- Email: [email protected]
Genetic counselling and prophylactic surgery in women from families with hereditary breast or ovarian cancer
COMMENTARY
Penis Urethra Bladder
Prostate Ultrasound probe
Rectum Level of dentate line
Needle direction through probe guide
Transrectal ultrasound-guided prostate biopsy Diagram shows relation between ultrasound probe, biopsy track, and dentate line during prostatic apex biopsy.
at high risk of cancer on the basis of an increased serum concentration of prostate-specific antigen, and require biopsy. An example of the demand for this procedure is reported by a European prostate-cancer screening trial11 that, with a cut-off for prostate-specific antigen of 3·0 ng/mL, had nearly a fifth of 7943 screened patients undergoing biopsy, with a cancer detection rate of 4·7%. The diagnosis of prostate cancer is being more aggressively pursued, and as screening becomes more widespread and biopsy thresholds with prostate-specific antigen fall, the numbers of biopsies will continue to rise. In addition to primary diagnostic biopsies, there is a corresponding increase in the number of patients with raised prostatespecific antigen but previous sets of negative biopsies that undergo repeat biopsies. In future, the active monitoring of patients already diagnosed with cancer at low risk of progression may also entail programmes of repeat biopsies, possibly every 2 years. Patients will not accept such investigations unless they are tolerable. Arguably, therefore, the effectiveness of prostate cancer screening and active monitoring could be jeopardised by a simple outpatient procedure for which there is currently no universally agreed standard of analgesia. We have no conflict of interest to declare.
*Christopher J Luscombe, Peter W Cooke Department of Urology, Royal Shrewsbury Hospital NHS Trust, Shrewsbury, Shropshire SY3 8XQ, UK (CJL); and Department of Urology, New Cross Hospital, Wolverhampton, West Midlands, UK (PWC) (e-mail: [email protected]) 1
2
3
4
5
6 7
8
Crundwell MC, Cooke PW, Wallace DM. Patients’ tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases. BJU Int 1999; 83: 792–95. Lynn NNK, Collins GN, Brown SC, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002; 90: 424–26. Ozden E, Yaman O, Gogus C, Ozgencil E, Soygur T. The optimum doses of and injection locations for periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, placebo controlled study. J Urol 2003; 170: 2319–22. Jones JS, Ulshaker JC, Nelson D, et al. Periprostatic local anaesthesia eliminates pain of office-based transrectal prostate biopsy. Prostate Cancer Prostatic Dis 2003; 6: 53–55. Lee-Elliott CE, Dundas D, Patel U. Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy. J Urol 2004; 171: 247–50. Jones JS, Zippe CD. Rectal sensation test helps avoid pain of apical prostate biopsy. J Urol 2003; 170: 2316–18. Manikandan R, Srirangam SJ, Brown SC, O’Reilly PH, Collins GN. Nitrous oxide vs periprostatic nerve block with 1% lidocaine during transrectal ultrasound guided biopsy of the prostate: a prospective, randomised, controlled trial. J Urol 2003; 170: 1881–83. Adamakis I, Mitropoulos D, Haritroupoulos K, Alamanis C, Stravodimos K, Gianopoulos A. Pain during ultrasonography guided
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaineprilocain cream. World J Urol 2003; [epub ahead of print] http://www.springerlink.com/app/home/contribution.asp?wasp=gafwvmv hwq2ghdrknrar&referrer=parent&backto=issue,19,22;journal,1,47;linkin gpublicationresults,id:101581,1 (accessed April 19, 2004). 9 Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anaesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomised clinical trial. J Urol 2004; 171: 730–33. 10 Davis M, Sofer M, Kim SS, Soloway MS. The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 2002; 167: 566–70. 11 Schroder FH, Denis LJ, Roobol M. The story of the European randomized study of screening for prostate cancer. BJU Int 2003; 92 (suppl 2): 1–13.
