physician assessment of family cancer history and referral for genetic evaluation in colorectal...
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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2004;2:813–819
hysician Assessment of Family Cancer History and Referralor Genetic Evaluation in Colorectal Cancer Patients
HILPA GROVER,* ELENA M. STOFFEL,*,‡ LAOTI BUSSONE,* ELIZABETH TSCHOEGL,*nd SAPNA SYNGAL*,‡,§
Population Sciences Division, Dana-Farber Cancer Institute, Boston; ‡Division of Gastroenterology, Department of Medicine,§
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ackground & Aims: An accurate family history is anssential component of cancer risk assessment. Ourim was to determine the concordance of family historyssessments made by physicians with patients’ self-eports and the frequency of referral for genetic evalu-tion in high-risk colorectal cancer (CRC) patients.ethods: A self-administered family cancer history
uestionnaire was completed by 387 consecutive CRCatients at their first visit to a gastroenterology cancerlinic. Physician notes from the first visit were reviewedo determine the concordance of the family cancer his-ory with patients’ self-reported history. Prevalence ofndividuals that satisfied the Bethesda guidelines forereditary colon cancer were compared with actualates of referral. Regression analyses were used to de-ermine factors associated with a comprehensive physi-ian evaluation of family history. Results: Oncologistsocumented a comprehensive family history in 59%184 of 311) of patients with a first- or second-degreeelative with cancer. Young age at diagnosis and a first-egree relative with CRC were not associated with aore comprehensive family history assessment. An in-
reasing number of cancers per family was a strongredictor of a less comprehensive family history assess-ent (odds ratio � 0.63; P < 0.0001). Seventy-five of
87 (19%) CRC patients met Bethesda guidelines forenetics assessment, however, only 13 of 75 (17%)ere referred. Conclusions: Increased complexity in
amily cancer history leads to a decrease in accuracy ofamily history, suggesting the need for systematic ap-roaches to facilitate family history assessment. Famil-
al cancer risk remains largely unrecognized and referralates for genetic evaluation for CRC syndromes are low.
amily history, an essential component of all medicalevaluations, is instrumental in determining an indi-
idual’s risk for developing cancer. It facilitates the strat-fication of patients into risk groups, allowing physicianso direct their efforts toward tailored screening for cancerrevention. Obtaining an accurate family history ofoung-onset cancer, multiple primary tumors, the pres-nce of associated malignancies, and numerous relatives
ith cancer is central to the recognition of familial canceryndromes. The study of such families with clustering ofultiple rare malignancies led to the identification of
i-Fraumeni syndrome, a cancer syndrome characterizedy sarcomas, brain tumors, leukemia, breast cancer, anddrenal cortical tumors in multiple relatives.1–3 Theenetic defects behind several cancer syndromes such asereditary breast/ovarian cancer, hereditary nonpolyposisolorectal cancer (HNPCC), familial adenomatous pol-posis, and hereditary papillary renal cell cancers haveeen established and testing for such genetic suscepti-ility is becoming increasingly available.Colorectal cancer (CRC) is the second leading cause of
ancer death in the United States. Hereditary syndromesharacterized by germline genetic mutations may ac-ount for 5%–6% of all CRC cases.4 The identificationf susceptible individuals is particularly important be-ause their risk for developing cancer exceeds that of theeneral population. Familial adenomatous polyposis,haracterized by the development of multiple (�100)denomas diffusely throughout the colon, confers aearly 100% risk for colorectal cancer.4 HNPCC, theost common inherited colon cancer syndrome, arises in
he absence of polyposis5,6 but is associated with an 80%ifetime risk for developing CRC.7,8 In addition to CRC,ndividuals with HNPCC are at a high risk for gastric,mall bowel, urinary tract, endometrial, and ovarian can-ers. A family history suggestive of a hereditary canceryndrome can be evaluated further by genetic testing.he results of such genetic testing serve to guide man-gement of both patients and their families. In familiesith an identified pathogenic mutation, the mutation-ositive members should be considered for intensiveancer surveillance and/or prophylactic surgery. In con-rast, those individuals without a known family muta-
Abbreviation used in this paper: CRC, colorectal cancer.© 2004 by the American Gastroenterological Association
1542-3565/04/$30.00PII: 10.1053/S1542-3565(04)00352-0
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814 GROVER ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2, No. 9
ion need not undergo aggressive cancer screening andequire the same surveillance recommended for the gen-ral population.9,10
The first step in determining an individual’s cancerisk is a methodologic analysis of their personal andamily history. There have been few reports on the fre-uency and the quality of the family cancer historyocumented in medical records. Furthermore, the pro-ortion of individuals presenting in a clinical settingho are at high risk as well as the success with which
hey are identified and evaluated is unclear. We reviewedhe family cancer history obtained from CRC patients intertiary care cancer center to study how family history
s obtained in clinical practice. The primary objective ofhis study was to compare the family history taken byhysicians during a clinical visit in a gastroenterologyancer clinic with patient self-reports in a written ques-ionnaire. Secondary aims were to determine the preva-ence of individuals who can be classified as high risk onhe basis of family history and the frequency with whichhese high-risk individuals are referred for genetic eval-ation.
