Correspondence

Case 32-2007: Bilateral Breast Cancer

N Engl J Med 2008; 358:970February 28, 2008

Article

To the Editor:

In the case of the woman with a second breast cancer, discussed by Winer et al. (Oct. 18 issue),1 hereditary breast cancer due to a BRCA2 mutation should be considered. The patient had two primary breast cancers at an advanced age and had a paternal aunt who had had breast cancer at the age of 90 years. The patient previously had vulvar carcinoma in situ. We and others have seen an increase in cervical and vulvar cancers in carriers of a BRCA2 mutation and a history of receiving the diagnosis of breast cancer late in life. Some patients also have had ovarian cancers in their 70s.

Patrick J. Morrison, M.D.
Belfast City Hospital, Belfast BT9 6LE, United Kingdom
patrick.morrison@belfasttrust.hscni.net

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 32-2007). N Engl J Med 2007;357:1640-1648
   Full Text | Web of Science | Medline

Author/Editor Response

As Dr. Morrison notes, the possibility of a familial predisposition to breast cancer, ovarian cancer, or both should be considered in any patient with breast cancer. It is estimated that 5 to 10% of all breast cancers are hereditary, half of which are related to a germ-line mutation in BRCA1 or BRCA2.1 Women with BRCA mutations are at risk for bilateral breast cancer, and bilateral disease increases the likelihood of identifying a mutation. Although our patient had bilateral breast cancer, these diagnoses were made at the ages of 56 and 62 years, and there was no other family history of breast or ovarian cancer, apart from a second-degree relative in whom breast cancer had been diagnosed at the age of 90 years. The significance of a past diagnosis of carcinoma in situ of the vulva is unknown. With the use of either the BRCAPRO or Myriad model, the patient has a 2 to 3% chance of harboring a germ-line mutation in BRCA1 or BRCA2.2 This level of risk is below the threshold that is generally set for the use of predictive testing,3 and for that reason, neither the clinical service nor the discussants raised the possibility of genetic testing.

Eric P. Winer, M.D.
Jay Harris, M.D.
Dana−Farber and Brigham and Women's Cancer Center, Boston, MA 02115

Barbara L. Smith, M.D., Ph.D.
Massachusetts General Hospital, Boston, MA 02114

3 References

1. 1

   Garber JE, Offit K. Hereditary cancer predisposition syndromes. J Clin Oncol 2005;23:276-292
   CrossRef | Web of Science | Medline

2. 2

   U.T. Southwestern Medical Center at Dallas, BayesMendel Group at Johns Hopkins. CancerGene, with BRCAPRO, MMRpro, and PancPRO. (Accessed February 7, 2008, at http://www4.utsouthwestern.edu/breasthealth/cagene/.)
   

3. 3

   American Society of Clinical Oncology. American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 2003;21:2397-2406
   CrossRef | Web of Science | Medline