Awareness of genetic testing for colorectal cancer predisposition among specialists in gastroenterology

From the patient to the population: Use of genomics for population screening

Genomic medicine is expanding from a focus on diagnosis at the patient level to prevention at the population level given the ongoing under-ascertainment of high-risk and actionable genetic conditions using current strategies, particularly hereditary breast and ovarian cancer (HBOC), Lynch Syndrome (LS) and familial hypercholesterolemia (FH). The availability of large-scale next-generation sequencing strategies and preventive options for these conditions makes it increasingly feasible to screen pre-symptomatic individuals through public health-based approaches, rather than restricting testing to high-risk groups. This raises anew, and with urgency, questions about the limits of screening as well as the moral authority and capacity to screen for genetic conditions at a population level. We aimed to answer some of these critical questions by using the WHO Wilson and Jungner criteria to guide a synthesis of current evidence on population genomic screening for HBOC, LS, and FH.

Evaluation of barriers to referral for cancer predisposition syndromes in pediatric oncology patients in the United States

Cancer predisposition syndromes (CPS) are underdiagnosed in the pediatric population, though the diagnosis of a CPS has important implications for the child and their family. CPS are often diagnosed by geneticists or oncologists with expertise in CPS following a malignancy. This requires a member of the care team, most commonly, the treating oncologist to suspect a CPS and refer the patient for CPS assessment. An online survey was distributed to members of the Children's Oncology Group to elucidate current referral practices and barriers to referral for patients suspected to have a CPS. Of the 183 respondents, 86.1% was pediatric oncologists and most (68.5%) used formal guidelines to aid in assessment. Most respondents indicated they would rarely refer patients with tumors highly associated with CPS for genetic assessment. Participants were more likely to refer patients with malignancy and additional features of a CPS than for a specific type of cancer, despite the use of guidelines. Parent knowledge of family history was considered the most challenging barrier to obtaining a family history, though a thorough pedigree was not consistently elicited. Providers indicated the most significant barrier to referral for CPS assessment was priority given the patient's immediate care needs. Identification of these barriers provides direction to focus efforts to increase referrals. Provider education about CPS, clear referral guidelines, and implementation of or increased collaboration with a genetic counselor in the pediatric oncology clinic may encourage CPS assessment and enable oncologists to focus on the patient's immediate care needs.

Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care

PURPOSE

Genetic and genomic health information increasingly informs routine clinical care and treatment. This systematic review aimed to identify the barriers and facilitators to integrating genetics and genomics into nurses' and physicians' usual practice (mainstreaming).

METHODS

A search of MEDLINE, EMBASE, CINAHL, and PsycINFO generated 7873 articles, of which 48 were included. Using narrative synthesis, barriers and facilitators were mapped to the Theoretical Domains Framework (TDF).

RESULTS

Barriers were limitations to genetics knowledge and skill, low confidence initiating genetics discussions, lack of resources and guidelines, and concerns about discrimination and psychological harm. Facilitators were positive attitudes toward genetics, willingness to participate in discussions upon patient initiation, and intention to engage in genetics education.

CONCLUSION

Nurses and physicians are largely underprepared to integrate genetic and genomic health information into routine clinical care. Ethical, legal, and psychological concerns surrounding genetic information can lead to avoidance of genetics discussions. The knowledge-practice gap could limit patients' and families' access to vital genetic information. Building the capacity of the current and next generation of nurses and physicians to integrate genetics and genomics into usual clinical practice is essential if opportunities afforded by precision medicine are to be fully realized.

Views of ophthalmologists on the genetics of age-related macular degeneration: Results of a qualitative study

Background

Age-related macular degeneration (AMD) is the leading cause of blindness in industrialized countries. It is a multifactorial disease of the retina modified by environmental/individual (e.g. smoking) and genetic factors. 34 independent genomic loci are associated with the risk to develop AMD; an interaction between smoking and genetics is currently investigated. It is unclear how the knowledge on the strong genetic component has entered the knowledge base of practicing ophthalmologists, and how they inform and counsel their (AMD) patients about it. In this study, we explore the ophthalmologists’ view on AMD genetics, and their inclination towards communicating genetic risks to patients.

Methods

We recruited a purposive sample of thirty German ophthalmologists (office based: n = 15, hospital employees: n = 15, f:8/30), who took part in a recorded semi-standardized interview. Transcripts were analyzed using content analysis.

Results

The majority of office-based ophthalmologists claimed to be unfamiliar with genetics of AMD, in contrast to hospital-affiliated ophthalmologists. Both office and hospital ophthalmologists were convinced that genetics lacks practical relevance in everyday patient care. Many withhold information on heritability or genetic background of AMD from patients and their relatives, for fear of unsettling those individuals. The relevance of the genetic component of AMD or an individuals’ high genetic risk for prevention, e.g. screening or lifestyle modifications in persons with adverse genetic profile, was rated low.

Conclusion

Developing genetic educational programs tailored to the routine care of ophthalmologists may be indicated, as well as a better two-way communication between research and practice. Exploring patient views about their expectations to being informed about genetic disease etiology, or about their individual risk, would help inform communication strategies.

Cancer screening behaviors and risk perceptions among family members of colorectal cancer patients with unexplained mismatch repair deficiency

Communication gaps in families with unexplained mismatch repair (MMR) deficiency (UMMRD) could negatively impact the screening behaviors of relatives of individual with UMMRD. We evaluated cancer risk perception, screening behaviors, and family communication among relatives of colorectal cancer (CRC) patients with UMMRD. Fifty-one family members of 17 probands with UMMRD completed a questionnaire about cancer risk perception, adherence to Lynch syndrome (LS) screening recommendations, and communication with relatives. Clinical data about the probands were obtained from medical records. Thirty-eight participants (78%) were worried from having cancer and twenty-one participants (42%) had undergone colonoscopy in the past 2 years, as recommended for LS families. In terms of screening for extracolonic cancers, only two eligible participants (3.9%) were screened for gastric, endometrial (10.0%), and ovarian (9.5%) cancers. Additionally, 5 participants (10%) underwent genetic counseling. Most participants were not told by anyone to be screened for extracolonic cancers (84, 85, and 95% for gastric, ovarian, and endometrial cancers, respectively). A minority of family members of CRC patients with UMMRD follow cancer screening as recommended for LS families. Health care providers should encourage patients with UMMRD to share information on LS-related cancers screening, especially extracolonic cancers, with their relatives.

