- Email: [email protected]
CERVICAL SYNDROME: A NEW SIGN?
788 CERVICAL CANCER SCREENING 17 editorial and
subsequent correspondence SIR,-Your Aug (Sept 14, pp 603-04) identify several shortcomings of the cytological screening programme in England and Wales, but three points, important for future planning, still need stressing. First, the most effective use of screening resources in the immediate future would almost certainly be a campaign to ensure that all unscreened women above age 35 have a smear taken. This will require careful planning to ensure that laboratories are not overloaded; assuming that resources are not increased, it will be necessary, at least temporarily, to decrease the number of repeat smears done on younger women. Second, while the need for computerised call and recall systems and for adequate follow-up of positive smears have rightly been stressed in recent discussions we also need a properly designed computer system to enable the results of the screening programme to be assessed. Preferably this should be done nationally but an alternative would be a system covering a few NHS regions. Within this population results of ’successive smears and subsequent investigations for each woman should be linked, and linkable also to cancer registration and mortality records. Detailed suggestions are made in a forthcoming IARC/UICC monograph. Monitoring of cervical cancer rates and the results of the screening programme is particularly necessary in view of the evidence that there is an increased incidence,and possibly a change in the natural history of the disease, in younger women. Third, there is general agreement that the screening programme has failed to achieve its objectives. Nevertheless it seems likely that it has not been so complete a failure as is sometimes assumed: there is good evidence that the recent increase is smaller than it would have been in the absence of screening. 1,2 Radcliffe Infirmary, Oxford OX2 6HE
the incurability of breast cancer. He does not. He accepts one flawed report as fact if it suits his argument, rejects a similarly flawed report as fact if it does not. He insists on the incurability of breast cancer but states that some tumours may never metastasise, thus negating the incurability thesis. He insists that only 30-40-year follow-up studies are worthwhile, when he knows very few exist, and he ignores Adair’s 30-year studyl with substantial survivals. He ignores the discrepancy between Bloom’s untreated series and the hundreds of similarly irregularly selected series of treated patients, showing results 3-5 times as good. His basic mistake is in accepting that cancer of the breast is a uniform type of cancer suitable for generalisations. It is not. Breast cancer is a peculiar collection of neoplasms of the widest variety of behaviour that happen to occur in the same organ. Breast cancer is notoriously unsuited to generalisations; no indicator, except node metastasis, correlates with prognosis consistently. Skrabanek would do well to consider a more realistic concept of the chance for cure for the full spectrum of breast cancer. All clinicians know that 10-20% of breast cancers are incurable despite earliest possible diagnosis and that 10-20% will never kill the patient because they never metastasise. The middle 70% or so present a hypothetical therapeutic interval which mammography enlarges to a small degree on the subclinical side. Mammography makes a small but definite contribution to survivals because enough subclinical cases have now been detected, treated, and verified histologically to confirm the existence of a group of real, long-term survivals, survivals for periods far longer than could be accounted for merely as extensions of lead time. Division of Surgical Oncology, Department of Surgery,
University of Louisville, School of Medicine,
Louisville, Kentucky 40292, USA
CONDICT MOORE
G. J. DRAPER 1 Adair F, Berg J, Joubert L, Robbins GF. Long-term followup of breast cancer patients the 30-year report Cancer 1974; 33: 1145-50
Draper GJ Trends in cervical cancer and carcinoma in situ in Great Britain. Br J Cancer 1984; 50: 367-75 Parkin DM, Nguyen-Dinh X, Day NE. The impact of screening on the incidence of cervical cancer in England and Wales. Br J Obstet Gynaecol 1985; 92: 150-57.
1. Cook GA,
2
SIR,-Reduction in mortality is now regarded as the most suitable end-point for evaluation of cervical screening programmes. Most of the deaths are in older women. By achieving a high uptake of screening in older women we can expect to achieve a larger decrease in mortality than if younger women continue to receive a disproportionate amount of screening, as described by Dr Husain (Sept 14, p 604). However, people in general value the life of a mother of young children more highly than other lives. (It is true that the earnings of such women are low, but the cost of replacing them with hired employees is considerable.) But they are valued in other than monetary terms and their value is hard to quantify. Perhaps in the belief that screening services are not sufficient to cope with demand from all age groups, grandmothers are stepping out of the queue in favour of their daughters and daughters-in-law. Possibly doctors who evaluate screening programmes might incorporate into their calculations an acknowledgement of relative values which the public instinctively assign to different lives. Department of Community Medicine, University of Sheffield, Sheffield S10 2RX
SIR,-Dr Skrabanek repeats the claim that there is no evidence of benefit from adjuvant chemotherapy in breast cancer. There is. 1-5 Skrabanek does not have to accept this evidence as valid, but he seems not to be even aware of it. L. A. PRICE
London W 1
Laboratory of Cellular ICRF Laboratories, London WC2A 3PX
Chemotherapy,
BRIDGET T. HILL
B, Redmond C, Wolmark N, Wieand HS Disease-free survival at intervals during and following completion of adjuvant chemotherapy. the NSABP experience from three breast cancer protocols. Cancer 1981, 48: 1273-80. DeVita VT. Only if you believe in magic. In Jones SE, Salmon SE, eds. Adjuvant therapy of cancer IV. Orlando: Grune & Stratton, 1984: 3-16. Peto R Review of mortality results in randomised trials in early breast cancer Lancet
1 Fisher
2
3.
