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BOWEL TRANSIT, STOOL WEIGHT, AND DIVERTICULAR DISEASE
564
samples for aromatic
amines would
help to elucidate this prob-
lem. Division of Occupational Health and Toxicology and Division of Environmental Carcinogenesis, American Health Foundation, New York, N.Y. 10019, U.S.A.
JEANNE MAGER STELLMAN DIETRICH HOFFMANN
BOWEL TRANSIT, STOOL WEIGHT, AND DIVERTICULAR DISEASE
SIR,-It will be unfortunate if the differing experiences of Dr Manousos and his colleagues (Aug. 13, p. 360) and Dr Glober’s group (July 16, p. 110), when studying the effect of stool weight on bowel transit, are allowed to confuse us about the importance of roughage addition in diverticulitis. I am sure that many clinicians, like myself, have found that although addition of bran may have a salutary effect on diverticulitis, its effect on the bowel function is very variable. There is an unfortunate belief that the addition of bran to the diet will cure constipation. Obviously, other factors may be at work; for example, the amount of exercise taken by those living in towns is probably very different from that taken by their country cousins. Dietary constituents other than fibre can also influence bowel habit, as anyone who has observed the effect of a large meat intake in the diet of a dog will readily understand. I believe that we should be investigating other factors which may be important in bowel function. General Hospital, Steelhouse Lane, Birmingham B4 6NH
SIR,-The authors of the
Fisher, B. New Engl. J. Med. 1975, 292, 117. Bonnadonna, G. ibid. 1976, 294, 405. 3. Pun, H. C., Campbell, R. A. Lancet, 1977, i, 1306. 4. Rose, D. P., Davis, T. E. ibid. p. 1174.
University Department of Surgery, Welsh National School of Medicine, Cardiff CF4 4XN
GEORGE T. WATTS
M. BAUM
ALPHA-1-ANTITRYPSIN AND RHEUMATOID ARTHRITIS
SIR,-We Wollheim
were
surprised
to
read that Dr
Sjoblom and Dr
(July 2, p. 41) often found relatively low
serum
concentrations in patients with active rheumatoid arthritis (R.A.). This is not our experience. In 44 patients with R.A. in whom we have been studying changes in
alpha-1-antitrypsin
acute-phase protein profiles,
paper on multimodal therapy for stage-n breast cancer (Aug. 20, p. 396) suggest that, as a result of their preliminary findings, allocation of patients to a control untreated group is no longer justifiable. This conclusion seems premature. There is little doubt, from this trial and two othersthat adjuvant chemotherapy for nodepositive carcinoma of the breast reduces the incidence of recurrent disease up to the first three years of observation. However, there is no evidence that these drugs improve the mortalityrate. It may yet turn out that delayed chemotherapy reserved for the appearance of overt distant metastases will achieve the same end result, with prophylactic chemotherapy merely delaying the appearance of the distant disease rather than abolishing it altogether. Some 25% of these women can expect 10 years of recurrence-free life so the potential harm to this subgroup must be balanced against the potential benefit to the majority. The hazards of combination chemotherapy in relation to bone-marrow suppression are well recognised but it should not be forgotten that these are immunosuppressive agents, and the long-term sequelae of chronic immunosuppression are still not known. Attention should also be drawn to a review3 of 64 patients who had been on long-term cyclophosphamide who subsequently had new malignancies after a mean latent period of 36 months. The other thing that concerns me about the widespread and unquestioning adoption of adjuvant chemotherapy is the possibility that these drugs achieve their effect in delaying the appearance of distant metastases through an endocrine pathway. Rose and Davis4 reported an important study where patients receiving adjuvant chemotherapy for stage-n breast cancers had their plasma oestrogens and adrenal and pituitary 1. 2.
therapy Group.
concentration
MULTIMODAL THERAPY FOR STAGE-II BREAST CANCER
histological
hormones monitored before and at six months on treatment. They provided convincing evidence that chemotherapy produces a chemical ovarian ablation. There are simpler and less toxic ways of achieving the same end. I do not wish to denigrate the importance of trials of chemotherapy for stage-n breast cancer, but I still feel it essential that control groups are retained and that endocrine manipulation should not be forgotten in the clamour to leap on the bandwagon of adjuvant chemotherapy. A trial to evaluate the anti-cestrogen tamoxifen (an agent virtually free of toxic side-effects) has just been launched for women with apparently early carcinoma of the breast. It would not surprise me if this simple non-toxic agent could achieve the same degree of inhibition of distant metastases as that produced by the aggressive chemotherapy regimen described by the Multicentre Breast Cancer Chemo-
mean
serum-alpha-1-antitrypsin
g/1 (range
1 -7—8-8g/1), whereas in 22 healthy young women the values ranged from 1-83 to 3.81 mean 2-68 g/1. Moreover values for alpha-1-antitrypsin was
3.97
seemed to be positively related to C-reactive protein concentration (see accompanying figure), which is an accepted index of disease activity. Serial studies2 confirmed that changes in alpha-1-antitrypsin concentrations in general reflect changes in disease activity; major variations can occur over short periods. Additionally in some patients, during rapid improvement or deterioration, C-reactive protein and alpha-1-antitrypsin
1. 2.
McConkey, B., Crockson, R. A., Crockson, Walsh, L., McConkey, B. Unpublished.