A comparison between Lynch syndrome and sporadic colorectal cancer survivors' satisfaction with their healthcare providers

This study evaluated provider satisfaction in a sample of colorectal cancer (CRC) survivors with and without Lynch syndrome (LS). Participants were case–case‐matched CRC survivors with (n = 75) or without (n = 75) LS (mean age of 55; range: 27–93). Participants completed a mailed questionnaire assessing demographics, clinical characteristics, healthcare utilization, psychosocial variables, and provider satisfaction. LS CRC survivors reported lower provider satisfaction scores on three subscales of the Primary Care Assessment Survey: communication (78.14 vs. 83.96; P < 0.05), interpersonal treatment (78.58 vs. 85.30; P < 0.05), and knowledge of the patient (60.34 vs. 69.86; P < 0.01). Among LS CRC survivors, predictors for mean communication and trust subscale scores were location of treatment and socioeconomic status. Higher mean depression scores also were associated with trust, while social support predicted higher satisfaction with communication. Sporadic CRC survivor satisfaction is driven largely by age (communication, interpersonal treatment) and patient anxiety (communication), while seeing a provider more often was associated with increased satisfaction with knowledge of the patient. LS CRC survivors reported lower levels of provider satisfaction than sporadic CRC survivors. LS survivors who received care at The University of Texas MD Anderson Cancer Center, a comprehensive cancer center (CCC), reported higher satisfaction than those receiving care at other institutions. Depressive symptoms and socioeconomic status may impact provider satisfaction ratings. Exploration of other potential predictors of provider satisfaction should be examined in this population. Additionally, further research is needed to examine the potential impact of provider satisfaction on adherence to medical recommendations in LS CRC survivors, particularly those being treated outside of CCCs.

How does genetic risk information for Lynch syndrome translate to risk management behaviours?

Background

There is limited research on why some individuals who have undergone predictive genetic testing for Lynch syndrome do not adhere to screening recommendations. This study aimed to explore qualitatively how Lynch syndrome non-carriers and carriers translate genetic risk information and advice to decisions about risk managment behaviours in the Australian healthcare system.

Methods

Participants of the Australasian Colorectal Cancer Family Registry who had undergone predictive genetic testing for Lynch syndrome were interviewed on their risk management behaviours. Transcripts were analysed thematically using a comparative coding analysis.

Results

Thirty-three people were interviewed. Of the non-carriers (n = 16), 2 reported having apparently unnecessary colonoscopies, and 6 were unsure about what population-based colorectal cancer screening entails. Of the carriers (n = 17), 2 reported they had not had regular colonoscopies, and spoke about their discomfort with the screening process and a lack of faith in the procedure’s ability to reduce their risk of developing colorectal cancer. Of the female carriers (n = 9), 2 could not recall being informed about the associated risk of gynaecological cancers.

Conclusion

Non-carriers and female carriers of Lynch syndrome could benefit from further clarity and advice about appropriate risk management options. For those carriers who did not adhere to colonoscopy screening, a lack of faith in both genetic test results and screening were evident. It is essential that consistent advice is offered to both carriers and non-carriers of Lynch syndrome.

Screening adherence and cancer risk perceptions in colorectal cancer survivors with Lynch-like syndrome

Cancer screening recommendations for patients with Lynch-like syndrome (LLS) are not well defined. We evaluated adherence to Lynch syndrome (LS) screening recommendations, cancer risk perceptions, and communication within the families among colorectal cancer (CRC) survivors with LLS. Thirty-four participants with LLS completed a questionnaire about risk perception, adherence to LS screening recommendations, and communication with relatives. Clinical data were obtained from medical records. Most participants (76%) believed they should undergo colonoscopy every 1-2 years. Only 41% correctly interpreted their genetic tests as uninformative negative or as variant of unknown significance for LS. Less than half had had an upper gastrointestinal endoscopy for screening purpose. Among female participants, 86% had been screened for endometrial cancer (EC) and 71% for ovarian cancer. Most participants had informed relatives about the CRC diagnosis and advised them to undergo CRC screening, but only 50% advised female relatives to be screened for EC and only one-third advised relatives to have genetic counseling. Most CRC survivors with LLS follow the same cancer screening recommended for LS patients but do not understand the meaning of LLS. Greater care must be devoted to communicating the implications of nondiagnostic germline mutation testing among patients with LLS.

Survey on knowledge, attitudes, and training needs of Italian residents on genetic tests for hereditary breast and colorectal cancer

Objectives. The aim of the study was to assess knowledge and attitudes of medical residents working in Università Cattolica del Sacro Cuore, Rome, Italy, on genetic tests for breast and colorectal cancer. Methods. We distributed self-administered questionnaire to the residents. Logistic regression models were used to evaluate the determinants of knowledge and attitudes towards the tests. Results. Of 754 residents, 364 filled in questionnaire. Around 70% and 20% answered correctly >80% of questions on breast and colorectal cancer tests, respectively. Knowledge on tests for breast cancer was higher among residents who attended course on cancer genetic testing during graduate training (odds ratio (OR): 1.72; 95% confidence interval (CI): 1.05–2.82) and inversely associated with male gender (OR: 0.55; 95% CI: 0.35–0.87). As for colorectal cancer, residents were more knowledgeable if they attended courses on cancer genetic testing (OR: 2.08; 95% CI: 1.07–4.03) or postgraduate training courses in epidemiology and evidence-based medicine (OR: 1.95; 95% CI: 1.03–3.69). More than 70% asked for the additional training on the genetic tests for cancer during the specialization school. Conclusion. The knowledge of Italian residents on genetic tests for colorectal cancer appears to be insufficient. There is a need for additional training in this field.

Are public health professionals prepared for public health genomics? A cross-sectional survey in Italy

Background

Public health genomics is an emerging multidisciplinary approach, which aims to integrate genome-based knowledge in a responsible and effective way into public health. Despite several surveys performed to evaluate knowledge, attitudes and professional behaviors of physicians towards predictive genetic testing, similar surveys have not been carried out for public health practitioners. This study is the first to assess knowledge, attitudes and training needs of public health professionals in the field of predictive genetic testing for chronic diseases.

Methods

A self-administered questionnaire was used to carry out a cross-sectional survey of a random sample of Italian public health professionals.