1984; ii 1205 SE, Glucksberg H, Foulkes M. Adjuvant chemotherapy for operable breast
4. Rivkin
with positive axillary nodes: a comparison of CMFVP versus L-Pam (Southwest Oncology Group Study). In: Jones SE, Salmon SE, eds Adjuvant therapy of cancer IV. Orlando Grune & Stratton, 1984 209-15. Bonadonna G, Valagussa P, Rossi A, et al. Ten-year experience with CMF-based adjuvant chemotherapy in resectable breast cancer. Breast Cancer Res Treat 1981, 5: cancer
5
95-115
CERVICAL SYNDROME: A NEW SIGN? HILARY PAGE
SIR,-Has anyone else noticed a small, discrete, claret-coloured on the skin of some patients with the chronic cervical syndrome? The stain is usually 4-5 cm long and 2 cm wide with the long axis in line with the cervical spine and the equator of the stain oval stain
BREAST CANCER SCREENING AND TREATMENT
SiR,—Dr Skrabanek’s paper in your Aug 10 issue is the latest in a long line of armchair scientists’ sermons to clinicians, chiding them for illogical attitudes and unreal beliefs about breast cancer and playing watchdog over their professional souls. One might charitably respond that such exercises are periodically healthy for all of us, if Skrabanek had a realistic and consistent concept of the nature of biological processes or if he had used some consistent selectivity in choosing what he considers fact in the argument for
the hairline. Over the past eight years I have become more aware of this sign, which fades as treatment renders the patient pain-free. The sign is seen in patients who have had neck-and-shoulder pain for at least 6 months and will be seen in any age-group. The latest instance was in a woman in her mid-twenties. I have never seen comparable staining associated with chronic lumbar pain. on
Medical Rehabilitation Unit, Uddingston, Glasgow G71 7NE
JOHN SIMPSON
subsequent correspondence SIR,-Your Aug (Sept 14, pp 603-04) identify several shortcomings of the cytological screening programme in England and Wales, but three points, important for future planning, still need stressing. First, the most effective use of screening resources in the immediate future would almost certainly be a campaign to ensure that all unscreened women above age 35 have a smear taken. This will require careful planning to ensure that laboratories are not overloaded; assuming that resources are not increased, it will be necessary, at least temporarily, to decrease the number of repeat smears done on younger women. Second, while the need for computerised call and recall systems and for adequate follow-up of positive smears have rightly been stressed in recent discussions we also need a properly designed computer system to enable the results of the screening programme to be assessed. Preferably this should be done nationally but an alternative would be a system covering a few NHS regions. Within this population results of ’successive smears and subsequent investigations for each woman should be linked, and linkable also to cancer registration and mortality records. Detailed suggestions are made in a forthcoming IARC/UICC monograph. Monitoring of cervical cancer rates and the results of the screening programme is particularly necessary in view of the evidence that there is an increased incidence,and possibly a change in the natural history of the disease, in younger women. Third, there is general agreement that the screening programme has failed to achieve its objectives. Nevertheless it seems likely that it has not been so complete a failure as is sometimes assumed: there is good evidence that the recent increase is smaller than it would have been in the absence of screening. 1,2 Radcliffe Infirmary, Oxford OX2 6HE
the incurability of breast cancer. He does not. He accepts one flawed report as fact if it suits his argument, rejects a similarly flawed report as fact if it does not. He insists on the incurability of breast cancer but states that some tumours may never metastasise, thus negating the incurability thesis. He insists that only 30-40-year follow-up studies are worthwhile, when he knows very few exist, and he ignores Adair’s 30-year studyl with substantial survivals. He ignores the discrepancy between Bloom’s untreated series and the hundreds of similarly irregularly selected series of treated patients, showing results 3-5 times as good. His basic mistake is in accepting that cancer of the breast is a uniform type of cancer suitable for generalisations. It is not. Breast cancer is a peculiar collection of neoplasms of the widest variety of behaviour that happen to occur in the same organ. Breast cancer is notoriously unsuited to generalisations; no indicator, except node metastasis, correlates with prognosis consistently. Skrabanek would do well to consider a more realistic concept of the chance for cure for the full spectrum of breast cancer. All clinicians know that 10-20% of breast cancers are incurable despite earliest possible diagnosis and that 10-20% will never kill the patient because they never metastasise. The middle 70% or so present a hypothetical therapeutic interval which mammography enlarges to a small degree on the subclinical side. Mammography makes a small but definite contribution to survivals because enough subclinical cases have now been detected, treated, and verified histologically to confirm the existence of a group of real, long-term survivals, survivals for periods far longer than could be accounted for merely as extensions of lead time. Division of Surgical Oncology, Department of Surgery,
University of Louisville, School of Medicine,
Louisville, Kentucky 40292, USA
CONDICT MOORE
G. J. DRAPER 1 Adair F, Berg J, Joubert L, Robbins GF. Long-term followup of breast cancer patients the 30-year report Cancer 1974; 33: 1145-50
Draper GJ Trends in cervical cancer and carcinoma in situ in Great Britain. Br J Cancer 1984; 50: 367-75 Parkin DM, Nguyen-Dinh X, Day NE. The impact of screening on the incidence of cervical cancer in England and Wales. Br J Obstet Gynaecol 1985; 92: 150-57.
