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Conservation Therapy for Breast Cancer
cillin V group's mean duration was 11 days, and the placebo group's was 17 days.
• • • Commentary: This report reviewed the potential benefit of antibiotic therapy in early acute sinus infections. The fact that only 58% were positive for infecting organisms supports the confusion in this arena. However, patient symptomatology was markedly improved in the antibiotic-treated group. Newer but more expensive antimicrobial therapy was not a part of this study.
Conservation Therapy for Breast Cancer Forrest AP, Stewart HJ, Everington D, Prescott RJ, McArdle CS, Harnett AN, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet 1996;
348:708-13.
Synopsis: Results of a randomized controlled trial of 585 patients <70 years old with primary breast cancer of <4 ern in size were reported from four specialists' units and seven other hospitals in Scotland. After rhe tumors were excised wirh 1-cm negative margins and an axillary node dissection, all patients received systemic therapy with either oral tamoxifen, 20 mg daily, or six 3-weekly intravenous bolus injections of cyclophosphamide, 600 mg, methotrexate, 50 mg, and fluorouracil, 600 mg per m-, depending on the estrogen receptor concentration in the primary rumor. These patients were then randomly allocated to postoperative radical radiotherapy, 5000 Gy to the breast with boost to the tumor bed, or to no further local treatment. Systemic chemotherapy was found to have been inappropriately assigned by estrogen receptor status in 121 patients, leaving a subsidiary analysis of 464 patients. When the estrogen receptor concentration was 220 fmol/mg protein, tamoxifen, 20 mg daily, was of ObsIRtclC18"S 3Cn G'!",,,oIOCls;s 1085-G8tJ2;g7i'S~
administered for at least 5 years; when it was <20 fmol/mg protein, the six 3-weekly intravenous bolus cyclophosphamide! methotrexate! fluorouracil chemotherapy was used. When the estrogen receptor status was unknown, patients received tamoxifen. The authors documented statistically significant improvement in event-free survival in the irradiated patients largely due to fewer locoregional relapses. The study concluded that radiotherapy to the residual breast tissue is advisable even when selective adjuvant systemic therapy is given.
• • • Commentary: This review did suffer from a break in protocol with the initial study. However, the authors corrected for this in their subsequent analysis, and the data were equally significant with the residual 464 patients. A dramatic decrease in ipsilateral breast recurrence with 14 (5%) in the irradiated group versus 51 (17%) in the nonirradiated group is significant. The applicability of these results is compromised by the authors inclusion of breast tumors up to 4 ern in size. However, when looking at those tumors of ::::2 em, there is still a dramatic difference of 4% in the irradiated group versus 26% in the nonirradiated group with local or regional recurrence. Because ofthe this, the authors did not think that the local regional relapse rate was related to size or to the menstrual status of the patient at the time of surgery. Even with node-negative patients, there was a difference of 4% in the radiation therapy group versus 21.2% in the nonirradiated group of local or regional relapse. This study offers strong evidence in support of the use of adjuvant radiation therapy in addition to chemotherapy in patients treated with conservative breast surgery.
Risks for Urinary Tract Infections Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A pro-
spective study of risk factors for symptomatic urinary tract infection in young women.
N EnglJMed 1996;335:468-74.
Synopsis: For this study, 796 women maintained daily diaries for a 6-month period to evaluate risk factors of urinary tract infections: 348 with a mean age of 23 from a university cohort and 448 with a mean age of 29 from a health maintenance organization cohort. Women in the university cohort had a risk of 0.7 urinary tract infections per person year, and women in the health maintenance organization had a risk of0.5 per person year. Identified risk factors for urinary tract infection were use of a diaphragm with spermicide (relative risk [RR] for 1, 3, and 5 days of use in the past week was 1.42, 2.83, and 5.68, respectively, in the university cohort [P<.OOOl] and 1.29,2.14, and 3.54, respectively, in the health maintenance organization cohort [P = .04]), recent sexual intercourse (RR for 1, 3, and 5 days with intercourse in the past week was 1.37, 2.56, and 4.81, respectively, in the university cohort [P< .001] and 1.24,1.91, and 2.96, respectively, in the health maintenance organization cohort [P = .002]). A history of recurring infection provided a relative risk of 5.58 in the university cohort and 2.10 in the health maintenance cohort. The authors concluded that recent sexual intercourse and recent use of diaphragm with spermicide, along with a history of recurrent urinary tract infections, provide an increased risk in this patient population.
