Referral of patients with a family history of breast/ovarian cancer--GPs' knowledge and expectations

A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States

Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools.

Highlights

There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.

Breast cancer knowledge & information seeking among African American women below screening age

OBJECTIVES

African American women below screening age disproportionately face greater mortality from breast cancer relative to peers of other races and African American women of screening age. The current study examines breast cancer knowledge and health information seeking of African American women below screening age.

METHODS

We collected survey data from 99 African American women below screening age on their breast cancer knowledge and health information seeking behaviors. As secondary analysis, we harmonized data from a previous study to compare breast cancer knowledge between African American women below and of (N = 209) screening age.

RESULTS

The average woman below screening age correctly answered 2.84 (SD=1.08) of six breast cancer knowledge items, 2.67 (SD=1.01) of five mammogram items, 1.44 (SD=0.86) of three treatment items, and had lower knowledge (p < .001) in each area relative to screening age women. Women below screening age sought information primarily from medical providers and the internet.

CONCLUSIONS

A strategy for eliminating early-onset breast cancer disparities impacting African American women is addressing the limited breast cancer knowledge in this age group. Practice Implications In addition to age-appropriate information for this group, guidance for medical providers would be beneficial, as providers are this group's most common source of health information.

Imagining genomic medicine futures in primary care: General practitioners' views on mainstreaming genomics in the National Health Service

Genomic medicine has captured the imaginations of policymakers and medical scientists keen to harness its health and economic potentials. In 2012, the UK government launched the 100,000 Genomes Project to sequence the genomes of British National Health Service (NHS) patients, laying the ground for mainstreaming genomic medicine in the NHS and developing the UK's genomics industry. However, the recent research and reports from national bodies monitoring genomic medicine's roll-out suggest both ethical and practical challenges for health-care professionals. Against this backdrop, this paper, drawing on qualitative research interviews with general practitioners (GPs) and documentary analysis of policy, explores GPs' views on mainstreaming genomic medicine in the NHS and implications for their practice. Analysing the NHS's genomic medicine agenda as a 'sociotechnical imaginary', we demonstrate that whilst sociotechnical imaginaries are construed as collectively shared understandings of the future, official visions of genomic medicine diverge from those at the forefront of health-care service delivery. Whilst policy discourse evokes hope and transformation of health care, some GPs see technology in formation, an unattainable 'utopia', with no relevance to their everyday clinical practice. Finding space for genomics requires bridging the gap between 'work as imagined' at the policy level and 'work as done' in health-care delivery.

Doctor-Patient Cancer Screening Communications among Church-based Chinese Adults - The Role of Caregiver Experience and Family History

Objective:

Significant gap exists in the literature examining cancer screening communication related factors among Chinese immigrants. This study examined the role of cancer caregiver experience and family history on doctor-patient cancer screening communication among church-based Chinese adults.

Methods:

A self-administered survey was conducted among adults from 9 Chinese churches (n=372). Cancer Communication was measured by “Dr. recommended screenings” and “Talked to doctors about cancer screenings”. The survey was developed in English and translated in Chinese.

Results:

Mean age was 44.31 (SD=14.74), 60% were males, 72% were married, majority had college education (85%), and 17% reported had been a primary cancer caregiver and 54% reported having family cancer history. Cancer caregivers scored higher on doctor-patient cancer communication, as well as cancer knowledge and screening norms. Participants with family cancer history were also more likely to talk to doctor about screening, as well as perceived higher cancer risk, lower health status, and screening barriers. Multiple regression analyses showed that primary caregiver experience was still a significant predictor on talking to doctors about cancer screenings (OR=2.1; 95%CI=[1.10, 4.01]; p=0.025), yet doctors more like to recommend screening among caregivers became non-significant. The significant influence of family cancer history on talking with doctors on cancer screenings also disappeared. Older age (OR=2.52; p=0.006) and being married (OR=2.45; p=0.022) were significant on predicting communication of cancer screenings with doctors. Data also showed that doctors were more likely to recommend cancer screenings to older (OR=2.75, p<.001), married (OR=2.57; p=0.006) adults.

Conclusion:

Current study calls attentions to primary cancer caregiver experience, family history, age, and marital factors when designing tailored doctor-patient cancer screening communication programs among church-based Chinese to address cancer disparities.

Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer

BACKGROUND

Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment.

OBJECTIVES

To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found.

MAIN RESULTS

A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials.

AUTHORS' CONCLUSIONS

There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.

Ensuring Best Practice in Genomic Education and Evaluation: A Program Logic Approach

Targeted genomic education and training of professionals have been identified as core components of strategies and implementation plans for the use of genomics in health care systems. Education needs to be effective and support the sustained and appropriate use of genomics in health care. Evaluation of education programs to identify effectiveness is challenging. Furthermore, those responsible for development and delivery are not necessarily trained in education and/or evaluation. Program logic models have been used to support the development and evaluation of education programs by articulating a logical explanation as to how a program intends to produce the desired outcomes. These are highly relevant to genomic education programs, but do not appear to have been widely used to date. To assist those developing and evaluating genomic education programs, and as a first step towards enabling identification of effective genomic education approaches, we developed a consensus program logic model for genomic education. We drew on existing literature and a co-design process with 24 international genomic education and evaluation experts to develop the model. The general applicability of the model to the development of programs was tested by program convenors across four diverse settings. Conveners reported on the utility and relevance of the logic model across development, delivery and evaluation. As a whole, their feedback suggests that the model is flexible and adaptive across university award programs, competency development and continuing professional development activities. We discuss this program logic model as a potential best practice mechanism for developing genomic education, and to support development of an evaluation framework and consistent standards to evaluate and report genomic education program outcomes and impacts.