1. Cook GA,
2
SIR,-Reduction in mortality is now regarded as the most suitable end-point for evaluation of cervical screening programmes. Most of the deaths are in older women. By achieving a high uptake of screening in older women we can expect to achieve a larger decrease in mortality than if younger women continue to receive a disproportionate amount of screening, as described by Dr Husain (Sept 14, p 604). However, people in general value the life of a mother of young children more highly than other lives. (It is true that the earnings of such women are low, but the cost of replacing them with hired employees is considerable.) But they are valued in other than monetary terms and their value is hard to quantify. Perhaps in the belief that screening services are not sufficient to cope with demand from all age groups, grandmothers are stepping out of the queue in favour of their daughters and daughters-in-law. Possibly doctors who evaluate screening programmes might incorporate into their calculations an acknowledgement of relative values which the public instinctively assign to different lives. Department of Community Medicine, University of Sheffield, Sheffield S10 2RX
SIR,-Dr Skrabanek repeats the claim that there is no evidence of benefit from adjuvant chemotherapy in breast cancer. There is. 1-5 Skrabanek does not have to accept this evidence as valid, but he seems not to be even aware of it. L. A. PRICE
London W 1
Laboratory of Cellular ICRF Laboratories, London WC2A 3PX
Chemotherapy,
BRIDGET T. HILL
B, Redmond C, Wolmark N, Wieand HS Disease-free survival at intervals during and following completion of adjuvant chemotherapy. the NSABP experience from three breast cancer protocols. Cancer 1981, 48: 1273-80. DeVita VT. Only if you believe in magic. In Jones SE, Salmon SE, eds. Adjuvant therapy of cancer IV. Orlando: Grune & Stratton, 1984: 3-16. Peto R Review of mortality results in randomised trials in early breast cancer Lancet
1 Fisher
2
3.
1984; ii 1205 SE, Glucksberg H, Foulkes M. Adjuvant chemotherapy for operable breast
4. Rivkin
with positive axillary nodes: a comparison of CMFVP versus L-Pam (Southwest Oncology Group Study). In: Jones SE, Salmon SE, eds Adjuvant therapy of cancer IV. Orlando Grune & Stratton, 1984 209-15. Bonadonna G, Valagussa P, Rossi A, et al. Ten-year experience with CMF-based adjuvant chemotherapy in resectable breast cancer. Breast Cancer Res Treat 1981, 5: cancer
5
95-115
CERVICAL SYNDROME: A NEW SIGN? HILARY PAGE
SIR,-Has anyone else noticed a small, discrete, claret-coloured on the skin of some patients with the chronic cervical syndrome? The stain is usually 4-5 cm long and 2 cm wide with the long axis in line with the cervical spine and the equator of the stain oval stain
BREAST CANCER SCREENING AND TREATMENT
SiR,—Dr Skrabanek’s paper in your Aug 10 issue is the latest in a long line of armchair scientists’ sermons to clinicians, chiding them for illogical attitudes and unreal beliefs about breast cancer and playing watchdog over their professional souls. One might charitably respond that such exercises are periodically healthy for all of us, if Skrabanek had a realistic and consistent concept of the nature of biological processes or if he had used some consistent selectivity in choosing what he considers fact in the argument for
the hairline. Over the past eight years I have become more aware of this sign, which fades as treatment renders the patient pain-free. The sign is seen in patients who have had neck-and-shoulder pain for at least 6 months and will be seen in any age-group. The latest instance was in a woman in her mid-twenties. I have never seen comparable staining associated with chronic lumbar pain. on
Medical Rehabilitation Unit, Uddingston, Glasgow G71 7NE
JOHN SIMPSON