Implementation of a referral tool designed to enhance family history screening during doctor’s visits may play a crucial role in identifying those at risk for cancer, according to a study presented at the 2019 American Society of Clinical Oncology Annual Meeting.
In the study, a questionnaire, created in collaboration with the Pancreatic Cancer Action Network and funded by Champions for Hope, was developed with a simple scoring algorithm to prompt referral for genetic counseling. The questionnaire was administered via email before the patient’s appointment or in the waiting room with a tablet interface.
In turn, patients with significant risk factors identified were contacted by their provider and offered genetic counseling.
Of 387 questionnaires completed, the researchers were able to identify 81 patients at an increased risk for cancer – for which 12 patients underwent genetic testing.
Overall, 3 patients reported with pathogenic variants, 5 with variants of uncertain significant and 6 had negative results.
In an interview with Oncology Nursing News, study authors Kristin Clift, MA, research program coordinator at the Center for Individualized Medicine, and Michael B. Wallace, MD, both from the Mayo Clinic, discussed the trial results and how they affect nurses’ daily practice.
Oncology Nursing News: What did the practice improvement project at Mayo Clinic consist of?
Clift: We wanted a better way to capture family history. So, we went to a company called Input Health and we developed a questionnaire with them and a genetic counselor, based off of NCCN guidelines, to create a score based on family history and a few other environmental and behavioral factors like smoking and obesity.
What is the biggest takeaway for patients from your study?
Clift: Everyone should be paying attention to their family history and updating their physicians regularly. That can really give your physicians a clue if you are at risk. We’ve actually identified three people who had a pathogenic or disease-causing variant that put them at risk for cancers. We were able to identify them and enroll them into enhanced screening and surveillance, and also we were able to impact their family members and give their family members genetic testing to offer them surveillance as well.
What role do nurses play in family history screening?
Clift: Dr. Wallace’s nurse has been a huge part of this. She has been seeing patients and I contact her whenever there is a patient at risk based on their family history and she contacts the patient and asks them if they are interested in pursuing genetic testing and talking with a genetic counselor. So, she is really the liaison.
The relationship with the nurse is really important because when patients are contacted by someone they didn’t know, they don’t respond or don’t go to the appointment. If the nurse contacts the patient, asking them about genetic counseling, then we have had a higher response rate.
Wallace: Generally, people who are administering these questionnaires are our nurses. So, when the patients come to the clinic, a lot of this information is gathered by the nurse. So, they obviously get vital signs, initial intake questionnaire, but they are also using this web-based application to administer a structured family history and risk assessment. In a way, it is good to take them out of the hands of the physician and into the hands of the nursing staff that can collect this information and then triage it appropriately.
Is there anything in particular from your study you hope nurses can take away from it?
Clift: Pay attention and ask your patients about their family history. Ask about first- and second-degree relatives and pay attention to any patterns like lots of cancers in family, or any particular cancers like breast cancer in a male. So, as they can learn a little bit about taking a family history and then what to do with that if they suspect something, refer them to a genetic counselor.
Wallace: The red flags that a lot of nurses should be aware of are, apart from having multiple family members with cancer, an individual who has multiple cancers. So, if an individual has two cancers themselves, that is a red flag. If a family member has ever had cancer at a young age, typically under the age of 50 to 50, that is often a red flag that it could be an inherited syndrome.
The two pieces that I would emphasize is that genetic testing is now being increasingly offered almost universally. The most recent NCCN guidelines recommend that almost every patient with previous cancer should get genetic testing. That is going to help us find more of these individuals at risk, and particularly their family members who are at risk. The second is that we now have effective cancer screening tools. We think about colonoscopy and colon cancer, mammograms and breast cancer, pap smears in gynecologic cancers. Now, there are effective pancreatic cancer screening tools, namely an MRI scan and an endoscopic ultrasound, and a lot of new ones are being developed as well. There are effective screening options for individuals who are at an increased risk.