BMJ 2014;348:g1863 doi: 10.1136/bmj.g1863 (Published 5 March 2014)
Page 1 of 1
Letters
LETTERS CONTRALATERAL MASTECTOMY AND BRCA1 AND BRCA2
Threshold for genetic testing in women with breast cancer needs to be determined 1
2
Narendra Nath Basu oncoplastic breast surgeon , Lester Barr oncoplastic breast surgeon , D Gareth 3 Evans professor of medical genetics and cancer epidemiology , Gary L Ross plastic and 3 reconstructive surgeon and honorary senior lecturer, University of Manchester Queen Elizabeth Hospital, Birmingham, UK; 2University Hospital of South Manchester, Manchester, UK; 3St Mary’s Hospital, Manchester, UK
1
US surveillance data describe a 150% increase in contralateral mastectomy in the past decade, so Metcalfe and colleagues’ study of survival in BRCA1 and BRCA2 mutation carriers undergoing contralateral mastectomy after breast cancer is timely.1 2 Since Angelina Jolie’s risk reducing surgery, clinicians often have to counsel patients asking for such procedures.
potentially life saving chemotherapy. BRCA1 carriers with high grade triple negative cancers are known to do better with aggressive treatment.5 Additionally, if the threshold for genetic testing is lowered, we may not have sufficient resources to provide complex reconstructions.
The authors discuss timing of gene mutation testing, showing a difference in type of mastectomy chosen (unilateral v bilateral) based on knowledge of mutation status. We found lower rates of bilateral mastectomy in those having later genetic testing.3 They mention “If genetic testing is performed routinely at time of diagnosis, comparisons of the various surgical treatments will become more straightforward.” The 2013 National Institute for Health and Care Excellence guidelines on familial breast cancer lowered the threshold for gene testing. We suggest judicious use of genetic testing because routine testing may affect psychological wellbeing.
Competing interests: None declared.
This study’s findings on survival benefit are similar to our own.3 In our series, however, uptake of contralateral risk reducing surgery was lower (15% v 50% in this study), highlighting variations in surgery uptake between North America and Europe.4
Routine genetic testing affects patients and clinicians. This process and subsequent reconstruction planning take time. Where complex procedures are required, operative planning may not be possible in a limited timeframe. This may delay
This paper’s findings have implications for rapid genetic testing at the time of breast cancer diagnosis. Knowledge of mutation status undoubtedly affects subsequent treatments, including adjuvant or neoadjuvant treatment and reconstructive options, but the threshold for genetic testing must be clearly determined. Full response at: www.bmj.com/content/348/bmj.g226/rr/688172. 1 2 3 4 5
Metcalfe K, Gershman S, Ghadirian P, Lynch HT, Snyder C, Tung N, et al. Contralateral mastectomy and survival after breast cancer in carriers of BRCA1 and BRCA2 mutations: retrospective analysis. BMJ 2014;348:g226. (11 February.) Tuttle T Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend towards more aggressive surgical treatment. J Clin Oncol 2007;25:5203-9. Evans DG, Ingham SL, Baildam A, Ross GL, Lalloo F, Buchan I, et al. Contralateral mastectomy improves survival in BRCA1/2 associated breast cancer. Breast Cancer Res Treat 2013;140:135-42. Guth U, Myrick ME, Viehl CT, Weber WP, Lardi Am, Schmid SM. Increasing rates of contralateral prophylactic mastectomy—a trend made in the USA? Eur J Surg Oncol 2012;38:296-301. Evans DG, Howell A. Are BRCA1- and BRCA2-related breast cancers associated with increased mortality? Breast Cancer Res 2004;6:E7.
Cite this as: BMJ 2014;348:g1863 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 1
Letters
LETTERS CONTRALATERAL MASTECTOMY AND BRCA1 AND BRCA2
Threshold for genetic testing in women with breast cancer needs to be determined 1
2
Narendra Nath Basu oncoplastic breast surgeon , Lester Barr oncoplastic breast surgeon , D Gareth 3 Evans professor of medical genetics and cancer epidemiology , Gary L Ross plastic and 3 reconstructive surgeon and honorary senior lecturer, University of Manchester Queen Elizabeth Hospital, Birmingham, UK; 2University Hospital of South Manchester, Manchester, UK; 3St Mary’s Hospital, Manchester, UK
1
US surveillance data describe a 150% increase in contralateral mastectomy in the past decade, so Metcalfe and colleagues’ study of survival in BRCA1 and BRCA2 mutation carriers undergoing contralateral mastectomy after breast cancer is timely.1 2 Since Angelina Jolie’s risk reducing surgery, clinicians often have to counsel patients asking for such procedures.
potentially life saving chemotherapy. BRCA1 carriers with high grade triple negative cancers are known to do better with aggressive treatment.5 Additionally, if the threshold for genetic testing is lowered, we may not have sufficient resources to provide complex reconstructions.
The authors discuss timing of gene mutation testing, showing a difference in type of mastectomy chosen (unilateral v bilateral) based on knowledge of mutation status. We found lower rates of bilateral mastectomy in those having later genetic testing.3 They mention “If genetic testing is performed routinely at time of diagnosis, comparisons of the various surgical treatments will become more straightforward.” The 2013 National Institute for Health and Care Excellence guidelines on familial breast cancer lowered the threshold for gene testing. We suggest judicious use of genetic testing because routine testing may affect psychological wellbeing.
Competing interests: None declared.
This study’s findings on survival benefit are similar to our own.3 In our series, however, uptake of contralateral risk reducing surgery was lower (15% v 50% in this study), highlighting variations in surgery uptake between North America and Europe.4
Routine genetic testing affects patients and clinicians. This process and subsequent reconstruction planning take time. Where complex procedures are required, operative planning may not be possible in a limited timeframe. This may delay
This paper’s findings have implications for rapid genetic testing at the time of breast cancer diagnosis. Knowledge of mutation status undoubtedly affects subsequent treatments, including adjuvant or neoadjuvant treatment and reconstructive options, but the threshold for genetic testing must be clearly determined. Full response at: www.bmj.com/content/348/bmj.g226/rr/688172. 1 2 3 4 5
Metcalfe K, Gershman S, Ghadirian P, Lynch HT, Snyder C, Tung N, et al. Contralateral mastectomy and survival after breast cancer in carriers of BRCA1 and BRCA2 mutations: retrospective analysis. BMJ 2014;348:g226. (11 February.) Tuttle T Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend towards more aggressive surgical treatment. J Clin Oncol 2007;25:5203-9. Evans DG, Ingham SL, Baildam A, Ross GL, Lalloo F, Buchan I, et al. Contralateral mastectomy improves survival in BRCA1/2 associated breast cancer. Breast Cancer Res Treat 2013;140:135-42. Guth U, Myrick ME, Viehl CT, Weber WP, Lardi Am, Schmid SM. Increasing rates of contralateral prophylactic mastectomy—a trend made in the USA? Eur J Surg Oncol 2012;38:296-301. Evans DG, Howell A. Are BRCA1- and BRCA2-related breast cancers associated with increased mortality? Breast Cancer Res 2004;6:E7.
Cite this as: BMJ 2014;348:g1863 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
