alexa Impact of the Cancer Risk Intake System on Patient-Clinician Discussions of Tamoxifen, Genetic Counseling, and Colonoscopy


Family Medicine & Medical Science Research

Author(s): Celette Sugg Skinner, Susan M Rawl, Barry K Moser

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The Cancer Risk Intake System (CRIS), a computerized program that “matches” objective cancer risks to appropriate risk management recommendations, was designed to facilitate patient-clinician discussion. We evaluated CRIS in primary care settings via a single-group, self-report, pretest-posttest design. Participants completed baseline telephone surveys, used CRIS during clinic visits, and completed follow-up surveys 1 to 2 months postvisit. Compared with proportions reporting having had discussions at baseline, significantly greater proportions of participants reported having discussed tamoxifen, genetic counseling, and colonoscopy, as appropriate, after using CRIS. Most (79%) reported CRIS had “caused” their discussion. CRIS is an easily used, disseminable program that showed promising results in primary care settings. Many individuals with elevated colorectal, breast, and ovarian cancer risks can benefit from surveillance,1–7 chemoprevention,8–12 and genetic counseling.13–16 Accordingly, the American Society of Clinical Oncology (ASCO) recommends that individuals at elevated cancer risk be counseled regarding surveillance (i.e., earlier, more frequent, or more extensive screening), chemoprevention, and prophylaxis.17 Although ASCO does not specify who should provide counseling, primary care clinicians are a likely source to whom patients will turn.18,19 Research has shown that clinician recommendation is the strongest predictor of cancer risk management behaviors20–23; there is support for focusing on patient-clinician discussions to encourage consideration of and participation in these behaviors. However, identifying which cancer risk management topics should be discussed is challenging and time consuming in primary care settings. Determining for whom surveillance, chemoprevention, or genetic counseling is appropriate involves consideration of multiple personal and familial factors that affect cancer risk and can thus be beyond clinicians' training or time constraints. For example, colon cancer surveillance guidelines are complex and require analysis of personal and familial risk to determine which test is recommended, when it should be initiated, and at what intervals to repeat it.6 Appropriate chemoprevention recommendations involve assessment of risk, potential contraindications, and personal preferences. Whether a patient might benefit from genetic counseling is based on personal risk and family history. It is not surprising, then, that too few at-risk individuals receive cancer risk management recommendations. Appropriate referral for and participation in cancer genetic counseling is inconsistent24,25; too few high-risk individuals are informed of the purpose and benefits of cancer genetic counseling.26,27 Not only is appropriate surveillance not achieved among individuals with elevated colorectal cancer risk, even their participation in routine screening is low.22,28,29 We sought to develop a system for efficiently facilitating patient-clinician discussions about cancer risk and risk management. Our computerized Cancer Risk Intake System (CRIS) assesses personal health history and medical conditions, family cancer history, and other risk factors for breast, ovarian, and colorectal cancers; a complex set of CRIS algorithms then uses these data to generate, for individuals and primary care clinicians, printed information tailored by the patient's risk. If objective risk is high enough, the tailored printout includes recommendations to consider one or more of the following: breast cancer chemoprevention via tamoxifen, genetic counseling, and colon cancer surveillance. In this study, patients completed baseline surveys by phone prior to clinic visits, used CRIS during the visit, and completed follow-up telephone interviews postvisit. We sought to answer the following questions: Following CRIS completion, were proportions of participants who reported having had discussions with their clinicians about tamoxifen, genetic counseling, or colon cancer surveillance significantly greater than the proportions reporting having done so at baseline? Did participants who reported having had such discussions following CRIS completion perceive that CRIS had “caused” the discussions? Which characteristics differentiated those who did versus did not have such discussions following CRIS completion? Analyses regarding tamoxifen discussion were performed among females whose breast cancer risk was high enough to warrant receipt of a tailored tamoxifen message. Analyses for genetic counseling discussions were performed among participants whose breast, ovarian, or colon cancer risk was high enough to warrant a tailored genetic counseling message. Analyses regarding discussions about colon cancer surveillance were performed among participants with high enough risk to warrant colonoscopy but who were currently nonadherent.

This article was published in PMC and referenced in Family Medicine & Medical Science Research

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