Materials and MethodsAll patients with a diagnosis of CRC whose first visit
o a multidisciplinary gastrointestinal cancer clinic was be-ween June 2001 and May 2002 received a standardized familyistory questionnaire before their visit. The 2-page familyistory questionnaire elicited information about the type ofancers diagnosed in relatives and the age at cancer diagnoses.he questionnaire specifically asked patients to indicate theumber of siblings and children they had. Family history ofolorectal, stomach, pancreatic, uterine, ovarian, breast, blad-er/kidney, brain, and thyroid cancers in first-, second-, andhird-degree relatives specifically was elicited. The family his-ory questionnaire was designed to provide enough informa-ion to allow drawing of family pedigrees (see Figure 1,vailable online at www.cghjournal.org). Questionnaires wereollected by research staff at the clinic visit before the oncologyonsultation and subsequently were tracked and archived. On-ology consultations consisted of evaluations by both staffastrointestinal oncologists and an oncology fellow. Althoughhey were aware that family cancer history was being collectedor a study, physicians did not know investigators wouldompare information from these forms with the family historyecorded in physician clinical notes. The computerized medicalecords documented by the staff oncologist and the oncologyellow at the first clinic visit of every patient that had anrchived family history questionnaire were reviewed retrospec-ively. Medical record review was confined to the first clinicisit because previous studies have shown that family history isore likely to be elicited in new patient visits than visits with
stablished patients.11
Cancer history pertaining to only first- and second-egree relatives was considered in the evaluation of the phy-icians’ family history assessment. Subjects who reported noancer diagnoses in first- and second-degree relatives on theuestionnaire were excluded from evaluation of the quality ofhe family history assessment. The combined family historybtained from the staff oncologist and the oncology trainee waslassified as comprehensive if: (1) the relative diagnosed withancer and the type of cancer in the physician’s note wasompletely concordant with the family history questionnaire;2) in addition to complete concordance, the physician’s noteontained additional information that was not in the question-aire; or (3) a family history of cancer was reported only in thehysician’s note with no cancer diagnoses recorded by theatient.
Statistical Analyses
Several characteristics that are used clinically to stratifyn individual’s risk for hereditary colon cancer syndromes werexamined individually to determine whether they were asso-iated with a comprehensive assessment of family cancer his-ory. Young age at cancer diagnosis of the proband (age � 45r), number of cancers among family members, and the pres-nce of a CRC or nongastrointestinal cancer among first-degreeelatives are all considered as potential risk factors for increasedamilial risk for cancer.
Proportions of individuals with a comprehensive familyistory were calculated. Age was analyzed in 3 groups (�45 yr,5–60 yr, �60 yr), and the number of cancers per family wasnalyzed as a continuous variable. All other variables (fulfillinghe Bethesda criteria, presence of a first-degree relative withancer, presence of a first-degree relative with CRC, presence offirst-degree relative with a HNPCC cancer, metastatic can-
er, presence of a right-sided cancer, rectal cancer, presence ofsecond primary cancer) were dichotomized into those pa-
ients with the particular variable vs. the individuals without.�2 tests were used for dichotomized variables and t tests
ere used for continuous variables to examine the univariateelationship of demographic variables and risk factors for he-editary colon cancer with a comprehensive family historyvaluation. The magnitude of the effect was quantified usingdds ratios. In order to determine independent predictors of anccurate family history assessment, multivariate logistic re-ression models were constructed that controlled for the phy-ician evaluating the patient, predictors that were clinicallyignificant, and predictors with a P value �0.1 on univariatenalysis. Statistical tests were performed using SAS softwareversion 8.2; SAS institute Inc, Cary, NC).