Genetics in primary care: validating a tool to pre-symptomatically assess common disease risk using an Australian questionnaire on family history

BACKGROUND

A positive family history for diabetes, cardiovascular diseases or various types of cancer increases the relative risk for these diseases by 2 to 5 times compared to people without a positive family history. Taking a family history in daily general practice is useful for early, pre-symptomatic risk assessment, but at the moment no standardized family history questionnaire is available in the Dutch language. In this study we used a 9-item questionnaire, previously developed and applied in an Australian study, to probe family history for 7 specific conditions. The aim of the present qualitative study was to test face and content validity of the Australian family history questionnaire in Dutch general practice and to advance the standardization of intake information at an international level. We conducted 10 cognitive interviews with patients over 4 rounds, using the verbal probing technique. This approach allows the collection of data through a series of probe questions, with the aim of obtaining detailed information. After each interview round we modified the questionnaire based on the answers of the interviewees. We also performed 10 semi-structured interviews with general practitioners (GPs) to get their opinion on the content and usability of the questionnaire in practice.

RESULTS

Patients varied in age and gender, and 4 patients were known to have a genetic disorder. The GPs varied in age, gender, clinical experience, type of practice and location. In the first round, seven problems were identified in the questionnaire in the categories Comprehension (1), Recall (2), Judgement (0), Response process (2) and Completeness, (2); by the fourth and final round no problems remained. The content and usability of the questionnaire were assessed positively.

CONCLUSIONS

When translated for everyday use in Dutch general practice, the Australian family history questionnaire showed a strong face and content validity, and GPs were positive regarding feasibility. Validation of this family history questionnaire could aid in the standardized integration of genetically relevant information in the electronic health record and clinical research. Conspicuous questionnaire information might alert the GP regarding specific conditions and enable detection of disease at an earlier stage. Additional questionnaire requirements needed however are accurate patient information and consistent, accessible locations in the electronic health record with a possibility to be automatically registered. By deriving a Dutch family history questionnaire convenient for GPs, we adapted a template that might also prove useful for other countries and other medical professionals. This development could make the rapid operationalization of readily available genetic knowledge feasible in daily practice and clinical research, leading to improved medical care.

Are we ready for the challenge of implementing risk-based breast cancer screening and primary prevention?

BACKGROUND

Increased knowledge of breast cancer risk factors provides opportunities to shift from a one-size-fits-all screening programme to a personalised approach, where screening and prevention is based on a woman's risk of developing breast cancer. However, potential implementation of this new paradigm could present considerable challenges which the present review aims to explore.

METHODS

Bibliographic databases were searched to identify studies evaluating potential implications of the implementation of personalised risk-based screening and primary prevention for breast cancer. Identified themes were evaluated using thematic analysis.

RESULTS

The search strategy identified 5699 unique publications, of which 59 were selected for inclusion. Significant changes in policy and practice are warranted. The organisation of breast cancer screening spans several healthcare delivery systems and clinical settings. Feasibility of implementation depends on how healthcare is funded and arranged, and potentially varies between countries. Piloting risk assessment and prevention counselling in primary care settings has highlighted implications relating to the need for extensive additional training on risk (communication) and prevention, impact on workflow, and professionals' personal discomfort breaching the topic with women. Additionally, gaps in risk estimation, psychological, ethical and legal consequences will need to be addressed.

CONCLUSION

The present review identified considerable unresolved issues and challenges. Potential implementation will require a more complex framework, in which a country's healthcare regulations, resources, and preferences related to screening and prevention services are taken into account. However, with the insights gained from the present overview, countries expecting to implement risk-based screening and prevention can start to inventory and address the issues that were identified.

Accuracy of ovarian and colon cancer risk assessments by U.S. physicians

BACKGROUND

Studies have shown a mismatch between published cancer screening and genetic counseling referral recommendations and physician-reported screening and referral practices. Inaccurate cancer risk assessment is one potential cause of this mismatch.

OBJECTIVE

To assess U.S. physicians' ability to accurately determine a woman's colon and ovarian cancer risk level.

DESIGN, PARTICIPANTS

Cross-sectional survey of U.S. family physicians, general internists, and obstetrician-gynecologists. A twelve-page questionnaire with a vignette of a woman's annual examination included a question about the patient's level of colon and ovarian cancer risk. The final study sample included 1,555 physicians weighted to represent practicing U.S. physicians nationally.

MAIN MEASURE

Accuracy of physicians' ovarian and colon cancer risk assessments.

KEY RESULTS

Overall, most physicians accurately assessed women's risk of ovarian (57.0%, CI 54.3, 59.6) and colon cancer (62.0%, CI 59.4, 64.6). However, 27.1% (CI 23.0, 31.6) of physicians overestimated the ovarian cancer risk among women at the same risk as the general population, and 65.1% (CI 60.2, 69.7) underestimated ovarian cancer risk among women at much higher risk than the general population. Physicians overestimated colon more than ovarian cancer risk (38.0%, CI 35.4, 40.6 vs. 27.1%, CI 23.0, 31.6) for women at the same risk as the general population.

