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In Reply

University of Minnesota, Department of Surgery, Division of Surgical Oncology, Minneapolis, MN

Elizabeth B. Habermann, Beth A. Virnig

Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN

Using the Surveillance, Epidemiology, and End Results cancer registry, we reported that the rate of contralateral prophylactic mastectomy (CPM) increased by 150% from 1998 to 2003 in the United States.¹ We appreciate the interest and comments from Briasoulis and Roukos regarding our study. We found that the CPM rate increased through the end of our study period with no diminution in the incline of the curve (Fig 2¹). Based on 2003 data, we estimate that about 10,000 patients with unilateral breast cancer undergo CPM in the United States each year. Also, since we excluded patients whose initial treatment was not CPM, but later underwent CPM, the rate is probably higher than we reported.

We agree with Briasoulis and Roukos that prophylactic surgery should be "rationally guided by genetic testing," but acknowledge that other nongenetic factors should be considered in choosing CPM. For example, for patients who have been treated with chest radiotherapy (eg, Hodgkin's disease) and subsequently develop breast cancer, CPM may be a rational choice because of the marked increased risk of contralateral breast cancer. Moreover, many patients have contraindications for breast-conserving treatment (tumor size, multiple tumors, or contraindications for breast radiotherapy) and require mastectomy. For some mastectomy patients, CPM may be appropriate especially if the contralateral breast is large, creating balance and symmetry difficulties after unilateral mastectomy. Also, a large remaining breast after unilateral mastectomy complicates symmetric reconstructive techniques. Finally, the presence of dense breast tissue on mammography, strong family history without an identified genetic mutation, lobular carcinoma in situ, and atypical hyperplasia may also be considered in the decision-making process.

Although CPM is effective in preventing contralateral breast cancer, it does not improve breast cancer mortality.^2-4 Still, many women with small unilateral breast cancer amenable to breast-conserving treatment request bilateral mastectomy despite the potential risks and complications. On the other hand, other women with advanced unilateral breast cancer desire CPM when, in fact, their risk of systemic metastases exceeds their risk of contralateral breast cancer. We agree with Briasoulis and Roukos that prospective studies evaluating decision-making processes leading to CPM are lacking. Specifically, research is needed to develop models and instruments to elucidate the decision-making processes among patients with breast cancer and their surgeons. This research is important and timely because it may ultimately provide decision aids for patients and their physicians.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Tuttle TM, Habermann E, Grund E, et al: Increasing use of contralateral prophylactic mastectomy for breast cancer patients: A trend toward more aggressive surgical treatment. J Clin Oncol 25:5203-5209, 2007[Abstract/Free Full Text]

2. McDonnell SK, Schaid DJ, Myers JL, et al: Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer. J Clin Oncol 19:3938-3943, 2001[Abstract/Free Full Text]

3. Herrinton LJ, Barlow WE, Yu O, et al: Efficacy of prophylactic mastectomy in women with unilateral breast cancer: A cancer research network project. J Clin Oncol 23:4275-4286, 2005[Abstract/Free Full Text]

4. Lostumbo L, Carbine N, Wallace J, et al: Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev 4:CD002748, 2004[Medline]

Related Correspondence

• Contralateral Prophylactic Mastectomy: Mind the Genetics
  Evangelos Briasoulis and Dimitrios H. Roukos
  JCO 2008 26: 1909-1910 [Full Text]

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