHODS

Clinicians were eligible for participation in the study if they worked in primary care, breast surgery, or genetics clinics. Female patients aged 18-70 years with no personal cancer history were eligible. Clinicians were first familiarized with iPrevent using hypothetical paper-based cases and then actor scenarios; subsequently, they used iPrevent with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent; patients also completed measures of BC worry, anxiety, risk perception, and knowledge pre- and 2 weeks post-iPrevent. Data were summarized using descriptive statistics.

RESULTS

The SUS and Acceptability questionnaires were completed by 19 of 20 clinicians and 37 of 43 patients. Usability was above average (SUS score >68) for 68% (13/19) clinicians and 76% (28/37) patients. The amount of information provided by iPrevent was reported as "about right" by 89% (17/19) clinicians and 89% (33/37) patients and 95% (18/19) and 97% (36/37), respectively, would recommend iPrevent to others, although 53% (10/19) clinicians and 27% (10/37) patients found it too long. Exploratory analyses suggested that iPrevent could improve risk perception, decrease frequency of BC worry, and enhance BC prevention knowledge without changing state anxiety.

CONCLUSIONS

The iPrevent prototype demonstrated good usability and acceptability. Because concerns about length could be an implementation barrier, data entry has been abbreviated in the publicly available version of iPrevent.

What characterizes cancer family history collection tools? A critical literature review

Background

Many tools have been developed for the standardized collection of cancer family history (fh). However, it remains unclear which tools have the potential to help health professionals overcome traditional barriers to collecting such histories. In this review, we describe the characteristics, validation process, and performance of existing tools and appraise the extent to which those tools can support health professionals in identifying and managing at-risk individuals.

Methods

Studies were identified through searches of the medline, embase, and Cochrane central databases from October 2015 to September 2016. Articles were included if they described a cancer fh collection tool, its use, and its validation process.

Results

Based on seventy-nine articles published between February 1978 and September 2016, 62 tools were identified. Most of the tools were paper-based and designed to be self-administered by lay individuals. One quarter of the tools could automatically produce pedigrees, provide cancer-risk assessment, and deliver evidence-based recommendations. One third of the tools were validated against a standard reference for collected fh quality and cancer-risk assessment. Only 3 tools were integrated into an electronic health records system.

Conclusions

In the present review, we found no tool with characteristics that might make it an efficient clinical support for health care providers in cancer-risk identification and management. Adequately validated tools that are connected to electronic health records are needed to encourage the systematic identification of individuals at increased risk of cancer.

Incorporating cancer risk information into general practice: a qualitative study using focus groups with health professionals

BACKGROUND

It is estimated that approximately 40% of all cases of cancer are attributable to lifestyle factors. Providing people with personalised information about their future risk of cancer may help promote behaviour change.

AIM

To explore the views of health professionals on incorporating personalised cancer risk information, based on lifestyle factors, into general practice.

DESIGN AND SETTING

Qualitative study using data from six focus groups with a total of 24 general practice health professionals from the NHS Nene Clinical Commissioning Group in England.

METHOD

The focus groups were guided by a schedule covering current provision of lifestyle advice relating to cancer and views on incorporating personalised cancer risk information. Data were audiotaped, transcribed verbatim, and then analysed using thematic analysis.

RESULTS

Providing lifestyle advice was viewed as a core activity within general practice but the influence of lifestyle on cancer risk was rarely discussed. The word 'cancer' was seen as a potentially powerful motivator for lifestyle change but the fact that it could generate health anxiety was also recognised. Most focus group participants felt that a numerical risk estimate was more likely to influence behaviour than generic advice. All felt that general practice should provide this information, but there was a clear need for additional resources for it to be offered widely.

CONCLUSION

Study participants were in support of providing personalised cancer risk information in general practice. The findings highlight a number of potential benefits and challenges that will inform the future development of interventions in general practice to promote behaviour change for cancer prevention.

Family history tools for primary care are not ready yet to be implemented. A systematic review

BACKGROUND

Taking the family history helps the doctor in estimating the probability of disease in individual patients. However, significant barriers to obtaining adequate family history information remain. Tools overcoming these barriers might support family physicians in this task.

OBJECTIVE

To review systematically the characteristics of existing family history tools and discuss their potential use in primary care.

METHODS

Studies were identified through searches of PubMed, Embase and Cinahl from 1 January 2002 until May 2012. All authors independently screened studies and included original research papers on family history tools of which assessment had been performed or was planned. We reviewed diseases for which family history information was collected, study setting, tool design, type of family history collection, presence of risk-assessment and recommendations for management, and assessment (categorized as either validity or benefit).

RESULTS

Eighteen family history tools were identified: six generic, two on cardiovascular disease and ten on cancer. The six generic tools were partly tested in primary care (3x), are mainly computerized (4x), rarely include management recommendations for the physician (1x) and were partly validated against a reference standard (genetic counsellor) (3x, plus one planned). Of the five specific tools studied in primary care, none was validated. No family history tool allows electronic transfer of family history information to electronic medical record systems. Use of a family history tool improved identification of patients at risk for disease.

