Axillary dissection in breast cancer

Axillary dissection in breast cancer

1221 go to the charlatans. Orthodox chemotherapy ought to be preferable to quackery, and possibly less expensive; moreover, on rare ensues. This supp...

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1221

go to the charlatans. Orthodox chemotherapy ought to be preferable to quackery, and possibly less expensive; moreover, on rare ensues. This support may be defensible as an indication for chemotherapy’ if one recognises that not every patient insists on chemotherapy and provided that it is the patient rather than the family or referring physician who is demanding treatment.

occasions,

an

unexpectedly good anti-tumour effect

psychological

Division of

Hematology and Oncology,

Department of Medicine, University of Alabama in Birmingham, Birmingham, Alabama 35294, USA 1. Omura GA. Indications for

cancer

GEORGE A. OMURA

chemotherapy. N Engl J Med 1982; 307: 826.

good review of advances in treatment for cancer with chemotherapy, which offer cures or remissions to many patients. But because "no disseminated neoplasm incurable in 1975 is curable today", and because he sees no further advances in the results of recent chemotherapeutic trials, he recommends that most patients receive only "symptom management and referral to a hospice". From the point of view of a patient with a disseminated neoplasm (for nine years) I am thankful that the latter advice was not followed in my case. Various chemotherapeutic regimens were given to me at SiR,—Dr Braverman gives

a

intervals, when the disease flared up, and some of the combinations effective. I thus gained years of time so that I could raise my children and see them finish college and graduate school. Braverman’s suggested programme would probably have denied me that time, and time is very important to me and those like me. Just because a tumour is not curable does not mean that it cannot be treated to give the patient precious extra time. Those medical oncologists who work in clinical research are painstakingly adding to knowledge that offers cures to some patients and extended life to those not now able to be cured. I believe their endeavour is admirable. were

Department of Pathology, State University of New York, Health Science Center, Brooklyn, NY 11203, USA

JOANNA SHER

Axillary dissection in breast cancer SiR,—Imust profoundly disagree with Professor Blichert-Toft and colleagues (April 20, p 988), and Mr Fentiman and Professor Mansel (Jan 26, p 221) who imply that "inadequate surgery to the axilla" of breast cancer patients is prejudicial to overall survival. Data that allegedly indicate "significantly poorer survival", quoted by Blichert-Toft et al, merely support the statistical rule that the stricter the method of staging used (clinical or pathological), the better the apparent survival in each stage. The information missing from the figures for these highly selected groups is the overall survival for the entire series, which is regularly ignored by those who seek more complex methods of staging. That is a matter to which I and Michael Curwen, who was medical statistician to St Bartholomew’s Hospital, first drew attention some 35 years ago/ and again more recently.2 The table shows the effects of applying different standards of staging to the same 1000 breast cancer patients by two independent

The observer who follows the stricter method of staging (whether by excessive clinical zeal, internal mammary node biopsy, or xylol clearance with meticulous search for nodes in fully dissected axilla) will invariably claim better apparent results in all stages. The effect of such overzealous staging is to shift certain patients from a more favourable to a less favourable stage, which paradoxically improves results in all stages, while leaving overall survival for the entire series unchanged.

Fentiman and.Mansel, in a recent press release from the Imperial Cancer Research Fund, have claimed "a conservative estimate of 3000 women being undertreated annually"; this statement is totally unjustified.2 On the contrary, there seems to be a growing tendency for many women to be overtreated, with increased morbidity and little or no benefit to survival. Clinical trialists often assume that larger numbers of patients and stricter staging add statistical respectability to their work. But different methods of staging destroy the opportunity of comparing like with like. Evidence of improved overall survival can only be based on the total number of patients seen. Even then, participating centres should not exclude patients who have had either non-

surgical or no treatment. Professor Neville and colleagues (May 4, p 1110) support the International Breast Cancer Study Group’s3 preoccupation with axillary node micrometastases, but ignore the fundamental statistical principles that I have described. If these groups continue to pursue their present goals, little benefit will be achieved and harm may be done to some of their patients. Cobden Hill House, 63 Cobden Hill, Radlett WD7 7JN, UK

1.

REGINALD MURLEY

Murley RS. Carcinoma of the breast: the assessment of results. Can Med Assoc J 1956;

74: 427-32. 2. Murley RS. Axillary dissection in primary breast cancer. Br Med J 1991; 302: 590-91. 3. Bettelheim R, Pnce KN, Gelber RD, et al. International (Ludwig) Breast Cancer Study Group: prognostic importance of occult axillary lymph node micrometastases from breast cancers. Lancet 1990; 335: 1565-68.

NSAIDs, misoprostol, and gastrointestinal

bleeding SIR,-The case-report of Dr Bannwarth and colleagues (April 20, p 973) is of interest for several reasons. I concur with the implied conclusion that one should not regard a patient as being risk-free for non-steroidal anti-inflammatory drug (NSAID) gastrointestinal effects merely because the protective agent misoprostol (a prostaglandin E1 analogue) has been co-prescribed. Few drugs ever provide complete efficacy. However, to put the case into context and to clarify misoprostol’s known activity, the following comments may be helpful. One of the largest endoscopic surveys undertaken, in more than 1400 patients with osteoarthritis or rheumatoid arthritis receiving any one of twenty-six NSAIDs long term, showed that two-thirds of patients taking ketoprofen had clinically significant gastroduodenal damage. This was roughly twice the rate associated with almost every other NSAID, except for aspirin.l "Clinically significant" damage was defined as ten or more erosions, visible vessle, oozing or intraluminal blood, or a gastric or duodenal ulcer. Almost 40% of patients with severe upper abdominal discomfort had ulceration. Although this is a poor correlation, it was still three times the rate of ulceration compared with that in patients with no symptoms. Consequently, even though symptoms in a NSAIDtaking population are poor predictors of gastroduodenal damage, they do seem to warrant investigation if severe and if associated with a mucosal insult, which is likely to be especially damaging. NSAIDs have recently been reported by Levi et a12 to impair the ulcer-healing process, and misoprostol may ameloriate this situation. However, in the patient reported by Bannwarth et al, since higher doses of ketoprofen were given when backpain developed and if systemic steroids were continued, an onerous burden seems to have been put on the protecting drug. Misoprostol was used at the 400 /.1g protective dose, which is half the dose recommended for ulcer healing. Also, although it may be unresolved as to whether steroids cause damage, they undoubtedly delay wound healing and may contribute to perpetuation of mucosal damage through a similar mechanism to that reported by Levi et a1 for NSAIDs.2 Did the patient comply with her misoprostol medication? The table highlights the importance of compliance and shows that misoprostol does protect against duodenal ulceration: it provides results for a recently completed double-blind study in which patients with arthritis who were taking either diclofenac or