Commentary (Garber): Advising Women at High Risk of Breast Cancer

Dr. Wood has provided a comprehensive but succinct review of the clinical management options available to women with an increased risk of breast cancer. He clearly defines his approach to riskstratification among women likely to see a breast surgeon with concerns about their breast cancer risk based on family history-ie, BRCA1/2 mutation carriers, those who have not yet been tested for BRCA1/2 mutations, and those who have tested negative for BRCA1/2 mutations but have sufficient family and personal history to have ongoing concern despite the negative test. In the past, breast surgeons might have seen a wider range of women at risk, but many are now too busy to see anyone who is not contemplating bilateral mastectomies. It is even more important, therefore, that they be familiar with the basic workings of genetic testing.

Dr. Wood points out that the appropriate person to first undergo genetic testing in a family may not be the person seeking the consultation, but rather, her living close relative with early onset breast or ovarian cancer. This may mean that the consulting patient does not return to the surgeon until after having seen another specialist providing genetic counseling and testing-a genetic counselor, nurse geneticist, or another physician who is providing breast cancer risk assessment and testing, sometimes after another relative has done so first.

Early Detection Options

In the absence of effective nonsurgical options for risk reduction, Dr. Wood focuses on early detection options. He carefully notes that large prospective studies evaluating the various options are not yet available. He considers clinical breast examination important and specifically cautions against failure to evaluate suspicious lesions immediately. Others have expressed concern about subjecting women with marked breast cancer risk to too many biopsies, based on imaging technologies of reduced specificity and the possibility that frequent biopsies could drive women to prophylactic mastectomy.[1]

Perhaps the difference is only a question of degree: A lesion considered suspicious by either a radiologist or an experienced breast specialist should be evaluated expeditiously with all available techniques. Sometimes ultrasound will cause a radiologist to reclassify a lesion observed on mammogram or magnetic resonance imaging (MRI) of the breast as less concerning, and recommend repeat imaging after 6 months. I don't think Dr. Wood would insist on a biopsy in this setting.

Breast MRI

The author's discussion of breast MRI, in light of recently published and presented data, places important emphasis on the sensitivity of the technology, particularly among younger women for whom the limited sensitivity of mammography has long been recognized. I agree that women with hereditary risk come to breast specialists for careful monitoring, which causes me to place more emphasis on the relative sensitivity of MRI, despite concerns about specificity of the technology. In their study from Memorial Sloan-Kettering Cancer Center, Robson et al observed substantial improvements in specificity when the studies were read by more experienced breast radiologists, suggesting an important learning curve of which the ordering physician should be aware.[1]

Concerns about the psychological reaction of women to intensive surveillance and frequent biopsies may well prove justified. Studies among usualrisk women with an abnormal mammogram showed that some experienced significant psychological distress after learning their results, and not all subsequently adhered to standard surveillance recommendations the following year.[2] Screening technologies are ultimately judged on the basis of their ability to reduce mortality, rather than their sensitivity, and Dr. Wood reminds us that none of them has yet been shown to affect breast cancer mortality among high-risk women.

Prophylactic Surgery

After critiquing the data evaluating the efficacy of tamoxifen and premenopausal prophylactic (salpingo) oophorectomy in reducing breast cancer risk, Dr. Wood focuses on the most unique and important aspect of his paper: a clear and informative discussion of the prophylactic surgical options available to very high-risk women. He notes the lack of available data comparing surgical approaches to prophylactic mastectomy and the widely held view that residual at-risk tissue should be minimized.

He also describes newer options that have not yet been compared directly for outcomes but have been designed to preserve varying amounts of nipple and areola, illustrating the tensions for surgeons between optimum risk reduction and optimum cosmetic result. He emphasizes the importance of appropriate reconstruction options and the very real trade-offs that women must understand to make truly informed decisions with their surgeons about this most effective but often most difficult option.

Conclusions

Dr. Wood's article reminds others in the breast care community of the value of having one or more surgeons available who can provide a balanced, thoughtful assessment and recommendations for high-risk women. These physicians serve as important partners in the management of this increasingly recognized population.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1.

Robson M, Morris E, Kauff N, et al: Breastcancer screening utilizing magnetic resonanceimaging (MRI) in carriers of BRCA mutations(abstract 362). Proc Am Soc Clin Oncol 22:91,2003.

2.

Lerman C, Trock B, Rimer BK, et al: Psychologicalside effects of breast cancer screening.Health Psychol 10:259-267, 1991.