Results

A response rate of 67.4% (797 questionnaires) was achieved. Italian public health professionals have the necessary attitudinal background to contribute to the proper use of predictive genetic testing for chronic diseases, but they need additional training to increase their methodological knowledge. Knowledge significantly increases with exposure to predictive genetic testing during postgraduate training (odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.05–2.88), time dedicated to continuing medical education (OR = 1.53, 95% CI = 1.14–2.04) and level of English language knowledge (OR = 1.36, 95% CI = 1.07–1.72). Adequate knowledge is the strongest predictor of positive attitudes from a public health perspective (OR = 3.98, 95% CI = 2.44–6.50). Physicians show a lower level of knowledge and more public health attitudes than other public health professionals do. About 80% of public health professionals considered their knowledge inadequate and 86.0% believed that it should be improved through specific postgraduate training courses.

Conclusions

Specific and targeted training initiatives are needed to develop a skilled public health workforce competent in identifying genomic technology that is ready for use in population health and in modeling public health genomic programs and primary care services that need to be developed, implemented and evaluated.

Knowledge, attitudes and referral patterns of lynch syndrome: a survey of clinicians in australia

This study assessed Australian clinicians’ knowledge, attitudes and referral patterns of patients with suspected Lynch syndrome for genetic services. A total of 144 oncologists, surgeons, gynaecologists, general practitioners and gastroenterologists from the Australian Medical Association and Clinical Oncology Society responded to a web-based survey. Most respondents demonstrated suboptimal knowledge of Lynch syndrome. Male general practitioners who have been practicing for ≥10 years were less likely to offer genetic referral than specialists, and many clinicians did not recognize that immunohistochemistry testing is not a germline test. Half of all general practitioners did not actually refer patients in the past 12 months, and 30% of them did not feel that their role is to identify patients for genetic referral. The majority of clinicians considered everyone to be responsible for making the initial referral to genetic services, but a small preference was given to oncologists (15%) and general practitioners (13%). Patient information brochures, continuing genetic education programs and referral guidelines were favoured as support for practice. Targeted education interventions should be considered to improve referral. An online family history assessment tool with built-in decision support would be helpful in triaging high-risk individuals for pathology analysis and/or genetic assessment in general practice.

Knowledge, attitudes and behavior of physicians regarding predictive genetic tests for breast and colorectal cancer

BACKGROUND

Genetic testing for cancer susceptibility is an emerging technology in medicine. This study assessed the knowledge, attitudes and professional behavior of Italian physicians regarding the use of predictive genetic tests for breast and colorectal cancer, including the BRCA1/2 and APC tests.

METHODS

A cross-sectional survey of a random sample of Italian physicians was performed in 2010 through a self-administered questionnaire.

RESULTS

A response rate of 69.6% (1079 questionnaires) was achieved. A significant lack of knowledge was detected, particularly for APC testing. Less than half of the physicians agreed on the importance of efficacy and cost-effectiveness evidence in the selection of predictive genetic tests to be offered to the patients. Multiple logistic regression analyses showed that education had a positive influence on knowledge, attitudes and, to a lesser extent, professional use. The factor most strongly related to the physicians' use of genetic testing was patients requests for breast (odds ratio=12.65; 95% confidence interval 7.77-20.59) or colorectal cancer tests (odds ratio=7.02; 95% confidence interval 3.61-13.64). A high level of interest for specific training was reported by almost all physicians surveyed.

CONCLUSIONS

Targeted educational programs are needed to improve the expertise of physicians, and, ultimately, to enhance the appropriate use of genetic tests in clinical practice.

Knowledge of and practice patterns for hereditary colorectal cancer syndromes in korean surgical residents

Purpose

Obtaining a detailed family history through detailed pedigree is essential in recognizing hereditary colorectal cancer (CRC) syndromes. This study was performed to assess the current knowledge and practice patterns of surgery residents regarding familial risk of CRC.

Methods

A questionnaire survey was performed to evaluate the knowledge and the level of recognition for analyses of family histories and hereditary CRC syndromes in 62 residents of the Department of Surgery, Seoul National University Hospital. The questionnaire consisted of 22 questions regarding practice patterns for, knowledge of, and resident education about hereditary CRC syndromes.

Results

Two-thirds of the residents answered that family history should be investigated at the first interview, but only 37% of them actually obtained pedigree detailed family history at the very beginning in actual clinical practice. Three-quarters of the residents answered that the quality of family history they obtained was poor. Most of them could diagnose hereditary nonpolyposis colorectal cancer and recommend an appropriate colonoscopy surveillance schedule; however, only 19% knew that cancer surveillance guidelines differed according to the family history. Most of our residents lacked knowledge of cancer genetics, such as causative genes, and diagnostic methods, including microsatellite instability test, and indicated a desire and need for more education regarding hereditary cancer and genetic testing during residency.

Conclusion

This study demonstrated that surgical residents' knowledge of hereditary cancer was not sufficient and that the quality of the family histories obtained in current practice has to be improved. More information regarding hereditary cancer should be considered in education programs for surgery residents.

Precancerous lesions in colorectal cancer

Colorectal cancer (CRC) is the third most common cause of cancer death in the world. The incidence rate (ASR) and age distribution of this disease differ between most of African-Middle-Eastern (AMAGE) and North America and Europe for many reasons. However, in all areas, "CRC" is considered as one of the most preventable cancers, because it might develop from variant processes like polyps and IBD in addition to the genetic pathogenesis which became very well known in this disease. We tried in this paper to review all the possible reasons of the differences in incidence and age between the west and AMAGE. Also we reviewed all the mutations that lead to the hereditary and familiar clustering of this disease with the correlations with the surrounding food and environment of different areas. Then, we focused on the precancerous pathology of this disease with special focusing on early detection depending on new endoscopy technology and most important genetic studies. We lastly reviewed the evidence of some of the surveillance and put suggestions about future surveillance programs and how important those programs are on the psychological aspect of the patients and their families.

Familial colorectal cancer risk assessment needs improvement for more effective cancer prevention in relatives

AIM

Twelve to thirty % of colorectal cancer (CRC) patients and relatives with an increased familial risk of CRC are referred for preventive measures. New guidelines recommend genetic counselling for high-risk families and surveillance colonoscopy for moderate-risk families. Assessment of familial risk of CRC and referral rates for these preventive measures were determined 1 year after the introduction of new guidelines.

METHOD

Assessment of familial risk of CRC and referral for preventive measures were measured in clinical practice among 358 patients with CRC in 18 hospitals using medical records and questionnaires. Additionally, a knowledge survey was performed among 312 clinicians.

