Family Practice Vol. 16, No. 5, 463-467
© Oxford University Press 1999
GPs' management of women seeking help for familial breast cancer
a Department of General Practice and
b Department of Medical Decision Making, Leiden University Medical Centre, The Netherlands.
GH de Bock, Department of General Practice, Leiden University Medical Centre, PO Box 2088, 2301 CB Leiden, The Netherlands.
de Bock GH, Vliet Vlieland TPM, Hakkeling M, Kievit J and Springer MP. GPs' management of women seeking help for familial breast cancer.Family Practice 1999; 16:463–467.
Received 12 February 1999; Accepted 13 May 1999.
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Abstract |
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Objective. We aimed to ascertain how often patients seek help for familial breast cancer in primary care, and to identify GPs management of these patients, in order to see whether guidelines are followed.
Methods. This was a descriptive study. GPs (n = 202) attending a postgraduate education programme were asked to fill in a questionnaire which included questions about the number of patients seeking help for familial breast cancer within the last 3 months and about their management strategies.
Results. About 80% of the GPs reported that they referred women with concerns about familial breast cancer for further diagnostics (mammography or ultrasound). For half these referrals a plan of regular appointments was set up, and one-eighth of the referrals included breast examination by a physician. Breast self-examination was advised in 50% of the cases. Estimates given to women regarding their breast cancer risk varied considerably. There was a strong relationship between risk estimates and management strategies.
Conclusions. Current guidelines regarding surveillance of women with breast cancer in the family were only partly followed. These guidelines do not give sufficient information to define whether there is an increased risk for breast cancer. These guidelines need to be refined.
Keywords. Breast self-examination, familial breast cancer, family physicians, mammography, screening.
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Introduction |
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Breast cancer is the cancer with the highest incidence in women in the Western countries, and comprises about 18% of all female cancer in the world.1 It is estimated that about 5–10% of breast cancer in Western countries is due to a genetic predisposition.2,3 With recent advances in cancer genetics, such as the identification of the cancer susceptibility genes BRCA1 and BRCA2, there is an increasing demand for genetic risk assessment and prevention.4
There are several guidelines that refer to the management of women with an increased familial breast cancer risk in primary care, including a plan of regular mammography, breast examination by a physician and breast self-examination.5–9 For patients with an increased familial breast cancer incidence, monthly breast self-examination is recommended, as well as half-yearly breast examination by a physician, and yearly mammography starting at the age of 25–30 (or 5 years before the age at which the earliest breast cancer was detected in the family). However, an increased familial breast cancer risk is not clearly defined.
Relatively little is known about the frequency of consultation and the actual management patterns regarding patients with a familial breast cancer risk in primary care. This information is essential to the evaluation and improvement of current guidelines regarding the management of patients with familial breast cancer risk in primary care. A representative sample of GPs was asked by means of a questionnaire about the number of patients they had seen with concerns about breast cancer due to a family history and about their management strategies regarding these patients.
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Methods |
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Setting and GPs
GPs attending a postgraduate education programme (1996/1997) in the Leiden area were asked to fill in a questionnaire on how frequently patients with a familial breast cancer risk consulted them and on their management strategies regarding these patients. One of the topics during the postgraduate education programme was ‘medical decision-making’. The ‘medical decision-making’ course started with a questionnaire on preventive behaviour regarding familial breast cancer risk in general practice. The Leiden area consists of 342 GPs; the attendance rate for the medical decision-making part was 60% (202/342). Of the 202 attending GPs, 200 returned a completed questionnaire. Their mean practice size was 2595 patients (SD = 700). In order to compare attenders and non-attenders (controls) with respect to sex, age and practice type, t-tests and chi-square tests were done. Table 1 shows that there were no statistically significant differences between the attenders and the non-attenders.
Questionnaire
The GPs were asked how many patients had consulted them in the last 3 months about their personal risk of developing breast cancer due to a positive family history and what their preventive management strategies had been. These management strategies were measured by means of two open-ended questions. First, the GPs were asked to describe the family history and their management regarding their ‘own’ GP case (the last patient who had consulted them with such a question). Secondly, they were asked to describe their management strategy regarding a pre-defined case (a female patient, 30 years of age, is consulting you about the implications of breast cancer recently detected in her only sister).
Data coding and analysis
The data regarding management strategies were extracted from the questionnaire and coded (yes or no) according to a coding scheme. The family histories in the GP cases were classified in the following way.
Group I. . There were no first-degree relatives with breast cancer in the family.
Group II. . There was a mother or one sister with breast cancer in the family (with or without a second-degree relative with breast cancer).
Group III. . There were at least two first-degree relatives with breast cancer, or there were one first-degree relative and at least two second-degree relatives with breast cancer. Furthermore, it was registered if there were breast symptoms in the patient herself, and whether the question was initiated by the patient or by the GP.
Regarding the GPs' management strategies, the following topics were discerned.
- History taking: a patient's family history (any breast cancer in a first- and second-degree relative, and, if applicable, age of onset and bilaterality, cancer of the ovary and other cancers), and the patient's anxiety about her family history.
- Physical examination: breast examination.
- Providing patient information: risk communication, breast self-examination and reassurance.
- Further diagnostics: mammography or ultrasound.
- Referral: surgery or a family cancer clinic.
- Surveillance: follow-up or conditional appointment in general practice, or regular mammography.
Data were entered into the statistical package SPSS-Windows. In order to explore the relationship between GP cases and management strategies, chi-square tests were done.
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Results |
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GP cases
Sixty-nine per cent (137/200) of the GPs had been consulted by women about their personal risk of developing breast cancer due to a positive family history within the previous 3 months. The number of patients varied from one to 10 (mean = 2.1 patients; SD = 1.5; median = 2).
