Cancer Risk Assessment by Rural and Appalachian Family Medicine Physicians

Abstract

Context Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region. Purpose To examine primary care physicians’ identification of hereditary cancers. Methods A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (N=176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed. Findings Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and Importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario. Conclusions Although rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.

Delivery of clinical genetic consultative services in the Veterans Health Administration

“…31,32 In addition, awareness of available genetic services is associated with referral. 31,33,34 Provider education on genetic topics was a key factor associated with ability to obtain a genetic consult within the VHA.…”

Primary care providers’ cancer genetic testing-related knowledge, attitudes, and communication behaviors: A systematic review and research agenda

“…34,35,38,39,41,42,44,[47][48][49][50]55,58 In seven studies, objective knowledge was assessed with a survey utilizing a scale or test to measure accurate understanding of basic genetic principles, clinical practice guidelines, and/or features of hereditary cancer syndromes. 35,38,39,42,47,48,50 In the other six studies, case scenarios or standardized patients were used to measure PCPs' abilities to identify high-risk patients and appropriate genetic testing situations. 32,34,41,44,49,55 Aside from articles reporting on the same sample, 38,48 there was no overlap in measures.…”

“…For instance, in a cross-sectional survey of 176 family practitioners, the modal score on a 10-point scale of factual hereditary breast and colorectal cancer knowledge was 6, with none of the sample accurately answering all items. 42 In addition, three studies examined objective knowledge pertaining to legal genetic discrimination protections. 39,44,53 Knowledge in this domain was concluded to be suboptimal; for instance, in a cross-sectional survey of 1120 family practitioners and internists, 9% had accurate knowledge about legal insurance protections related to genetic test results.…”

“…53 Ten studies examined PCPs' self-reported subjective or perceived knowledge. 33,37,[42][43][44][45]47,50,51,55 Although there was no overlap in measures, studies consistently reported a lack of PCPs' confidence in their genetic testing-related knowledge. For example, in a cross-sectional survey of 1311 family practitioners, 54% were not confident in their knowledge of genetic testing in primary care including testing for breast cancer risk.…”

“…33,34,[41][42][43][44][45]51,52,55,56 Of these, five studies examined PCPs' views about ethical, legal, or social implications of testing. 33,41,43,44,55 These studies noted varying beliefs about the effect of genetic testing on patients' anxiety.…”