Clinical Cases

Taking a Family History of cancer: We Can Do Better

June 25, 2012 Chemotherapy, Clinical Cases, Hematology, Therapeutics No comments , ,

June 7, 2012 (Chicago, Illinois) — Family history can be important in establishing risk for primary and secondary cancer and identifying people who might be candidates for genetic counseling and testing.

According to data presented here at the 2012 Annual Meeting of the American Society of Clinical Oncology (ASCO), community oncologists are better at documenting family history in patients with breast and colorectal cancer than expected, but there is still room for improvement.

“Family history is the best criteria we have right now to identify people who are at risk for hereditary cancer syndrome and are candidates for referral and genetic testing,” said lead author Marie Wood, MD, professor of medicine, director of the familial cancer program and deputy director of hematology/oncology at the University of Vermont in Burlington.

It is critical to identify people with an above-average risk for a primary cancer and who should get additional screening, she explained during a press briefing, where highlights of the study were presented. “Cancer survivors who have a strong family history should get above-average screening for the cancer they already had and for additional cancers,” Dr. Wood said.

The researchers found that age at cancer diagnosis within the family history was documented less than half the time,” Dr. Wood noted.

“This was more commonly documented for breast cancer than for colorectal cancer patients,” she said. “When we looked at the difference between breast and colon cancer patients, it was always statistically significant.

We can and should do better.

Overall, the researchers found a high rate of documentation of cancer in first-degree relatives, albeit with a low documentation of the age at cancer diagnosis. “Family-history taking is also clearly better for breast cancer patients than colon cancer patients. We are hoping to do more with this dataset to try to figure out why that is,” Dr. Wood explained. “We can and should do better.”

The patients who underwent genetic testing received good counseling, consent documentation, and a discussion of results. “But there were low rates of referral for both counseling and testing for those who would actually benefit from it,” she said.

Family History Defines Proper Treatment

“This is a multifaceted issue and this is the first national program to help practices improve,” said Nicholas Vogelzang, MD, chair of the ASCO Cancer Communications Committee and medical director at the US Oncology Comprehensive Cancer Centers of Nevada.

Dr. Vogelzang, who moderated the press briefing and who was not involved in the study, noted that taking a good family history “is fairly laborious” and can take up to an hour to complete. This is impractical for most community oncology practices; it is hoped that the process can be expedited with the Internet.

“It is surprising how little people know about their families,” he said. It is estimated that among patients with prostate, colon, and breast cancer, about 30% are at risk for genetically transmitted disease, he explained.

In the discussion that followed Dr. Wood’s presentation, Dr. Vogelzang emphasized the practical benefits of taking a family history. He illustrated his point with the case of one of his patients — a 48-year old man with metastatic prostate cancer who was not responding well to standard treatment. After taking a thorough family history, it was revealed that his mother, sister, and aunt had all died of breast cancer.

Dr. Vogelzang said that the presentation of the man’s cancer suggested BRCA gene mutations; he had metastases in the liver and adrenals, but the cancer had not entered the skeletal system. The patient was treated with a breast cancer chemotherapy regimen and he responded beautifully.

Study Details

Previous studies have demonstrated low rates of family-history documentation and low referral rates for genetic counseling and testing, according to the researchers. The Quality Oncology Practice Initiative (QOPI) was developed by ASCO “to promote excellence in cancer care by helping practices create a culture of self-examination and improvement.” QOPI uses measurement, feedback, and improvement tools for hematology/oncology practices.

Last year, ASCO began testing new QOPI measures to evaluate the practice of family-history taking and referral for genetic counseling and testing in patients with breast cancer or colorectal cancer, explained Dr. Wood. They assessed the presence or absence of cancer in first- and second-degree relatives, age at cancer diagnosis, referral for genetic testing and counseling, and outcomes of referral.

“Our group developed pilot test questions for breast cancer and color cancer patients” using “expert consensus and participation from ASCO prevention and quality committees,” she noted.

