Family history of breast cancer
http://www.100md.com
《英国医生杂志》
Authors' reply
EDITOR—We thank Evans and Easton for highlighting the inconsistency between our suggested management and that suggested by the NICE guidelines on familial breast cancer.1 The purpose of the pedigree in the article was mainly illustrative and used in the context of how to take a family history, which is why we were careful to say "to make sure... check with guidelines" in the text.
Evans and Easton acknowledge that when we wrote the article the then draft NICE guidelines agreed with our suggestion that the woman in our example would not be offered mammography. Along with many of our clinical colleagues, we were unaware that there had been a change in the final version of the NICE guidelines so that our patient would now be offered mammography. We are not clear why this change was made from a previously fairly widely accepted consensus2 since the NICE document does not present supporting evidence for this new recommendation. Although the collaborative paper is cited as evidence,3 it only examines the risk from two first degree relatives with breast cancer. This is echoed in the NICE guidance itself: "for women with one first degree and one second degree relative we do not have direct estimates."
There is as yet no evidence that mammography in women under 50 reduces mortality from the disease. Although early detection is possible and there is some consensus that those with a very strong family history of breast cancer should be offered mammography under the age of 50, much of the evidence on which the NICE guidelines are based is category IV. We suggest that the cut-off point between family history groups for which different managements are suggested is to some extent arbitrary. Mammography in those under 50 is currently through the symptomatic breast screening services, thus putting pressure on already overstretched services. The risk that our patient would develop breast cancer before the age of 50 (when she would enter the national breast screening programme) is approximately 1.5-3% compared with 1-2% for the general population.
We commend the NICE committee for their thorough review of an area where evidence is currently limited and hope that this correspondence encourages constructive dialogue on implementing the guidelines.
Anneke Lucassen, consultant in clinical genetics
Wessex Clinical Genetics Service, The Princess Anne Hospital, Southampton SO16 5YA annekel@soton.ac.uk
Eila Watson, deputy director
Cancer Research UK Primary Care Education Research Group, University of Oxford, Oxford OX3 7LF
Competing interests: None declared.
References
McIntosh A, Shaw C, Evans G, Turnbull N, Bahar N, Barclay M, et al. Clinical guidelines and evidence review for the classification and care of women at risk of familial breast cancer. London: National Collaborating Centre for Primary Care, University of Sheffield, 2004. (NICE guideline CG014.)
Cancer Research UK Primary Care Education Research Group. Familial breast and ovarian cancer pack. Oxford: Cancer Research UK Primary Care Education Research Group, 2001. www.dphpc.ox.ac.uk/crcpcerg/resources/genpack.htm (accessed 5 March 2005).
Collaborative Group on Hormonal Factors in Breast Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58 209 women with breast cancer and 101 986 women without the disease. Lancet 2001;358: 1389-99.
EDITOR—We thank Evans and Easton for highlighting the inconsistency between our suggested management and that suggested by the NICE guidelines on familial breast cancer.1 The purpose of the pedigree in the article was mainly illustrative and used in the context of how to take a family history, which is why we were careful to say "to make sure... check with guidelines" in the text.
Evans and Easton acknowledge that when we wrote the article the then draft NICE guidelines agreed with our suggestion that the woman in our example would not be offered mammography. Along with many of our clinical colleagues, we were unaware that there had been a change in the final version of the NICE guidelines so that our patient would now be offered mammography. We are not clear why this change was made from a previously fairly widely accepted consensus2 since the NICE document does not present supporting evidence for this new recommendation. Although the collaborative paper is cited as evidence,3 it only examines the risk from two first degree relatives with breast cancer. This is echoed in the NICE guidance itself: "for women with one first degree and one second degree relative we do not have direct estimates."
There is as yet no evidence that mammography in women under 50 reduces mortality from the disease. Although early detection is possible and there is some consensus that those with a very strong family history of breast cancer should be offered mammography under the age of 50, much of the evidence on which the NICE guidelines are based is category IV. We suggest that the cut-off point between family history groups for which different managements are suggested is to some extent arbitrary. Mammography in those under 50 is currently through the symptomatic breast screening services, thus putting pressure on already overstretched services. The risk that our patient would develop breast cancer before the age of 50 (when she would enter the national breast screening programme) is approximately 1.5-3% compared with 1-2% for the general population.
We commend the NICE committee for their thorough review of an area where evidence is currently limited and hope that this correspondence encourages constructive dialogue on implementing the guidelines.
Anneke Lucassen, consultant in clinical genetics
Wessex Clinical Genetics Service, The Princess Anne Hospital, Southampton SO16 5YA annekel@soton.ac.uk
Eila Watson, deputy director
Cancer Research UK Primary Care Education Research Group, University of Oxford, Oxford OX3 7LF
Competing interests: None declared.
References
McIntosh A, Shaw C, Evans G, Turnbull N, Bahar N, Barclay M, et al. Clinical guidelines and evidence review for the classification and care of women at risk of familial breast cancer. London: National Collaborating Centre for Primary Care, University of Sheffield, 2004. (NICE guideline CG014.)
Cancer Research UK Primary Care Education Research Group. Familial breast and ovarian cancer pack. Oxford: Cancer Research UK Primary Care Education Research Group, 2001. www.dphpc.ox.ac.uk/crcpcerg/resources/genpack.htm (accessed 5 March 2005).
Collaborative Group on Hormonal Factors in Breast Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58 209 women with breast cancer and 101 986 women without the disease. Lancet 2001;358: 1389-99.