• • • Commentary: Sexual activity has long been recognized as a potentiator of urinary tract infection. "Honeymoon cystitis" has long been an acknowledged problem. Other factors thought to be associated include de-
Januarv/Fehruarv 1997 • ACOG CLINICAL REVIEW. 11
• • • Commentary: This report reviewed the potential benefit of antibiotic therapy in early acute sinus infections. The fact that only 58% were positive for infecting organisms supports the confusion in this arena. However, patient symptomatology was markedly improved in the antibiotic-treated group. Newer but more expensive antimicrobial therapy was not a part of this study.
Conservation Therapy for Breast Cancer Forrest AP, Stewart HJ, Everington D, Prescott RJ, McArdle CS, Harnett AN, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet 1996;
348:708-13.
Synopsis: Results of a randomized controlled trial of 585 patients <70 years old with primary breast cancer of <4 ern in size were reported from four specialists' units and seven other hospitals in Scotland. After rhe tumors were excised wirh 1-cm negative margins and an axillary node dissection, all patients received systemic therapy with either oral tamoxifen, 20 mg daily, or six 3-weekly intravenous bolus injections of cyclophosphamide, 600 mg, methotrexate, 50 mg, and fluorouracil, 600 mg per m-, depending on the estrogen receptor concentration in the primary rumor. These patients were then randomly allocated to postoperative radical radiotherapy, 5000 Gy to the breast with boost to the tumor bed, or to no further local treatment. Systemic chemotherapy was found to have been inappropriately assigned by estrogen receptor status in 121 patients, leaving a subsidiary analysis of 464 patients. When the estrogen receptor concentration was 220 fmol/mg protein, tamoxifen, 20 mg daily, was of ObsIRtclC18"S 3Cn G'!",,,oIOCls;s 1085-G8tJ2;g7i'S~
administered for at least 5 years; when it was <20 fmol/mg protein, the six 3-weekly intravenous bolus cyclophosphamide! methotrexate! fluorouracil chemotherapy was used. When the estrogen receptor status was unknown, patients received tamoxifen. The authors documented statistically significant improvement in event-free survival in the irradiated patients largely due to fewer locoregional relapses. The study concluded that radiotherapy to the residual breast tissue is advisable even when selective adjuvant systemic therapy is given.
• • • Commentary: This review did suffer from a break in protocol with the initial study. However, the authors corrected for this in their subsequent analysis, and the data were equally significant with the residual 464 patients. A dramatic decrease in ipsilateral breast recurrence with 14 (5%) in the irradiated group versus 51 (17%) in the nonirradiated group is significant. The applicability of these results is compromised by the authors inclusion of breast tumors up to 4 ern in size. However, when looking at those tumors of ::::2 em, there is still a dramatic difference of 4% in the irradiated group versus 26% in the nonirradiated group with local or regional recurrence. Because ofthe this, the authors did not think that the local regional relapse rate was related to size or to the menstrual status of the patient at the time of surgery. Even with node-negative patients, there was a difference of 4% in the radiation therapy group versus 21.2% in the nonirradiated group of local or regional relapse. This study offers strong evidence in support of the use of adjuvant radiation therapy in addition to chemotherapy in patients treated with conservative breast surgery.
Risks for Urinary Tract Infections Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A pro-
spective study of risk factors for symptomatic urinary tract infection in young women.
N EnglJMed 1996;335:468-74.
Synopsis: For this study, 796 women maintained daily diaries for a 6-month period to evaluate risk factors of urinary tract infections: 348 with a mean age of 23 from a university cohort and 448 with a mean age of 29 from a health maintenance organization cohort. Women in the university cohort had a risk of 0.7 urinary tract infections per person year, and women in the health maintenance organization had a risk of0.5 per person year. Identified risk factors for urinary tract infection were use of a diaphragm with spermicide (relative risk [RR] for 1, 3, and 5 days of use in the past week was 1.42, 2.83, and 5.68, respectively, in the university cohort [P<.OOOl] and 1.29,2.14, and 3.54, respectively, in the health maintenance organization cohort [P = .04]), recent sexual intercourse (RR for 1, 3, and 5 days with intercourse in the past week was 1.37, 2.56, and 4.81, respectively, in the university cohort [P< .001] and 1.24,1.91, and 2.96, respectively, in the health maintenance organization cohort [P = .002]). A history of recurring infection provided a relative risk of 5.58 in the university cohort and 2.10 in the health maintenance cohort. The authors concluded that recent sexual intercourse and recent use of diaphragm with spermicide, along with a history of recurrent urinary tract infections, provide an increased risk in this patient population.
• • • Commentary: Sexual activity has long been recognized as a potentiator of urinary tract infection. "Honeymoon cystitis" has long been an acknowledged problem. Other factors thought to be associated include de-
Januarv/Fehruarv 1997 • ACOG CLINICAL REVIEW. 11