Letters

Family histories of cancer in primary care

Referrals might be made on the basis of women's anxiety

Nurse led clinic may provide better service than computer program

Referrals might be made on the basis of women's anxiety

EDITORI read with interest the paper by Emery et al on using different methods of assessing genetic risk for breast and ovarian cancer and also the previous paper by Emery with a different set of coauthors. ^{1 2} In both these papers the authors assume that general practitioners have the time and will to take on new responsibilities and skills. Emery et al state that only three of the 36 general practitioners in the study were able to find the paper management guidelines for referral.¹ It is hard to imagine that they are first going to find the computer software, remember how to use it, and then remember how to interpret the results during a five minute appointment. They cannot then just refer to a specialist or not; they would have to give some form of counsellinganother new skill to learn and remember. There is evidence to suggest that general practitioners are reluctant to take on these new roles.³

Emery et al assume that the aim is to try to stop unnecessary referrals to genetic clinics. Most referrals are made to local breast units, of which there are more than 100 in the country doing family history screening, whose staff are used to discussing the risks of and necessity for screening. In our breast unit we send a questionnaire to patients referred because of a family history risk, asking for details of their relatives, and then only see the ones who meet guidelines for screening. We send a detailed letter to the others explaining why their risk is low; patients at very high risk are referred on to the genetics service. This allows general practitioners to refer women to us on the basis of their anxiety and their own perceived risk rather than their actual risk, and saves doctors from having to find a piece of paper with rather complicated guidelines or a computer programme which they have forgotten how to use. A study of this evaluation method (submitted for publication) has shown that we end up seeing 50% of the patients referred, the other 50% at low or no elevated risk being very satisfied with the method.

M H Shere, clinical assistant. 
Breast Care Centre, Frenchay Hospital, Bristol BS16 1ND mike.shere{at}north-bristol.swest.nhs.uk

Nurse led clinic may provide better service than computer program

EDITORWe welcome the development of tools to aid the assessment of genetic risk in primary care, as reported by Emery et al in their paper,¹ but we do not believe that general practitioners are ideally placed to provide the counselling and reassurance required for patients at perceived extra risk of developing breast cancer.

We have developed a family history clinic led by a nurse, to which general practitioners can refer all patients concerned about their cancer risk. The nurse underwent training in the regional cancer genetics centre. Before their appointment, patients are given time to look into their family history in more detail so that an accurate pedigree can be drawn up and a risk group assigned. This clinic has the advantage of providing reassurance and accurate advice within the environment of a specialist local clinic in an unhurried atmosphere.

Patients at low risk often need as much explanation and advice as those at higher risk. The selected subgroup of patients at high risk can be referred to the regional cancer genetics centre, if they wish. Patients at moderate risk can be advised of appropriate trials of screening. Referrals can be made by any general practitioner who feels he or she lacks the wherewithal to advise patients. In addition to providing specialist advice at a local level this clinic has also reduced the burden of referrals to the regional cancer genetics centre. Overall we believe that this provides a better service than a general practitioner armed with a computer program.

Emma Gray, specialist registrar general surgery. 
Neil Rothnie, consultant breast surgeon. 
Amanda Fowler, clinic sister. 
Southend Breast Unit, Southend Hospital, Southend SS0 0RY