The recently published NICE guideline on the classification and care of women at risk of familial breast cancer outlines several important roles for GPs.1
The vast majority of women with a family history of breast cancer will not be classified as high risk and will not develop breast cancer. This is an important message for GPs to share with women who present with concerns.
However, the guideline explicitly states that healthcare professionals generally should not actively seek to identify women with a family history of breast cancer.
The guideline is divided into two main parts. The first is an aid to the classification of women at risk into three groups:
- Low risk (lifetime risk of <17%, i.e. near to the risk of the general population)
- Moderate risk (17-29%)
- High risk (=>30%).
The second part of the guideline describes the care recommended for each of these groups from primary as well as secondary and tertiary care.
GPs will be expected to take a detailed family history to calculate an individual's risk and refer those who are at moderate or high risk. GPs should, however, be able to manage the low risk group.
Recommendations for primary care management of patients who do not require referral include providing verbal and written advice, individually tailored information and reassurance backed up by written material and a source of local and national contacts. However, women should be advised to come back if there is a change in family history or if breast symptoms develop.
GPs should also discuss breast awareness and ways to minimise risk, such as breast-feeding, weight management and smoking cessation.
The 10-page quick reference guide version of the guideline contains an algorithm outlining the referral pathways for the various risk groups (see Guideline will help GPs assess risk of familial breast cancer). I found the two boxes on referral criteria for greater than moderate risk and moderate risk very helpful. These show, in an easily assimilated pictorial format, the way to classify women into the correct risk groups.
They also give clear definitions of a first, a second and a third degree relative and what constitutes a paternal history.
Also included in the guideline are useful – but probably little known – facts, such as the 5 to 10-fold increased risk for carrying BRCA1 and BRCA2 genetic mutations of women with a Jewish ancestry. Such a genetic history warrants direct referral to the tertiary services which, in our area, means a specialised genetics unit.
This new guideline gives clear advice to GPs on classifying and managing patients with concerns about a family history of breast cancer. Its success will depend on good local implementation policies.
- National Institute for Clinical Excellence. The classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care. NICE Clinical Guideline 14. London: NICE www.nice.org.uk.