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INFORMATION IN PRACTICE: Jon Emery, Robert Walton, Michael Murphy, Joan Austoker, Pat Yudkin, Cyril Chapman, Andrew Coulson, David Glasspool, and John Fox Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases BMJ 2000; 321: 28-32 [Abstract] [Full text]

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Computer support for interpreting family histories in Primary Care

M H Shere   (4 July 2000)

Primary care- the right setting for discussion of family history risk?

Morph May   (19 July 2000)

Computer support for interpreting family histories in Primary Care 4 July 2000
M H Shere, Clinical Assistant Breast care Centre, Frenchay Hospital, Bristol Send response to journal: Re: Computer support for interpreting family histories in Primary Care	Dear Sir, I read with interest Emery et al.'s paper on using different methods of assessing genetic risk for breast and ovarian cancer and also his previous paper in your journal (1). In both these papers they make the assumption that General Practitioners have the time and will to take on new resposibilities and skills. In the paper they state that only 3 of the 36 GPs in the study were able to find the paper management guidelines for referral. 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 5 minute appointment. They cannot then just refer to a specialist or not, they would have to give some form of counselling, another new skill to learn and remember. There is evidence to suggest that GPs are reluctant to take on these new roles (2). Another assumption which is made, is that the aim is to try and stop unnecessary referrals to genetic clinics. In fact, the vast majority of referrals are made to local breast units of which there are more than a 100 in the country doing family history screening, who are used to discussing the risk 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, very high risk patients are referred onto the genetics service. This allows the GP to refer us women based on their anxiety and own perceived risk rather than their actual risk and saving him or her from having to find a piece of paper with rather complicated guidelines or a computer programme which he or she has 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 were very satisfied with the method. Dr. M.H. Shere 1. Emery J, Walton R, Coulson A, Glasspool D, Ziebland S, Fox J. A qualitative evaluation of computer support for recording and interpreting family histories of breast and ovarian cancer in Primary Care. BMJ 1999; 319: 32-6 2. Kumar S, Gantley M. Tensions between policy makers and general practitioners in implementing new genetics: grounded theory interview study. BMJ 1999; 319: 1410-13
Primary care- the right setting for discussion of family history risk? 19 July 2000
Morph May Send response to journal: Re: Primary care- the right setting for discussion of family history risk?	EDITOR- Whilst we applaud the development of tools to aid the assessment of genetic risk in primary care (1), we do not necessarily feel that general practioners are ideally placed to provide the counselling and reassurance required for patients at perceived extra risk of developing breast cancer. We have developed a nurse led family hstory clinic to which general practioners can refer all patients concerned about their cancer risk. The nurse underwent training in the regional cancer genetics centre. Prior to their appointment patients are given time to look into their family history in more detail so 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. Low risk patients often need as much explanation and advice as those at higher risk. The selected subgroup of high risk patients can be referred to the regional cancer genetics centre should they so wish. Patients at moderate risk can be advised of appropriate trials of screening. Referrals can be made by any general practitioner who feels he/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 feel that this provides a better service than a general practioner 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, Prittlewell Chase,Southend SS0 0RY 1.Emery J,Walton R, Murphy M, Austoker A, Yudkin P, Chapman C, Coulson A, Glasspool , Fox J. Computer support for interpreting family histories fo breast and ovarian cancer in primary care; comparative study with simulated cases. BMJ 2000;321:28-32 (1 July)