In total, 136 GPs gave a description of the last patient who had consulted them. For 13 described patients (10%), the question had been initiated by the GP. Eight of these patients had presented with breast symptoms, and questions about breast cancer in the family were part of the GP's routine. For two patients, the GP brought the topic up himself because the family was known to have members with breast cancer. In one case, the GP brought the subject up because a prescription for a hormone replacement therapy had been prescribed, and in two cases the reason was unspecified.
Nineteen per cent (26/136) of the described patients had no first-degree relatives with breast cancer; 65% (89/136) of the described patients had one first-degree relative with breast cancer or one first-degree relative and one second-degree relative with breast cancer. Fifteen per cent (21/136) of the GP cases comprised patients with at least two first-degree relatives with breast cancer (20) or one first-degree relative and at least two second-degree relatives with breast cancer.1 Fourteen per cent (20/134) of the patients had physical symptoms (pain or lump in breast).
Strategies regarding the pre-defined case
GPs' management strategies regarding the pre-defined case are presented in Table 2.
History taking.. About 60% of the GPs recorded taking some type of family history, mostly a short one.
Physical examination. . More than half the GPs indicated that they would perform a breast examination.
Providing patient information. . Nearly three-quarters of the GPs would provide the patient with some form of information. Of these, one-third would mention a risk estimate. Verbal risk estimates varied from "the risk is possibly increased" (one GP) to "there is a small increase in risk" (20 GPs) and "there is an increase in risk" (40 GPs). Quantified estimates of risk increments were "three-times over", "doubled", "50% increase", "10% increase" and "more than the expected". About half the GPs recorded that they would inform the patient about breast self-examination.
Further diagnostics. . Eighty per cent of the GPs recorded that they would refer the patient for further diagnostics, a mammography being the most frequent option.
Referral. . One-fifth of the GPs considered a referral to a family cancer clinic.
Surveillance. . Half the GPs arranged some form of surveillance. The options chosen most often were a regular mammography or a follow-up appointment. A follow-up appointment was mostly made for another breast examination.
Strategies regarding the GP cases
The relations between the GP cases and the reported management strategies are presented in Table 3
. When comparing the results in Table 3 with those in Table 2, the overall number of mentioned management strategies is lower for the GP cases than for the pre-defined case. One-third of the patients were advised to perform breast self-examination. Patients were referred to a surgeon only when there were symptoms, or when the mammography was suspect.
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Group I. . (With no first-degree relatives with breast cancer in the family.) In this group, nearly 60% of the patients had additional symptoms. About half of these patients (n = 13) were referred, mostly for a single mammography. Of these referred patients, 12 had additional symptoms.
Group II. . (With a mother or one sister with breast cancer in the family [with or without a second-degree relative].) In this group there were statistically significant more referrals for mammography than in Group I and Group III. These mostly concerned mammography or ultrasound (n = 65); for 31 patients, mammograms were started on a regular basis. For another 12 patients, regular breast examination was started. For a small sample (n = 7), mammograms on a regular basis as well as regular breast examination were started.
Group III. . (With at least two first-degree relatives with breast cancer, or with one first-degree relative and at least two second-degree relatives with breast cancer.) In this group there were two non-referred patients who both had additional symptoms. Most referrals to a family cancer clinic were done in this group, and the GPs did statistically significant less surveillance (less mammography and less breast examination).
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Discussion |
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About 80% of the GPs reported they referred women with concerns about familial breast cancer for further diagnostics (mammography or ultrasound). Half these referrals were set up as a plan of regular appointments, and one-eighth included breast examination by a physician. Breast self-examination was advised in 50% of the cases. Estimates given to women regarding their breast cancer risk varied considerably. There was a strong relationship between risk estimates and management strategies.
A major point of consideration is whether these management patterns are in line with the guidelines mentioned in the introduction. Regarding the pre-defined case, 88% of the GPs would refer such a patient for a mammography or ultrasound. Regarding the GP cases, three-quarters of the patients from Group II (with a mother or one sister with breast cancer in the family [with or without a second-degree relative with breast cancer]), similar to the patients described in the guidelines, were referred for a mammography or ultrasound. Regarding the pre-defined case and the GP cases (Groups II and III), only half these referrals were to take place on a regular basis. Only one-third of these referrals was to take place on a regular basis in combination with breast examination by the GP. Breast self-examination was advised for 50 and 30% of the patients, respectively. There were considerable differences in history taking. The assessment of the age of onset of the breast cancer in the family, information that is needed in order to follow the guidelines, is part of the history-taking for only a small number of GPs (7%). Assessment of risk and giving the patient risk estimates are not covered in the current guidelines.
The response to the questionnaire was very high; the responders (attenders) were similar to the group not invited to answer this questionnaire (non-attenders). We used free recall instead of a structured recall method in our study, which had the advantage that the questionnaire was short, easy to fill in and precluded bringing up ideas. A limitation of the method is the use of a retrospective method based on physicians' self-reports, which might overestimate or underestimate the GPs' performance.10 However, our results regarding mammograms correspond to a recent publication in which it is concluded that many breast cancer relatives with a possible increased risk do not undergo regular mammography screening.11
It is concluded that current guidelines regarding surveillance of women with breast cancer in the family are followed only in part. These guidelines do not give sufficient information to define when a breast cancer risk is increased. There is a need to refine these guidelines.
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Acknowledgments |
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We would like to thank F Khan from the General Practice and Primary Care Research Unit, University of Cambridge, UK, for her valuable comments on earlier versions of this paper.
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References |
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