CONCLUSIONS

Physicians' misestimation of patient ovarian and colon cancer risk may put average risk patients in jeopardy of unnecessary screening and higher risk patients in jeopardy of missed opportunities for prevention or early detection of cancers.

Effectiveness of oncogenetics training on general practitioners' consultation skills: a randomized controlled trial

PURPOSE

General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills.

METHODS

In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires.

RESULTS

Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored.

CONCLUSION

The general practitioner-specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care.

Proposed roadmap to stepwise integration of genetics in family medicine and clinical research

We propose A step-by-step roadmap to integrate genetics in the Electronic Patient Record in Family Medicine and clinical research. This could make urgent operationalization of readily available genetic knowledge feasible in clinical research and consequently improved medical care.Improving genomic literacy by training and education is needed first. The second step is the improvement of the possibilities to register the family history in such a way that queries can identify patients at risk. Adding codes to the ICPC chapters "A21 Personal/family history of malignancy" and "A99 Disease carrier not described further" is proposed. Multidisciplinary guidelines for referral must be unambiguous. Electronical patient records need possibilities to add (new) family history information, including links between individuals who are family members. Automatic alerts should help general practitioners to recognize patients at risk who satisfy referral criteria. We present a familial breast cancer case with a BRCA1 mutation as an example.

Improving identification of lynch syndrome patients: a comparison of research data with clinical records

Current evidence suggests poor identification and referral of Lynch syndrome patients. This study evaluated the strategies by which patients with endometrial cancer were referred to genetics services. Data from clinic-based patients with endometrial cancer enrolled through the Australian National Endometrial Cancer population-based research study with detailed family history information were analyzed. The Amsterdam II criteria, the revised Bethesda guidelines, and criteria adapted for this study was assessed using personal/family history information. The percentages of patients referred and who could have been referred to genetics services, and the performance of each criterion for identifying possible mismatch-repair (MMR) gene mutation carriers, based on tumor MMR immunohistochemistry (IHC), were determined. Research data indicated that 236/397(59%) of patients with endometrial cancer had family/personal history of cancer, including 14 (4%) who fulfilled Amsterdam II criteria. Family history information was noted in the hospital records for only 61(15%) patients, including 7/14 (50%) of patients meeting Amsterdam criteria, and always less extensively than that recorded in the research setting. Only 13 patients (two meeting Amsterdam criteria) were referred for genetic assessment. Of 58 patients with tumor MMR protein-IHC loss, the Amsterdam criteria and Bethesda guidelines identified only three and 34% of these possible germline mutation carriers, respectively. Greater sensitivity (60%) was obtained using a single criterion proposed by our study, ≥2 first-degree or second-degree relatives reporting Lynch cancers. Hospital records indicate poor recognition of family history. Application of research methods show improved identification and may facilitate appropriate referrals of endometrial cancer patients with possible Lynch syndrome.

Patterns of cancer genetic testing: a randomized survey of Oregon clinicians

Introduction. Appropriate use of genetic tests for population-based cancer screening, diagnosis of inherited cancers, and guidance of cancer treatment can improve health outcomes. We investigated clinicians' use and knowledge of eight breast, ovarian, and colorectal cancer genetic tests. Methods. We conducted a randomized survey of 2,191 Oregon providers, asking about their experience with fecal DNA, OncoVue, BRCA, MMR, CYP2D6, tumor gene expression profiling, UGT1A1, and KRAS. Results. Clinicians reported low confidence in their knowledge of medical genetics; most confident were OB-GYNs and specialists. Clinicians were more likely to have ordered/recommended BRCA and MMR than the other tests, and OB-GYNs were twice as likely to have ordered/recommended BRCA testing than primary care providers. Less than 10% of providers ordered/recommended OncoVue, fecal DNA, CYP2D6, or UGT1A1; less than 30% ordered/recommended tumor gene expression profiles or KRAS. The most common reason for not ordering/recommending these tests was lack of familiarity. Conclusions. Use of appropriate, evidence-based testing can help reduce incidence and mortality of certain cancers, but these tests need to be better integrated into clinical practice. Continued evaluation of emerging technologies, dissemination of findings, and an increase in provider confidence and knowledge are necessary to achieve this end.

Symptoms and risk factors of ovarian cancer: a survey in primary care

In spite of the increased awareness of ovarian cancer symptoms, the predictive value of symptoms remains very low. The aim of this paper is to obtain the views of general practitioners (GPs) in relation to symptom-based detection of ovarian cancer and to assess their knowledge for family history of breast and/or ovarian cancer as a predisposing factor for ovarian cancer. In this questionnaire survey, postal questionnaires were sent to 402 GPs in 132 primary care clinics, out of which we obtained 110 replies (27.4%). Approximately 26% of respondent GPs thought that the symptoms were more likely to be frequent, sudden, and persistent, and one-fifth were unsure of the importance of family history of breast cancer in relation to ovarian cancer. The participant GPs scored a set of symptoms for their relevance to ovarian cancer from 0 (not relevant) to 10 (most relevant). The highest scored symptoms were abdominal swelling (mean ± SD, 8.19 ± 2.33), abdominal bloating (7.01 ± 3.01), and pelvic pain (7.46 ± 2.26). There was a relative lack of awareness for repetitive symptoms as well as gastrointestinal symptoms as an important feature in a symptom-based detection of ovarian cancer.

