Re: Population-Based Study of Contralateral Prophylactic Mastectomy and Survival Outcomes of Breast Cancer Patients

Article (PDF Available)inJournal of the National Cancer Institute 102(17):1371-2; author reply 1372-3 · September 2010with13 Reads
DOI: 10.1093/jnci/djq298 · Source: PubMed    JNCI
Correspondence 1371
Re: Population-Based Study
of Contralateral Prophylactic
Mastectomy and Survival
Outcomes of Breast Cancer
In the article by Bedrosian et al. (1) entitled
“Population-based study of contralateral
prophylactic mastectomy and survival out-
comes of breast cancer patients,” the authors
used the Surveillance, Epidemiology, and
by guest on October 14, 2011jnci.oxfordjournals.orgDownloaded from
1372 Correspondence
JNCI Vol. 102, Issue 17 
  September 8, 2010
End Results (SEER) database to determine
whether contralateral prophylactic mastec-
tomy (CPM) is associated with improved
breast cancer–specific survival rates. Patients
who were diagnosed with unilateral breast
cancer between 1998 and 2003 were in-
cluded in this study. The authors concluded
that “CPM is associated with a small im-
provement (4.8%) in 5-year breast cancer–
specific survival mainly in young women
with early-stage estrogen receptor-negative
breast cancer.”
However, a closer look at the data
raises some serious concerns about this
analysis. The authors report that young
patients (<50 years) with estrogen recep-
tor–negative breast cancer undergoing
CPM have a 5-year breast cancer–specific
survival rate of 88.5% as compared with
83.7% for the non-CPM group. The only
plausible way that CPM improves breast
cancer survival is by reducing the risk of
a potentially fatal contralateral breast
cancer. However, the cumulative inci-
dence of contralateral breast cancer was
less than 1% among patients not re-
ceiving CPM. Even if every patient who
developed contralateral breast cancer
died immediately at the time of the diag-
nosis of the contralateral cancer, the sur-
vival benefit for CPM would still be less
than 1%. Instead, most metachronous
contralateral breast cancers are stage I
cancers with a 5-year survival rate ex-
ceeding 90% (2). In this study, the me-
dian follow-up time was only 47 months
from the diagnosis of the first cancer; this
duration of time is obviously insufficient
to determine a survival benefit from
CPM, which would require a woman with
unilateral breast cancer to develop con-
tralateral breast cancer and subsequently
die of that contralateral breast cancer, all
within 47 months.
The authors suggest that SEER may
underestimate the actual cumulative inci-
dence of contralateral breast cancer. From
the Early Breast Cancer Trialists’
Collaborative Group analysis, the annual
risk of contralateral breast cancer among
women who did not receive endocrine
therapy was 0.5% (3). Thus, the expected
cumulative 5-year risk of contralateral
breast cancer for patients with estrogen
receptor–negative breast cancer would be
about 2.5%. Because patients do not die
immediately at the time of diagnosis of
contralateral breast cancer and usually have
early-stage contralateral cancers, the
reported 4.8% absolute survival benefit at
5 years is clearly not possible even if SEER
underestimated the rate of contralateral
breast cancer.
The observations in this population-
based study can be simply explained by
selection bias. Patients who undergo more
aggressive breast cancer surgery (CPM)
are healthier, more likely to receive che-
motherapy, and therefore, more likely to
survive their rst cancer. Importantly,
SEER does not report the use of endo-
crine therapy or chemotherapy, perfor-
mance status, family history, or BRCA
The use of CPM has dramatically
increased in the United States during the
past decade (4). The conclusion from the
study by Bedrosian et al. that CPM
improves breast cancer survival rates in
some women is not justified and may lead
more patients to undergo unnecessary
breast cancer surgery.
1. Bedrosian I, Hu CY, Chang GJ. Population-
based study of contralateral prophylactic mas-
tectomy and survival outcomes of breast
cancer patients. J Natl Cancer Inst. 2010;
2. Houssami N, Ciatto S, Martinelli F, Bonardi
R, Duffy SW. Early detection of second
breast cancers improves prognosis in breast
cancer survivors. Ann Oncol. 2009;20(9):
3. Early Breast Cancer Trialists’ Collaborative
Group. Polychemotherapy for early breast
cancer: an overview of the randomized trials.
Lancet. 1998;352(9132):930–942.
4. Tuttle TM, Habermann EB, Grund EH, et al.
Increasing use of contralateral prophylactic
mastectomy for breast cancer patients: a trend
toward more aggressive surgical treatment.
J Clin Oncol. 2007;25(33):5203–5209.
Affiliation of authors: Department  of  Surgery, 
University of Minnesota, Minneapolis, MN. 
Correspondence to: Todd  M.  Tuttle,  MD, 
Department of Surgery, University of Minnesota, 
420  Delaware  St  SE,  Minneapolis,  MN  55455 
DOI: 10.1093/jnci/djq298
© The Author 2010. Published by Oxford University 
Press. All rights reserved. For Permissions, please 
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