Correspondence
Radiation Therapy for Breast Cancer
N Engl J Med 2009; 360:1362-1363March 26, 2009
- Article
To the Editor:
In his Clinical Therapeutics article on radiation therapy for early-stage breast cancer after breast-conserving surgery, Buchholz (Jan. 1 issue)1 states that “the breast remains tender to palpation and the skin remains hyperpigmented for 6 to 9 months after treatment but then returns to normal.” Since many readers of this informative article are not radiation oncologists, I think that it is important that this point be clarified so that normal changes that occur are not misinterpreted.
The skin of the treated breast never returns completely to normal. The treated skin is drier, often in the region of the areola and inframammary fold. Also, the degree of persistent hyperpigmentation of the skin is quite variable and is most noticeable as a rule in women with a dark complexion. There is often a variable degree of peau d'orange, in large part because of the lumpectomy and sentinel-node or axillary dissection, and it is most commonly seen in patients with large, pendulous breasts. The treated breast generally feels firmer and may have “a lift” as compared with the untreated breast.
1 ReferencesArthur D. Hamberger, M.D.
Memorial Hermann Northwest Hospital, Houston, TX 77008
arhamber@yahoo.com 1
Buchholz TA . Radiation therapy for early-stage breast cancer after breast-conserving surgery. N Engl J Med 2009;360:63-70
Full Text | Web of Science | Medline
To the Editor:
Buchholz points out that breast-conserving surgery followed by whole-breast irradiation for early breast cancer is the standard of care even among patients with a family history of the disease. He cites two studies published in 1998 to provide support for this inference. However, more current experimental and clinical data consistently indicate the importance of heritability in breast cancer.1 Patients with high-penetrance heritable mutations in either the BRCA1 or BRCA2 gene face a 30% risk of cancer in the contralateral breast and an increased risk of ipsilateral recurrence.2,3
Now genetic testing guides the treatment decision. Patients with BRCA mutations (5 to 10% of patients with breast cancer) may benefit more from bilateral mastectomy than from breast-conserving therapy. They can be spared the late adverse effects of radiotherapy in the heart, lung, and contralateral breast.4 Women with early disease are at low risk for distant recurrence and have a good prognosis. Preventing local recurrences in the ipsilateral or contralateral breast, which may be the first isolated events, is a priority. Bilateral mastectomy with a good cosmetic result by means of appropriate reconstruction should be considered in patients with BRCA mutations.5
5 ReferencesDimitrios H. Roukos, M.D.
Ioannina University School of Medicine, 45110 Ioannina, Greece
droukos@cc.uoi. gr 1
Roukos DH ,Briasoulis E . Individualized preventive and therapeutic management of hereditary breast ovarian cancer syndrome. Nat Clin Pract Oncol 2007;4:578-590
CrossRef | Web of Science | Medline2
Metcalfe K ,Lynch HT ,Ghadirian P , et al. Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol 2004;22:2328-2335
CrossRef | Web of Science | Medline3
Pierce LJ ,Levin AM ,Rebbeck TR , et al. Ten-year multi-institutional results of breast-conserving surgery and radiotherapy in BRCA1/2-associated stage I/II breast cancer. J Clin Oncol 2006;24:2437-2443
CrossRef | Web of Science | Medline4
Hooning MJ ,Aleman BM ,Hauptmann M , et al. Roles of radiotherapy and chemotherapy in the development of contralateral breast cancer. J Clin Oncol 2008;26:5561-5568
CrossRef | Web of Science | Medline5
Roukos DH . Genetics and genome-wide association studies: surgery-guided algorithm and promise for future breast cancer personalized surgery. Expert Rev Mol Diagn 2008;8:587-597
CrossRef | Web of Science | Medline
Author/Editor Response
Hamberger is correct in stating that radiation treatments change the skin and soft tissues of the breast. It is important for primary care physicians to recognize that hyperpigmentation of the skin and breast edema are expected, normal tissue reactions. As stated in the article, these signs and symptoms resolve over time in the majority of patients. Some patients have subtle residual pigmentation changes that last a lifetime, and others have permanent loss of breast volume related to the surgical resection and the adjuvant irradiation.
Roukos raises the important consideration of how best to manage breast cancer arising in women with a known predisposing germ-line mutation in a tumor-suppressor gene, such as a mutation in BRCA1 or BRCA2. I agree that such patients should be offered the option of bilateral mastectomy (with or without immediate reconstruction) because their lifetime risk of the development of a second breast cancer is high. This risk appears to be significantly lower if they elect to undergo a prophylactic oophorectomy to address the risk of the development of an ovarian cancer.1
Only 7% of patients with breast cancer have an inherited high-penetrance tumor-suppressor gene mutation. When there is a family history of breast cancer, many physicians and patients overestimate the probability of such a mutation. This overestimation can result in an avoidance of breast-conserving therapy, when it is clearly a safe option. A family history such as that described in the case vignette in the article is not a contraindication for breast-conserving surgery and irradiation. Indeed, despite the positive family history of breast cancer in the patient described, she would be thought to have such a low probability of a germ-line mutation in BRCA1 or BRCA2 that genetic screening to detect a mutation would not be indicated, according to the testing criteria of the National Comprehensive Cancer Network.2
2 ReferencesThomas A. Buchholz, M.D.
University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
tbuchhol@mdanderson.org 1
Pierce LJ ,Levin AM ,Rebbeck TR , et al. Ten-year multiinstitutional results of breast-conserving surgery and radiotherapy in BRCA1/2-associated stage I/II breast cancer. J Clin Oncol 2006;24:2437-2443
CrossRef | Web of Science | Medline2
National Comprehensive Cancer Network. Genetic/familial high-risk assessment: breast and ovarian. Clinical practice guidelines in oncology. (Accessed March 6, 2009, at http://www.nccn.org/professionals/physician_gls/PDF/genetics_screening.pdf.)
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