A self-administered family history questionnaire improves identification of women who warrant referral to genetic counseling for hereditary cancer risk

OBJECTIVES

This study was undertaken to assess a self-administered family history questionnaire in order to better identify women within a gynecologic oncology practice for referral to genetic counseling services.

METHODS

Returning patients at an outpatient gynecologic oncology clinic completed a self-administered family health history questionnaire and a detailed telephone interview. A genetic counselor separately assessed blinded information garnered from the questionnaire, structured genetic interview, and electronic medical records to determine whether these data warranted referral to genetic counseling based on established criteria. The structured genetic interview was considered the gold standard to which the questionnaire and medical record information were compared.

RESULTS

Of the 45 total participants in the study, 26 (58%) were identified from the structured genetic interview as meeting criteria for referral to genetic counseling. The questionnaire identified 21 (81%) of these 26 referrals, while the medical record identified 13 (50%) of these 26 referrals. This led to a 62% increase in referral capture by the questionnaire. The median time to complete the questionnaire was 17 min (range 5-57 min). Thirty-four participants (75.6%) had more family members with cancer identified on the questionnaire compared to the electronic medical record. The questionnaire identified fewer family members with cancer in the five cases that were missed for appropriate referral.

CONCLUSIONS

Current standard clinical practices are insufficient at identifying patients in need of referral to genetic counseling. A self-administered questionnaire improves recognition of candidates for genetic counseling in a gynecologic oncology practice.

GenetiKit: a randomized controlled trial to enhance delivery of genetics services by family physicians

BACKGROUND

Patients look to their family physicians (FPs) for credible information and guidance in making informed choices about genetic testing. FPs are challenged by lack of knowledge and the rapid pace of genetic discovery. There is an urgent need for effective interventions to facilitate integration of genetics into family medicine.

OBJECTIVE

To determine if a multi-faceted knowledge translation intervention would improve skills, including referral decisions, confidence in core genetics competencies and knowledge.

METHODS

Randomized controlled trial involving FPs in four communities in Ontario, Canada (two urban and two rural). The intervention consisted of an interactive educational workshop, portfolio of practical clinical genetics tools and knowledge service called Gene Messenger. Outcome measures included appropriate genetics referral decisions in response to 10 breast cancer scenarios, decisional difficulty, self-reported confidence in 11 genetics core competencies, 3 knowledge questions and evaluation of intervention components 6 months afterwards.

RESULTS

Among the one hundred and twenty-five FPs randomized, 80 (64%) completed the study (33 control, 47 intervention). Intervention FPs had significantly higher appropriate referral decision scores [6.4/10 [95% confidence interval (CI) 5.8-6.9] control, 7.8/10 (95% CI 7.4-8.2) intervention] and overall self-reported confidence on core genetics competencies [37.9/55 (95% CI 35.1-40.7) control, 47.0/55 (95% CI 44.9-49.2) intervention]. Over 90% of FPs wanted to continue receiving Gene Messengers and would recommend them to colleagues. No significant differences were found in decisional difficulty or knowledge.

CONCLUSIONS

This study demonstrated that a complex educational intervention was able to significantly improve practice intent for clinical genetics scenarios found in primary care, as well as confidence in genetics skills.

Primary care physicians' use of family history for cancer risk assessment

Background

Family history (FH) assessment is useful in identifying and managing patients at increased risk for cancer. This study assessed reported FH quality and associations with physician perceptions.

Methods

Primary care physicians practicing in two northeastern U.S. states were surveyed (n = 880; 70% response rate). Outcome measures of FH quality were extent of FH taken and ascertaining age at cancer diagnosis for affected family members. Predictors of quality measured in this survey included: perceived advantages and disadvantages of collecting FH information, knowledge of management options, access to supportive resources, and confidence in ability to interpret FH.

Results

Reported collection of information regarding second degree blood relatives and age of diagnosis among affected relatives was low. All hypothesized predictors were associated with measures of FH quality, but not all were consistent independent predictors. Perceived advantages of taking a family history, access to supportive resources, and confidence in ability to identify and manage higher risk patients were independent predictors of both FH quality measures. Perceived disadvantages of taking a family history was independently associated one measure of FH quality. Knowledge of management options was not independently associated with either quality measure.

Conclusions

Modifiable perception and resource factors were independently associated with quality of FH taking in a large and diverse sample of primary care physicians. Improving FH quality for identification of high risk individuals will require multi-faceted interventions.

General practitioners' attitudes to assessment of genetic risk of common disorders in routine primary care

In 2003, the UK Department of Health set out the genetics white paper, a plan for action and investment with particular emphasis on integration of genetic health care into primary care. Since the delivery of the genetics white paper, there has been little exploration of UK primary care doctors' attitudes towards extending their role to include provision of routine genetics services. We explored explore general practitioners' (GPs) attitudes towards provision of genetic health care including routine family history screening and familial risk assessment for common disorders in primary care using a quantitative, evaluative postal survey. Only 25% (797 of 3160) of the GPs returned a completed questionnaire. Although 32% of GPs supported collection of family history information and 41.5% familial risk assessment, 18% were not willing to offer these services even if training is provided. Of the GPs, 50% stated they recognized when referral to genetics services is appropriate, although 43% felt unprepared to collect family history or assess familial risk. Lack of training within the last 3 years was a significant predictor of feeling unprepared to undertake these activities (OR = 2.53,p = 0.012). A substantial group of GPs remain unprepared or unwilling to provide genetic health care. GPs' attitudes to delivery of genetic health care are significantly influenced by factors such as a lack of evidence of the direct benefits to patients, local guidelines and specialist services. These factors need addressing if delivery of genetic health care is to be incorporated into routine primary care.

