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Breast cancer advice set to cut referrals

GPs have welcomed detailed guidelines from the National Institute for Clinical Excellence on which women to refer for familial breast cancer in the hope it will cut inappropriate referrals.

Draft guidance issued by the institute last week demands GPs take a detailed family cancer history in any women with breast symptoms or 'concerns' about familial breast cancer before any discussion of risks and options.

Patients should research the breast cancer history of first- and second-degree relatives, including aunts, uncles and grandparents on both sides of the family.

In accompanying patient guidance, NICE directs women worried over high familial rates to GPs.

But Dr Peter Rose, a member of the guidelines review board and a GP in Benson, Oxfordshire, warned GPs had 'enormous educational needs' to enable them to identify high-risk women, although 'most GPs are very willing to accommodate genetic medicine in their everyday work'.

He said the guidelines should stem the 'exponential rise' in GP referrals to genetic services, adding: 'We are in a really difficult situation. There can't be a GP in the country who hasn't faced this issue.'

The guidelines state GPs need not actively seek women at risk of familial breast cancer but should raise the issue with over-35s taking oral contraceptives or women considering long-term HRT.

GPs should provide every worried woman with written, evidence-based information on population- and family-

level risk, breast awareness and breast-feeding, and lifestyle advice including risks of HRT and contraceptives, the guidance advises.

Such information should be agreed at national level where possible.

Women do not need a referral where only one family member over 40 or two above age 60 have suffered from breast cancer in most cases. But some exceptional circumstances should trigger an automatic referral (see box

below).

GPs should ask a specialist where 'standard reassurance' does not convince women they are not at high risk.

Dr Jon Emery, GP member of the guideline development group, said the list of referral criteria was 'necessarily inclusive' as evidence suggested GPs and women tended to overestimate the risk associated with one affected relative.

Dr Emery, a GP in Cambridge and research fellow at the University of Cambridge, added the guidance should help GPs feel more confident when advising patients.

The average GP has around one consultation per month on the issue.

Familial breast cancer: when to refer

Refer if any breast cancer in:

 · First-degree female relative diagnosed before 40 or male before 60

 · First-degree relative with bilateral breast cancer where first tumour diagnosed before 50

 · Two first- or second-degree relatives on same side of the family, average diagnosis age before 60 (one a first-degree relative)

 · Two first- or second-degree relatives on same side of family, one male diagnosed at any age, the other diagnosed before 60 (one a first-degree relative)

 · Two second-degree relatives on same side of family diagnosed before 50

 · First- or second-degree relative diagnosed before 60 and first- or second-degree relative with ovarian cancer at any age (one a first-degree relative)

 · Three first- or second-degree relatives on same side of family diagnosed at any age

Refer if relatives do not fulfil standard criteria where any family history of:

 · Bilateral breast cancer; male breast cancer; ovarian cancer; Jewish ancestry; sarcoma under 45; glioma or childhood adrenal cortical carcinomas; complicated patterns of multiple cancers at a young age; 'very strong' paternal history

 · Also refer women with mutations in BRCA1/2 or TP53 genes already identified or where at least 20 per cent chance of this

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