General Practitioners and Breast Surgeons in France, Germany, Netherlands and the UK show variable breast cancer risk communication profiles

This international survey is the first to assess how European GPs and specialised practitioners caring for healthy women under breast cancer surveillance regard their responsibility for assessing and communicating genetic, environmental and lifestyle breast cancer risk factors to their patients.

First, the majority of these European practitioners reported that they frequently assessed family history and hormonal replacement therapy (HRT) but only occasionally discussed patients’ lifestyle BC risk factors such as obesity, physical exercise and alcohol (Table 2). Breast surgeons communicated more frequently than GPs with their patients about all the breast cancer risk factors studied, except for HRT and oral contraception. Health providers from the Netherlands communicated much less frequently about patients’ lifestyle BC risk factors than those from the other countries, especially Germany, whereas French and UK doctors gave intermediate responses to this question.

The relatively similar attitudes to discussing patients’ family history and HRT risks observed in the various countries may have been due to the large body of research results published during the last fifteen years on the assessment of breast cancer genetic risks [7,12] and the deleterious effects of hormonal replacement therapy [23]. This knowledge has now been quite widely applied in the clinical practices of these practitioners, who seem to be convinced of their relevance as the result of either their initial/vocational training, the guidelines published or peer group recommendations. This was not found to be the case as far as lifestyle and changeable risk factors such as obesity, physical exercise and alcohol consumption are concerned. The importance of these factors has only been recognized quite recently, based on a lower level of evidence than with risk factors which have been studied in the framework of genetic testing and cancer genetic referrals, or HRT prescription in the context of menopausal symptoms. In addition, these factors are sometimes not even mentioned in the national guidelines for GPs and BSs. In view of the increasing evidence available that obesity, lack of physical exercise and probably high alcohol consumption rates contribute to breast cancer, there is certainly room for improvement in the guidelines published and physicians’ lifestyle recommendations to patients [24].

Secondly, the majority of the sample (more than two thirds) declared that they expressed the absolute risks numerically and framed them negatively when presenting them to patients (Table 4). Risks and relative risks were described verbally by only a minority of the respondents (less than 44%). The five profiles identified, corresponding to the preferred risk presentation formats (RPFs), differed in several respects: those of the relative majority of the respondents were incomplete, since they omitted to frame the cancer risks negatively, i.e., they did not mention the probability of not developing cancer (Cluster 2). Cluster 2 included more than one third of the sample and consisted more frequently of GPs and French practitioners, who expressed the opinion that they were responsible for explaining the risks as part of primary prevention and cancer screening efforts, but that they could not be expected to present a comprehensive picture of the risks. It has been recommended that healthcare providers should focus on the most relevant risks [14,15,19], and the respondents in cluster 2 obviously thought it was not relevant to talk about the chances of not developing cancer. This attitude might be judged to be inacceptable, since it is known to bias patients’ decision-making, which is contrary to the principle of patients’ freedom of choice and their right to express their own preferences. Cluster 4, “Risks presented in all 4 ways” along with cluster 3, “No verbal formulation”, which can be said to adhere most closely to the ‘best standards’ defined in the literature [14,15], differed in that cluster 3 more frequently consisted of younger doctors practicing in countries other than Germany/the UK. The “No verbal formulation & No relative risks mentioned” group could be said to consist of practitioners wanting to inform their patients quickly and simply about the risks, avoiding the difficult problem of explaining the relative risks, which has been found to help patients decide between the options available [19], but can be hard for patients to understand [15], as well as the rather delicate problem of presenting the risks verbally. On the other hand, risk presenters in the “Absolute numerical risks not presented” group could be said to show a more paternalistic attitude: making patients’ cancer risk perception as low as possible by presenting the absolute risk figures and emphasizing the probability of not developing the disease. These practitioners were more frequently GPs working in countries other than the UK. This paternalistic attitude is known to increase with age [25], and has often been observed mainly in male doctors [25]. This was not found to be the case here. The reason why the attitudes of the doctors surveyed here, as reflected in their risk presentation formats, were so variable may be that many of them had undergone very little formal training in the basic principles of risk communication [16] and that it is very difficult to apply theoretical recommendations in a real life context [19,26,27] in terms which can be easily understood by the patients [18,28].

This study has several limitations. First, it is about self-reported risk communication practices, which may differ from physicians’ actual practices. These declared practices are likely to be a combination between what the doctors said they would do and what they thought they ought to do. In addition, the vignettes used here provided only a short description of the complex clinical context. The results should be interpreted accordingly. Secondly, the questionnaire used in this study was mailed to the doctors eligible to participate, and the response rate obtained was low despite the reminders made by mail and telephone. The low response rate certainly reduce the possibility of generalizing the results obtained by taking them to be representative of doctors’ risk communication attitudes in a given country. Any country-specific differences will have to be investigated further. Although the response rate was low, it was comparable to that obtained in other surveys of this kind [29]. However, this survey is one of the few sources of information about an international sample of GPs’ and BSs’ self-reported cancer risk communication practices. It is of particular interest to note the different response rates obtained from one speciality and one country to another, since a low response rate can also be taken to reflect a low level of interest in the topic under investigation. It has been suggested that the most interested doctors are more likely to answer questionnaires and are therefore likely to be over-represented in the study sample.

The occupational characteristics of the practitioners working in various countries’ healthcare systems have to be taken into account when interpreting the data collected. The role of the “GP gatekeeper” in the UK’s and Netherlands’ healthcare systems differs from what occurs in France and Germany, especially as regards referrals, prescriptions and the existence of highly specialized secondary and tertiary care centres. For example, mammographic screening of healthy women at risk is performed in the UK by breast surgeons, whereas this activity is mostly carried out in France by Gynaeco-Obstetricians, who form a very heterogeneous group of practitioners, some of whom are medical gynaecologists (who do not carry out surgical interventions and deal very little with breast cancer patients), while others are involved only in obstetric care or specialize in breast surgery.

The differences between the breast cancer risk communication profiles observed among non-geneticist healthcare providers in these four European countries reflect the specificities of the respective healthcare systems, and especially the content of medical training programs and guidelines. Risk communication skills should be part of a core communication curriculum intended not only for geneticists/cancer geneticists and genetic counsellors, but also for primary care providers [30]. Qualitative studies might help to understand why practitioners adopt specific communication practices. The need for risk communication skills has been underestimated in healthcare providers’ initial and vocational training programs. In view of the current trend to investigate all the possible actionable scientific, medical and social risk factors involved in breast cancer, this topic would be worth investigating more closely.