Family history information from both the physician notesnd the completed family history questionnaire were used todentify study subjects who met clinical criteria that meritedurther evaluation for hereditary colon cancer. To this end, weetermined the proportion of individuals who satisfied theethesda criteria for HNPCC. Developed by a consortium in997 to identify the individuals who may benefit from geneticvaluation for HNPCC,12 the Bethesda criteria are broad
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uidelines that are of use in categorizing individuals at risk forereditary CRC. Pathology report confirmation of CRC wasvailable for 100% of patients and reports were reviewed inddition to the family history to determine the proportion ofndividuals who satisfied each of the Bethesda criteria. Con-ultation notes were reviewed for discussion or appraisal of risktatus, recommendations, and referrals for genetic evaluationr history of previous genetic testing. As it is possible that theocus of the first visit was on cancer care and referrals were
ade at a later date, we randomly reviewed 25% of follow-upotes to determine if referrals for genetic evaluation were maden subsequent appointments. The computerized medicalecord was also reviewed more than 6 months after the pa-ient’s first visit to determine whether they had undergonevaluation in our institution’s cancer genetics clinic. The studyeceived approval from the Dana-Farber Cancer Institute’snstitutional Review Board.
ResultsA family history questionnaire was completed by
8% (387 of 395) of patients seen for their first oncologyisit at the gastrointestinal cancer clinic between June001 and May 2002. We retrospectively reviewed theecords of 387 consecutive CRC patients who had com-leted the questionnaire for demographic and familyistory information. Patient characteristics are providedn Table 1. Patients were seen by 1 of 9 staff oncologistsith a median age of 41 years (range, 37–59 yr). The
verage number of patients per physician was 48. Familyistory was documented in 375 of 387 (97%) physicianotes. Family history reported by physicians was com-letely concordant with patients’ reports on the ques-ionnaire or contained additional information in 67%258 of 387) of cases. Of the 311 individuals with a first-r second-degree relative with cancer, family historyeported by physicians was completely concordant orontained information additional to that recorded in theuestionnaire in 59% (184 of 311) of the notes reviewed.f the 41% (127 of 311) of notes in which the familyistory assessment was partially or completely discor-
able 1. Patient Characteristics
Total
ndividuals 387en 189 (49%)edian age (range) 58 (19–92 yr)verage cancers/family (range) 3.2 (1–10)aucasian 382 (99%)etastatic cancer 161 (41%)
ndividuals with a first-degree relative with cancer 228 (59%)ndividuals with a first-degree relative with CRC 61 (16%)ndividuals with one or more relatives with a
HNPCC-associated tumor 175 (45%)
ant, in 29% (37 of 127) physicians had reported aegative cancer history or had not documented a familyistory. In 54% (69 of 127) of notes only some of theancers in the questionnaire had been documented, andn 17% (21 of 127) the questionnaire and the physician’sote contained completely discordant information (Table). Physicians did not document 32% (265 of 834) ofancers reported by patients. Nearly one third (85 of65) of these notes missed cancers that occurred inrst-degree relatives. Notably, close to one fifth of allolon cancers (33 of 165) as well as half of all endometrialancers (11 of 23) were undocumented. Sixty-eight per-ent (30 of 44) of the endometrial and colon cancersissed were in first- or second-degree relatives.Although young age at cancer diagnosis (age � 45 yr)
nd presence of colon cancer in a first-degree relative areresumed to be among the most important risk factorsor familial CRC, these features were not significantlyssociated with a comprehensive family history assess-ent in this cohort of CRC patients. None of the iden-
ified risk factors for familial CRC predicted a compre-ensive family history assessment by physicians. Inontrast, the presence of increasing numbers of cancersmong relatives of CRC patients was significantly asso-iated with a less concordant family history assessmentodds ratio, 0.65; 95% confidence interval, 0.56–0.76; P
0.0001). In exploring the impact of clinical criteriaesigned to highlight individuals at highest risk forRC, satisfying the Bethesda criteria for HNPCC wasot associated with a more comprehensive family historyssessment (odds ratio, 0.72; 95% confidence interval,.42–1.25; P � 0.25) (Table 3).Multiple logistic regression analysis revealed that in-
reasing numbers of cancers among family members washe strongest independent predictor of a less comprehen-
able 2. Family History Among Individuals With a First- orSecond-Degree Relative With Cancer
Family history Total (%)
ncologist notes with a comprehensive familycancer history 184 (59)
Concordance between questionnaire andphysician’s note 141 (77)
Additional information in physician’s note 30 (16)Information only recorded in physician’s note 13 (7)
ncologist notes without a comprehensive familycancer history 127 (41)
No history recorded or negative history 37 (29)History incomplete with additional information
in questionnaire 69 (54)Discordant information in physician’s note and
questionnaire 21 (17)otal 311
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816 GROVER ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2, No. 9
ive family history assessment (odds ratio, 0.63; 95%onfidence interval, 0.53–0.74; P � 0.0001). This indi-ated a significant decrease in the likelihood of a concor-ant or more detailed family cancer history documenta-ion by oncologists as the prevalence of cancer in theamily increased (Table 4).
