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BACKGROUND: Cancer risk assessment begins in the primary care clinician's office. Essential components of that process include: 1) documentation of personal and family cancer information; 2) identification of families at increased risk for cancer; 3) modification of cancer screening recommendations according to degree of risk; 4) referral of high-risk individuals to cancer genetics clinics. The purpose of this study was to examine these 4 components of primary care cancer risk assessment using data abstracted from patient records at an academic family medicine center. METHODS: Ambulatory records of 734 patients were reviewed in their entirety for information relevant to cancer risk assessment. Detail of cancer information was categorized as comprehensive, adequate, or inadequate. Patient records were categorized as suggestive of average, moderate, or high genetic risk for cancer. For patients with a family history of colorectal cancer, modification of colon cancer screening to reflect degree of cancer risk was assessed. Finally, the frequency of cancer genetic referral in high-risk individuals was noted. RESULTS: The presence or absence of a family history of cancer was documented in 97.8% of records. There was insufficient information to adequately assess risk in 69.5% of charts. Detail of family cancer documentation was associated with personal history of cancer (P = .001), patient age (P = .001), and physician training status (P = .042), but not with patient or physician gender, duration of care, or completion of a genogram. For persons with a family history of colorectal cancer, compliance with cancer screening individualized to degree of risk was achieved in 50% of patients. Ten patients met criteria for moderate or high genetic risk for cancer. None had been offered cancer genetics consultation. CONCLUSIONS: Nearly all records documented the presence or absence of a family history of cancer. However, in those with a positive family history, the detail of information was insufficient to permit risk assessment in over two thirds of individuals; risk-stratified colon cancer screening was not achieved in half of the patients with a family history of colorectal cancer; individuals at moderate or high cancer risk were not identified as such; and those at high risk were not offered cancer genetics referral. In addition to collecting adequate family cancer information, family physicians need to adopt explicit risk assessment criteria to identify, and to optimally care for, those at increased genetic risk for cancer.