RESULTS

Sixty-seven % of patients with an increased familial risk (n = 65/97) were referred for preventive measures, as were 23% (61/261) of low-risk patients. The uptake of genetic counselling in high-risk families was 33% (12/36). The uptake of surveillance colonoscopy in moderate-risk families was 34% (21/61). In the knowledge survey clinicians correctly determined familial risk in 55% and preventive measures in 65% of cases.

CONCLUSION

Currently 67% of individuals with an increased familial risk of CRC were referred for preventive measures. Only one-third were referred in accordance with guidelines.

Recording of family history is associated with colorectal cancer stage

BACKGROUND

Colorectal cancer (CRC) associated with Lynch syndrome usually presents at a relatively young age. The Revised Bethesda Guidelines advise screening for Lynch syndrome in patients diagnosed with CRC and a positive family history (FH) of CRC and other Lynch-related cancers.

OBJECTIVE

To evaluate recording of the FH and identify factors associated with recording in young patients with CRC.

PATIENTS AND METHODS

In one academic and two nonacademic hospitals, of all patients diagnosed with CRC at the age of 60 years or younger between 1999 and 2007, electronic medical records were evaluated for a recorded FH of CRC and other Lynch-related cancers. Patient and tumor characteristics were retrieved from the Dutch Comprehensive Cancer Centre and the Dutch Pathological Archive.

RESULTS

A total of 676 patients were identified. FH was recorded in 395/676 (58%) patients. From 1999 to 2007, recording improved with an odds ratio (OR) of 1.10 [95% confidence interval (CI) 1.03-1.17] per year. Stage III CRC (OR 1.71, 95% CI 1.07-2.75) and administration of chemotherapy (OR 1.84, 95% CI 1.17-2.89) were associated with recording in multivariate analysis. Other factors, including age at diagnosis, sex, surgery, radiotherapy, proximal tumor localization, poor differentiation, and mucinous histology, were not associated with recording.

CONCLUSION

A FH of CRC and other Lynch-related cancers was not recorded in ∼40% of young CRC patients and recording improved only slightly over the years. As a first step in the identification of Lynch-related cancer families, physicians should be trained to record a detailed FH in the work-up of all newly diagnosed CRC patients.

Key genetic considerations in the management of suspected hereditary colorectal cancer

SUMMARY Hereditary bowel cancer syndromes account for up to 5% of colorectal cancer (CRC) incidence. Presentation of CRC under the age of 50 years should alert clinicians to a possible underlying genetic predisposition. This article focuses on Lynch syndrome (hereditary nonpolyposis CRC). Regular bowel screening is effective in reducing the risk of CRC and improving overall survival in Lynch syndrome families. The issues surrounding the clinical diagnostic criteria and the shortcomings of the referral process are described, and it is questioned whether a universal strategy for diagnosis should be employed. This article summarizes the evidence for the benefit of bowel screening and suggests practical steps to help ensure compliance with screening recommendations. Finally, it is discussed how collaboration between geneticists, gastroenterologists and surgeons can inform surgical decision-making for the benefit of the patient.

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.

Screening for Familial Colorectal Cancer Risk amongst Colonoscopy Patients New to an Open-Access Endoscopy Center

Purpose. We evaluated a questionnaire to aid in the recognition of CRC risk, as well as patient interest in their risk status within an open-access endoscopy center. Methods. A questionnaire was administered to new patients presenting for colonoscopy from May 2007 to February 2008. 287 patients were enrolled. Family history was evaluated using Amsterdam 1, II, and Revised Bethesda criteria. Recognition of risk and referral for counseling was assessed. Patients' interest to be contacted by a genetic counselor was also assessed. Results. 13.2 % (38/287) of patients met Revised Bethesda criteria. Of these, 18 (47.4 %) were previously told about their increased risk for CRC. Only 1 patient who met Revised Bethesda criteria (2.6 %) was previously referred for genetics, whereas none of the 3 patients who met Amsterdam I or II criteria were referred. 23.7 % of high-risk patients did not want to be contacted if found to be at increased risk for cancer. Conclusion. In our open-access endoscopy system, a significant number of high-risk patients remain unidentified and underreferred for genetic counseling due to numerous barriers. Our findings lend support to taking a public health approach to identifying those at risk for Lynch syndrome by implementing universal screening of all CRC specimens.

Lynch syndrome: barriers to and facilitators of screening and disease management

Background

Lynch syndrome is a hereditary cancer with confirmed carriers at high risk for colorectal (CRC) and extracolonic cancers. The purpose of the current study was to develop a greater understanding of the factors influencing decisions about disease management post-genetic testing.

Methods

The study used a grounded theory approach to data collection and analysis as part of a multiphase project examining the psychosocial and behavioral impact of predictive DNA testing for Lynch syndrome. Individual and small group interviews were conducted with individuals from 10 families with the MSH2 intron 5 splice site mutation or exon 8 deletion. The data from confirmed carriers (n = 23) were subjected to re-analysis to identify key barriers to and/or facilitators of screening and disease management.

Results

Thematic analysis identified personal, health care provider and health care system factors as dominant barriers to and/or facilitators of managing Lynch syndrome. Person-centered factors reflect risk perceptions and decision-making, and enduring screening/disease management. The perceived knowledge and clinical management skills of health care providers also influenced participation in recommended protocols. The health care system barriers/facilitators are defined in terms of continuity of care and coordination of services among providers.

Conclusions

Individuals with Lynch syndrome often encounter multiple barriers to and facilitators of disease management that go beyond the individual to the provider and health care system levels. The current organization and implementation of health care services are inadequate. A coordinated system of local services capable of providing integrated, efficient health care and follow-up, populated by providers with knowledge of hereditary cancer, is necessary to maintain optimal health.

Barriers to and motivations for physician referral of patients to cancer genetics clinics

Although it is well known that under-referral of colon cancer patients to cancer genetics clinics is a chronic problem, no study has yet examined why physicians may be ordering testing independently rather than referring patients to cancer genetics clinics. The current study explored variables which may impact a physician's preference for ordering testing independently or referring patients to outside cancer genetics experts. An online questionnaire, distributed to the membership of the American College of Gastroenterology and the American Society of Colorectal Surgeons, yielded responses from 298 physicians. Motivations to refer to cancer genetics clinics rather than order testing independently included fear of genetic discrimination and a belief that patients benefit from genetic counseling about the risks, benefits and consequences of testing. These results suggest that in order to increase referrals, genetic counselors must educate physicians about the unique benefits patients receive from participating in genetic counseling.