Nineteen percent (75 of 387) of CRC patients hadersonal or family histories that met the Bethesda criteriaor HNPCC (Table 5). Of the 75 individuals (represent-ng 75 families) who fulfilled the Bethesda criteria, 1atient satisfied the Amsterdam criterion (criterion 1),0 had 2 or more CRCs (criterion 2), and 18 had arst-degree relative with an HNPCC-associated tumor,ith 1 cancer diagnosed before 45 years of age (criterion). Fifty-five patients had a diagnosis of CRC before 45ears of age (criterion 4). Seven of these patients hadight-sided CRCs with an undifferentiated pattern onistopathology (criterion 5), and 4 were signet ring–typeRCs (criterion 6). Thirty-seven percent of those pa-
able 3. Univariate Analysis of the Association of FactorsPredicting a Comprehensive Family HistoryAssessment
VariableOdds ratio (95%
confidence interval) P value
ge at cancer diagnosisYoung (�45 yr) 0.79 (0.42–1.48) 0.46Middle (45–60 yr) 0.98 (0.62–1.56) 0.94Old (�60 yr) 1.14 (0.73–1.81) 0.55
emale gender 0.98 (0.62–1.54) 0.92umber of family cancers 0.65 (0.56–0.76) �0.0001ethesda criteria 0.72 (0.42–1.25) 0.25irst-degree relative with colon
cancer 1.25 (0.76–2.06) 0.37irst-degree relative with a
HNPCC-associated cancer 1.02 (0.72–1.44) 0.92irst-degree relative with cancer 0.87 (0.72–1.06) 0.18etastatic cancer 0.84 (0.53–1.33) 0.46econd primary cancer 0.67 (0.29–1.53) 0.34ight-sided cancer 1.05 (0.65–1.70) 0.84ectal cancer 0.90 (0.55–1.45) 0.66
OTE. Increasing number of family cancers was associated with aess comprehensive family history assessment.
able 4. Multivariate Analysis Assessing the RelativeImportance of Factors Predicting a ComprehensiveFamily History Assessment
VariableOdds ratio (95%
confidence interval) P value
irst-degree relative with coloncancer 1.68 (0.99–2.87) 0.06
oung age (�45 yr) 0.87 (0.45–1.70) 0.68umber of family cancers 0.63 (0.53–0.74) �0.0001
OTE. Increasing number of family cancers was associated with aess comprehensive family history assessment.
