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Journal of Clinical Oncology, Vol 23, No 6 (February 20), 2005: pp. 1330-1331 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.173
The Choice of Bilateral Prophylactic MastectomyPaoli-Calmettes Institute, Université de la Méditerranée, Marseille, France To the Editor: Scientific evidence like that presented by Schwartz et al1 deserves to be shared and may lead to some substantial changes in recommendations for the management of cancer-prone persons. About bilateral prophylactic mastectomy (BLM), French perspectives had been cautious2 even if recently more prone to support the procedure.3 Maybe fast counseling and fast testing could steer choices for informed women toward a higher acceptability, as observed in the survey of Schwartz et al.1 There is, however, in the presented data, a striking result: up to twice as many women with stage II and III breast cancer, compared with stage 0 and I breast cancer, have chosen the BLM. This intervention is seen as reducing quality of life4; therefore, the end point we are looking for is an increased life expectancy (high enough to counterbalance the decrease in quality of life). The value of BRCA mutation as an independent prognostic factor is still controversial.3,5-7 Therefore BLM seems—always for the unaffected breast and mainly for the affected one—to be a mid- to long-term strategy. Thus, the highest positive outcome will be seen in women for whom life expectancy has not been altered as such by a first cancer (the one under treatment). Three hypotheses could be proposed to explain the paradoxical rates observed in the survey of Schwartz et al.1 First, there is a shared causality for both high-stage cancers and willingness to undergo BLM. For instance, specific mutations could induce particularly poor-prognosis breast cancers with both a high death rate within the family, leading to an increased risk perception, and an increased probability of developing personally a high-stage cancer. However, the lack of definite genotype-phenotype correlations makes this hypothesis risky. Second, women with a disease diagnosed at a late stage could perceive the screening procedure as insufficient (information that should had been given before the procedure), making radical surgery more attractive. Lastly, there is a misunderstanding about the meaning and the aim of BLM. Some women may perceive this intervention as a will to increase the aggressiveness of the treatment that could fit the aggressiveness of the disease. If the two prior hypotheses make sense, that last one, if confirmed, should be seen as a flaw in the informed-decision process. Whatever is at stake in that decision, women with stage II and III breast cancer shouldhave a statistically lower medical benefit from BLM than women with stage 0 and I breast cancer. A few years ago, in a different context, Savulescu and Momeyer8 argued that consent should not only be informed but also based on rational beliefs. Information is a necessity—a first mandatory step. How can we help to transform information into knowledge to improve decisions? Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Schwartz MD, Lerman C, Brogan B, et al: Impact of BRCA1/BRCA2 counseling and testing on newly diagnosed breast cancer patients. J Clin Oncol 22:1823-1829, 2004
2. Newman L: French National Ad Hoc Committee strongly resists prophylactic mastectomy. J Natl Cancer Inst 93:339, 2001 3. Eisinger F, Bressac B, Castaigne D, et al: Identification et prise en charge des prédispositions héréditaires aux cancers du sein et de l'ovaire (mise à jour 2004). Bull Cancer 91:219-237, 2004[Medline]
4. Grann VR, Jacobson JS, Thomason D, et al: Effect of prevention strategies on survival and quality-adjusted survival of women with BRCA1/2 mutations: An updated decision analysis. J Clin Oncol 20:2520-2529, 2002 5. Verhoog LC, Berns EM, Brekelmans CT, et al: Prognostic significance of germline BRCA2 mutations in hereditary breast cancer patients. J Clin Oncol 18:119S-124S, 2000 (suppl 21)
6. Stoppa-Lyonnet D, Ansquer Y, Dreyfus H, et al: Familial invasive breast cancers: Worse outcome related to BRCA1 mutations. J Clin Oncol 18:4053-4059, 2000 7. Eerola H, Vahteristo P, Sarantaus L, et al: Survival of breast cancer patients in BRCA1, BRCA2, and non-BRCA1/2 breast cancer families: A relative survival analysis from Finland. Int J Cancer 93:368-372, 2001[CrossRef][Medline] 8. Savulescu J, Momeyer RW: Should informed consent be based on rational beliefs? J Med Ethics 23:282-288, 1997[Abstract] Related Article
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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