CLINICAL MANAGEMENT OF FAMILIES WITH HEREDITARY COLORECTAL CANCER SYNDROMES

Hereditary colorectal cancer syndromes can be associated with a lifetime risk of CRC of >70% in the absence of specialized surveillance. Diagnosing a genetic predisposition to cancer allows clinicians to tailor cancer prevention strategies for patients and families at highest risk. Once a genetic syndrome has been identified in a family, communication with family members, timely implementation of screening tests and/or surgeries, and psychosocial support are all instrumental for effective cancer prevention.Molecular screening of tumors, computerized risk assessment models, and genetic testing can help clinicians identify individuals at risk for hereditary cancer syndromes. This review discusses some of the complexities involved in the diagnosis and management of families with hereditary CRC syndromes and provides strategies for coordinating clinical care.

General practitioner management of genetic aspects of a cardiac disease: a scenario-based study to anticipate providers' practices

It is increasingly recognised that genetics will have to be integrated into all parts of primary health care. Previous research has demonstrated that involvement and confidence in genetics varies amongst primary care providers. We aimed to analyse perceptions of primary care providers regarding responsibility for genetic tasks and factors affecting those perceptions. Postal questionnaire including a hypothetical case management scenario of a cardiac condition with a genetic component was sent to random samples of medically qualified general practitioners in France, Germany, Netherlands, Sweden and UK (n = 1,168). Logistic regression analysis of factors affecting primary care practitioners' willingness to carry out genetic tasks themselves was conducted; 61% would take a family history themselves but only 38% would explain an inheritance pattern and 16% would order a genetic test. In multivariate analysis, only the country of practice was consistently predictive of willingness to carry out genetic tasks, although male gender predicted willingness to carry out the majority of tasks studied. The stage of career at which education in genetics had been provided was not predictive of willingness to carry out any of the tasks analysed. Country of practice is significantly predictive of attitudes towards genetics in primary care practice and therefore genetic education structure and content in Europe will need to be significantly tailored towards country-specific approaches.

Muir-Torre syndrome: Facts and controversies

The cutaneous presentation of a tumor sometimes has implications for a patient and his or her family, and Muir-Torre syndrome is an example of this. Because a single skin lesion can have broad consequences, it is important for clinicians to be aware of Muir-Torre syndrome. The definition, potential clues, the role of ancillary testing (microsatellite, immunohistochemical, and genetic), and screening recommendations are reviewed.

An examination of the psychosocial factors influencing colorectal cancer patients' communication of colorectal cancer patient risk with their siblings

This study examined psychosocial factors influencing colorectal cancer (CRC) patients' communication with their first-degree relatives regarding their CRC risk. Among a sample of CRC patients who were members of a colon registry in New York (n = 127), 60% reported discussing CRC risk with their siblings. These discussions were related to the CRC patients' age of diagnosis, such that those diagnosed before age 45 years were more likely to communicate with their siblings about CRC risk. Despite advances made in CRC prevention, compliance with screening recommendations among individuals who may be at familial risk for the disease is low. Perhaps this underrepresentation reflects how CRC patients communicate with their first-degree relatives about their potential risk for the disease. This study examined the psychosocial factors influencing whether CRC patients communicate with their siblings about CRC risk. The sample included CRC patients with siblings who enrolled in a colon disease registry at a NYC metropolitan hospital. Participants completed questionnaires regarding their current psychosocial functioning, perceived risk of sibling's development of CRC, and communication of CRC risk with their siblings. Patients were predominantly Caucasian, with a mean age of 60.4 years. Of the 127 patients, 60% engaged in discussions with their siblings regarding their CRC risk. Patients diagnosed with CRC before the age of 45 years were more likely to discuss the risk of CRC with their siblings (P < 0.01). These data suggest that CRC patients may serve as an effective vehicle to promote CRC screening and support the need for health care providers to not only educate patients of the familial risk of CRC, but to also encourage these patients to communicate this information with their siblings.

How can we reach them? Information seeking and preferences for a cancer family history campaign in underserved communities

Individuals with a family history of cancer are at elevated risk for the disease, and web-based tools are available to assist in assessing risk. Preferences for a potential campaign to promote awareness of the role of family history in cancer risk were sought, guided by McGuire's Input-Output Persuasion Model. A randomized telephone survey administered to five underserved communities assessed potential campaign messages, channels, sources, receivers, and destinations and use of the Internet (n = 101). Information sources sought about hereditary cancer and their predictors were assessed. Nearly half of the sample was African American and had annual income below $25,000. Most (59%) had Internet access at home. Few differences emerged as a function of race (African American vs. Other). The Internet was the most common (43%) first source sought for hereditary cancer information, followed by physicians (23%). In univariate multinomial logistic regression models, those with a high school education or more and those with greater family history (trend) were more likely than those without to choose the Internet as their first source of information over physicians. Our survey provided a wealth of information for understanding how to best launch our family history cancer risk communication campaign. Education level affected information seeking, and efforts are under way to lessen this potential barrier.

Family history? The forgotten question in high-risk colorectal cancer patients

AIM

The aim of the study was to investigate the frequency and detail of family history recorded for patients diagnosed with potentially high-risk colorectal cancer, and to determine the proportion of these patients referred to a high-risk assessment clinic.

METHOD

Medical records of patients diagnosed with colorectal cancer under the age of 50 admitted to a major Sydney teaching hospital were reviewed. The proportion of records containing information about family history was calculated. Associations between recording of family history and demographic and clinical characteristics of patients were investigated. Logistic regression modelling was performed to identify significant, independent predictors of study outcomes.

RESULTS

Of 113 patients with colorectal cancer diagnosed under the age of 50 years, 61 (54%, 95% CI: 44-63%) had an entry in their hospital medical record about family history. Family history was significantly less likely to be recorded for females, for those admitted via the Emergency Department, and for those with shorter lengths of stay. A significant family history was found in 51% of the 61 patients who had a family history recorded. Records of patients attending specialist colorectal surgeons were significantly more likely to contain information about family history than those who attended other specialists (P = 0.04). Only 14 patients (12%, 95% CI: 7-20%) were formally referred for further genetic assessment.

CONCLUSION

These results suggest that family history is still being neglected in routine clinical practice, and high-risk assessment services are underutilized, implying the need for further dissemination of guidelines with regard to the recognition and management of hereditary colorectal cancer.