Cancer genetics evaluation: barriers to and improvements for referral

Despite the availability of cancer susceptibility testing, little information exists regarding physicians' selection and referral of eligible patients. This study provides insight into whom, why, and when physicians refer for cancer genetics evaluation, as well as their comfort level within this role. Eighty-two physicians (51 primary care, 15 gynecology, 11 surgery and 5 oncology) completed a survey (response rate: 34%) regarding cancer genetics referral practices. Of these, 59% reported an awareness of the hospital's cancer genetics program. Program awareness was greater among oncologists, surgeons, and gynecologists than among primary care physicians (p < 0.0001). Patients were referred for enhanced risk assessment (88%), improved medical management (85%), and concern for family members (83%). Patient eligibility was based on family cancer history (96%), patient cancer history (83%), and patient request (73%). Patients were not referred mainly due to patient disinterest (54%) or physician concern about either insurance coverage (44%) or insurance discrimination (31%). Primary care physicians were less comfortable with identifying patients for referral (p < 0.001) and with discussing genetics (p < 0.002) than specialists. The largest barriers to referral were lack of program awareness and limited knowledge regarding patient eligibility, improved insurance coverage, and antidiscrimination legislation. Physician-targeted marketing and education may improve the referral process.

Clinical genetics issues encountered by family physicians

PURPOSE

To describe the genetics-related clinical issues encountered by family physicians, and the medical problems they referred to genetics consultants.

METHODS

Questionnaires were mailed to a nationwide, random sample of 498 practicing family physicians, asking how many times in the past year they discussed genetic information about 19 familial or genetic conditions with patients and what proportion of the families with each genetic condition were referred for genetics consultation. Factor analysis was used to group the conditions.

RESULTS

The response rate was 38% (n = 190). Respondents were similar to non-respondents except that more were women. Most family physicians reported discussing the genetics of common cancers, cardiovascular disease, and Alzheimer's disease with two or more patients in the past year. Thirteen percent had referred families for genetics assessment of breast-ovarian cancer but only two made genetics referrals for cardiovascular disease or dementia. 25% to 50% of family physicians had addressed genetic issues in at least one family with hemoglobinopathy, a blood clotting disorder, hemochromatosis, mental illness, vision loss or deafness, chromosome abnormality, infertility or pregnancy loss, congenital anomalies, mental retardation, and neurofibromatosis. Most cases were not referred to geneticists. Of respondents, 23% said that genetics consultation is very difficult to obtain or unavailable and 18% listed ethical and social dilemmas related to pursuing genetic diagnosis.

CONCLUSION

Nationwide, family physicians address a variety of genetics issues with patients, most frequently consulting geneticists for perinatal conditions and familial cancers. Access to genetics consultation is more difficult in rural areas. These data may be used in organizing genetics services and in planning professional education programs for primary care clinicians.

Interactive genetic counseling role-play: a novel educational strategy for family physicians

BACKGROUND

Family physicians (FPs) are increasingly involved in delivering genetic services. Familiarization with aspects of genetic counseling may enable FPs to help patients make informed choices.

PURPOSE

Exploration of interactive role-play as a means to raise FPs' awareness of the process and content of genetic counseling.

METHODS

FPs attending two large Canadian family medicine conferences in 2005 were eligible -- 93 participated. FPs discussed a case during a one-on-one session with a genetic counselor. Evaluation involved pre and post intervention questionnaires

RESULTS

FPs' baseline genetic knowledge was self-rated as uniformly poor. Baseline confidence was highest in eliciting family history and providing psychosocial support and lowest in discussing risks/benefits of genetic testing and counseling process. Post-intervention, 80% of FPs had better appreciation of family history and 97% indicated this was an effective learning experience.

CONCLUSIONS

Role-play with FPs is effective in raising awareness of the process and content of genetic counseling and may be applied to other health disciplines.

The current status of medical genetics instruction in US and Canadian medical schools

PURPOSE

Relatively little is known about how medical genetics is being taught in the undergraduate medical curriculum and whether educators concur regarding topical priority. This study sought to document the current state of medical genetics education in U.S. and Canadian accredited medical schools.

METHOD

In August 2004, surveys were sent from the Indiana University School of Medicine to 149 U.S. and Canadian medical genetics course directors or curricular deans. Returned surveys were collected through June 2005. Participants were asked about material covered, number of contact hours, year in which the course was offered, and what department sponsored the course. Data were collated according to instructional method and course content.

RESULTS

The response rate was 75.2%. Most respondents (77%) taught medical genetics in the first year of medical school; only half (47%) reported that medical genetics was incorporated into the third and fourth years. About two thirds of respondents (62%) devoted 20 to 40 hours to medical genetics instruction, which was largely concerned with general concepts (86%) rather than practical application (11%). Forty-six percent of respondents reported teaching a stand-alone course versus 54% who integrated medical genetics into another course. Topics most commonly taught were cancer genetics (94.2%), multifactorial inheritance (91.3%), Mendelian disorders (90.3%), clinical cytogenetics (89.3%), and patterns of inheritance (87.4%).