Genetic counselling and prophylactic surgery in women from families with hereditary breast or ovarian cancer The identification1,2 of the two breast cancer genes, BRCA1 and BRCA2, in 1994 and 1995, respectively, and the recognition that mutations in these genes are associated with increased susceptibility to breast and ovarian cancer have led to mutation testing of at-risk families. Many women from families with hereditary breast or ovarian cancer consider bilateral prophylactic mastectomy and/or salpingo-oophorectomy as a strategy to reduce their risk of developing cancer. Decisions about early detection and prophylactic options for high-risk women are particularly difficult because of the uncertain effectiveness of cancer screening and the complexity of the issues to be considered (panel). For high-risk women who have had a mastectomy for breast cancer, decisions about the role of a contralateral mastectomy or indeed bilateral mastectomy after breast conservation are even more complex. Therefore, women considering their risk-management options should have access to genetic counselling, to allow them to make informed decisions. Timothy Rebbeck and colleagues3 recently showed that bilateral prophylactic mastectomy led to a 90% reduction in the risk of breast cancer in carriers of BRCA1 and BRCA2, thus lending further support to the mounting evidence of the procedure’s effectiveness.4 And, in another recent report, Katrina Armstrong and colleagues5 found that bilateral oophorectomy also leads to similar reductions in the risk of ovarian cancer, and, in premenopausal women, the operation decreases the risk of breast cancer by 50%. Because evidence is lacking about the effect of hormone replacement therapy on life expectancy in high-risk women, these investigators did a decision analysis in a simulated cohort, and found that prophylactic oophorectomy increased life expectancy in mutation carriers regardless of whether hormone replacement therapy was used after oophorectomy. However, we need empirical data to confirm these results. We have found6 that women’s intentions to undergo prophylactic mastectomy were correlated with high levels of anxiety about breast cancer, which raises concerns that women might choose surgical intervention without fully anticipating the psychological and medical effects. However, a study7 of actual uptake showed that women who declined the procedure were more prone to anxiety; women who underwent prophylactic mastectomy showed significantly decreased psychological morbidity compared with those who declined the procedure. Reducing the risk of ovarian cancer and worry about cancer are the main decision-making factors in women who have opted for prophylactic oophorectomy.8 A prospective 1841
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
Genetic counselling issues in women considering prophylactic surgery Bilateral prophylactic mastectomy Effectiveness in reducing risk of breast cancer including residual risk Timing of prophylactic mastectomy (eg, when risk increases) Surgical considerations: Total vs skin-sparing vs subcutaneous mastectomy Plans for breast reconstruction, including nipple reconstruction Type of breast reconstruction (implants or tissue transfer) Surgical complications Cost of surgery Psychosocial considerations: Discussion of motivating factors (perceived risk, family experiences, cancer worry) Psychological impact Psychosexual impact (body image and sexuality) Plans for breast feeding Bilateral prophylactic salpingo-oophorectomy Effectiveness of reducing risk of ovarian and breast cancer, including residual risk Timing of prophylactic oophorectomy (eg, when risk increases, after childbearing) Surgical considerations: Laparotomy vs laparoscopy Consideration of hysterectomy (to eliminate need for progesterone and risk of endometrial cancer if taking tamoxifen) Surgical complications Cost of surgery Hormonal considerations in premenopausal women: Loss of fertility Onset of menopause Increased risk for coronary artery disease and osteoporosis Role of hormone replacement therapy in reducing symptoms Effect of hormone replacement therapy on risk of breast cancer Psychosocial considerations: Plans for childbearing Psychosexual impact (libido) Family experiences of ovarian cancer Familial obligations
