RAPID RESPONSE Variations in rates: why we need clinical management recommendations Denise Avard, PhD (1), Jaques Simard, PhD (2), Doug Horsman, MD, FRCPC (3), Brenda J. Wilson, MBChB, MSc, MRCP, FFPH (4), Wendy S. Meschino, MD, FRCPC (5), Charmaine Kim Sing, MBChB, FRCPC (3), Marie Plante, MD, FRCSC (2), Andrea Eisen, MD, FRCPC (6), Heather E. Howley, MSc (4)

1. Université de Montréal, Centre de recherche en droit public, denise.avard@umontreal.ca
2. Centre Hospitalier Universitaire de Québec and Université Laval, Québec, QC
3. British Columbia Cancer Agency, Vancouver BC
4. University of Ottawa, Department Epidemiology and Community Medicine, Ottawa, ON
5. North York General Hospital and University of Toronto, Toronto ON
6. University of Toronto, Toronto Sunnybrook Regional Cancer Centre, Toronto ON

August 31, 2007 This piece is a Rapid Response to the article Variation in Rates of Uptake of Preventive Options in BRCA1 and BRCA2 Mutation Carriers Across Canada. Competing interests: None declared.

The identification of BRCA1 and BRCA2 genes for hereditary breast and ovarian cancer (HBOC) has increased the use of predictive genetic testing. This capability has spurred the development of clinical services in most Canadian provinces that provide cancer genetic services (including surveillance or interventions) to those affected and their family members.

Metcalfe and colleagues recently reported that the uptake of preventive measures (such as mastectomy, oophorectomy, treatment with Tamoxifen or Raloxifene, and MRI screening) varied across Canada, with the lowest uptake in Montreal.1 One reason for these variations, they speculate, may be differences in health care professionals’ acceptance and recommendation of such preventive procedures. They indicate that future research is needed to explain these differences. This raises questions of whether the lack of consistent national recommendations for clinical management of individuals carrying a deleterious BRCA1 and BRCA2 mutations contributes to these differences.

The Integration Group of the Canadian Strategy for Cancer Control has noted that policies addressing the prevention, detection, diagnosis, treatment, and cure of breast cancer are far from consistent across Canada.2

To address this lack of consistency and to coordinated clinical services across Canada, The National Hereditary Cancer Task Force was formed. The National Hereditary Cancer Task Force is collaboration between the Canadian Association of Provincial Cancer Agencies (CAPCA), the Interdisciplinary HEalth Research International Team on BReast CAncer susceptibility (INHERIT BRCAs) and GeneSens (a CIHR funded network a Canadian researching genetics health policy and services). The Task Force developed the Clinical Management Recommendations for Surveillance and Risk Reduction Strategies for Hereditary Breast and Ovarian Cancer among Individuals Carrying a Deleterious BRCA1 and BRCA2 Mutation.3 These recommendations were developed by a rigorous process using the highest level of evidence possible and by a multidisciplinary team of clinicians, experts and researchers, with input from representatives from the public and government agencies. The recommendations pertain to surveillance and risk-reduction management only, specifically: (1) surveillance options including breast self-examination and clinical breast examination, breast screening by imaging, ovarian cancer surveillance, and male carrier surveillance; and (2) risk-reduction strategies including prophylactic mastectomy and salpingo-oophorectomy, pharmacoprevention, and the use of exogenous hormones. Their aim is to assist physicians and patients to make a balanced and informed clinical decision.

We recognize that there might be difficulties in implementing these recommendations. Some will be due to the guidelines themselves, or to the availability of services.4 It also might be difficult to make them work within the Canadian health care system which, with ten provinces and three territorial health care systems, often represents a range of visions. In addition, there are issues of reimbursement, the incidence and prevalence of the condition, access to medications, availability of physicians and specialists, and patient and physician perceptions to take into account.

However, when making decisions about clinical care, recommendations have been shown to reduce variations in clinical care and to promote high quality consistent care.5 While we acknowledge that the uptake of preventive measures does not necessarily translate into better outcomes, we strongly believe that the National Hereditary Cancer Task Force recommendations provide an excellent resource that will help physicians and patients make beneficial health care choices in a more consistent manner.

References

1. Metcalfe KA, Ghadirian P, Rosen B, Foulkes W, Kim Sing C, Eisen A, et al. Variation in Rates of Uptake or Preventive Options by Canadian Women Carrying the BRCA1 and BRCA2 Genetic Mutation. Open Medicine 2007;1(2):92-98.
2. Canadian Strategy for Cancer Control. Establishing the Strategic Framework for the Canadian Strategy for Cancer Control (Discussion Paper), July 2006. Available.
3. Horsman D, Wilson BJ, Avard D, Meschino WS, Kim Sing C, Plante M, et al. Clinical Management Recommendations for Surveillance and Risk-Reduction Strategies for Hereditary Breast and Ovarian Cancer among individuals carrying a deleterious BRCA1 or BRCA2 Mutation. J Obstet Gynaecol Can 2007;29(1):45-60.
4. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8(6):iii-72.
5. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ 1999; 318(7183):593-596.

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