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Adherence to BRCA testing, counseling recommendations poor in the US
Trivers KF. Cancer. 2011; doi: 10.1002/cncr.26166
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Genetic counseling and testing for BRCA mutations is recommended for women at high-risk for breast or ovarian cancer, but discouraged among those at average risk. However, a recent analysis demonstrated that many physicians do not adhere to current recommendations.
Using a vignette-based survey of US family physicians, general internists and obstetrician/gynecologists, researchers from the CDC and the University of Washington School of Medicine in Seattle, determined that less than half of physicians recommend referral for counseling or testing to high-risk women.
“This finding is concerning, given the availability of evidence-based interventions to decrease breast and ovarian cancer risk in these high-risk women,” Katrina F. Trivers, PhD, MSPH, of the CDC, and colleagues wrote.
More than 3,000 physicians were surveyed (n=3,200) and 1,878 responded. The vignette, which asked about genetic counseling and testing at annual examination, varied patient age, race, insurance status and ovarian cancer risk.
Self-reported adherence to recommendations against BRCA counseling or testing among average-risk women was 71%; adherence was higher for women covered by Medicaid than those with private insurance (77% vs. 66%), according to bivariate analysis. Among high-risk women, adherence was 41% and physicians were more likely to report adherence for younger women than for older women (57% adherence for a 35-year-old vs. 27% adherence for a 51-year-old).
Compared with male physicians, female physicians reported higher adherence (35% vs. 50%). Additionally, adherence was highest among obstetrician/gynecologists at 57%, followed by internists at 41% and family physicians at 34%. Physicians in urban settings were more likely than those in rural settings to adhere to recommendations (44% vs. 25%).
According to the researchers, physician-estimated risk for ovarian cancer was the strongest predictor for adherence to recommendations for both average- and high-risk women; a more accurate estimate was associated with better adherence. Seventy-eight percent of physicians who correctly estimated risk among average-risk women adhered to recommendations to not offer genetic testing or counseling, compared with 26% of those who incorrectly estimated risk for these patients. The same was true when physician estimates correctly classified women as high-risk: 65% reported adherence to recommendations vs. 5%.
“Despite the existence of evidence-based guidelines related to referral for genetic counseling and testing for hereditary breast and ovarian cancer, many physicians report practices contrary to these recommendations, with too many average-risk women being referred for genetic counseling or testing, and too few high-risk women receiving these important services,” the researchers said.
They added that efforts to increase adherence to guidelines, particularly among male physicians, family physicians and general internists, are needed. Additionally, efforts to decrease referral and testing among average-risk women should also be applied.
Disclosure: The researchers reported no relevant financial disclosures.
In many ways, it is distressing that the primary care providers who are at the forefront of preventative medicine in the United States utilize genetic counseling and screening sub-optimally. This study describes how primary care providers infrequently refer high-risk women (with strong family histories of malignancy) for genetic counseling and testing for BRCA 1/2 mutations, yet still refer a significant proportion of average-risk women who are unlikely to have an identifiable hereditary increased risk for developing malignancy.
On the other hand, these observations should not be entirely surprising: Primary care providers have a wide breath of knowledge that must be mastered, genetic risk stratification is often confusing and complicated, and we are all acutely aware of the limited time constraints every caregiver has to spend with patients in the clinic, to say nothing of the inadequate time for Continuing Medical Education in a demanding practice. These challenging issues almost certainly contribute to inappropriate genetic counseling/screening referral patterns.
The missed opportunities to intervene in high-risk patients with decisions that could impact the future development of cancer, as well as the unnecessary misuse of medical resources in average risk patients, leave room for improvement.
Although perfecting the optimal medical setting for this task is not likely to be an easy feat, ongoing awareness of and education on this issue at the primary care level is an essential starting point.
Stephen Y. Chui, MD
Division of Hematology and Medical Oncology, Department of Medicine
Director of Breast Cancer Clinical Research (Acting), Knight Cancer Institute
Oregon Health & Science University
Kristine Lethert, MD
Senior breast cancer fellow, Division of Hematology and Medical Oncology
Oregon Health & Science University
Disclosure: Dr. Chui reports receiving research funding from Bayer BioOncology and GlaxoSmithKline; speaking honoraria from Genentech, Amgen, GlaxoSmithKline and Sanofi-Aventis; and consulting fees from Genentech, Amgen and GlaxoSmithKline. Dr. Lethert reports no disclosures.
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