study8 showed a significant reduction in anxiety about ovarian cancer after prophylactic surgery. However, women were found to have unmet information needs about prophylactic oophorectomy, and the associated use of hormone replacement therapy and its link with breast cancer, that might compromise their ability to make informed decisions.8 We audiotaped, transcribed, and coded9 the genetic counselling of 158 women, from families with a high risk of breast cancer, at their initial session before starting genetic testing, and found that prophylactic mastectomy and oophorectomy were discussed in half the consultations. The discussion was started by the clinician in only about a third of these consultations, and the remainder were at the woman’s initiative. This lack of discussion may reflect clinicians’ reluctance to appear directive, or that they do not wish to create undue anxiety. A physician’s recommendation may be a powerful determinant for uptake of prophylactic oophorectomy, and the apparent reluctance of clinicians to discuss prophylactic surgery may, in itself, be 1842
perceived by women as an indirect recommendation against the surgery.8,10 The benefits and risks of prophylactic mastectomy were discussed in only 14% and 24% of consultations, respectively.9 The perceived benefits of oophorectomy were covered in 14%, and the risks in 16% of consultations. Prophylactic mastectomy was more likely to be discussed with women who had medical or allied health-training, and prophylactic oophorectomy was discussed more often with women who were affected with breast cancer or who had a family history of breast and ovarian cancer.11 The discussion of prophylactic mastectomy and oophorectomy was significantly associated with women’s expectations being met but there was no significant association between discussion of prophylactic surgery and anxiety.11 Hence, our findings suggest that women wish to discuss prophylactic surgery, and such discussion does not cause psychological distress. Decisions about prophylactic surgery remain difficult for high-risk women and their clinicians, and it is appropriate for physicians to ask women if they have considered prophylactic surgery and if they wish to discuss it in more detail. Comprehensive assessment of genetic risk can have a substantial role in the management of high-risk women who are considering prophylactic surgery. In addition, women are likely to benefit from interventions aimed at facilitating shared and informed decision-making.8 Because risk perceptions and attitudes to the management of the risk for breast cancer seem to be affected by previous experiences of cancer in the family,7 such interventions should explicitly address precounselling factors, such as personal beliefs, the psychological effect of the family medical history (eg, the death of other family members from breast or ovarian cancer), levels of worry about breast cancer, and perceived risk.6 We have no conflict of interest to declare.
*Elizabeth Lobb, Bettina Meiser WA Centre for Cancer & Palliative Care, Edith Cowan University, Perth 6018, Western Australia, Australia (EL); and Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, New South Wales, Australia (BM) (e-mail: [email protected]) 1
Miki Y, Swensen J, Shattuck-Eidens D, et al. A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1. Science 1994; 266: 66–71. 2 Wooster R, Bignell G, Lancaster J, et al. Identification of the breast cancer susceptibility gene BRCA2. Nature 1995; 378: 789–92. 3 Rebbeck T, Friebel T, Lynch H, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 2004; 22: 1055–62. 4 Hartmann L, Degnim A, Schaid D. Prophylactic mastectomy for BRCA1 and BRCA2 carriers: progress and more questions. J Clin Oncol 2004; 22: 981–82. 5 Armstrong K, Schwartz J, Randall T, Rubin S, Weber B. Hormone replacement therapy and life expectancy after prophylactic oophorectomy in women with BRCA1/2 mutations: a decisional analysis. J Clin Oncol 2004; 22: 1045–54. 6 Meiser B, Butow P, Friedlander M, et al. Intention to undergo prophylactic mastectomy in women at increased risk of developing hereditary breast cancer. J Clin Oncol 2000; 18: 2250–57. 7 Hatcher M, Fallowfield L, A’Hern R. The psychological impact of prophylactic mastectomy: prospective study using questionnaires and semistructured interviews. BMJ 2001; 322: 76–79. 8 Tiller K, Meiser B, Butow P, et al. Psychological impact of prophylactic oophorectomy in women at risk of developing ovarian cancer. Gynecol Oncol 2002; 86: 212–19. 9 Lobb EA, Butow P, Meiser B, et al. Tailoring communication in consultations with women from high-risk breast cancer families. Br J Cancer 2002; 87: 502–08. 10 Hallowell N. Advising on the management of genetic risk: offering choice or prescribing action? Health Risk Society 1999; 1: 267–80. 11 Lobb EA, Butow P, Meiser B, et al. Communication and information-giving in high risk breast cancer consultations: influence on patient outcomes. Br J Cancer 2004: 90: 321–27.
