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ŒSOPHAGEAL CANCER AFTER GASTRIC SURGERY
135 to support a patient’s request that his life be ended. If there are too many human beings, the answer
England)
take a far more responsible attitude to bringing into the world rather than eliminating those already here. That way could be the prelude to many sinister practices. Possibly, we may one day live to see a society so conditioned that many in it wish to die. But should the doctor ever be asked to participate in the logical implications which will follow ? Can he act against life without becoming an enemy to what is best in society and without contradicting his own therapeutic calling ? His work is to heal, in the widest sense of that word. This, both logically and practically, precludes his being made an agent of death.
must
be
to
new ones
by Wilson1 and by myself. Here I shall summarise thepublished clinical statistics on oestrogen substitution. Thereis also a considerable body of evidence to support the viewthat cestrogens exert a preventive action against newgrowths by activating immune mechanisms.3 In four independent studies 1,4--6 involving 1130 femalepatients treated with oestrogen substitution therapy, the total number of cancers (all types) found was 2 as against an expected number of 74 (see table). The results of SUMMARY OF FOUR REPORTS OF OESTROGEN-SUBSTITUTION THERAPY
C. G. SCORER.
Hillmgdon, Middlesex.
ŒSOPHAGEAL CANCER AFTER GASTRIC SURGERY SIR,-We agree with Dr. Macdonald and his colleagues (Jan. 2, p. 19) that, to show whether gastric surgery precancer, comparison should be made with a cancer of similar age and sex distribution. However, their paper raises several questions. It is important to know the proportion of cases in the Nottingham area not admitted to the two district general hospitals. The southeastern region of Scotland, where our investigation was done, has a relatively static population, and we know that only 10 of our 102 patients were treated in other hospitals. In addition, we know that case-notes can be very inaccurate, and this must cast doubt on any retrospective study. In our own series, from a radiotherapy unit with a very high standard of case-recording, 2 of the 8 cases were unrecorded, and details were obtained only by specific questioning of the patients about previous operations as part of the prospective study. Furthermore, 2 patients had the operation recorded incorrectly. It was necessary to examine general-practice records and notes from other hospitals to complete the data. Thus, we cannot agree with the statement: " It seems unlikely that our negative results could be explained by a failure to note previous gastric surgery in oesophagealcancer patients. Such a selective failure might have been expected to occur, if at all, in patients whose second disease involved the lower rather than the upper digestive tract." We have now studied, prospectively, 178 consecutive patients with proven squamous oesophageal cancer from this region, and 11 have had previous gastric surgery. These additional details will be published in full shortly. It is important that studies should be undertaken in other regions but we feel that these should be prospective.
disposes to oesophageal
Department of Therapeutics and Radiotherapy,
Royal Infirmary, Edinburgh.
J. C. SHEARMAN S. J. ARNOTT.
DAVID
IS CANCER PREVENTIBLE ? SiR,ŃVery little attention has been given to the problem of cancer prevention except in relation to the control of exogenous factors. The data are inevitably scanty, take years or decades to obtain, and there is a general reluctance from experience to accept hopeful evidence of any kind in this field. Possibly this is why the evidence on cestrogen substitution therapy for women has been so little considered. There is even an astonishingly persistent claim, in some medical quarters and in the lay Press, that oestrogens are
Bakkebased on 1422 patients, which are " vitiated " by the fact that the therapeutic schedule was changed from continuous oestrogen administration to cyclic after 1945, yields an expected number of cancers of 96 as against an observed number of 5 cases. Continuous (i.e., non-cyclic) oestrogen therapy is no longer accepted, and 4 of these 5 cases of (uterine) cancer occurred before 1945. It istherefore felt that the data in the table printed here more accurately represent the results of acceptable modes ofoestrogen preventive therapy than Bakke’s figures (see alsoGordon 8 and West et a1.9). If the data in my table and those of Bakke are based onindependent random events with the given expected numbers, the probability of obtaining 2 or less would be 2-05 X 10-29 in my table and 5 or less 1.46 X 10-34 in Bakkes" figures, as follows from the Poisson distribution. Theexpected number of cancer cases is estimated on the basis. of duration of observation period, age distribution, and local statistics. The expected number of (all forms of) cancer as given by Gordon 4 and Wilson 1 were accepted by the editors of the Yearbook of Cancer (1963-64). The above findings indicate that, of every 100 women " fated by nature " to develop cancer, 97 may be prevented from getting it if one bases one’s estimate on the best set of data (my table), 95 if one makes a pessimistic " estimate based on Bakke’s figures, and 98 if one uses only the dataafter 1945 in Bakke’s material. The conclusion that, at least for the age-periods and sex under discussion, cancer is alargely preventible disease appears inescapable. This conclusion is not new. In 1963, Professor Bakke, commenting on the 5 cases "of cancer found as against the 96 cases expected7 wrote: It would seem that 95% of women who would ordinarily have gotten cancer, had been saved from this disease by hormone therapy." This strongly suggests that oestrogen substitution therapy-which incidentally also provides strong protection against cardiovascular degeneration 3-constitutes a rational means of cancer prophylaxis in the postmenopausal female. "
1. 2. 3.
