Breast cancer risk without BRCA – how much?

Dr Stephen Norod - lead researcher
Dr Stephen Norod - lead researcher

6 year prospective Canadian study following 1492 women in 365 families. All negative for BRCA1 and 2 mutations. Families followed up had 2 or more breast cancer diagnosis under 50y or 3 diagnosis at any age. 65 women developed breast cancer instead of the expected 15 expected for a population without a family history. Giving a four fould increased risk. Compared to the presence of BRCA1/2 mutations which confer a 7 fold increased risk.

Important to take the family history especially in women. Tamoxifen as prophylaxis? Quick research: it is a licenced indication ( 20mg qd x5 years according to epocaratesRx) but need to weigh up increased risk of stroke, PE and uterine malignancies. When is someone going to design an easy to use risk comparison tool?

Ethics mnemonic iMRCGP – ABCDE

In the i/nMRCGP you may get a patient that presents an ethical dilemma. The patient who has had a stroke and is now not fit to drive, should you breach your confidentiality and tell the authorities or not? A male patient who has come for a vasectomy because his female partner would like him to have one, they have one child. Is the patient acting autonomously, should you recommend this to the patient and so on.

When dealing with these patients it is good to have a framework to hang your questons on and the outcome of your consultation. A simple menmonic is the following one: ABCDE which stands for:

A – Autonomy: Is the patient acting because s/he wants to do it or is someone else pushing them into this action? Are you being forced to act because of the patient demand (‘Give me this drug doctor!’ Response: You have the right to ask for the medication but I as a doctor have the right based on my professional judgement to prescribe or not, to force me would be to breach my autonomy)

B – Beneficence: i.e. do good and not harm. I could give just refer the patient for his vasectomy but has he thoought about if the marriage goes wrong and he starts a new relationship that the vasectomy is very difficult to reverse and he may not have children in the future? If I agree to prescribe this drug to this patient then will this set a trend in the future i.e. harming other doctors and the doctor patient realtionship. If I prescribe the most expensive drug always first am I causing harm to society and the exchequer?

C – Confidentiality – Mother comes to speak about son, who is 19 – an adult. You have to maintain confidentiality. You could breach it with the permission of the other i.e. son happy to talk about his case with his mother, but if you sense this is difficult what do you do? Stick to keeping confidentiality in the abscence of permission. If two patients come together, you can always ask one to step out of the room for a short while, take permission from the other or ask any potentially embarassing questions: i.e. have you had sexual partners etc.

D – Duty : Duty of care to the patient, yourself (you do not have to be at the back and call of someone and you can let them know that there are certain procedures and hours and these should be followed), staff (sticking to general guidelines or working practices in your surgery), and society (resources, not misuring them etc.)

E – Equity – Being euqal with your resources between patients.