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In Reply:

Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC

Eisinger et al raise the important point that bilateral mastectomy (BLM) has the greatest potential benefit for patients whose life expectancy has been altered least by their current breast cancer (ie, those with stage 0 or I disease). Yet, as they correctly point out, we found that the rate of BLM was higher among patients diagnosed with stage II or III breast cancer, compared with stage 0 or I. Among several possible explanations for this finding, the authors suggest that this may reflect a flaw in the informed decision process. This possibility should be taken seriously given previous concerns about patients' ability to assimilate complex genetic information during the highly stressful postdiagnostic period.^1,2

We cannot definitively rule out the possibility that participants in our study misunderstood the purpose of BLM. However, there are several factors that increase our confidence that participants were making informed decisions. First, as we reported in the article, stage II or III participants in our study had a higher rate of positive test results than our stage 0 or I participants. Thus, the higher rate of BLM among patients with stage II or III disease may simply reflect the higher proportion of mutation carriers in this group. It is not clear why we found higher rates of BRCA1/BRCA2 mutations among participants with stage II or III breast cancer. However, this difference is most likely due to a referral bias in which physicians may have been more likely to refer those stage II or III patients with a good prognosis, a highly suggestive family history, and an interest in BLM, resulting in higher rates of positive test results and higher rates of BLM on receipt of positive test results.

Second, although it may be the case that prognosis is poor for stage III breast cancer, we only had five stage III participants in our study. In contrast, the prognosis for many stage II breast cancer patients is quite favorable. Breast cancer–specific mortality for regional disease remains low at 5-year follow-up and is below 50% as far as 28-years postdiagnosis for patients diagnosed before age 50 years.³ Thus, BLM is a reasonable option for many newly diagnosed stage II patients.⁴ Importantly, preference for BLM is likely to be highly influenced by the experience of being diagnosed with stage II breast cancer. For example, as discussed by Eisinger et al, compared with patients diagnosed with early-stage disease, patients diagnosed with stage II disease may have less confidence in early-detection methods. As a result, stage II patients who learn that they carry a mutation may place a higher value on preventing future breast cancer rather than relying on early detection. Similarly, stage II patients are far more likely than stage 0 or I patients to require adjuvant chemotherapy. The prospect or experience of adjuvant chemotherapy may result in a willingness to trade off the immediate quality-of-life benefits associated with conservative treatment to avoid a second breast cancer and the prospect of another round of aversive chemotherapy in the future.

Finally, it is important to note that our genetic counseling protocol explicitly emphasized the role of BLM in reducing the risk for developing a new breast cancer in the unaffected breast and not reducing the risk for recurrence or metastases from the existing breast cancer. Still, we agree with Eisinger et al that future research in this area must focus on identifying optimal approaches to providing genetic information to enhance patient decision making.

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[Abstract/Free Full Text]

2. Robson ME, Boyd J, Borgen PI, et al: Hereditary breast cancer. Curr Probl Surg 38:387-480, 2001[CrossRef][Medline]

3. Schairer C, Ming PJ, Carroll L, et al: Probabilities of death from breast cancer and other causes among female breast cancer patients. J Natl Cancer Inst 96:1311-1321, 2004[Abstract/Free Full Text]

4. Meijers-Heijboer H, Brekelmans CTM, Menke-Pluymers MM, et al: Use of genetic testing and prophylactic mastectomy and oophorectomy in women with breast or ovarian cancer from families with a BRCA or BRCA2 mutation. J Clin Oncol 21:1675-1681, 2003[Abstract/Free Full Text]

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Related Correspondence

• The Choice of Bilateral Prophylactic Mastectomy
  F. Eisinger, L. Huiart, and H. Sobol
  JCO 2005 23: 1330-1331 [Full Text]

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Schwartz, M. D. Articles by Isaacs, C. Search for Related Content PubMed Articles by Schwartz, M. D. Articles by Isaacs, C. Related Articles Related Correspondence Social Bookmarking                            What's this?