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Prophylactic mastectomy cuts cancer risk in women with BRCA mutations
SCIENCE AND MEDICINE
NEWS WHO’s blood-safety initiative: a vain effort? set up in strategic locations—are far more effective, he argues. “I worked in a very remote hospital in Sierra Leone that was often completely cut off from communication for up to 2 weeks. We had a very busy obstetric and surgery service, but we always had enough blood.” WHO would “sweep such ‘bush’ systems aside with its grandiose central blood-bank scheme”, says DeCosas, but such schemes “work only for a short while and then fall apart because they are so ‘out of sync’ with the rest of the health-care system, road system, and electric supply”. Locally adapted solutions are viewed as “third-class” by specialists in Europe, he observes. “But what do they know about the problems faced by a lone district medical officer with 100 miles of dirt road and a broken jeep between him and the next regional hospital, and a woman with a ruptured uterus on the operating table?”, he asks. Science Photo Library
big. A safe blood supply requires safe blood donors, and these have to be altruistic donors, not remunerated donors, particularly in developing countries.” Such an approach “has been carried out in some countries with very poor resources, such as Zimbabwe, and these are models for others”, he asserts. But Josef DeCosas, Focus on safety director of the Southern African AIDS Training Programme in Zimbabwe, disagrees. Organised blood-transfusion services work in Zimbabwe because the WHO statistics on blood safety country has a network of roads ● 80% of the world’s population has access to and telephones, and vehicles 20% of the world’s safe blood supply. and fuel are available, he says. ● Transfusion or injection of unsafe blood “In most other African counaccounts for 8–16 million hepatitis B virus tries, the ‘organised’ central infections, 2·3–4·7 million hepatitis C virus blood-transfusion services take infections, and 80 000–160 000 HIV an enormous chunk of the infections each year. health-care budget and service ● 20% of donated blood is not tested for all only the university hospital in transfusion-transmissible infections. the capital.” By contrast, local ● 25% of maternal deaths from pregnancysystems adapted to local conrelated causes are linked with loss of blood. ditions—eg, small refrigerators with rotating stocks of blood
HO’s new blood-safety campaign, launched in conjunction with World Health Day on April 7, aims to increase the availability of safe blood in developing countries. The organisation has issued “a telling set of facts and figures on the state of the world’s blood supply” to spur governments to establish national transfusion systems. But critics say the approach is unworkable in the very regions it aims to protect. “Transfusion services work best when they are nationally coordinated and supported by the government”, insists Jean Emmanuel, WHO’s director of blood safety and clinical technology. “In India for example, you could organise by states because it’s so
W
Marilynn Larkin
Prophylactic mastectomy cuts cancer risk in women with BRCA mutations
P
rophylactic mastectomy substantially reduces the risk of breast cancer in women with mutations in the breast-cancer genes BRCA1 or BRCA2, according to a study presented at the annual meeting of the American Association of Cancer Research (San Francisco, CA, USA; April 2). Lynn Hartmann and co-workers at the Mayo Clinic (Rochester, MN, USA) looked at the clinical course of 28 women who had had bilateral prophylactic mastectomies because of a family history of breast cancer. The women had the operation an average of 15 years ago, when the two breast-cancer genes had not yet been identified. In this study, Hartmann and her co-workers determined that 17 of the 28 women had BRCA defects known to increase cancer risk,
THE LANCET • Vol 355 • April 8, 2000
whereas 11 had mutations whose significance is unknown. Since previous studies have found that women who inherit harmful mutations of these genes have a 56–85% lifetime risk of developing breast cancer, 10·7 of the women would have been expected to develop breast cancer during the 15-year follow-up period. However, none of the 28 women developed breast cancer, representing a 90% (CI 50–100%) reduction in risk, Hartmann told the conference. The study reinforces results published by Hartmann’s group last year. That research looked at breast-cancer incidence in 639 women—214 at high risk of breast cancer based on family history and 425 at moderate risk—who had had prophylactic mastectomies. Median
follow-up was 14 years. Of those 639 women, 37·4 would have been expected to develop breast cancer, and 10·4 to die of the disease. But only four developed breast cancer and none died from the disease: an 89% reduction in the risk of disease and an 100% reduction in the risk of death (N Engl J Med 1999; 340: 77–84). Nevertheless, Hartmann said her centre did not recommend the procedure to high-risk women because of the substantial financial and emotional cost of the operation. Women at risk should consider two other options, she said: close monitoring or prophylactic treatment with the anti-oestrogen compound, tamoxifen. Michael McCarthy
