THE MANAGEMENT OF BREAST CANCER IN HEALTH CARE

The Management of Beast Cancer In Health Care

The Management Of Breast Cancer In Health Care

Background:

We surveyed primary care providers to evaluate breast cancer risk assessment and management practices.

Methods:

Primary care providers included staff (attendings, fellows, nurse practitioners) and residents practicing =1 session/week in an outpatient general medicine practice or community practices. Of 201 eligible providers, 107 (53%) completed a self-administered questionnaire ascertaining attitudes, perceived barriers, and clinical practices related to assessing and managing breast cancer risk.

Results:

Of providers, 96% mostly or definitely agreed that assessing breast cancer risk was a primary care provider's responsibility. In assessing risk, most providers reported usually or always asking about family history (71%), but fewer usually or always ask about parity (48%), biopsies (40%), or menarche (35%), and most never calculate Gail scores (76%). In managing women at high risk for breast cancer, many providers reported usually or always communicating increased risk to patients (58%) and tailoring screening based on risk (53%); however fewer providers usually or always discuss chemoprevention (13%) or genetic testing (16%) or refer to specialists (35%). Addressing more immediate issues (25%) and lacking confidence in knowledge of risk and risk assessment (20%) were the most commonly reported barriers to assessing risk (n = 83).

Conclusion:

Primary care providers generally assess breast cancer risk primarily using family history, potentially missing women at increased risk based on other criteria. In addition, although providers tailor screening and refer women at high risk to specialists, they infrequently discuss chemoprevention or genetic testing. Addressing perceived barriers to assessing risk may improve care.

1. Introduction

Breast cancer risk may be conferred by genetic factors or by hormonal, familial, or other factors. Inherited risk accounts for 5-10% of breast cancers [Clauss, 1992], and approximately 16% of women of screening age nationwide have increased risk as assessed by Gail score [Freedman, 2003] and [Sabatino, 2004]. In clinical settings, 28% of women in one large internal medicine practice had a family history of breast cancer, and 9% had a “significant” family history of breast or ovarian cancer [Lewis, 2004]. In another study, 9-53% of white women and 3-13% of black women in community practices had increased breast cancer risk [U.S. Preventive Services Task Force, 2002].

Breast cancer risk can influence decisions regarding screening [Armstrong, 2004], [ACOG Committee Opinion], and [G. Pichert, B. Bolliger, K. Buser and O. Pagani, 2003], chemoprevention [Pichert, 2003] and [Gail, Brinton, Byar, Corle, 1989], and referral for genetic counseling and testing, prophylactic surgery, and further evaluation. The U.S. Preventive Services Task Force (USPSTF) recommends that providers discuss chemoprevention with women at increased risk and low risk for adverse effects [U.S. Preventive Services Task Force, 2002], and that women with a family history suggestive of BRCA mutations be referred for genetic counseling and evaluation [Kinsinger, Harris, Woolf, Sox and Lohr, 2002]. The USPSTF recommends against routine referral of women without suggestive family histories [Berry, E.S. Iversen and D.F. Gudbjartsson et al, 2002], indicating the importance of a balanced approach to risk assessment, to ...