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© 2003 American Society for Clinical Oncology
Hereditary Breast Cancer: Shared Communication and CareDepartment of Medical Oncology, Queen Elizabeth II Health Science Centre, Maritime Hereditary Cancer Service, IWK Health Center Halifax, Nova Scotia, Canada To the Editor: In the otherwise excellent article by Lynch et al,1 there was one disappointment: the lack of discussion regarding the role of the medical oncologist at the "genetic counseling bedside." Witnessing the tragedy of malignant diagnoses on a daily basis gives oncologists a particular insight regarding the issues and anxieties that can be raised during genetic counseling, as well as a unique expertise when discussing potential prophylactic interventions. A number of examples may serve to illustrate the point. The discussion regarding adjuvant chemotherapy for breast and colon cancer is somewhat akin to interpreting a deleterious BRCA1 mutation. Oncologists frequently interpret group probabilities within an individual context regarding risk of cancer recurrence (penetrance). As well, hours are spent reviewing the goals, risks and limitations of adjuvant (preventive) therapy to reduce risk of an event that may or may not occur in any one particular individual. As such, medical oncologists can use well-developed communication skills that can be easily adapted to the genetic counseling environment. The well established role of tamoxifen in the adjuvant therapy of hormonally-responsive breast cancer requires a constant reframing against the overestimation of potential risk as freely publicized in much of the popular media. Review of the potential utility of tamoxifen as chemoprevention for unaffected, high-risk individuals requires an even more thorough explanation based on a comprehensive knowledge of both risks and benefits and falls well within the purview of many medical oncologists. In reassuring the affected patient who is convinced that she bears responsibility for her breast cancer, despite regular breast self-examination, oncologists often refocus perspective on the unrealistic expectations of screening tests in disease detection. Most screening examinations recommended for high-risk individuals, especially for younger women, have poor sensitivity. Categoric screening recommendations may lead to significant adaptive difficulties in those diagnosed with disease, despite faithful adherence to screening guidelines. An oncologic perspective can assist in the individualization of surveillance recommendations and may help to promote realistic expectations of imperfect tests. At all stages, a medical oncologist interested in cancer genetics can provide guidance, clarification, reassurance, and direction based on first-hand knowledge of the devastation of a cancer diagnosis, an appreciation for the unpredictability of the disease, and an understanding of the limitations of screening. We have no doubt that "hereditary cancer has come of age in medical oncology."1 Medical oncology must now come of age in medical genetics to the benefit of all those seeking counseling and testing. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest. REFERENCE
1. Lynch HT, Snyder CL, Lynch JF et al: Hereditary Breast-Ovarian Cancer at the Bedside: Role of the Medical Oncologist. J Clin Oncol 21:740–753, 2003
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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