Wilson, R. A. J. Am. med. Ass. 1962, 182, 327. Defares, J. G. Ned. Tijdschr. Geneesk. 1966, 110, 1276. Defares, J. G. The Control of Aging and its Diseases. Amsterdam,
4.
Gordon, G. S. Round table conference on the menopause and the roles of estrogens. Excerpta Medica Foundation, May, 1962. Schleyer-Saunders, E. Med. Press, 1960, 294, 337. Geist, S. H., Walter, R. I., Salmon, U. J. Am. J. Obstet. Gynec. 1941, 42, 242. Bakke, J. L. West. J. Surgery Obstet. Gynec. 1963, 71, 241. Gordon, G. S. Texas J. Med. 1961, 57, 740. West, R. A., Brevatti, R. E., Wilson, T. H. West. J. Surgery Obstet. Gynec. 1963, 71, 110.
1969.
5. 6.
carcinogenic. given in the reviews
7. 8.
Shearman, D. J. C., Finlayson, N. D. C., Arnott, S. J., Pearson, J. G. Lancet, 1970, i, 581.
9.
A critical evaluation of this claim is 1.
England)
take a far more responsible attitude to bringing into the world rather than eliminating those already here. That way could be the prelude to many sinister practices. Possibly, we may one day live to see a society so conditioned that many in it wish to die. But should the doctor ever be asked to participate in the logical implications which will follow ? Can he act against life without becoming an enemy to what is best in society and without contradicting his own therapeutic calling ? His work is to heal, in the widest sense of that word. This, both logically and practically, precludes his being made an agent of death.
must
be
to
new ones
by Wilson1 and by myself. Here I shall summarise thepublished clinical statistics on oestrogen substitution. Thereis also a considerable body of evidence to support the viewthat cestrogens exert a preventive action against newgrowths by activating immune mechanisms.3 In four independent studies 1,4--6 involving 1130 femalepatients treated with oestrogen substitution therapy, the total number of cancers (all types) found was 2 as against an expected number of 74 (see table). The results of SUMMARY OF FOUR REPORTS OF OESTROGEN-SUBSTITUTION THERAPY
C. G. SCORER.
Hillmgdon, Middlesex.
ŒSOPHAGEAL CANCER AFTER GASTRIC SURGERY SIR,-We agree with Dr. Macdonald and his colleagues (Jan. 2, p. 19) that, to show whether gastric surgery precancer, comparison should be made with a cancer of similar age and sex distribution. However, their paper raises several questions. It is important to know the proportion of cases in the Nottingham area not admitted to the two district general hospitals. The southeastern region of Scotland, where our investigation was done, has a relatively static population, and we know that only 10 of our 102 patients were treated in other hospitals. In addition, we know that case-notes can be very inaccurate, and this must cast doubt on any retrospective study. In our own series, from a radiotherapy unit with a very high standard of case-recording, 2 of the 8 cases were unrecorded, and details were obtained only by specific questioning of the patients about previous operations as part of the prospective study. Furthermore, 2 patients had the operation recorded incorrectly. It was necessary to examine general-practice records and notes from other hospitals to complete the data. Thus, we cannot agree with the statement: " It seems unlikely that our negative results could be explained by a failure to note previous gastric surgery in oesophagealcancer patients. Such a selective failure might have been expected to occur, if at all, in patients whose second disease involved the lower rather than the upper digestive tract." We have now studied, prospectively, 178 consecutive patients with proven squamous oesophageal cancer from this region, and 11 have had previous gastric surgery. These additional details will be published in full shortly. It is important that studies should be undertaken in other regions but we feel that these should be prospective.
disposes to oesophageal
Department of Therapeutics and Radiotherapy,
Royal Infirmary, Edinburgh.