CONCLUSIONS

The findings provide important baseline data relative to guidelines recently established by the Association of American Medical Colleges. Ultimately, improved genetics curricula will help train physicians who are knowledgeable and comfortable discussing and answering questions about genetics with their patients.

Referral to cancer genetic counseling: are there stages of readiness?

As genetic awareness spreads among healthcare providers and the general public, and evidence mounts to show the efficacy of cancer control methods, referrals to cancer genetic counseling services for risk assessment are becoming more common. However, few studies have examined referral patterns to genetics and even less is known about referral uptake to clinical cancer genetic counseling. We investigated outcome of genetics referral in 43 affected women attending a breast cancer treatment program who were referred based on having BRCA mutation carrier risks > or =10%. Within 6 months, of the 36 women we were able to recontact, 13 (36%) came to an appointment at the cancer genetic counseling clinic (Acceptors), 10 (27%) said they intended to come in the future (Intenders), and 13 (36%) said they would not consider genetic counseling (Decliners). Referral uptake was framed by elements of the Transtheoretical model (TTM) to determine if decisional balance scores (DBSs), a summary of an individual's "Pro" and "Con" opinions related to genetic testing, correlated with their decision to follow through. Mean DBS's were strongly negative for the Decliner group (-7.4), weakly negative for the Intender group (-1.1), and positive for the Acceptor group (5.4). The difference in the DBS along the continuum was due more to the mean "Con" score decreasing, rather than the mean "Pro" score increasing. Theoretical frameworks are needed to study adherence to referral for cancer genetic counseling. Stage-based theories may have a role to play.

Familial breast cancer: management of 'lower risk' referrals

Up to 40% of referrals from primary care to ‘breast cancer family clinics’ prove to be of women whose assessed risk falls below the guidelines' threshold for management in secondary or tertiary care, despite recommendations that they should be screened out at primary care level. A randomised trial, involving 87 such women referred to the Tayside Familial Breast Cancer Service compared two ways of communicating risk information, letter or personal interview. Both were found to be acceptable to referred women and to their family doctors, although the former expressed a slight preference for interview. Only four women returned to their family doctors with continuing concerns about breast cancer. Nevertheless, understanding of information provided by either route was unsatisfactory, with apparent confusion about both absolute and relative risks of breast cancer. Substantial minorities appear to believe that they are at no increased risk at all, or even below the population level of risk, while others remain convinced that their personal risk has been underestimated. Family history record forms, completed by the referred women, preferably with the assistance of relatives, are crucial to full assessment of familial risk but one quarter of women referred to the Tayside Familial Breast Cancer Service currently do not complete and return these forms ahead of their clinic appointment. Further collaboration between primary care and the Breast Cancer Family Service is required to improve provision for concerned women whose risks fall below the threshold for special surveillance and to maximise effective use of the family history record form.

Population-based study of the prevalence of family history of cancer: implications for cancer screening and prevention

PURPOSE

Family history assessment is gaining importance as a potential public health tool to help determine susceptibility to common cancers. Population-based data on the prevalence of having a family history of common cancers are scant.

METHODS

We queried survey questions from the National Health Interview Survey, an annual nationwide survey of approximately 36,000 households in the United States, to determine the prevalence of persons reporting one or more first-degree relatives with breast, colorectal, lung, prostate, or ovarian cancer.

RESULTS

Breast cancer was the most common condition noted for family members (7.74% of respondents), followed by lung cancer (7.10%), colorectal cancer (4.96%), prostate cancer (4.68%), and ovarian cancer (1.79%). A family history of cancer was more commonly reported by older persons, whites, women, and high-income groups.

CONCLUSION

A substantial proportion of persons in the United States report having a close family member with cancer, and thus may be eligible for earlier or more aggressive cancer screening services.

Analysis of referrals to a multi-disciplinary breast cancer genetics clinic: practical and economic considerations

Analysis of activity was undertaken in an established regional clinic providing risk assessment, counselling, screening and management for women with a family history of breast or ovarian cancer. The objectives were to determine: (1) how closely the route and pattern of referrals matched official guidelines (2) whether the previously recorded socio-economic imbalance among clinic clientele persisted and (3) the economic and practical consequences of committing resources to verification and extension of reported family histories. The findings were: (1) after some years of operation, the proportion of referrals direct from primary care had increased from less than 50% to over 75%, with a concomitant slight decrease in overall referral rate; (2) the socio-economic distribution of patients referred had become less selective and (3) extension and verification of reported family histories led to a redistribution of risk categories, increasing the proportion of referrals judged to be in the "low risk" category, from 25% (based on referral letter alone) to 41% (at the end of the process). The costs associated with this approach are offset by the savings generated and it allows specialised counselling and screening services to be targeted more efficiently.

Breast cancer risk and provider recommendation for mammography among recently unscreened women in the United States

BACKGROUND AND OBJECTIVE

Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women.

DESIGN

Cross-sectional study using 2000 National Health Interview Survey.

PARTICIPANTS

In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years.

MEASUREMENTS AND ANALYSIS

We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years.

RESULTS

Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation.

CONCLUSIONS

Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk.

Earlier Diagnosis of Autosomal Dominant Polycystic Kidney Disease: Importance of Family History and Implications for Cardiovascular and Renal Complications

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a common and serious cause of hereditary renal disease. The emerging possibilities to intervene early in the disease course elevate the importance of both accurate and early diagnosis of ADPKD. Family history analysis is a simple and inexpensive approach to identifying individuals at risk for ADPKD. We hypothesized that advances in knowledge of and potential interventions for ADPKD have led to increased use of family history screening.