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Penis Urethra Bladder
Prostate Ultrasound probe
Rectum Level of dentate line
Needle direction through probe guide
Transrectal ultrasound-guided prostate biopsy Diagram shows relation between ultrasound probe, biopsy track, and dentate line during prostatic apex biopsy.
at high risk of cancer on the basis of an increased serum concentration of prostate-specific antigen, and require biopsy. An example of the demand for this procedure is reported by a European prostate-cancer screening trial11 that, with a cut-off for prostate-specific antigen of 3·0 ng/mL, had nearly a fifth of 7943 screened patients undergoing biopsy, with a cancer detection rate of 4·7%. The diagnosis of prostate cancer is being more aggressively pursued, and as screening becomes more widespread and biopsy thresholds with prostate-specific antigen fall, the numbers of biopsies will continue to rise. In addition to primary diagnostic biopsies, there is a corresponding increase in the number of patients with raised prostatespecific antigen but previous sets of negative biopsies that undergo repeat biopsies. In future, the active monitoring of patients already diagnosed with cancer at low risk of progression may also entail programmes of repeat biopsies, possibly every 2 years. Patients will not accept such investigations unless they are tolerable. Arguably, therefore, the effectiveness of prostate cancer screening and active monitoring could be jeopardised by a simple outpatient procedure for which there is currently no universally agreed standard of analgesia. We have no conflict of interest to declare.
*Christopher J Luscombe, Peter W Cooke Department of Urology, Royal Shrewsbury Hospital NHS Trust, Shrewsbury, Shropshire SY3 8XQ, UK (CJL); and Department of Urology, New Cross Hospital, Wolverhampton, West Midlands, UK (PWC) (e-mail: [email protected]) 1
2
3
4
5
6 7
8
Crundwell MC, Cooke PW, Wallace DM. Patients’ tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases. BJU Int 1999; 83: 792–95. Lynn NNK, Collins GN, Brown SC, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002; 90: 424–26. Ozden E, Yaman O, Gogus C, Ozgencil E, Soygur T. The optimum doses of and injection locations for periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, placebo controlled study. J Urol 2003; 170: 2319–22. Jones JS, Ulshaker JC, Nelson D, et al. Periprostatic local anaesthesia eliminates pain of office-based transrectal prostate biopsy. Prostate Cancer Prostatic Dis 2003; 6: 53–55. Lee-Elliott CE, Dundas D, Patel U. Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy. J Urol 2004; 171: 247–50. Jones JS, Zippe CD. Rectal sensation test helps avoid pain of apical prostate biopsy. J Urol 2003; 170: 2316–18. Manikandan R, Srirangam SJ, Brown SC, O’Reilly PH, Collins GN. Nitrous oxide vs periprostatic nerve block with 1% lidocaine during transrectal ultrasound guided biopsy of the prostate: a prospective, randomised, controlled trial. J Urol 2003; 170: 1881–83. Adamakis I, Mitropoulos D, Haritroupoulos K, Alamanis C, Stravodimos K, Gianopoulos A. Pain during ultrasonography guided
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaineprilocain cream. World J Urol 2003; [epub ahead of print] http://www.springerlink.com/app/home/contribution.asp?wasp=gafwvmv hwq2ghdrknrar&referrer=parent&backto=issue,19,22;journal,1,47;linkin gpublicationresults,id:101581,1 (accessed April 19, 2004). 9 Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anaesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomised clinical trial. J Urol 2004; 171: 730–33. 10 Davis M, Sofer M, Kim SS, Soloway MS. The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 2002; 167: 566–70. 11 Schroder FH, Denis LJ, Roobol M. The story of the European randomized study of screening for prostate cancer. BJU Int 2003; 92 (suppl 2): 1–13.