ients fulfilling Bethesda criteria met criteria 1, 2, and/or. Twelve patients met more than 1 Bethesda criterion.Thirteen of the 75 (17%) individuals who met the
ethesda criteria for HNPCC were referred for geneticvaluation. Among the individuals who met Bethesdariteria 1–3, only 3 of 28 (11%) were identified forenetic referral. Of the 25 individuals who were noteferred, 12 had a comprehensive family history and 9 ofhe 13 individuals without a comprehensive assessmentad concordant assessment of HNPCC cancers evenhough other cancers were missed in physician notes.his included an individual who met the Amsterdamriterion for HNPCC who was not referred despite doc-mentation of 3 colon cancers in the oncologist’s note.verall, 21 of 25 individuals who met Bethesda criteria–3 were not referred for genetic evaluation despiteaving a concordant assessment of HNPCC-associatedancers. Ten of 47 individuals who exclusively metoung-onset Bethesda criteria (criteria 4–6) were iden-
able 5. Distribution of Individuals Fulfilling BethesdaCriteria and Rates of Referral for GeneticsEvaluation
Bethesda criterionNumber of
subjects (%)
Individualsreferred for
geneticevaluation
(%)
otal 75 13 (17.3)Bethesda criteria 1–3 28 (37.3) 3 (10.7)
Amsterdam criteriona 1 0Individuals with 2 HNPCC-related
cancers 10 3Individuals with a HNPCC-
associated cancer and 1 first-degree relative with CRC or aHNPCC-related extracolonicb
cancer (1 cancer diagnosed atage �45 yr) 18 0
Bethesda criteria 4–6 exclusively 47 (62.6) 10 (21.3)Individuals with CRC or endometrial
cancer diagnosed at age �45 yr 55 11Individuals with right-sided CRC
with an undifferentiated patternon histopathology diagnosed atage �45 yr 7 2
Individuals with signet-type CRCdiagnosed at age �45 yr 4 2
OTE. Number of subjects in the distribution of individual criterionxceed the total number of individuals who satisfied the Bethesdariteria because 12 individuals met �1 criterion.Amsterdam criteria are defined as 3 relatives with CRC, with 1elative a first-degree relative of the other 2, spanning 2 generations,ith at least 1 cancer diagnosed before 50 years.Extracolonic cancers include endometrial, ovarian, gastric, hepato-iliary, small bowel, and transitional cell carcinoma of the renal pelvisr ureter.ethesda criteria from Rodriguez-Bigas et al.12
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ified for genetic evaluation and accounted for 77% of theeferrals.
DiscussionThe results of our study show that although fam-
ly history of cancer is frequently obtained during med-cal evaluations, its accuracy is often limited. Whenompared with patient self-reported information pro-ided by CRC patients on a written questionnaire, nearlyne third of cancers in first-degree relatives were notocumented by physicians in patients’ medical records.f interest, the accuracy of cancer history decreased with
n increase in the number of cancer diagnoses in theamily. From the pattern of malignancies omitted, itppears that in many cases only a family history of colonancer was elicited and cancers beyond first-degree rela-ives were ignored. Of the HNPCC tumors, cancer of thendometrium, which has the highest relative risk and ismong the most specific for HNPCC,13 was not docu-ented in more than half of physician notes when a
amily history was present. Finally, individuals who metstablished criteria for further genetic evaluation oftenere not identified as high-risk. In some cases, informa-
ion about HNPCC-related cancers was not recorded byhysicians; however, in many cases physicians elicitedhe relevant information but did not appear to recognizets clinical implications. Patients appeared more likely toe referred for genetic evaluation because of their youngge at cancer diagnosis than on the basis of familyistory, despite the fact that family history may be aore specific predictor for the presence of a HNPCC
ene mutation.14 Consequently, recommendations forenetic assessment were made for only a small fraction ofndividuals who met the Bethesda guidelines for hered-tary CRC.
In 1979, Lynch et al.15 reviewed 200 charts of patientsndergoing treatment at an oncology clinic and foundhat more than half lacked a documented family history.ore recent studies and ours have shown improved rates
f family history assessment with 78% to 97% of med-cal records containing at least some documentation ofamily cancer history.16,17 There have been few studies,owever, that have examined the quality of family his-ory assessment. Sweet et al.16 compared patient-enteredamily history information into a computer kiosk withamily history obtained by physicians and found thatigh- and moderate-risk patients were often not identi-ed by physicians owing to inadequate detail of physi-ian family history assessment. In addition to confirmingheir findings, our study shows that, in contrast to whatne would hope, risk factors that increase the likelihood
f having a hereditary form of cancer, such as youngnset of disease or a first-degree relative with cancer, didot lead to closer attention to the family history becausehese factors did not predict improved accuracy of familyistory assessment. In contrast, those individuals whoere potentially at highest risk of having a hereditary
ancer owing to the presence of multiple affected rela-ives were less likely to have a comprehensive familyistory assessment. Although the first assumption maye that physicians stopped documenting the cancers oncehey had made an assessment of increased familial risk inatients who had numerous affected family members, theow referral rates for further genetic evaluation in theseatients suggests that this was not the case. Even whenhysicians had recorded family history information ac-urately they did not always incorporate this into patientare; over 80% of the patients in our study who metethesda criteria 1–3 had a comprehensive HNPCC