METHODS

We distributed surveys to 1,527 subjects from our ADPKD research database to determine the extent to which examination of family history was used to diagnose ADPKD, by birth cohort.

RESULTS

Six hundred thirty-seven subjects with ADPKD (42%) completed and returned surveys. Family history analysis led to the initial ADPKD diagnosis in 49% of all subjects overall. In the birth-cohort analysis, ADPKD was more likely to have been diagnosed in individuals born between 1951 and 1974 because of family history (55% versus 38%; P < 0.0002) and patients were younger at diagnosis (27 versus 39 years; P < 0.0001) than individuals born before 1951.

CONCLUSION

In a large cohort of subjects with ADPKD, we found increased use of family history analysis as a tool for diagnosing ADPKD and earlier age of diagnosis in the more recent birth cohort. This trend may reflect increased overall awareness of ADPKD by physicians, as well as encouraging hypertension and proteinuria treatment outcome data that may depend on intervening early in the course of disease.

Adjusting the estimated proportion of breast cancer cases associated with BRCA1 and BRCA2 mutations: public health implications

PURPOSE

Mutations in BRCA1 or BRCA2 genes increase breast cancer risk. Assuring reliability of information about these mutations is increasingly important to the health care community; mutation testing is becoming more widespread. We describe a methodology for assessing such information.

METHODS

Our approach integrates four interdependent epidemiologic parameters: (1) the probability of developing breast cancer, (2) the proportion of breast cancer cases with a BRCA1 or BRCA2 mutation, (3) the proportion of women that carries a mutation, and (4) the proportion of women with a mutation that develops cancer. We assess the plausibility of estimates of these parameters from published reports and commonly accessed information sources.

RESULTS

Assuming a fixed probability of developing breast cancer, the following estimates for the other three epidemiologic parameters are derived for women by age 70: 1% to 2% of all breast cancer cases are associated with a BRCA1 or BRCA2 mutation; 1 in 300 to 1 in 465 women carry a mutation; and 35 to 65% of mutation carriers develop breast cancer. Within these ranges, however, only selected combinations are plausible. The proportion of mutation-related breast cancer is lower than listed in some common information sources (1 to 2% vs 6%). Also, penetrance is somewhat lower and the carrier rate somewhat higher.

CONCLUSIONS

The four epidemiologic parameters can be integrated to test their plausibility. BRCA1 and BRCA2 mutations are associated with only one-third as many breast cancer cases in the general population as reported by commonly accessed information sources.

A pilot study of spatial patterns in referrals to a multicentre cancer genetics service

OBJECTIVES

To analyse spatial and temporal patterns in patients referred to a cancer genetics service in order to monitor service utilization and accessibility.

METHODS

Postcodes of patients during a 4-year period were used to examine spatial patterns using a Geographical Information System (GIS). Referral rates were compared visually and statistically to explore yearly variation for administrative areas in Wales.

RESULTS

There has been a four-fold increase in actual referrals to the service over the period of study. The variance between unitary authority referral rates has decreased from the inception of the service from an almost ten-fold difference between lowest and highest in year 1 to less than a three-fold difference in year 4.

CONCLUSIONS

This study shows the potential of GIS to highlight spatial variations in referral rates across Wales. Although the disparity in referral rates has decreased, trends in referral rates are not consistent. Ongoing research will examine those referral and referrer characteristics affecting uptake.

Harnessing the potential of cancer genetics in healthcare

The advancement of knowledge in genetics will have a profound effect on prediction, prevention, and treatment of cancer. It has the potential to offer more personalised healthcare that accords with an individual's genetic profile. However, the complex medical, ethical, legal, and psychosocial issues brought by our ability to test healthy individuals for cancer predisposition and the fast pace of advances in genetics pose great challenges to the medical community. Individuals and families are unlikely to benefit from an effective and ethical application of new genetic knowledge unless high quality cancer-genetics services are developed and integrated into mainstream healthcare, more research is undertaken into the prevention, causes, and treatment of cancer, and further efforts are made to improve public understanding and acceptance of cancer genetics.

GENETIC TESTING IN PRIMARY CARE

Rapid advances in genetic research are leading to an expanding array of genetic tests. Primary care providers will increasingly be challenged to identify patients whose symptoms, physical findings, or family history indicate the need for genetic testing, and to determine how to use genetic information most effectively to improve disease prevention. In addressing these challenges, practitioners will need to consider the range of different uses of genetic testing, including diagnosis in symptomatic and asymptomatic people, risk assessment, reproductive decision-making, and population screening. They will need a set of core skills and knowledge to evaluate family history and to recognize clinical findings that indicate genetic risk. At the same time, the primary care perspective will contribute to the evaluation of appropriate uses of genetic testing. A partnership between medical genetics and primary care will help to ensure the development of effective policies, educational tools, and practice guidelines for the coming era of genomic health care.

