Zosia Chustecka
Oncologists seeing a new patient with cancer should take a family history, specifically asking about cancer in first- and second-degree relatives, says the American Society of Clinical Oncology (ASCO) in a new expert statement.
Published online February 3 in the Journal of Clinical Oncology, the new recommendations were compiled by a panel of 15 experts, led by Karen Lu, MD, from the University of Texas M.D. Anderson Cancer Center in Houston.
These are the first ever recommendations on taking a family history in cancer patients, ASCO noted, although the society has previously provided guidance on genetic testing and inherited cancer predispositions.
"An adequate family history is key to identifying those patients whose cancer may be associated with inherited genetic factors," ASCO president Clifford A. Hudis, MD, FACP, said in a statement. It can "unlock important information that can help an oncologist determine the best course of individualized treatment," he added.
However, there is an issue with how to get reimbursement for the time spent collecting such information, the authors note. "It is not clear how best to bill for this service," they point out.
Dr. Hudis acknowledged this is an issue, and said "an increase in reimbursement for this service would help providers — many of whom are already time-challenged by the current fee-for-service reimbursement structure — devote the additional time needed to perform this important component of high-quality cancer care."
In addition, existing electronic health systems "lack the functionality needed to capture adequate family history data," the authors note.
Despite these barriers, however, they propose that taking a family history for all oncology patients is an "achievable near-term goal for all oncology practices."
About 10% to 15% of All Cancers
About 5% to 10% of all cancers are attributable to a hereditary cancer predisposition syndrome, the authors write. These include hereditary breast and ovarian cancers linked to the BRCA1/2 mutations, and also Lynch syndrome, which increases the risk for colorectal and several other cancers. Identifying patients who have such a syndrome "has significant benefit" for both patients and their relatives, they comment.
For the patients, such knowledge can have an impact on the treatment that is recommended (e.g., deciding on surgery for BRCA carriers), as well as inform surveillance and prevention strategies for their increased risk for secondary malignancies.
For relatives, such knowledge can lead to predictive genetic testing and more precise risk management with screening and prevention strategies.
Tracing Cancer in Close Relatives
Tracing history back to 3 generations is the current norm in medical genetics, but after reviewing the available evidence, ASCO concluded that reported family history is most accurate in close relatives, and loses accuracy in more distant relatives. A history of cancer in first- and second-degree relatives is often sufficient, the authors conclude.
Hence, for every patient with cancer, ASCO recommends ascertaining whether there is any history of cancer in first-degree relatives, including parents, children, and full siblings, and in second-degree relatives, including grandparents, aunts/uncles, nieces/nephews, grandchildren, and half-siblings.
For each relative with a history of cancer, ASCO recommends recording details such as age at diagnosis and type of primary cancer(s), as well as lineage (maternal and/or paternal), ethnicity, and results of any cancer genetic testing in any relative.
"Red flags" for hereditary cancer predisposition include early age of onset of cancer, multiple affected relatives with cancer on the same side of the family, and multiple primary tumors, especially in the same organ (e.g., breast, colon, or kidney) in a single individual, the authors write.
Patients should also be asked directly if they have any knowledge of cancer predisposition, genetic testing, or ethnicity that may be relevant (e.g., Ashkenazi Jewish ancestry is associated with a higher prevalence of BRCA1/2 mutations). "Therefore, patients with breast and/or ovarian cancers should be specifically asked if they have any Jewish ancestry on their maternal or paternal side," the authors write, and if they do, "a much lower threshold for testing should be adopted."
Family history should be ascertained at the patient’s first visit, but should also be reassessed as and when more information comes to light. Once patients discuss their cancer diagnosis with relatives, sometimes new facts emerge.
"Ongoing hereditary risk assessment is part of high-quality oncology care," Dr. Hudis commented.
Already Being Done, But Not Enough
Oncologists are already making some moves toward taking family history in cancer patients, but there is "significant room for improvement," concludes another study published online February 3 in the Journal of Clinical Oncology. This study was presented at the ASCO 2012 annual meeting, and reported in some detail at that time.
The study reports results from a survey of 271 practices participating in ASCO’s Quality Oncology Practice Initiative in 2011. It looked at genetic counseling and testing practices for 10,466 patients with either breast or colorectal cancer.
The authors, led by Marie Wood, MD, from the University of Vermont in Burlington, found that 77.0% of all medical records reviewed had documented the presence or absence of cancer in first-degree relatives, and 61.5% had done so for second-degree relatives.
However, a complete family history was documented in less than 40.0% of patients.
Referral for genetic counseling/testing occurred in 22.1% of all patients.However, less than half (42.7%) of those who were likely to have a hereditary form of cancer were referred.
The authors note that oncologists were more likely to look for clues to hereditary cancer among patients with breast cancer, compared with those with colorectal cancer. There was a significantly higher rate of documentation for breast compared with colorectal cancer patients, they note. Among patients who were likely to have hereditary cancer, 52.2% of patients with breast cancer but only 26.4% of patients with colorectal cancer were referred for genetic counseling/testing.
"Our study highlights the continued need for education and support for oncology providers on gathering and documenting family history," the authors conclude.
"Getting an adequate family history into the medical records is the first step in ensuring that the proper patients are referred for genetic counseling/testing," they add.
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