The U.S. Preventive Services Task Force recently recommended that primary care physicians screen women with a familial risk assessment tool if they have a family history of breast, ovarian, tubal or peritoneal cancer, or if they have Ashkenazi Jewish ancestry, to determine their risk for BRCA1/2 mutations.
Although the recommendation received a “B” grade, the task force acknowledged that approaches to risk screening and strategies to improve access to genetic counseling require additional research.
Healio Primary Care asked Sterling N. Ransone, MD, FAAFP, a family physician in Deltaville, Virginia, and an American Academy of Family Physicians board member, to discuss the challenges related to implementing the USPSTF’s BRCA1/2 recommendation and how to address genetic counseling with patients in the primary care setting. – by Janel Miller
Q: How challenging will it be to follow these recommendations? How can th ose barriers can be overcome ?
A : The first part of the USPSTF recommendations — the USPSTF guidance that recommends screening in patients who have a family history of or have had breast, ovarian, fallopian tube and peritoneal cancer and/or are of Ashkenazi Jewish ancestry — can quickly and easily be obtained through ‘yes’ or ‘no’ questions.
The challenge in implementing the recommendations will occur in conducting genetic testing in women who are at increased risk based on that criteria. The limited appointment windows that many clinicians have with their patients are not designed to let the patient and physician spend the time they need to learn about the genetic testing process during routine checkups. Clinicians may find it easier to set up appointments that are exclusively designed to discuss BRCA 1/2 or provide their colleagues like nurse practitioners and physicians assistants with the USPSTF recommendations so that they are familiar with the recommendations and can answer patients’ questions about them.
Q : Walk us through the process of how a clinician raises the issue of screening and genetic testing with a patient.
A : 1) Take the medical-ese language in the recommendation statements and make it more mainstream. Take time to thoroughly discuss the benefits, the risks and the rewards of these procedures. Make sure the patient understands how serious, and unfortunately, sometimes deadly breast cancer can be. 2) Listen to the patient’s concerns and do your best to answer them. These discussions are often a marker of how much the patients you have had for a long time trust you.
If the patient is relatively new to your practice, ask about previous tests that they took under the advice of their previous clinician, such as those for BP or diabetes, and build on that. Explain that screening and genetic testing can save lives. You may also find it helpful to refer to celebrities that have ascertained that they are at risk for BRCA 1/2 and have taken action to reduce that risk.
Whether the patient has been part of your panel for 4 weeks or 4 decades, ask and be prepared to answer lots of questions. Those clinicians who encounter patients who are in a hurry, or don’t want to discuss the genetic test at the time of the appointment, should be understanding of the situation and do their best to make the patient schedule an appointment where genetic testing is the only topic of discussion.
Q : How frequently does genetic testing for BRCA1/2 need to occur?
A : If a patient took a genetic test after 2013 and the results are negative for BRCA 1/2, the patient never needs to take that test again. However, genetic tests conducted before 2013 were not designed to look for BRCA 1/2, so patients who had the test prior to that year will need to be tested again. Regardless of when the genetic test was taken, the patient should still be encouraged to get a mammogram annually.
U.S. Preventive Services Task Force. JAMA. 2019;doi10.1001/jama.2019.10987.
Disclosure: Ransone reports no relevant financial disclosures.