Cancer risk assessment from family history: Gaps in primary care practice

,

Original Research

Cancer risk assessment from family history: Gaps in primary care practice

J Fam Pract. 2002 October;51(10):1-1

By

Randa D. Sifri, MD

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References

1. Brownson RC, Davis JR, Simms SG, Kern TG, Harmon RG. Cancer control knowledge and priorities among primary care physicians. J Cancer Educ 1993;8:35-41.

2. Emery J, Rose P. Expanding the role of the family history in primary care (editorial). Br J Gen Pract 1999;49(441):260-1.

3. Smith RA, von Eschenbach AC, Wender RC, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001;51:38-75.

4. Polednak AP. Screening for colorectal cancer by primary-care physicians in Long Island (New York) and Connecticut. Cancer Detect Prev 1989;13:301-9.

5. Acton RT, Burst NM, Casebeer L, et al. Knowledge, attitudes, and behaviors of Alabama’s primary care physicians regarding cancer genetics. Acad Med 2000;75:850-2.

6. Summerton N, Garrood PV. The family history in family practice: a questionnaire study. Fam Pract 1997;14:285-8.

7. Del Mar C, Lowe JB, Adkins P, Arnold E. What is the quality of general practitioner records in Australia? Aust Fam Phys 1996;suppl 1:S21-5.

8. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality?. J Fam Pract 1998;46:390-6.

9. Medalie JH, Zyzanski SJ, Goodwin MA, Stange KC. Two physician styles of focusing on the family. J Fam Pract 2000;49:209-15.

10. de Bock GH, Perk DC, Oosterwijk JC, Hageman GC, Kievit J, Springer MP. Women worried about their familial breast cancer risk-a study on genetic advice in general practice. Fam Pract 1997;14:40-3.

11. Graham ID, Logan DM, Hughes-Benzie R, et al. How interested is the public in genetic testing for colon cancer susceptibility? Report of a cross-sectional population survey. Cancer Prev Control 1998;2:167-72.

12. Bosompra K, Flynn BS, Ashikaga T, Rairikar CJ, Worden JK, Solomon LJ. Likelihood of undergoing genetic testing for cancer risk: a population-based study. Prev Med 2000;30:155-66.

13. Kinney AY, Choi YA, DeVellis B, Kobetz E, Millikan RC, Sandler RS. Interest in genetic testing among first-degree relatives of colorectal cancer patients. Am J Prev Med 2000;18:249-52.

14. Petersen GM, Larkin E, Codori AM, et al. Attitudes toward colon cancer gene testing: survey of relatives of colon cancer patients. Cancer Epidemiol Biomarkers Prev 1999;8(4 pt 2):337-44.

15. Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility, adopted on February 20, 1996. J Clin Oncol 1996;14:1730-6.

16. Rogers J, Halloway R. Completion rate and reliability of the self-administered genogram. Fam Pract 1990;7:149-51.

17. Rogers J, Durkin M, Kelly K. The family genogram: an underutilized clinical tool. N J Med 1985;82:887-92.

18. Rogers J, Durkin M. The semi-structured genogram interview: I. Protocol, II. Evaluation. Fam Syst Med 1984;2:176-87.

19. Shore WB, Wilkie HA, Croughan-Minihane M. Family of origin genograms: evaluation of a teaching program for medical students. Fam Med 1994;26:238-43.

20. Physicians lax in screening patients with family history of adenomatous polyps. Reuters Health 2000;May 22.

Address reprint requests to Randa Sifri, MD, Department of Family Medicine, 1015 Walnut Street, Suite 401, Philadelphia, PA 19107. E-mail: randa.sifri@mail.tju.edu.

To submit a letter to the editor on this topic, click here: jfp@fammed.uc.edu.

ABSTRACT

OBJECTIVE: To determine whether an adequate amount of family history is being collected and recorded by family practitioners to appropriately identify patients at increased risk for cancer.

STUDY DESIGN: Retrospective chart audit.