Integrating genetics as practices of primary care

This study examines the responses of general practitioners (GPs) in Vic., Australia to an increased emphasis on genetics in primary care. A qualitative analysis of focus group interviews with GPs in regional and metropolitan areas and one focus group interview with genetics experts showed that despite the emphasis placed on genetics by the experts, GPs remained ambivalent to the routine integration of genetics into general practice. This response from GPs has been noted in several studies and is most commonly attributed to GPs' lack of knowledge about genetics. In this study we argue that a 'cognitive deficit' understanding of the problem excludes many of the factors that GPs regard as important in relating genetics to primary care. We show that GPs' ambivalence emerges from how they situate genetics within practices of patient care and in relation to what they regard as good patient management. We found that GPs respond most enthusiastically to genetics and genetic testing if they feel it changes their management in ways they consider of benefit to their patients. GPs have specialist skills in managing the heterogeneity of patient care and these skills enable them to situate genetics relative to the overall needs of patients. Preparing GPs to 'do' genetics when the need arises by finding ways to make genetics information available to them as the need arises would facilitate the integration of genetics as practices of primary care.

Family physician self-efficacy with screening for inherited cancer risk

BACKGROUND

Recent evidence has shown low and inconsistent rates of family history screening among generalist physicians. Little has been done to investigate the physician factors likely to mediate this behavior. We investigated family physicians' beliefs about screening their patients for inherited cancer risk, measuring their perceptions of self-efficacy and the importance of screening.

METHODS

We mailed a cross-sectional, 1-page questionnaire to all active members (691) of the Massachusetts Academy of Family Physicians, measuring their attitudes about predictive genetic cancer screening.

RESULTS

We received responses from 300 of the 691 members (43%). Although 87% believed screening to be important, less than two thirds believed they were effective in screening.

CONCLUSIONS

Many family physicians lack confidence in their ability to screen patients for a family history of cancer despite recognizing its importance to their practice.

Community genetics and community medicine

In the decades to come, molecular genetic insights and techniques will have great influence on prevention and health care. Health care providers should anticipate important new developments rather than just wait and see. For community doctors, who can impossibly oversee all relevant developments in sufficient detail, close communication with the community and clinical genetic specialists is necessary to keep pace with progress. With regard to genetic counselling and reproductive medicine, working agreements between primary care and specialist centres are important. General communication about hereditary issues can be dealt with by well informed GPs, with appropriate computerized decision support, but in order to address specific risks and disorders consultation at a clinical genetic centre is preferred. In clinical medicine, much work is being done on DNA-based 'dia-prognosis' and more targeted interventions. Estimations of when such innovations will really have an impact range from 2005 to beyond 2020, and there are still many uncertainties, especially regarding common multifactorial disorders. Community-based genetic epidemiology has become a basic science in understanding the human genome. Clinical epidemiological methodology can contribute a lot to the quality of molecular clinico-genetic studies. Long-term follow-up to evaluate predictions and interventions needs more attention, and can easily be integrated into primary care medicine. In view of the ambition to develop more tailormade interventions, research methodology will be challenged regarding n = 1 studies. With respect to counselling and clinical practice, many ethical issues, relevant for community medicine, have to be considered in the domains of both reproductive medicine and clinical practice. Doctors, patients and society, traditionally battling to reduce diagnostic and prognostic uncertainties, must now learn to cope with approaching certainties. As for all new technologies, cost-effectiveness is an important topic for genetics. Increased cost-effectiveness because of better targeted interventions may be counterbalanced by the price of the new technologies and an expanding indicated population. In view of current developments, community practitioners must integrate community genetics into their daily routine, and critically anticipate possibly relevant innovations. More efforts in genetic risk assessment and communication are necessary in undergraduate and postgraduate training. A multidisciplinary approach is needed, in collaboration with primary care-oriented genetic specialists. Efforts to educate the public and (potential) patients should start at an early age, and must focus on what (future) health care users need for a balanced appraisal of genetic information and for optimal decision making in health promotion and health care.

Achieving utility with family history: colorectal cancer risk

Family history of chronic disease is rapidly becoming a research tool for targeting participants at increased risk. Its current usefulness in clinical practice remains unknown. This paper details the possible utility and complications in using family history in a primary care setting, using colorectal cancer risk as the health issue. Where available, we cite data to support the issues that could arise. Where there are no studies, we invite further research. The potential of family history as a health improvement tool is still under review.

Women's views of consultations about familial risk of breast cancer in primary care

Developments within genetic testing may increase demands on general practitioners to advise about family history of breast cancer (FHBC). This descriptive, qualitative study, investigated women's views of GP consultations about FHBC and their context. Participants were women from the general population who had experienced a primary care consultation in which FHBC was mentioned, as reported by the practitioner. Information about women's views of consultation context was obtained from 72 telephone interviews. More in-depth information about context and women's evaluations of FHBC consultations were obtained from a sub-sample of 20 face to face interviews. FHBC was rarely the main focus of consultations. It featured as a part of an overall discussion of breast symptoms, treatment and cancer risk. Women's understanding of heredity and disease was often idiosyncratic and might differ from biomedical models. A main task for clinicians appeared to be appropriate reassurance. Failure to reassure was linked to a failure to provide explanations at the woman's level of understanding. Clinicians cannot assume that patients share their perceptions of the mechanisms of disease and heredity. Instead they need to ascertain the patient's understanding and provide explanations accordingly. GPs need to have, or access, enough knowledge to inform and reassure.

Genetics education for primary-care providers

In an era of growing knowledge about genetics and health, primary-care physicians will have increasing responsibility for evaluating genetic risk and using genetic tests. Although most have little knowledge of genetics, their expertise in the prudent use of technology is relevant to the task. Successful educational programmes will need to forge partnerships between primary care and genetics.