amily history assessment, yet they were not referred forenetic evaluation.It is important to address the limitations of our study.e relied on physicians’ dictated notes for data collec-
ion. It is possible that physicians elicited a more exten-ive cancer history that was not recorded in the note. Itlso is possible that referrals for genetic evaluation wereot made at the initial visit but were made later inreatment once acute management issues had been re-olved. To address these possibilities we reviewed fol-ow-up notes for 25% of the patients and did not find anyases in which genetic referrals were made or familyistory was re-addressed. The most prevalent topic athese visits was the patient’s response to the chemother-py regimen, and further cancer risk assessment was notiscussed.For our determination of a comprehensive physician
amily history assessment and subsequently the identifi-ation of high-risk individuals we relied on patient self-eports for family history as the gold standard. Priortudies have shown that the accuracy of patient-reportedistory varies from 68% to 89%, depending on theatient population.18–22 Although it is possible thatatient reports may have contained inaccurate informa-ion, in routine clinical practice physicians must baseheir risk assessment and recommendations on patientistory because medical record confirmation is rarelyeadily available for family members’ diagnoses. Ourndings that 19% of patients had indications for geneticssessment are similar to another study performed in aertiary care cancer center.16 Our study was performed atgastrointestinal oncology clinic with gastrointestinal
ncologists who were knowledgeable with regard to he-
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818 GROVER ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2, No. 9
editary CRC syndromes and therefore the prevalence ofigh-risk patients may be lower in other settings andeserves further study.Our findings have several implications. First, the low
ates of comprehensive physician assessment of familyancer history and the decrease as complexity of familyancer history increased suggests that there is need for aore methodologic approach to obtaining family his-
ory. The development of more consistent methods ofecording and analyzing family history information maymprove family history assessment and consequently leado the identification of individuals who may benefit fromurther risk evaluation. Second, it is clear that a substan-ial proportion of CRC patients meet criteria that indi-ate the need for further genetic evaluation based onxisting guidelines. Early identification of these patientsay allow for timely initiation of appropriate surveil-
ance or prophylactic surgery, thus dramatically decreas-ng mortality. In individuals with hereditary colon can-er, such procedures can provide a 13- to 15-yearncrement in life expectancy as compared with no inter-ention.23 Recent studies have shown that physicianwareness of diagnostic guidelines for hereditary canceryndromes is limited.24,25 Our findings of the low ratesf referrals for further genetic assessment in high-riskatients lend support to these data.Third, our study suggests that the focus of the care of
ancer patients remains primarily on the treatment of thealignancy. Unfortunately, viewing the diagnosis of
ancer as an opportunity for prevention of future canceriagnoses often is neglected. For the index case, theiagnosis of a hereditary cancer syndrome has implica-ions for the frequency of future surveillance of CRCcolonoscopy should be performed every 1–2 years forNPCC patients rather than every 3–5 years for sporadic
ases),4,26 and may indicate the need to screen for extra-olonic tumors (e.g., endometrial cancer in women).4,10
n addition, the implications of the diagnosis for otheramily members is often neglected. The diagnosis ofereditary cancer impacts the future management ofamily members with regard to both age of onset andrequency of CRC surveillance, as well as interventionsecessary for early detection of associated malignancies.t is increasingly being recognized that physicians have aegal and ethical duty to warn family members whenereditary diseases are present.27 Although the extent ofhis responsibility may be debated,28 certainly discussionf the implications of a potentially hereditary cancer withhe index patient being treated is an acceptable andeasible minimum standard to achieve.
In conclusion, the explosion of the field of humanenetics has created new opportunities for the diagnosisf a multitude of inherited diseases; nonetheless, theamily cancer history remains instrumental in the iden-ification of hereditary cancer syndromes. The evaluationf family history must be an integral part of patient careo recognize possible hereditary syndromes and adviseenetic evaluation. The incorporation of more systematicnd standardized methods of recording family history inlinical practice may enhance the efficiency with whichamily history is recorded, allowing physicians to focusn cancer prevention.
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Address requests for reprints to: Sapna Syngal, M.D., M.P.H., Assis-ant Professor of Medicine, Dana-Farber Cancer Institute, 44 Binneytreet, Smith 209, Boston, Massachusetts 02114. e-mail:[email protected]; fax: (617) 632-4088.
Supported in part by a National Institutes of Health grant07CA08453 for studying identification and cancer screening in he-
editary colon cancer families (to S.S.).