Knowledge about hereditary nonpolyposis colorectal cancer; mutation carriers and physicians at equal levels

Background

Identification and adequate management of individuals at risk for hereditary nonpolyposis colorectal cancer (HNPCC) is crucial since surveillance programmes reduce morbidity and mortality. We investigated knowledge about key features of HNPCC in at risk individuals and physicians in surgery, gynecology and oncology.

Methods

Data were collected using a questionnaire which was answered by 67 mutation carriers and 102 physicians from the southern Swedish health care region. The statements were related to colorectal cancer, heredity and surveillance and the physicians were also asked questions about cancer risks and surveillance strategies.

Results

Both groups answered questions on colorectal cancer risk, surveillance and genetic testing well, whereas answers about inheritance and risks for HNPCC associated cancer were less accurate. Only half of the family members and one third of the physicians correctly estimated the risk to inherit an HNPCC predisposing mutation. Among family members, young age (<57 years), female sex and recent genetic counseling significantly correlated with better results. Physicians generally underestimated the risk of HNPCC associated cancers and three out of four suggested a later starting age for surveillance than recommended.

Conclusion

The finding of similar levels of knowledge about key features of HNPCC in at risk individuals and physicians reflect the challenge physicians face in keeping up to date on hereditary cancer and may have implications for the clinical management and professional relations with HNPCC family members.

Hereditary colorectal cancer syndromes and the role of the surgical oncologist

The expanding understanding of the genetic basis to hereditary colon cancer syndromes is dismantling previously conceived categorizations and shedding light on why those schemes often failed in past. This review highlights evolving concepts regarding the genetic diagnosis and clinical management of the more commonly inherited colorectal cancer syndromes, including a discussion of recently described familial syndromes. This review also addresses clinician responsibilities in recognition of familial syndromes and provision of counseling.

Cancer risk assessment by rural and Appalachian family medicine physicians

CONTEXT

Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region.

PURPOSE

To examine primary care physicians' identification of hereditary cancers.

METHODS

A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (n = 176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed.

FINDINGS

Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario.

CONCLUSIONS

Though rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.

Identification of patients at increased risk for colorectal cancer in an open access endoscopy center

GOALS

To determine whether patients referred for open access endoscopy (OAE) are being appropriately identified as "increased risk" or "average risk" for colorectal cancer (CRC) by referring physicians.

BACKGROUND

OAE allows nongastroenterologists to schedule elective endoscopies without prior consultation with a gastroenterologist. It is unknown how accurately referring physicians identify CRC risk of such patients.

METHODS

We retrospectively reviewed the records of outpatients referred to a single OAE center for screening or surveillance colonoscopy from July 1, 2001 to November 8, 2002. Before colonoscopy, a 3-question tool was used to stratify each patient as average risk or increased risk for CRC. CRC risk assessment was compared with the referring physician's indication for colonoscopy. Chi-square testing was used to compare the incidence of neoplastic polyps between average risk and increased risk patients.

RESULTS

Two hundred eighty-eight patients met inclusion criteria. Referring physicians accurately identified 61% of 126 increased risk patients, including 13 of 19 patients (68%) with a personal history of CRC, 29 of 61 patients (48%) with a family history of CRC, 47 of 61 patients (77%) with a personal history of colonic polyps, and 0 of 8 patients (0%) who met clinical criteria for hereditary nonpolyposis colorectal cancer. Adenomatous polyps were found in 24% of average risk patients compared with 41% of increased risk patients (P<0.01).

CONCLUSIONS

In an OAE system, referring physicians often fail to correctly identify patients at increased risk for CRC. Our 3-question tool for risk assessment helps to better identify patients at increased risk of CRC and can be used by gastroenterologists to stratify patients referred for OAE.

Promotion of cancer family history awareness: Jameslink Cancer Risk Assessment Tool at community health fairs

This article examines the impact of providing personalized familial cancer risk assessments with the Jameslink Cancer Risk Assessment Tool. Users of the Jameslink (N = 166) at eight community health fairs completed a survey including demographic, psychosocial and behavioral variables to better understand responses to the Jameslink. No differences were found between whites and those of other races for variables of interest, indicating suitability of the Jameslink for diverse populations. Those with higher Jameslink-assessed risk had higher perceived risk of cancer. Approximately half (53.8%) reported that they would speak to their physician about their Jameslink-assessed risk. A regression found Jameslink-assessed risk, cancer worry, and perceived risk of cancer predicted intentions to speak to a physician about their risk. In addition, open-ended data provided suggestions to improve the Jameslink. Changes in content and format were suggested; however most were happy with the program and encouraged its promotion. The lack of findings for differences as a function of race bolsters the use of computerized Cancer Risk Assessment Tools in diverse communities. The positive feedback of users and the close association between cancer risk assessment, perceived risk, and intention to speak to a physician are supportive of continued use and development of Cancer Risk Assessment Tools in the community to promote awareness of cancer risk.

Syndromic colon cancer: lynch syndrome and familial adenomatous polyposis

Colon cancer, the third leading cause of mortality from cancer in the United States, afflicts about 150,000 patients annually. More than 10% of these patients exhibit familial clustering. The most common and well characterized of these familial colon cancer syndromes is hereditary nonpolyposis colon cancer syndrome (Lynch syndrome), which accounts for about 2% to 3% of all cases of colon cancer in the United States. We review the current knowledge of familial cancer syndromes, with an emphasis on Lynch syndrome and familial adenomatous polyposis.

Most patients with colorectal tumors at young age do not visit a cancer genetics clinic

PURPOSE

This study examined the referral process for genetic counseling at a cancer genetics clinic in patients with colorectal cancer and to search for determinants of variation in this referral process.

METHODS

Patients who were recently diagnosed with colorectal cancer at a young age or multiple cancers associated with Lynch syndrome, hereditary nonpolyposis colorectal cancer, (N = 119) were selected from PALGA, the nationwide network and registry of histopathology and cytopathology in the Netherlands. In a retrospective analysis, we examined whether these patients visited a cancer genetics clinic and identified determinants for referral to such a clinic. Factors of patients, professional practice, and hospital setting were explored with logistic regression modeling.

RESULTS

Thirty-six (30 percent) patients visited a cancer genetics clinic. Seventy percent of patients whom the surgeon referred to a cancer genetics clinic decided to visit such a clinic. Analysis of determinants showed that patients with whom the surgeon discussed referral and that were treated in a teaching hospital were more likely to visit a cancer genetics clinic.

