Axillary dissection in breast cancer

Axillary dissection in breast cancer

438 Axillary dissection in breast cancer SiR,—The provocative viewpoint article by Mr Fentiman and Professor Mansel (Jan 26, p 221) has clearly pr...

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438

Axillary dissection

in breast

cancer

SiR,—The provocative viewpoint article by Mr Fentiman and Professor Mansel (Jan 26, p 221) has clearly produced an emotional impact already, triggered by newspaper, radio, and television exposure which has had a profound effect on women who have woken up to the fact that they may have been mistreated. A newspaper reporter who contacted me for my reaction to the paper assured me that a suggestion had been made that each year 10 000 women in the UK were being treated inadequately. This was two days before the article appeared. I waited with interest, therefore, to read the article itself-and found in it no mention of the 10 000 victimised women, so this must have come from a press briefing. I was pleased by the emphasis on the importance of lymph nodal information but disappointed that Fentiman and Mansel did not make it clear that for a proportion of women with breast cancer axillary dissection may be harmful or unnecessary. Those who present with advanced disease are better treated by combinations of radiation and systemic therapy rather than surgery; for women with early in-situ carcinoma Fentiman and Mansel would, I am sure, agree that extensive studies have demonstrated the unlikelihood that lymph-node removal would assist management; and there are also elderly patients for whom tamoxifen, with or without localised surgery, is often satisfactory management. I agree that lymph-node sampling lacks precision and definition. The removal of fatty tissue adjacent to the axillary tail often provides histological disappointment. However, useful information, especially in older patients, may be achieved by level I dissection of the axilla, which is an anatomically valid operation with good and guaranteed nodal yield. When this is negative, "skip lesions" are very unlikely. Your contributors, in common with many surgeons concerned with breast surgery, have taken no heed of David Patey and Richard Handley, who proved the importance of second interspace internal mammary node sampling. This is easy and effective and produces information with sometimes even more dire significance than that gained from the axilla. The need for axillary histology should not be associated with a blind spot for the anterior mediastinum. I agree that it is wrong to add radiation to lymph-node dissection since arm oedema is overwhelmingly likely. I was, however, disturbed by an apparent contradiction. Fentiman and Mansel start by saying that when dissection is carried out correctly there is a "less than 5% instance of lymphoedema". However, in their concluding paragraph they say that "arm lymphoedema is a very rare complication after axillary clearance alone". A lot of women already undergo axillary dissection, and Fentiman and Mansel demand that we should do even more. That may well provide a significant increase in the arm swelling and recurrent lymphangitis which can be a long-term penance for a substantial number of women. I hope that clinicians will continue to be permitted some degree of intelligent and considered selection of procedures in the management of women with breast cancer. Guildford Medical Centre,

Royal Surrey County Hospital, Guildford, Surrey GU2 5XX, UK

P. S. BOULTER

SIR,-Mr Fentiman and Professor Mansel present a well-argued for routine axillary dissection in the primary treatment of operable breast cancer. They are right to draw attention to the need for axillary dissection in premenopausal women to identify node-positive patients who might benefit from adjuvant chemotherapy. However, they are on less strong ground in questioning the efficacy of radiotherapy to the axilla and in suggesting that delayed treatment of the axilla may adversely influence survival. Trials comparing radical mastectomy versus simple mastectomy with radiotherapy have shown no significant

case

difference in survivall,2 and an overview of trials showed that delayed treatment to the axilla was not associated with a significant reduction in survival.’ For these reasons many surgeons will continue to treat selected postmenopausal patients with nonpalpable axillary nodes by simple mastectomy or local excision

without axillary dissection. One has in mind elderly patients or those with small or medially placed tumours where the likelihood of axillary metastasis is small. Moreover, there has been no trial to compare adequate radiotherapy to the axilla versus axillary dissection following local excision and, in the absence of such a trial, there is no reason to condemn the former. There is also controversy surrounding the treatment of small screen-detected cancers. Articles in The Lancet are liable to be quoted in the media and this is unavoidable when matters of public interest are raised. However, I was most disturbed to hear a BBC radio news broadcast in which it was clearly implied that lives were being lost because surgeons were failing to carry out axillary dissection. Fentiman was interviewed and did nothing to dispel this impression. Criticism of a professional colleague to the lay public has traditionally been regarded as unethical and it is no less objectionable when it is directed at a group rather than at an individual. Such publicity can only serve to increase anxiety and undermine the confidence of patients. It is far better that we discuss these matters through your columns. Department of Surgery, Royal Preston Hospital, Preston PR2 4HT, UK

1 Lythgoe JP, Palmer MK. Manchester regional breast study Surg 1982; 69: 693-96

J.

P. LYTHGOE

5 and 10 year results Br J

2. Cuzick

J, Stewart H, Peto R, et al Overview of randomized trials comparing radical mastectomy without radiotherapy against simple mastectomy with radiotherapy in breast cancer. Cancer Treat Rep 1987; 71: 7-14 3. Cuzick J, Stewart H, Peto R, et al. Overview of randomized trials of post-operative adjuvant radiotherapy in breast cancer. Cancer Treat Rep 1987; 71: 15-29.

** the

Mr Fentiman and Professor Mansel’s response to criticisms of publicity their paper attracted follows.-ED. L.

SIR,-We will respond later to comments by Professor Boulter, Mr Lythgoe, and many others to our arguments in favour of axillary clearance as an integral part of the treatment of early invasive breast cancer. We are criticised for the publicity attendant upon the article. Medical correspondents would have written a story about our viewpoint article with or without our cooperation. In such circumstances, it is the policy of the ICRF to provide a press release giving facts and, where necessary, explanations of matters which would be clear to the expert reader but not to the lay media. Medical correspondents are seldom medically qualified. Although they deal all the time with medical matters, they have to work across the whole of medicine and have no opportunity to gain in-depth knowledge of any particular area. In the ICRF press release we provided a conservative estimate of 3000 women being undertreated annually, a figure that the Daily Telegraph reporter who spoke to Boulter, used in that newspaper’s story. Had we not done this calculation, journalists would have attempted it themselves, with results even less pleasing to many clinicians. Lythgoe criticises us for attacking our colleagues. That is precisely what we set out to do in the article and it would be impossible to pretend otherwise in a radio interview: the interviewer had already read the article, which made our position clear. We feel that an important element of breast cancer treatment is being omitted and it is perfectly ethical to state that we believe that axillary clearance should be done, in the face of the evidence that only 16%o of surgeons doing conservation do take biopsy specimens from the axilla.1 The media see it as their role to take up issues that affect their readers. It is impossible to argue that they should not do so and it is in the interest of everyone to try to ensure that both the point of viev and the underlying facts are reported accurately. ICRF Clinical Oncology Unit, Guy’s Hospital, London SE1 9RT, UK

IAN S. FENTIMAN

of

Department Surgery, Withington Hospital, Manchester

R. E. MANSEL

1. Gazet JC, Rainsbury RM, Ford HT, Powles TJ, Coombes RC. Surgen of treatment of primary breast cancer in Great Britain Br Med J 1985; 290: 1793-95