CONCLUSION

Several promising family history tools for primary care have been developed but large-scale implementation cannot be advised yet, based on available validation studies.

Communicating risk of hereditary breast and ovarian cancer with an interactive decision support tool

OBJECTIVE

Women with hereditary breast and ovarian cancer syndrome (HBOC) face a higher risk of earlier, more aggressive cancer. Because of HBOC's rarity, screening is recommended only for women with strong cancer family histories. However, most patients do not have accurate history available and struggle to understand genetic concepts.

METHODS

Cancer in the Family, an online clinical decision support tool, calculated women's HBOC risk and promoted shared patient-provider decisions about screening. A pilot evaluation (n=9 providers, n=48 patients) assessed the tool's impact on knowledge, attitudes, and screening decisions. Patients used the tool before wellness exams and completed three surveys. Providers accessed the tool during exams, completed exam checklists, and completed four surveys.

RESULTS

Patients entered complete family histories (67%), calculated personal risk (96%), and shared risk printouts with providers (65%). HBOC knowledge increased dramatically for patients and providers, and many patients (75%) perceived tool results as valid. The tool prompted patient-provider discussions about HBOC risk and cancer family history (88%).

CONCLUSIONS

The tool was effective in increasing knowledge, collecting family history, and sparking patient-provider discussions about HBOC screening.

PRACTICE IMPLICATIONS

Interactive tools can effectively communicate personalized risk and promote shared decisions, but they are not a substitute for patient-provider discussions.

Exploring attitudes, beliefs, and communication preferences of Latino community members regarding BRCA1/2 mutation testing and preventive strategies

PURPOSE

To inform development of a culturally sensitive hereditary breast and ovarian cancer communication initiative and related clinical genetic services.

METHODS

Five focus groups were conducted with 51 female and male Latinos. Educational materials were designed to communicate information about hereditary breast or ovarian cancer and availability of relevant clinical services or prevention strategies. Focus groups explored participants' knowledge, attitudes, and beliefs about hereditary breast and ovarian cancer, BRCA1/2 testing, and communication preferences for hereditary breast and ovarian cancer health messages.

RESULTS

Overall, awareness of familial breast and ovarian cancer and availability of genetic risk assessment was low. Once informed, participants held favorable attitudes toward risk assessment and counseling services. Critical themes of the research highlighted the need to provide bilingual media products and use of a variety of strategies to increase awareness about hereditary cancer risk and availability of clinical genetic services. Important barriers were identified regarding family cancer history communication and cancer prevention services. Strategies were suggested for communicating cancer genetic information to increase awareness and overcome these barriers; these included both targeted and tailored approaches.

CONCLUSION

This research suggests that cancer genetic communication efforts should consider community and cultural perspectives as well as health care access issues before widespread implementation.

Literacy assessment of family health history tools for public health prevention

OBJECTIVES

This study aimed to systematically identify and evaluate the readability and document complexity of currently available family history tools for the general public.

METHODS

Three steps were undertaken to identify family history tools for evaluation: (a) Internet searches, (b) expert consultation, and (c) literature searches. Tools identified were assessed for readability using the Simple Measure of Gobbledygook (SMOG) readability formula. The complexity of documents (i.e., forms collecting family history information) was assessed using the PMOSE/IKIRSCH document readability formula.

RESULTS

A total of 78 tools were identified, 47 of which met the criteria for inclusion. SMOG reading grade levels for multimedia-based tools ranged from 10.1 to 18.3, with an average score of 13.6. For print-based tools, SMOG ranged from 8.7 to 14.1, with an average score of 12.0. Document complexity ranged from very low complexity (level 1 proficiency) to high complexity (level 4 proficiency).

CONCLUSION

The majority of tools are written at a reading grade level that is beyond the 8th grade average reading level in the United States. The lack of family history tools that are easy to read or use may compromise their potential effectiveness in identifying individuals at increased risk for chronic diseases in the general population.

Patient interest in recording family histories of cancer via the Internet

PURPOSE

This study investigated the interest of mammogram patients in using electronic tools for recording their family histories of cancer (FHC).

METHODS

Semistructured interviews were conducted with 65 patients visiting a breast center at a referral hospital in Cleveland, Ohio.

RESULTS

Most (n = 40; 62%) respondents expressed interest in using an electronic tool for recording FHC and associated its use with a range of benefits to themselves, their families, and their health care providers. Women who were not interested (n = 25; 38%) in using an electronic tool for recording FHC were concerned about privacy issues, computer proficiency, and giving up the opportunity to provide family history information directly to the health care provider. Interest in using an electronic tool for recording FHC was not significantly associated with age, race, level of education or income, personal or FHC, or Internet access and frequency of use.

CONCLUSION

Electronic documentation of FHC was seen as largely desirable. However, clinical services to facilitate systematic family history documentation are likely to require more than one avenue for collecting and communicating this information, as not everyone who wants to provide a FHC to a health care provider is comfortable using the Internet to do so.