Genetic counselling and prophylactic surgery in women from families with hereditary breast or ovarian cancer The identification1,2 of the two breast cancer genes, BRCA1 and BRCA2, in 1994 and 1995, respectively, and the recognition that mutations in these genes are associated with increased susceptibility to breast and ovarian cancer have led to mutation testing of at-risk families. Many women from families with hereditary breast or ovarian cancer consider bilateral prophylactic mastectomy and/or salpingo-oophorectomy as a strategy to reduce their risk of developing cancer. Decisions about early detection and prophylactic options for high-risk women are particularly difficult because of the uncertain effectiveness of cancer screening and the complexity of the issues to be considered (panel). For high-risk women who have had a mastectomy for breast cancer, decisions about the role of a contralateral mastectomy or indeed bilateral mastectomy after breast conservation are even more complex. Therefore, women considering their risk-management options should have access to genetic counselling, to allow them to make informed decisions. Timothy Rebbeck and colleagues3 recently showed that bilateral prophylactic mastectomy led to a 90% reduction in the risk of breast cancer in carriers of BRCA1 and BRCA2, thus lending further support to the mounting evidence of the procedure’s effectiveness.4 And, in another recent report, Katrina Armstrong and colleagues5 found that bilateral oophorectomy also leads to similar reductions in the risk of ovarian cancer, and, in premenopausal women, the operation decreases the risk of breast cancer by 50%. Because evidence is lacking about the effect of hormone replacement therapy on life expectancy in high-risk women, these investigators did a decision analysis in a simulated cohort, and found that prophylactic oophorectomy increased life expectancy in mutation carriers regardless of whether hormone replacement therapy was used after oophorectomy. However, we need empirical data to confirm these results. We have found6 that women’s intentions to undergo prophylactic mastectomy were correlated with high levels of anxiety about breast cancer, which raises concerns that women might choose surgical intervention without fully anticipating the psychological and medical effects. However, a study7 of actual uptake showed that women who declined the procedure were more prone to anxiety; women who underwent prophylactic mastectomy showed significantly decreased psychological morbidity compared with those who declined the procedure. Reducing the risk of ovarian cancer and worry about cancer are the main decision-making factors in women who have opted for prophylactic oophorectomy.8 A prospective 1841
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
Genetic counselling issues in women considering prophylactic surgery Bilateral prophylactic mastectomy Effectiveness in reducing risk of breast cancer including residual risk Timing of prophylactic mastectomy (eg, when risk increases) Surgical considerations: Total vs skin-sparing vs subcutaneous mastectomy Plans for breast reconstruction, including nipple reconstruction Type of breast reconstruction (implants or tissue transfer) Surgical complications Cost of surgery Psychosocial considerations: Discussion of motivating factors (perceived risk, family experiences, cancer worry) Psychological impact Psychosexual impact (body image and sexuality) Plans for breast feeding Bilateral prophylactic salpingo-oophorectomy Effectiveness of reducing risk of ovarian and breast cancer, including residual risk Timing of prophylactic oophorectomy (eg, when risk increases, after childbearing) Surgical considerations: Laparotomy vs laparoscopy Consideration of hysterectomy (to eliminate need for progesterone and risk of endometrial cancer if taking tamoxifen) Surgical complications Cost of surgery Hormonal considerations in premenopausal women: Loss of fertility Onset of menopause Increased risk for coronary artery disease and osteoporosis Role of hormone replacement therapy in reducing symptoms Effect of hormone replacement therapy on risk of breast cancer Psychosocial considerations: Plans for childbearing Psychosexual impact (libido) Family experiences of ovarian cancer Familial obligations
