ASCO Issues New Recommendations for Family History-Taking in Oncology Setting
When oncologists see a new patient, they should emphasize careful documentation of first- and second-degree cancer family history, according to new recommendations published by the American Society of Clinical Oncology. The recommendations are the first to focus on family history-taking specifically in oncology to help determine patients’ personal genetic risk for cancer. Published in the Journal of Clinical Oncology, these recommendations aim to help oncologists more effectively identify patients with a predisposition to hereditary cancer and determine individualized short- and long-term management and treatment strategies based on their specific genetic status.
ASCO worked to establish new recommendations that meet the goals of accurate and informative medical history-taking without imposing an unnecessary level of detail on the patient and the clinician. The current standard in medical genetics, genetic counseling, and research settings is a comprehensive recording of three generations. However, after reviewing the available evidence, ASCO concluded that reported family history is most accurate in close relatives and loses accuracy in more distant relatives. On the basis of this data, a history of cancer in first- and second-degree relatives is often sufficient to assess a patient’s empiric risk of common cancers or a patient’s risk of a second primary cancer.
Inherited Cancers
Inherited cancers account for 10% of all cancers. Taking a focused family history, in combination with the patient’s personal history of cancer, allows the oncology provider to determine whether the patient may have a cancer that is driven by inherited genes and therefore would benefit from additional genetic counseling and testing. Ultimately, this information can be used to personalize treatment decisions as well as survivorship plans, including appropriate surveillance and prevention for patients’ increased risk of second cancers. For example, in the short term, BRCA1/BRCA2-positive genetic test results can affect surgical decisions and may have an impact on treatment options.
“Genetic factors are a key component of precision medicine because they can unlock important information that can help an oncologist determine the best course of individualized treatment,” said ASCO President Clifford A. Hudis, MD, FACP. “An adequate family history is key to identifying those patients whose cancer may be associated with inherited genetic factors.”
An Adequate Family History in Cancer Care
For patients with cancer, ASCO recommends obtaining, at a minimum, whether there is any history of cancer in first- and second-degree relatives. First-degree relatives include parents, children, and full siblings. Second-degree relatives include grandparents, aunts and uncles, nieces and nephews, grandchildren, and half-siblings. For each relative with cancer, ASCO recommends recording age at diagnosis and type of primary cancer(s), as well as lineage (maternal and/or paternal), ethniticity, and the results of any cancer genetic testing in any relative.
Patients should be asked specifically if there is a known hereditary cancer predisposition syndrome, prior genetic testing, and for any information regarding ethnicity that may be relevant, since a lower threshold for testing could be warranted in some situations. ASCO further recommends that the family history be recorded at a patient’s initial visit to the oncology provider, and be reassessed if new information about family members diagnosed with cancer becomes available.
“Ongoing hereditary risk assessment is part of high-quality oncology care,” Dr. Hudis said. “These recommendations provide clarity, guidance and support for the oncology professional and other specialists regarding what information to collect for a cancer family history and how to interpret it.”
Addressing Barriers to Implementation
A separate analysis of data from ASCO’s Quality Oncology Practice Initiative (QOPI®) was also published today in the Journal of Clinical Oncology. QOPI is an oncologist-led, practice based quality assessment and improvement program with the goal of promoting excellence in cancer care. As a preliminary measure, the current QOPI report indicates that of breast and colorectal patients with a first-degree family history of cancer, 79.8% were documented in their chart, and for those with a second-degree family history of cancer, 64.6% were documented. These results document a greater opportunity for oncologists to maximize the potential of family history-taking, and set a baseline for further quality improvement efforts.
While oncologists regularly participate in the collection of cancer family histories, some barriers may remain. Certain obstacles, such as a patient’s limited knowledge of his or her family medical history, may hinder the accuracy and therefore utility of our interpretation of genetic risk. ASCO recommends increasing patient education and awareness on the importance of a family history and the significance of a cancer risk assessment for patients and their family. ASCO’s patient website, Cancer.Net, will offer an article and infographic, as well as a cancer family history questionnaire patients can download.
ASCO also notes that the increasing use of electronic health records (EHRs) can help providers overcome challenges to adopting these new recommendations. Devoting a portion of the EHR to family history-taking could allow clinicians to seamlessly integrate the collection, assessment, and interpretation of family history into standard patient care.
Finally, ASCO is concerned that many insurers do not adequately reimburse for the time required to take a full cancer family history.
“An increase in reimbursement for this service would help providers—many of whom are already time-challenged by the current fee-for-service reimbursement structure—devote the additional time needed to perform this important component of high-quality cancer care,” said Dr. Hudis.
ASCO will be providing a comprehensive update of cancer genetics including family history assessment at its Annual Meeting. For more information about ASCO’s prevention and genetics work, visit www.asco.org/practice-research/familial-risk-assessment-management.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