In September and October 2011, Dr. Wood and colleagues evaluated these measures in 272 practices (6569 patients with breast cancer and 3897 with colorectal cancer). In the charts of these patients, 77.4% documented the presence or absence of cancer in first-degree relatives (breast cancer in 81.2% and colorectal cancer in 77.4%; P = < .001).

In addition, 61.5% of the charts documented the presence or absence of cancer in second-degree relatives (breast cancer in 68.9% and colorectal cancer in 57.3%; P ≤ .001).

The age at cancer diagnosis was documented for all relatives with cancer in 30.7% of the charts, and referral for counseling and/or testing was documented in 22.1% of the charts (breast cancer in 29.1% and colorectal cancer in 19.6%; P ≤ .001).

For patients with hereditary risk, defined by selected risk guidelines, the charts of 52.2% of breast cancer patients but only 26.4% of colorectal cancer patients documented referral for genetic counseling and testing. When genetic testing was performed by the practice, consent was documented 77.7% of the time and discussion of the results was documented 78.8% of the time.

The authors have disclosed no relevant financial relationships.

2012 Annual Meeting of the American Society of Clinical Oncology: Abstract CRA1505. Presented June 4, 2012.

A serious drug interaction was found last week in 416 Hospital

May 2, 2012 Anticoagulant Therapy, Cardiology, Clinical Cases, Drug Interactions, Therapeutics 1 comment , , , ,

Fluoxetine Capsule.

Last week, before the “May 1st Labor Festival” an old man came to outpatient pharmacy to take his medications. Someone doctor (Neurology Clinics of 416 Hospital) prescribled the drug – Fluoxetine Capsule – to the old man.

When I was dispensing the fluoxetine capsule (Dosage and frequency : 20mg po Qd) to the lovely old man, he told me that he had taken a heart surgery not long ago and he was taking warfarin to prevent cardiac incidents such as acute myocardial infarction.

He didn’t tell me what kind of heart surgery he had taken and the dosage and frequency of warfarin. But I speculated that there might be some cardiac diseases with him and some device such as mechanical valve had been implanted into his heart. So he needs to take anticoagulant to prevent cardiac incidents such as acute myocardial infarction and so on.

The old man inquired me wheth he could take warfarin and fluoxetine in combination. So I checked the two agents in Medscape Multi-Drug Interaction Checker on my android phone and three drug interactons was found among which one was serious and two were significant. They are:

1. Serious: fluoxetine increases levels of warfarin by decreasing metabolism. This drug interaction possibly is serious or life-threatening. It is recommended to use alternatives if available or monitor closely.

2. Significant: fluoxetine will increase the level or effect of warfarin by affecting hepatic enzyme CYP2C19 metabolism. Significant interaction. To monitor closely.

3. Significant: fluoxetine will increase the level or effect of warfarin by affecting hepatic enzyme CYP2C9/10 metabolism. Potential for interaction. To monitor.

So I was hesitant to dispense fluoxetine capsule to him and I warned him to avoid the combination use of these two drugs. If there were no alternatives and he must take fluoxetine I recommended him to monitor his INR twice weekly at least. If the INR exceeds the normal range or the symptom of haemorrhage turns up, the dosage of these two drugs must be adjusted, or the combination use must be stopped.

Discussion:

Fluoxetine and warfarin are different drugs. But they have a same point that they both are metabolise by the same hepatic enzymes such as CYPC19, CYP2C9, CYP2C10. So when one drug is being metabolized, the other one can play a role as antagonist. The result is that the levels of both two drugs are enhanced by each other, espically both two drugs are long-term administered. Because both levels are increased so the rate of adverse drug reactions increases too. For fluoxetine patients may have the adverse drug reactions such as headache, nausea, insomnia and so on. For warfarin patients may have ADRs such as cholesterol embolus syndrome, tissue necrosis, and the most serious – hemorrhage.

Above is the clinical case of drug interaction I met last week. Hope it will be useful for our clinical pharmacists.