CONCLUSION

The referral process is not optimally carried out. To deliver optimal care for patients suspected of hereditary colorectal cancer, this process must be improved with interventions focusing on patient referral by surgeons and raising awareness in nonteaching hospitals.

The importance of genetic counseling for individuals with schizophrenia and their relatives: potential clients' opinions and experiences

Genetic counseling is a health service, which has been indicated for individuals with psychiatric conditions in their families. However, little is known about the awareness and/or experiences of genetic counseling of this group. This study was designed to assess the awareness and perceptions of genetic counseling among individuals affected by schizophrenia and their relatives. Data was collected via two online surveys. Study participants either had schizophrenia or had a relative with schizophrenia and were recruited via links from schizophrenia web sites. This study was granted IRB approval. Sixty-eight individuals with schizophrenia and 145 relatives completed the surveys. Ninety-four percent of all respondents had not been offered genetic counseling. Zero percent of affected individuals and only 5% of relatives had received genetic counseling. Forty-four percent of affected individuals and 41% of relatives indicated that their family planning decisions were influenced by the presence of schizophrenia in their family. Seventy four percent of relatives and 72% of people with schizophrenia thought genetic counseling would be useful to them. Respondents indicated that they felt genetic counseling would be useful for them and that they would like to see a genetic counselor. However, few individuals are being offered genetic counseling services. The awareness of genetic counseling needs to be raised among physicians and families affected by schizophrenia.

Cancer genetics: consultants' perceptions of their roles, confidence and satisfaction with knowledge

RATIONALE, AIMS AND OBJECTIVES

Genetic testing for susceptibility for common cancers is widely available. Cancer specialists and specialists in other areas may have a role in identifying and referring patients who would benefit from a consultation with a specialist in genetics. This study aimed to find out which consultants believed that genetic testing was relevant to their practice. We also wanted to determine their views of their roles in relation to genetic testing, their confidence in these roles, and the value of different educational tools.

METHODS

This was a self-completed, cross-sectional, postal survey of all the consultants in Northern Ireland (n=520, response rate=59.3%) identified from the Central Services Agency list.

RESULTS

Three hundred and ninety questionnaires were returned (44%). A total of 28.6% did not complete the questionnaire stating that genetics was not relevant to their practice. Few consultants reported having consultations related to genetic disease, receiving training in genetics and referring to genetics services. There was some dissatisfaction with their current knowledge of genetics and they believed that guidelines and educational tools may be useful. The respondents lacked confidence in undertaking some of their roles. Through their responses to the cancer scenarios, these consultants showed that they would offer appropriate advice and referrals. Many consultants did not know if family history information should be provided to insurance companies.

CONCLUSIONS

Some consultants may require further training to enable them to fulfil their roles in relation to genetics. Tools or guidelines to assist with referral decisions may also be useful. Consultants may need clearer guidance regarding the provision of family history information to insurance companies.

In search of a familial cancer risk assessment tool

Approximately one in three individuals will be affected by cancer in their lifetime in the United States, and some are at elevated risk because of family history. Although assessment of family history of cancer and cancer risk is the standard of care, the current health-care system appears unable to meet this need. Because individuals are increasingly using the Internet, web-based cancer risk assessment tools (CRATs) may provide a way to meet this need. The purpose of this review was to evaluate the types of familial CRATs available on the Internet and their nature. The current review evaluated five CRATs identified through an Internet search based on (i) their ability to identify those at the highest risk of cancer (i.e. those with hereditary cancer syndromes), (ii) their strengths and limitations based on criteria adapted from Rich and colleagues (2004, 2005), (iii) their readability based on four readability calculations, and (iv) their quality based on criteria from Health on the Net. The general limitations of CRATs as a whole were also delineated, including concerns about availability to those who are poor and underserved and those who have lower levels of literacy. Recommendations for future tools include assessing risk for a greater number of diseases, using theoretically driven approaches to increase the likelihood that individuals will engage in appropriate health behaviors, and making a greater effort to reach diverse populations.

Genetic education for non-geneticist health professionals

OBJECTIVES

It was the aim of this study to assess educational needs and priorities in genetics amongst non-genetic health professionals.

METHODS

The methods used included website reviews and direct contact with individuals and organisations involved in health professional education.

RESULTS AND CONCLUSIONS

Health professional education and training differed in structure with wide variation in the content and duration of genetics education provided. Evidence from the UK, France and Germany indicates that genetics professionals are influencing the genetics content of medical curricula. In post-graduate training, some specialist regulators have adopted specific genetics education requirements, but many programmes lack any explicit genetics. We show that within each country, a sometimes confusing plethora of organisations has responsibility for setting, assessing and delivering medical and midwifery education.

Genetic education and nongenetic health professionals: Educational providers and curricula in Europe

PURPOSE

Advances in and diffusion of genetic technology mean that nongeneticist health professionals have an increasing need to develop and maintain genetic competencies. This has been recognized by patient support groups and the European Commission. As the first phase of the GenEd (Genetic Education for Nongenetic Health Professionals) project, we investigated health professional education at undergraduate, postgraduate, and continuing levels in terms of genetic content and delivery.

METHODS

Information was collected in the five GenEd partner countries (France, Germany, Netherlands, Sweden, and the UK) by reviewing published curricula and web sites and by directly contacting educational and regulatory organizations. Information was also requested from a further six South and East European collaborators (Greece, Hungary, Italy, Lithuania, Poland, and Spain).

RESULTS

Health professional education and training differed in structure with wide variation in the content and duration of genetic education provided. France and Germany have national undergraduate medical curricula but with minimal overt genetic content, mainly confined to basic science courses. In Sweden, Netherlands, and the UK, the content is largely at the discretion of individual universities. Evidence from the UK, France, and Germany indicates that genetic professionals are influencing the genetic content of medical curricula. In postgraduate training, some specialist regulators have adopted specific genetic educational requirements, but many programs lack any explicit genetics. Within each country many organizations have responsibility for setting, assessing, and delivering medical and midwifery education.

CONCLUSIONS

Due to the multiplicity of organizations involved in the provision of genetic education, changing professional education is likely to be challenging. However, it may be that development of a multiprofessional consensus across Europe is achievable. The strategy adopted by the US National Coalition for Health Professional Education in Genetics may be helpful.

