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Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases

BMJ 2000; 321 doi: (Published 01 July 2000) Cite this as: BMJ 2000;321:28
  1. Jon Emery (jon.emery{at}, Cancer Research Campaign primary care oncology research fellowa,
  2. Robert Walton, senior research fellowa,
  3. Michael Murphy, directora,
  4. Joan Austoker, directorb,
  5. Pat Yudkin, lecturer in medical statisticsc,
  6. Cyril Chapman, consultant clinical geneticistd,
  7. Andrew Coulson, research fellowe,
  8. David Glasspool, research fellowe,
  9. John Fox, heade
  1. a ICRF General Practice Research Group, Division of Public Health and Primary Health Care, Institute of Health Sciences, University of Oxford, Oxford OX3 7LF,
  2. b Cancer Research Campaign Primary Care Education Research Group, Division of Public Health and Primary Health Care, University of Oxford,
  3. c Department of Primary Health Care, University of Oxford,
  4. d Department of Clinical Genetics, Oxford Radcliffe NHS Trust, Churchill Hospital, Oxford OX3 7JL,
  5. e ICRF Advanced Computation Laboratory, PO Box 123, London WC2A 3PX
  1. Correspondence to: J Emery
  • Accepted 11 May 2000


Objectives: To evaluate the potential effect of computer support on general practitioners' management of familial breast and ovarian cancer, and to compare the effectiveness of two different types of computer program.

Design: Crossover experiment with balanced block design.

Participants: Of a random sample of 100 general practitioners from Buckinghamshire who were invited, 41 agreed to participate. From these, 36 were selected for a fully balanced study.

Interventions: Doctors managed 18 simulated cases: 6 with computerised decision support system Risk Assessment in Genetics (RAGs), 6 with Cyrillic (an established pedigree drawing program designed for clinical geneticists), and 6 with pen and paper.

Main outcome measures: Number of appropriate management decisions made (maximum 6), mean time taken to reach a decision, number of pedigrees accurately drawn (maximum 6). Secondary measures were method of support preferred for particular aspects of managing family histories of cancer; importance of specific information on cancer genetics that might be provided by an “ideal computer program.”

Results: RAGs resulted in significantly more appropriate management decisions (median 6) than either Cyrillic (median 3) or pen and paper (median 3); median difference between RAGs and Cyrillic 2.5 (95% confidence interval 2.0 to 3.0; P<0.0001). RAGs also resulted in significantly more accurate pedigrees (median 5) than both Cyrillic (median 3.5) and pen and paper (median 2); median difference between RAGs and Cyrillic 1.5 (1.0 to 2.0; P<0.0001). The time taken to use RAGs (median 178 seconds) was 51 seconds longer per case (95% confidence interval 36 to 65; P<0.0001) than pen and paper (median 124 seconds) but was less than Cyrillic (median 203 seconds; difference 23. (5 to 43; P=0.02)). 33 doctors (92% (78% to 98%)) preferred using RAGs overall. The most important elements of an “ideal computer program” for genetic advice in primary care were referral advice, the capacity to create pedigrees, and provision of evidence and explanations to support advice.

Conclusions: RAGs could enable general practitioners to be more effective gatekeepers to genetics services, empowering them to reassure the majority of patients with a family history of breast and ovarian cancer who are not at increased genetic risk.


  • Funding The Cancer Research Campaign funded this study. JE and JA are funded by the Cancer Research Campaign. RW, MM, PY, and JF are funded by the Imperial Cancer Research Fund. AC and DG are funded by the Economic and Social Research Council and the Imperial Cancer Research Fund.

  • Competing interests CC has been paid as a consultant and has been reimbursed for attending conferences by Cherwell Scientific Publishing, which produces Cyrillic. After completion of this study, JE has been paid as a consultant by Cherwell Scientific Publishing.

  • Embedded Image An extra table detailing the study's balanced block design appear on the BMJ website

  • Accepted 11 May 2000
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