1245
NEWS WHO’s blood-safety initiative: a vain effort? set up in strategic locations—are far more effective, he argues. “I worked in a very remote hospital in Sierra Leone that was often completely cut off from communication for up to 2 weeks. We had a very busy obstetric and surgery service, but we always had enough blood.” WHO would “sweep such ‘bush’ systems aside with its grandiose central blood-bank scheme”, says DeCosas, but such schemes “work only for a short while and then fall apart because they are so ‘out of sync’ with the rest of the health-care system, road system, and electric supply”. Locally adapted solutions are viewed as “third-class” by specialists in Europe, he observes. “But what do they know about the problems faced by a lone district medical officer with 100 miles of dirt road and a broken jeep between him and the next regional hospital, and a woman with a ruptured uterus on the operating table?”, he asks. Science Photo Library
big. A safe blood supply requires safe blood donors, and these have to be altruistic donors, not remunerated donors, particularly in developing countries.” Such an approach “has been carried out in some countries with very poor resources, such as Zimbabwe, and these are models for others”, he asserts. But Josef DeCosas, Focus on safety director of the Southern African AIDS Training Programme in Zimbabwe, disagrees. Organised blood-transfusion services work in Zimbabwe because the WHO statistics on blood safety country has a network of roads ● 80% of the world’s population has access to and telephones, and vehicles 20% of the world’s safe blood supply. and fuel are available, he says. ● Transfusion or injection of unsafe blood “In most other African counaccounts for 8–16 million hepatitis B virus tries, the ‘organised’ central infections, 2·3–4·7 million hepatitis C virus blood-transfusion services take infections, and 80 000–160 000 HIV an enormous chunk of the infections each year. health-care budget and service ● 20% of donated blood is not tested for all only the university hospital in transfusion-transmissible infections. the capital.” By contrast, local ● 25% of maternal deaths from pregnancysystems adapted to local conrelated causes are linked with loss of blood. ditions—eg, small refrigerators with rotating stocks of blood
HO’s new blood-safety campaign, launched in conjunction with World Health Day on April 7, aims to increase the availability of safe blood in developing countries. The organisation has issued “a telling set of facts and figures on the state of the world’s blood supply” to spur governments to establish national transfusion systems. But critics say the approach is unworkable in the very regions it aims to protect. “Transfusion services work best when they are nationally coordinated and supported by the government”, insists Jean Emmanuel, WHO’s director of blood safety and clinical technology. “In India for example, you could organise by states because it’s so
W
Marilynn Larkin
Prophylactic mastectomy cuts cancer risk in women with BRCA mutations
P
rophylactic mastectomy substantially reduces the risk of breast cancer in women with mutations in the breast-cancer genes BRCA1 or BRCA2, according to a study presented at the annual meeting of the American Association of Cancer Research (San Francisco, CA, USA; April 2). Lynn Hartmann and co-workers at the Mayo Clinic (Rochester, MN, USA) looked at the clinical course of 28 women who had had bilateral prophylactic mastectomies because of a family history of breast cancer. The women had the operation an average of 15 years ago, when the two breast-cancer genes had not yet been identified. In this study, Hartmann and her co-workers determined that 17 of the 28 women had BRCA defects known to increase cancer risk,
THE LANCET • Vol 355 • April 8, 2000
whereas 11 had mutations whose significance is unknown. Since previous studies have found that women who inherit harmful mutations of these genes have a 56–85% lifetime risk of developing breast cancer, 10·7 of the women would have been expected to develop breast cancer during the 15-year follow-up period. However, none of the 28 women developed breast cancer, representing a 90% (CI 50–100%) reduction in risk, Hartmann told the conference. The study reinforces results published by Hartmann’s group last year. That research looked at breast-cancer incidence in 639 women—214 at high risk of breast cancer based on family history and 425 at moderate risk—who had had prophylactic mastectomies. Median
follow-up was 14 years. Of those 639 women, 37·4 would have been expected to develop breast cancer, and 10·4 to die of the disease. But only four developed breast cancer and none died from the disease: an 89% reduction in the risk of disease and an 100% reduction in the risk of death (N Engl J Med 1999; 340: 77–84). Nevertheless, Hartmann said her centre did not recommend the procedure to high-risk women because of the substantial financial and emotional cost of the operation. Women at risk should consider two other options, she said: close monitoring or prophylactic treatment with the anti-oestrogen compound, tamoxifen. Michael McCarthy
1245