Hereditary breast/ovarian and colorectal cancer genetics knowledge in a national sample of US physicians

BACKGROUND

Clinically relevant genetics knowledge is essential for appropriate assessment and management of inherited cancer risk, and for effective communication with patients. This national physician survey assessed knowledge regarding basic cancer genetics concepts early in the process of introduction of predictive genetic testing for breast/ovarian and hereditary non-polyposis colorectal cancer (HNPCC) syndromes.

METHODS

A stratified random sample was selected from the American Medical Association Masterfile of all licensed physicians. In total, 1251 physicians (820 in primary care, 431 in selected subspecialties) responded to a 15 minute questionnaire (response rate 71%) in 1999-2000. Multivariate logistic regression analyses were conducted to identify demographic and practice characteristics associated with accurate response to three knowledge questions.

RESULTS

Of the study population, 37.5% was aware of paternal inheritance of BRCA1/2 mutations, and 33.8% recognised that these mutations occur in <10% of breast cancer patients. Only 13.1% accurately identified HNPCC gene penetrance as >or=50%. Obstetrics/gynaecology physicians, oncologists, and general surgeons were significantly more likely than general and family practitioners to respond accurately to the breast/ovarian questions, as were gastroenterologists to the HNPCC question.

CONCLUSIONS

These nationally representative data indicate limited physician knowledge about key cancer genetics concepts in 1999-2000, particularly among general primary care physicians. Specialists were more knowledgeable about syndromes they might treat or refer elsewhere. Recent dissemination of practice guidelines and continued expansion of relevant clinical literature may enhance knowledge over time. In addition to educational efforts to assist physicians with the growing knowledge base, more research is needed to characterise the organisational changes required within the healthcare system to provide effective cancer genetics services.

A clinician's guide to hereditary colon cancer

Approximately 10% of patients diagnosed with colorectal cancer are at risk for a hereditary form of the disease. At-risk patients can be offered genetic counseling and testing to determine whether they carry a detectable mutation for such a syndrome. If so, this information provides the clinician with valuable data about the patient's risk for other cancers, and what further surveillance and risk reduction options should be incorporated into the management plan. Mutation identification within a family also makes it possible for other family members to learn if they are at risk for the same syndrome. There are many hereditary colorectal cancer syndromes, and the clinician must know what essential information should be elicited from a family history and which patients should be referred for genetic counseling and testing.

Age and manifestation related symptoms in familial adenomatous polyposis

BACKGROUND

To identify early symptoms of familial adenomatous polyposis with a view to improve early diagnosis and treatment. Diagnosis on the basis of genetic testing is usually limited to where there is a known family history, so FAP is more usually diagnosed on clinical grounds. Except for those identified via FAP registers, the majority of patients are symptomatic at the time of diagnosis.

METHODS

We undertook a retrospective study of 143 FAP patients treated at the Department of Surgery, University of Erlangen between 1971 and 2000. We identified patterns of symptoms, endoscopic findings and extracolonic manifestations in three age groups.

RESULTS

FAP was diagnosed clinically on the basis of symptoms in 84% (120/143) of these patients. Most presented with intestinal symptoms such as colonic bleeding (68%) and diarrhea (42%). All but one of the patients between 20 and 40 years old had rectal polyps (98.7%, 75/76), whereas in those over 40 years old the prevalence was 76% (35/46). Non-specific symptoms such as abdominal pain, fatigue and bloating were less frequent and were mainly reported by patients older than 40.

CONCLUSION

The commonest presenting features of FAP are alteration of bowel habit and rectal bleeding, but both are found in many other conditions. Patients with these findings need immediate endoscopy to allow prompt diagnosis and prophylactic surgery.

Physician assessment of family cancer history and referral for genetic evaluation in colorectal cancer patients

BACKGROUND AND AIMS

An accurate family history is an essential component of cancer risk assessment. Our aim was to determine the concordance of family history assessments made by physicians with patients' self-reports and the frequency of referral for genetic evaluation in high-risk colorectal cancer (CRC) patients.

METHODS

A self-administered family cancer history questionnaire was completed by 387 consecutive CRC patients at their first visit to a gastroenterology cancer clinic. Physician notes from the first visit were reviewed to determine the concordance of the family cancer history with patients' self-reported history. Prevalence of individuals that satisfied the Bethesda guidelines for hereditary colon cancer were compared with actual rates of referral. Regression analyses were used to determine factors associated with a comprehensive physician evaluation of family history.

RESULTS

Oncologists documented a comprehensive family history in 59% (184 of 311) of patients with a first- or second-degree relative with cancer. Young age at diagnosis and a first-degree relative with CRC were not associated with a more comprehensive family history assessment. An increasing number of cancers per family was a strong predictor of a less comprehensive family history assessment (odds ratio = 0.63; P < 0.0001). Seventy-five of 387 (19%) CRC patients met Bethesda guidelines for genetics assessment, however, only 13 of 75 (17%) were referred.

CONCLUSIONS

Increased complexity in family cancer history leads to a decrease in accuracy of family history, suggesting the need for systematic approaches to facilitate family history assessment. Familial cancer risk remains largely unrecognized and referral rates for genetic evaluation for CRC syndromes are low.

Who gets the information about genetic testing for cancer risk? The role of race/ethnicity, immigration status, and primary care clinicians

This study identified factors associated with awareness of genetic testing for cancer risk in the US general population. Multiple logistic regression analysis was used to analyze data from the 2000 National Health Interview Survey. The strong predictors were education, race/ethnicity, immigration status, health status, interaction with health professionals, controlling for socioeconomic status, cancer diagnosis, family history of cancer, and perceived personal cancer risk. The substantial lack of awareness of genetic testing among immigrant and ethnic populations warrants further research and tailored educational interventions. Ways to improve quality of patient interactions with non-genetic clinicians in promoting public knowledge of genetic testing for cancer risk are also worthy of further exploration.

Teaching clinical management skills for genetic testing of hereditary nonpolyposis colorectal cancer using a Web-based tutorial

PURPOSE

To pilot and evaluate an interactive Web-based continuing medical education tutorial on clinical management of hereditary nonpolyposis colon cancer (HNPCC) and genetic testing.

METHODS

Gastroenterology fellows and genetic counseling trainees were asked to read standard written materials before taking the tutorial. A pretest/post-test assessment was used to measure change in subjects' clinical management skills.

RESULTS

Subjects made the correct management decision 63.9% of the time before the tutorial and 81.1% of the time after the tutorial (P < 0.001).

CONCLUSIONS

Supplementing written materials with an interactive program may assist medical professionals in integrating their knowledge of HNPCC and genetic testing into clinical practice.