Primary care

Raising concerns about family history of breast cancer in primary care consultations: prospective, population based study

Women's Concerns Study Group. 

Correspondence to: Ann Louise Kinmonth, General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 2SR alk25{at}medschl.cam.ac.uk

Following the availability of genetic tests for the genes for breast cancer BRCA1 and 2, genetic centres have reported increasing referral, often of women who are at low risk of breast cancer but who are concerned about their chances of inheriting it, and they have called for better management in primary care.¹ To inform appropriate management strategies we counted consultations in primary care in which a family history of breast cancer was mentioned. We obtained ethical approval from the Cambridge local research ethics committee.

	Population, method, and results

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Nineteen of the 36 partnerships with four or more partners in one health authority were recruited by letter and visit (mean list size 8904 (SD 2231); 74% training practices). A total of 240 clinicians participated: 152 doctors and 88 nurses, including locums and those working part time.

Each practice collected data over four weeks between August 1997 and July 1998. After all consultations with women aged 16 or older, clinicians recorded the patient's reference number, birth date, mention of a family history of breast cancer or other cancers, breast symptoms, risk of breast cancer, and who first mentioned any of these topics. Consultation data were checked against records of attendance at the practice. Agreement between the patient and clinician on who first mentioned a family history of breast cancer was assessed in a selected subsample of women. These women were invited to participate in a telephone interview by letter (no reminders). Respondents included 39 of 107 women classified as originating discussion of a family history of breast cancer and 33 of a 10% sample of those classified as not originating such discussions (total 681). Data were double-entered and analysed using STATA 5.0 (Statacorp, College Station, TX).

Eighteen of 19 practices participated, and 20 614 of 24 269 consultations (85%) were usable. A sensitivity analysis that assumed that all missing consultations came from the practice with the highest or lowest rate of reporting for a family history of breast cancer gave results within the confidence intervals of the main analysis. No differences in frequency of mentions of family history of breast cancer by clinicians were found over time.

Of the topics recorded, breast symptoms were mentioned in consultation most often, and family history of cancers other than breast cancer least often (table). Mention of a family history of breast cancer was recorded in 3.7% of consultations. Clinicians were 6.6 times more likely to raise the issue of family history of breast cancer than were women and were more likely to raise the issue in all topics counted.

Fifty of 72 women interviewed recalled mention of family history of breast cancer during their consultation; 42/50 agreed with the reporting clinician as to who raised the issue. Those disagreeing reported that the clinician, and not themselves, had done so. Five women reported consulting with specific concerns about family history of breast cancer.

	Comment

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In consultations with their general practitioners women raised the issue of a family history of breast cancer relatively infrequently, in only 5/1000 consultationsan average of 0.6 per clinician per month. This is consistent with the few other data available. ^{2 3} In contrast, consultations in which women initiated discussion of breast symptoms were four times more common.

Applying list sizes and rates of consultation from the study practices allows a rough comparison with the morbidity statistics for general practice. For each 1000 women (16 years) on the list, about 15 a year will raise the issue of a family history of breast cancer. Almost 10 times that number (141) consult for contraceptive advice, and three times that number consult for menstrual disorders.⁴

Interviews with women suggested that only a minority consult with specific concerns about family history. Primary care teams might manage these women most appropriately by training a team member in assessment and management techniques, possibly with computer support.⁵

Much has been made of the potential of the media for raising women's concerns about familial risk of breast cancer. These data draw attention to the potential of the primary care team itself to influence women's views through repeated inquiry about family history in the consultation.

	Acknowledgments

We thank all the participating practice managers, general practitioners, practice nurses, and receptionists in the following practices of the Cambridge and Huntingdon Health Authority: Dr Brimblecombe and partners, Dr Brodie and partners, Dr Draper and partners, Dr Ferreira and partners, Dr Gant and partners, Dr Grande and partners, Dr Hewlett and partners, Dr Horne and partners, Dr Irons and partners, Dr King and partners, Dr Kuczynska and partners, Dr Kuczynski and partners, Dr Newby and partners, Dr Ridsdill-Smith and partners, Dr Sackin and partners, Dr Smerdon and partners, Dr Smith and partners, Dr Tulloch and partners, Dr Woods and partners. We thank Anna Martin, research assistant in the General Practice and Primary Care Research Unit, Cambridge, for her contribution to data collection and Julie Grant who coordinated and produced the manuscript. Joan Austoker, Truuske De Bock, Arthur Hibble, Frankie Lasman, Paul Pharoah, and Ron Zimmern gave valuable support and advice.

Contributors: This paper is authored by the Women's Concerns Study Group, which comprises Fawzia Hyland, Ann Louise Kinmonth, Theresa M Marteau (writing committee); Simon Griffin, Paul Murrell, David Spiegelhalter, Chris Todd, Fiona Walter (study executive); Bob Berrington, Martin Bobrow, and James Mackay (co-applicants). All authors have commented on and approved the manuscript, and ALK will act as a guarantor. Further details of the authors' affiliations are given on the website.

	Footnotes

Funding: NHS National Cancer Research and Development Programmeproject NCP/B22c. Theresa M Marteau is funded by the Wellcome Trust, and James Mackay is funded by the Cancer Research Campaign.

Competing interests: None declared.

Full details of all authors and their affiliations are on the BMJ's website

	References

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1.	Kinmonth AL, Reinhard J, Bobrow M, Pauker S. The new genetics: implications for clinical services in Britain and the United States. BMJ 1998; 316: 767-770[Free Full Text].
2.	Emery J, Watson E, Rose P, Andermann A. A systematic review of the literature exploring the role of primary care in genetic services. Fam Pract 1999; 16: 426-445[Abstract/Free Full Text].
3.	De Bock GH, Perk DC, Oosterwijk JC, Hageman GC, Kievit J, Springer MP. Women worried about their familial breast cancer riska study on genetic advice in general practice. Fam Pract 1997; 14: 40-43[Abstract/Free Full Text].
4.	McCormick A, Fleming D, Charlton J. Morbidity statistics from general practice: fourth national study 1991-1992 . London: HMSO, 1995.
5.	Emery J, Walton R, Coulson A, Glasspool D, Ziebland S, Fox J. Computer support for recording and interpreting family histories of breast and ovarian cancer in primary care (RAGs): qualitative evaluation with simulated patients. BMJ 1999; 319: 32-36[Abstract/Free Full Text].

(Accepted 18 September 2000)