study8 showed a significant reduction in anxiety about ovarian cancer after prophylactic surgery. However, women were found to have unmet information needs about prophylactic oophorectomy, and the associated use of hormone replacement therapy and its link with breast cancer, that might compromise their ability to make informed decisions.8 We audiotaped, transcribed, and coded9 the genetic counselling of 158 women, from families with a high risk of breast cancer, at their initial session before starting genetic testing, and found that prophylactic mastectomy and oophorectomy were discussed in half the consultations. The discussion was started by the clinician in only about a third of these consultations, and the remainder were at the woman’s initiative. This lack of discussion may reflect clinicians’ reluctance to appear directive, or that they do not wish to create undue anxiety. A physician’s recommendation may be a powerful determinant for uptake of prophylactic oophorectomy, and the apparent reluctance of clinicians to discuss prophylactic surgery may, in itself, be 1842
perceived by women as an indirect recommendation against the surgery.8,10 The benefits and risks of prophylactic mastectomy were discussed in only 14% and 24% of consultations, respectively.9 The perceived benefits of oophorectomy were covered in 14%, and the risks in 16% of consultations. Prophylactic mastectomy was more likely to be discussed with women who had medical or allied health-training, and prophylactic oophorectomy was discussed more often with women who were affected with breast cancer or who had a family history of breast and ovarian cancer.11 The discussion of prophylactic mastectomy and oophorectomy was significantly associated with women’s expectations being met but there was no significant association between discussion of prophylactic surgery and anxiety.11 Hence, our findings suggest that women wish to discuss prophylactic surgery, and such discussion does not cause psychological distress. Decisions about prophylactic surgery remain difficult for high-risk women and their clinicians, and it is appropriate for physicians to ask women if they have considered prophylactic surgery and if they wish to discuss it in more detail. Comprehensive assessment of genetic risk can have a substantial role in the management of high-risk women who are considering prophylactic surgery. In addition, women are likely to benefit from interventions aimed at facilitating shared and informed decision-making.8 Because risk perceptions and attitudes to the management of the risk for breast cancer seem to be affected by previous experiences of cancer in the family,7 such interventions should explicitly address precounselling factors, such as personal beliefs, the psychological effect of the family medical history (eg, the death of other family members from breast or ovarian cancer), levels of worry about breast cancer, and perceived risk.6 We have no conflict of interest to declare.
*Elizabeth Lobb, Bettina Meiser WA Centre for Cancer & Palliative Care, Edith Cowan University, Perth 6018, Western Australia, Australia (EL); and Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, New South Wales, Australia (BM) (e-mail: [email protected]) 1
Miki Y, Swensen J, Shattuck-Eidens D, et al. A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1. Science 1994; 266: 66–71. 2 Wooster R, Bignell G, Lancaster J, et al. Identification of the breast cancer susceptibility gene BRCA2. Nature 1995; 378: 789–92. 3 Rebbeck T, Friebel T, Lynch H, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 2004; 22: 1055–62. 4 Hartmann L, Degnim A, Schaid D. Prophylactic mastectomy for BRCA1 and BRCA2 carriers: progress and more questions. J Clin Oncol 2004; 22: 981–82. 5 Armstrong K, Schwartz J, Randall T, Rubin S, Weber B. Hormone replacement therapy and life expectancy after prophylactic oophorectomy in women with BRCA1/2 mutations: a decisional analysis. J Clin Oncol 2004; 22: 1045–54. 6 Meiser B, Butow P, Friedlander M, et al. Intention to undergo prophylactic mastectomy in women at increased risk of developing hereditary breast cancer. J Clin Oncol 2000; 18: 2250–57. 7 Hatcher M, Fallowfield L, A’Hern R. The psychological impact of prophylactic mastectomy: prospective study using questionnaires and semistructured interviews. BMJ 2001; 322: 76–79. 8 Tiller K, Meiser B, Butow P, et al. Psychological impact of prophylactic oophorectomy in women at risk of developing ovarian cancer. Gynecol Oncol 2002; 86: 212–19. 9 Lobb EA, Butow P, Meiser B, et al. Tailoring communication in consultations with women from high-risk breast cancer families. Br J Cancer 2002; 87: 502–08. 10 Hallowell N. Advising on the management of genetic risk: offering choice or prescribing action? Health Risk Society 1999; 1: 267–80. 11 Lobb EA, Butow P, Meiser B, et al. Communication and information-giving in high risk breast cancer consultations: influence on patient outcomes. Br J Cancer 2004: 90: 321–27.
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.