POPULATION: Charts from 500 randomly chosen patients, 40 to 60 years of age, were audited. Of those charts, 400 were from a large academic family practice and 50 charts each were from 2 small community family practices in the greater Philadelphia area.

OUTCOMES MEASURED: General features of family history taking were recorded, including presence of a family history and date when recorded, evidence of updated family history data, and presence of a genogram. Cancer features recorded included mention of family history of cancer or colon polyps and, if positive, identification of which relative was affected, site of cancer, and age of diagnosis or death.

RESULTS: Most charts (89%) had some family history information recorded, and 55% listed a family history of cancer, either positive or negative. Of the 356 relatives affected with cancer, an age of diagnosis was documented in only 8%; of 183 first-degree relatives with cancer, only 7% had a documented age of diagnosis. Two percent of all charts had any mention of a family history of colon polyps. Sixty-five percent of family histories were recorded at the first visit, and only 35% had any updated family history information.

CONCLUSIONS: The number and type of family histories currently being recorded by family practitioners are not adequate to fully assess familial risk of cancer. New strategies will need to be developed to better prepare providers for risk-based clinical decision making.

Taking a family history is a significant component of providing comprehensive primary care because family history provides key psychosocial and medical risk information.^1,2 As our understanding of the genetic basis for disease grows, obtaining an accurate and complete family history is likely to gain increasing relevance as a vital source of data to guide counseling and testing. Patients who have a first-degree relative with a colon neoplasm or prostate cancer are advised to screen differently from those who do not.³ Failure to gather accurate or complete family data prevents the clinician from providing advice that is consistent with screening guidelines. Understanding how primary care clinicians gather family history data is necessary to identify gaps in current performance and to develop strategies to bridge these gaps.

Several studies have used physician self-report to assess the current level of taking a family history in primary care. In 1 study, 90% of surveyed physicians stated that they obtain a family history of cancer from their patients, with 77% to 80% inquiring about a family history of colorectal cancer in their patients who are at least 40 years of age.³ In another study, 63% to 85% of responding physicians reported obtaining a family history of cancer from 76% to 100% of their patients.⁵ Respondents in 1 study reported obtaining family histories of colorectal cancer in only 30.7% of patients, breast cancer in 48.4% of patients, and coronary disease and hypertension in 94.3% of patients.⁶ However, data on actual performance of family history taking are sparse.^7,8 The physicians in the Direct Observation of Primary Care study obtained a family history during 51% of new visits and 22% of established visits. A genogram was present in 11% of charts, and documentation of a family history of breast cancer or colorectal cancer was found in 40% of charts. Further analysis from this study showed that providers who more frequently obtained and recorded family history information performed more preventive care services for their patients.⁹

First-degree relatives of cancer patients appear to be interested in and receptive to information about their risk and in the possibility of genetic counseling.^10-14 In fact, many patients overestimate their likelihood of getting cancer based on family history¹⁰; primary care providers thus have the opportunity to counsel and relieve anxiety in their patients. Family history is an important tool to define risk and guide referral, counseling, and testing.

This article presents the findings of a descriptive study of the review of 500 charts from 3 different family practice offices. We documented general family history components and completeness related to a family history of cancer, including whether enough family history information was collected to appropriately identify patients at increased risk for cancer.

Methods

Data were collected from 500 patient charts from 3 family practice offices in the greater Philadelphia area. Patients who were in the practice for at least 1 year, made a minimum of 2 visits between June 1, 1997 and June 1, 2000, and were between the ages of 40 and 60 years at 1 of those visits were included. Fifty charts were selected by using a random starting point at each of 2 small (1 to 3 providers) private practices, and 400 charts were randomly selected from all eligible charts in a large academic practice (more than 60 providers). The large practice had nearly 1500 patients who fit the selection criteria, and the total population did not differ from the random sample in mean age, sex, or race (P < .05). Total population characteristics were not available for the 2 smaller practices.