COMMENTARY

Family History Is Never 'Noncontributory'

Mark A. Lewis, MD

Disclosures

November 15, 2019

This transcript has been edited for clarity.

Hi. I am Mark Lewis, director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah, and a contributor to Medscape.

I want to talk about the importance of family. This has a lot of meaning for me because family and illness in the family are the reasons I studied medicine, and oncology in particular.

Tolstoy had a saying that all happy families are alike, but every unhappy family is unhappy in their own way. And I would say that every healthy family appears similar, but every family grappling with illness has to do so in their own way. That is why I believe it is so important to take a good and detailed family history.

This may happen only once during the entire longitudinal encounter with the patient. It tends to happen at the first visit when there are so many other things to talk about, especially if you're dealing with a new cancer diagnosis. The family history, frankly, can be swept aside. But the word that I particularly hate to see in the medical record is "noncontributory." There is hardly any medical condition where it's not important to know about that illness in relatives of the patient.

For example, my father was 42 years old when he was told that he had a form of lung cancer. Before that, his only medical problem had been kidney stones. And despite his strong efforts to reduce calcium intake in his diet, he continued to develop those kidney stones. That was really a bothersome problem for him, but it was then superseded by this lung malignancy. He died when I was 14, and I didn't have any access to his medical records at that point.

Later, I got sick in a similar way. I was just about to start my oncology training. I had abdominal pain and I found that I, too, had a high calcium level. That was actually the key clue I needed to see a pattern in my family; very few conditions cause high calcium levels in consecutive generations. That's when I started to ask questions about my father's medical history. I learned that the form of lung cancer he had was quite specifically a neuroendocrine tumor that grew out of his thymus. That fact plus two consecutive generations of family members with high calcium levels allowed me to see a pattern: That pattern is MEN-1, or multiple endocrine neoplasia type 1. Being able to see this pattern has cast my entire family in a different light. It turns out that my paternal uncle died of a pituitary tumor, and my paternal grandfather also died of a mysterious tumor in his chest. It's only in hindsight that I can see that all of these men actually shared a diagnosis and all died from the same root cause, which was MEN-1.

So when I see a family history taken either without sufficient detail or not taken at all, that really bothers me. Please, please, please take the time when you're first meeting a patient to ask about the health status of their relatives. Record it in as much detail as you can, including details that may seem inconsequential. It may later turn out, as in my case and my family's case, to actually have great importance. Particularly when it comes to cancer, try to note the site and the age at diagnosis. Again, this may allow you to see patterns of hereditary tumor syndromes.

I have one last person to introduce to you. [Speaking to son.] Tell the audience your name.

"Alan."

Who are you named after?

"My grandfather."

That's right. You have your grandfather's name. And what else did he share with us? He had the same medical problem we have, right?

My son is 8 years old, and my wife and I are able to take care of him in a completely different and proactive manner, knowing that he also carries MEN-1. I believe that his health is likely to be better than mine, and I certainly hope that he will live longer, better, and with fewer complications than me, my dad, or my grandfather.

Alan and I have a secret handshake that we do as Lewis men, to share our linkage. Obviously, we can't do that on camera or you'll know our secret. But from him and me, and my dad who's no longer with us, we want to remind you that family matters. This is what a family history looks like.

Thank you for listening.

Mark A. Lewis, MD, is director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah. He has an interest in neuroendocrine tumors, hereditary cancer syndromes, and patient-physician communication.

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