Making Good Decisions about Breast Cancer Chemoprevention

• breast neoplasms
• adjuvant chemotherapy
• tamoxifen
• raloxifene
• selective estrogen receptor modulators
• decision support techniques

Women worry about many things. When the worry is about health, breast cancer tops many women's lists. The fear is not irrational, and it often has a personal face. Nearly 1 in 10 women has a first-degree relative with breast cancer, and many more know a close friend or acquaintance with the disease (1). Public health agencies and advocacy groups actively promote breast cancer awareness. Popular magazines publish heart-rending stories of young women with breast cancer (2). Thus, it is not surprising that women, especially young women, have exaggerated perceptions of their risk for breast cancer (3, 4).

Worry can motivate behavior to prevent disease, but it can also cloud perspective. A community survey found that 23% of women expressed interest in breast cancer chemoprevention (5). Worry about breast cancer was the strongest predictor of interest, but there was no association between interest and objectively estimated personal risk. Smokers were nearly twice as likely as nonsmokers to express interest in chemoprevention. Mortality rates underscore the irony of this finding. Of 1000 fifty-year-old women who smoke, 4 will die of breast cancer in the ensuing 10 years, whereas 13 will die of heart attacks, 10 of lung cancer, and 6 of stroke (6).

Clinicians need perspective, too. Specialists may neglect competing diseases as they focus attention on what can be done within their area of interest. Primary care clinicians must respond to women's concerns about breast cancer and be proactive in helping them to identify the most promising opportunities to improve or maintain health. Setting priorities among the many interventions that compete for time in the clinical encounter is difficult—and missing opportunities is justifiably a source of worry for clinicians. Furthermore, clinicians are increasingly being asked to involve patients in decisions that have no clear best …