A. P.
Q. Jl Med. 1972, 41, 115.
&agr;1 A.T.(g/l) Relation between C-reactive protein (CRP) and trypsin concentrations in 44 patients with R.A.
alpha-1-anti-
samples for aromatic
amines would
help to elucidate this prob-
lem. Division of Occupational Health and Toxicology and Division of Environmental Carcinogenesis, American Health Foundation, New York, N.Y. 10019, U.S.A.
JEANNE MAGER STELLMAN DIETRICH HOFFMANN
BOWEL TRANSIT, STOOL WEIGHT, AND DIVERTICULAR DISEASE
SIR,-It will be unfortunate if the differing experiences of Dr Manousos and his colleagues (Aug. 13, p. 360) and Dr Glober’s group (July 16, p. 110), when studying the effect of stool weight on bowel transit, are allowed to confuse us about the importance of roughage addition in diverticulitis. I am sure that many clinicians, like myself, have found that although addition of bran may have a salutary effect on diverticulitis, its effect on the bowel function is very variable. There is an unfortunate belief that the addition of bran to the diet will cure constipation. Obviously, other factors may be at work; for example, the amount of exercise taken by those living in towns is probably very different from that taken by their country cousins. Dietary constituents other than fibre can also influence bowel habit, as anyone who has observed the effect of a large meat intake in the diet of a dog will readily understand. I believe that we should be investigating other factors which may be important in bowel function. General Hospital, Steelhouse Lane, Birmingham B4 6NH
SIR,-The authors of the
Fisher, B. New Engl. J. Med. 1975, 292, 117. Bonnadonna, G. ibid. 1976, 294, 405. 3. Pun, H. C., Campbell, R. A. Lancet, 1977, i, 1306. 4. Rose, D. P., Davis, T. E. ibid. p. 1174.
University Department of Surgery, Welsh National School of Medicine, Cardiff CF4 4XN
GEORGE T. WATTS
M. BAUM
ALPHA-1-ANTITRYPSIN AND RHEUMATOID ARTHRITIS
SIR,-We Wollheim
were
surprised
to
read that Dr
Sjoblom and Dr
(July 2, p. 41) often found relatively low
serum
concentrations in patients with active rheumatoid arthritis (R.A.). This is not our experience. In 44 patients with R.A. in whom we have been studying changes in
alpha-1-antitrypsin
acute-phase protein profiles,
paper on multimodal therapy for stage-n breast cancer (Aug. 20, p. 396) suggest that, as a result of their preliminary findings, allocation of patients to a control untreated group is no longer justifiable. This conclusion seems premature. There is little doubt, from this trial and two othersthat adjuvant chemotherapy for nodepositive carcinoma of the breast reduces the incidence of recurrent disease up to the first three years of observation. However, there is no evidence that these drugs improve the mortalityrate. It may yet turn out that delayed chemotherapy reserved for the appearance of overt distant metastases will achieve the same end result, with prophylactic chemotherapy merely delaying the appearance of the distant disease rather than abolishing it altogether. Some 25% of these women can expect 10 years of recurrence-free life so the potential harm to this subgroup must be balanced against the potential benefit to the majority. The hazards of combination chemotherapy in relation to bone-marrow suppression are well recognised but it should not be forgotten that these are immunosuppressive agents, and the long-term sequelae of chronic immunosuppression are still not known. Attention should also be drawn to a review3 of 64 patients who had been on long-term cyclophosphamide who subsequently had new malignancies after a mean latent period of 36 months. The other thing that concerns me about the widespread and unquestioning adoption of adjuvant chemotherapy is the possibility that these drugs achieve their effect in delaying the appearance of distant metastases through an endocrine pathway. Rose and Davis4 reported an important study where patients receiving adjuvant chemotherapy for stage-n breast cancers had their plasma oestrogens and adrenal and pituitary 1. 2.
therapy Group.
concentration
MULTIMODAL THERAPY FOR STAGE-II BREAST CANCER
histological
hormones monitored before and at six months on treatment. They provided convincing evidence that chemotherapy produces a chemical ovarian ablation. There are simpler and less toxic ways of achieving the same end. I do not wish to denigrate the importance of trials of chemotherapy for stage-n breast cancer, but I still feel it essential that control groups are retained and that endocrine manipulation should not be forgotten in the clamour to leap on the bandwagon of adjuvant chemotherapy. A trial to evaluate the anti-cestrogen tamoxifen (an agent virtually free of toxic side-effects) has just been launched for women with apparently early carcinoma of the breast. It would not surprise me if this simple non-toxic agent could achieve the same degree of inhibition of distant metastases as that produced by the aggressive chemotherapy regimen described by the Multicentre Breast Cancer Chemo-
mean
serum-alpha-1-antitrypsin
g/1 (range
1 -7—8-8g/1), whereas in 22 healthy young women the values ranged from 1-83 to 3.81 mean 2-68 g/1. Moreover values for alpha-1-antitrypsin was
3.97
seemed to be positively related to C-reactive protein concentration (see accompanying figure), which is an accepted index of disease activity. Serial studies2 confirmed that changes in alpha-1-antitrypsin concentrations in general reflect changes in disease activity; major variations can occur over short periods. Additionally in some patients, during rapid improvement or deterioration, C-reactive protein and alpha-1-antitrypsin
1. 2.
McConkey, B., Crockson, R. A., Crockson, Walsh, L., McConkey, B. Unpublished.
A. P.
Q. Jl Med. 1972, 41, 115.
&agr;1 A.T.(g/l) Relation between C-reactive protein (CRP) and trypsin concentrations in 44 patients with R.A.
alpha-1-anti-