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Originally published as JCO Early Release 10.1200/JCO.2009.22.6969 on August 17 2009 © 2009 American Society of Clinical Oncology.
Reply to M.M. Mohiuddin et alUniversity of California San Francisco, San Francisco, CA The need for a multidisciplinary approach to patients with breast cancer from Mohiuddin and Regine1a is one shared by most breast cancer specialists. In the study by Collins et al,1 each patient and provider was required to review a 45-minute educational video, which was developed by surgeons, radiation oncologists, and the Foundation for Informed Medical Decision Making to ensure a balanced message. The important assumption in the article by Collins et al1 and our editorial2 is that the choice of surgical therapy is an intensely personal one. The idea that breast conservation is the right decision, if medically eligible, for every woman is simply not correct. For some women, "the desire to avoid radiation" may be related to distance to a radiation center, transportation needs, career factors, negative experiences with radiation of family or friends, or a desire to complete local therapy in one step. With new developments in targeted radiation options, women's choices will likely change with time. For some, their cosmetic outcome is as important as their cancer treatment. As a result, with improvements in reconstruction techniques, desire for symmetry, and to avoid screening may be factors that have driven the mastectomy rate up over the past few years. In the Collins et al study,1 most women who opted for mastectomy did not choose reconstruction, and based on the surveys, their choice reflected their values. Other investigators cite different reasons for mastectomy. A study by McCahill et al3 suggests that in their population, medical contraindications (eg, positive margins, extensive ductal carcinoma in situ) to breast conservation are more common than patient choice as the surgical indication, but this was not the case in the study from Collins et al. The sense of peace of mind, which is criticized by Mohiuddin and Regine,1a often is related to patients' experiences with screening and biopsy as well as the realization that they will worry less if the breast tissue is gone. When giving women a choice, it is important to recognize that not everyone views the options as equal and that some may make choices that are different from what their providers might choose. The value of this study is that it was conducted in the context of a shared decision making tool (the video and booklet), which helps to provide balanced information. For women whose concern is related to radiation techniques, potential complications, or questions about relative contraindications, a preoperative visit to a radiation oncologist is warranted and is important to make sure that patients are not making choices based on incorrect information. The authors express concern that patients are not being given accurate data concerning the local failure rate for breast conserving therapy (BCT) versus mastectomy. Everyone agrees that the data show that mortality is not impacted by local treatment decisions. However, local control rates differ slightly, and they differ based on stage of presentation. In the studies the authors cited, two of the studies only included T1 tumors. The European Organisation for the Research and Treatment of Cancer presented a randomized controlled trial of breast conservation versus modified radical mastectomy for T2 tumors with local recurrence rate of 20% in the breast conservation arm versus 12% in the mastectomy arm.4 Over decades, as shown by the 20-year follow-up of breast conservation trials, mastectomy will avoid the chance of a second primary in the operated breast. Although this risk is very small (in the 8.8% to 14.3% range), and is equivalent to the risk of a contralateral cancer, that risk is real and avoided by mastectomy.5,6 The patients eligible for BCT have been extended to include those with T3 and T4 tumors after neoadjuvant therapy and given appropriate breast size.7,8 For larger tumors after neoadjuvant chemotherapy, the local recurrence risk is acceptable but higher than those patients undergoing mastectomy with either pre- or postoperative chemotherapy; however, the numbers of patients in these studies are small and further study is needed.9,10 The quality-of-life argument in favor of BCT would be more convincing if any of the studies cited had included breast reconstruction after mastectomy. In a quality surgical consultation, the option of reconstruction should be discussed with the patient. Cocquyt et al11 published a study in which quality-of-life scores in patients with BCT were compared with those who underwent skin-sparing mastectomy with immediate reconstruction. The outcome scores were found to be equivalent between the two groups. Further, Waljee et al12 describe decreased quality of life in BCT patients who have breast asymmetry after their cancer treatment. In closing, we absolutely agree with Mohiuddin and Regine1a that the multidisciplinary perspective is critical and valuable. However, we feel this study helps us understand that women make treatment decisions very differently. When offered both surgical options, each woman has a different set of values and experiences that shapes her decision, independent of medical counsel or media presentations designed to assist with decision making. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: Laura Esserman, Foundation for Informed Decision Making (C) Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None REFERENCES
1a. Mohiuddin MM, Regine WF: Consenting the patient with early-stage breast cancer: "Informed" only after multi-disciplinary evaluation. J Clin Oncol 27:e158–e159, 2009. 1. Collins ED, Moore CP, Clay KF, et al: Can women with early-stage breast cancer make an informed decision for mastectomy? J Clin Oncol 27:519–525, 2009. 2. Throckmorton AD, Esserman LJ: When informed, all women do not prefer breast conservation. J Clin Oncol 27:484–486, 2009. 3. McCahill LE, Privette AR, Hart MR, et al: Are mastectomy rates a reasonable quality measure of breast cancer surgery? Am J Surg 197:216–221, 2009.[CrossRef][Medline] 4. van Dongen JA, Voogd AC, Fentiman IS, et al: Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst 92:1143–1150, 2000. 5. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227–1232, 2002. 6. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–1241, 2002. 7. Clark J, Rosenman J, Cance W, et al: Extending the indications for breast-conserving treatment to patients with locally advanced breast cancer. Int J Radiat Oncol Biol Phys 42:345–350, 1998.[CrossRef][Medline] 8. Gonzalez-Angulo AM, Walters R, Broglio K, et al: Using response to primary chemotherapy to select postoperative therapy: Long-term results from a prospective phase II trial in locally advanced primary breast cancer. Clin Breast Cancer 8:516–521, 2008.[CrossRef][Medline] 9. Touboul E, Buffat L, Lefranc J-P, et al: Possibility of conservative local treatment after combined chemotherapy and preoperative irradiation for locally advanced noninflammatory breast cancer. Int J Radiat Oncol Biol Phys 34:1019–1028, 1996.[CrossRef][Medline] 10. Mauriac L, MacGrogan G, Avril A, et al: Neoadjuvant chemotherapy for operable breast carcinoma larger than 3 cm: A unicentre randomized trial with a 124-month median follow-up Institut Bergonie Bordeaux Groupe Sein (IBBGS). Ann Oncol 10:47–52, 1999. 11. Cocquyt VF, Blondeel PN, Depypere HT, et al: Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment. Br J Plast Surg 56:462–470, 2003.[CrossRef][Medline] 12. Waljee JF, Hu ES, Ubel PA, et al: Effect of esthetic outcome after breast-conserving surgery on psychosocial functioning and quality of life. J Clin Oncol 26:3331–3337, 2008.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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