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Journal of Clinical Oncology, Vol 25, No 10 (April 1), 2007: pp. 1292 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.10.1253
Is Prophylactic Cranial Irradiation a Possible Option for Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer?Gaziantep University School of Medicine, Gaziantep Oncology Hospital, Gaziantep, Turkey To the Editor: We have read with interest the article by Gabos et al.1 Actually, their results are not surprising. It has already been shown that human epidermal growth factor receptor 2 (HER-2) overexpression is a poor prognostic factor for breast cancer and that tumors expressing HER-2 have a greater metastasis tendency. However, investigators for one large study have reported that HER-2 does not increase the risk of cerebral metastases in breast cancer.2 We have a few additional comments regarding this article. First, we do not agree that prophylactic cranial irradiation is warranted. In this study, brain as the first metastasis site only occurred in 27 of 301 patients. The remaining 41 of 301 HER-2–positive patients had other metastasis sites. If this data is generalized, 10% of the HER-2–positive patients would have brain metastasis, a percentage which is compatible with previous epidemiologic studies. We feel that it is not reasonable to apply cranial irradiation (CRI) in HER-2–positive patients, given a percentage as low as this. Although the incidence of brain metastases is greater in small-cell lung cancer,3 prophylactic CRI is not routinely recommended. Furthermore, CRI has many complications. In addition, we do not know whether giving CRI improves survival; consequently, both effectiveness and cost effectiveness are concerns.4 We also ask the following questions: were HER-2–positive patients given the same treatment options? And, why were treatment options not included as a variable during univariate analysis? It would be nice to know which chemotherapy regimens were used in the HER-2–positive patients. Finally, the authors have suggested a screening test for brain metastasis. However, early detection of distant metastasis has not been shown to improve survival rates.5 Hence, we do not agree with this suggestion, believing that CRI is not cost effective or likely to increase survival. We believe that such investigations only are warranted once a patient becomes symptomatic. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest. REFERENCES
1. Gabos Z, Sinha R, Hanson J, et al: Prognostic significance of human epidermal growth factor receptor positivity for the development of brain metastasis after newly diagnosed breast cancer. J Clin Oncol 24:5658-5663, 2006 2. Tham YL, Sexton K, Kramer R, et al: Primary breast cancer phenotypes associated with propensity for central nervous system metastases. Cancer 107:696-704, 2006[CrossRef][Medline] 3. Lee JJ, Bekele BN, Zhou X: Decision analysis for prophylactic cranial irradiation for patients with small-cell lung cancer. J Clin Oncol 24:3597-3603, 2006 4. Belka C, Budach W, Kortmann RD, et al: Radiation induced CNS toxicity–molecular and cellular mechanisms. Br J Cancer 85:1233-1239, 2001[CrossRef][Medline] 5. Smith TJ, Davidson NE, Schapira DV, et al: American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol 17:1080-1082, 1999
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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