J. C. SHEARMAN S. J. ARNOTT.
DAVID
IS CANCER PREVENTIBLE ? SiR,ŃVery little attention has been given to the problem of cancer prevention except in relation to the control of exogenous factors. The data are inevitably scanty, take years or decades to obtain, and there is a general reluctance from experience to accept hopeful evidence of any kind in this field. Possibly this is why the evidence on cestrogen substitution therapy for women has been so little considered. There is even an astonishingly persistent claim, in some medical quarters and in the lay Press, that oestrogens are
Bakkebased on 1422 patients, which are " vitiated " by the fact that the therapeutic schedule was changed from continuous oestrogen administration to cyclic after 1945, yields an expected number of cancers of 96 as against an observed number of 5 cases. Continuous (i.e., non-cyclic) oestrogen therapy is no longer accepted, and 4 of these 5 cases of (uterine) cancer occurred before 1945. It istherefore felt that the data in the table printed here more accurately represent the results of acceptable modes ofoestrogen preventive therapy than Bakke’s figures (see alsoGordon 8 and West et a1.9). If the data in my table and those of Bakke are based onindependent random events with the given expected numbers, the probability of obtaining 2 or less would be 2-05 X 10-29 in my table and 5 or less 1.46 X 10-34 in Bakkes" figures, as follows from the Poisson distribution. Theexpected number of cancer cases is estimated on the basis. of duration of observation period, age distribution, and local statistics. The expected number of (all forms of) cancer as given by Gordon 4 and Wilson 1 were accepted by the editors of the Yearbook of Cancer (1963-64). The above findings indicate that, of every 100 women " fated by nature " to develop cancer, 97 may be prevented from getting it if one bases one’s estimate on the best set of data (my table), 95 if one makes a pessimistic " estimate based on Bakke’s figures, and 98 if one uses only the dataafter 1945 in Bakke’s material. The conclusion that, at least for the age-periods and sex under discussion, cancer is alargely preventible disease appears inescapable. This conclusion is not new. In 1963, Professor Bakke, commenting on the 5 cases "of cancer found as against the 96 cases expected7 wrote: It would seem that 95% of women who would ordinarily have gotten cancer, had been saved from this disease by hormone therapy." This strongly suggests that oestrogen substitution therapy-which incidentally also provides strong protection against cardiovascular degeneration 3-constitutes a rational means of cancer prophylaxis in the postmenopausal female. "
1. 2. 3.
Wilson, R. A. J. Am. med. Ass. 1962, 182, 327. Defares, J. G. Ned. Tijdschr. Geneesk. 1966, 110, 1276. Defares, J. G. The Control of Aging and its Diseases. Amsterdam,
4.
Gordon, G. S. Round table conference on the menopause and the roles of estrogens. Excerpta Medica Foundation, May, 1962. Schleyer-Saunders, E. Med. Press, 1960, 294, 337. Geist, S. H., Walter, R. I., Salmon, U. J. Am. J. Obstet. Gynec. 1941, 42, 242. Bakke, J. L. West. J. Surgery Obstet. Gynec. 1963, 71, 241. Gordon, G. S. Texas J. Med. 1961, 57, 740. West, R. A., Brevatti, R. E., Wilson, T. H. West. J. Surgery Obstet. Gynec. 1963, 71, 110.
1969.
5. 6.
carcinogenic. given in the reviews
7. 8.
Shearman, D. J. C., Finlayson, N. D. C., Arnott, S. J., Pearson, J. G. Lancet, 1970, i, 581.
9.
A critical evaluation of this claim is 1.