- Email: [email protected]
Delays in diagnosis in breast cancer
CORRESPONDENCE
Delays in diagnosis in breast cancer Sir—Your correspondents on the delay in diagnosis in breast cancer (June 19, p 2154)1 address the question as to whether there was any discrepancy between the studies by Michael Richards (April 3, p 1119)2 a n d Richard Sainsbury (April 3, p 1132)3 and their colleagues and what the effect of them should be on policy in breast cancer referral. The A u d i o Journal of Oncology (1999, vol 7, no 3) carried an interview with Richards, but did not mention the work of Sainsbury and colleagues, clearly conveying a message that delay was deleterious. Neither study may be a fair comment on contemporary practice. The patients on whom both studies are based include many who were treated before the era of systemic adjuvant therapy. Treatment for these patients would be surgery and radiotherapy except for patients who presented with metastases. Adjuvant hormonal therapy with tamoxifen became common practice during the second half of Sainsbury and colleagues’ study. However, adjuvant chemotherapy, which was initially used only in the treatment of premenopausal women with lymph-node involvement, was received by only 51% of patients who were included in their study in 1991.4 The treatment studied in their patients, therefore, is not likely to delay death by affecting the onset of metastatic disease. A study of the order in which adjuvant chemotherapy and radiotherapy is received by patients 5 has indicated that patients for whom chemotherapy is delayed have a worse outcome than patients who receive chemotherapy before radiotherapy. This difference depends on the development of metastatic disease. If the difference in timing of a few weeks generates a measurable difference in outcome then we expect that delays of this magnitude or greater due to delays in presentation or in the provision of service would also have an effect on outcome. Future studies should therefore be population based, to exclude selection bias, but the study participants should all be residents of the catchment area of a service provider that functions in accordance with current practice. S M Crawford Oncology Department, Airedale General Hospital, Keighley BD20 6TD, UK 1
Benson EA; Nosarti C, et al; Patel R, Richards MA, et al; Bentzen SM, et al.
1478
2
3
4 5
Delay in diagnosis in breast cancer. Lancet 1999; 353: 2154–56. Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35. Crawford SM. Breast cancer: have we lost our way? Lancet 1993; 341: 771. Recht A, Come SE, Henderson IC, et al. The sequencing of chemotherapy and radiation therapy after conservative surgery for early-stage breast cancer. N Engl J Med 1996; 334: 1356–61.
Naff not NEAT Sir—Imagine you are a senior administrator charged with implementing a new, government-funded programme of biomedical research. How might you set about this task? First, think up a suitably catchy acronym, and if you can work in a weak pun, so much the better. A creditable example is the UK Department of Health’s NEAT (New and Emerging Applications of Technology) programme. Next, draw up a set of guidelines for applicants. Since this is a new scheme, its remit should appear to be much broader than it actually is to ensure that the scheme does not founder at the outset. Do not provide any examples of the type of applications you seek to encourage; instead include a gamut of vague descriptors such as strategic, applied, and generalisable outputs, but throw in a few meaningless caveats like not pump priming or trouble shooting (you should not seem too desperate to part with tax-payers’ money). Guidance notes should also include selection criteria. However, do not commit yourself; adopt the banal—eg, state that applications must be of good scientific quality. Make a sly attempt to curry favour with potential applicants by first inviting only outline applications of, say, three sides, but confound this request by asking for, within these constraints, details of background, proposed methodology, outcome, methods for dissemination and implementation, innovation, relevance, value, costeffectiveness, references, and biographical details of all co-applicants. Do not forget to include copious advice notes replete with patronising minutiae. As an example, the phrase—please ensure that all the pages are stapled together in the correct order—is hard to beat. Be aware that the applicant, having submitted only an outline, will be expecting a rapid decision as to his or
her progress to the next stage. Disabuse them of this reasonable assumption; an outline submitted in March can be sat upon until, say, late September, and a further nice touch here is not to inform the applicants of this arrangement until 2 months after their initial submission. With any luck, in view of the parlous state of UK academic funding, you will be inundated with applications quite in excess of the resources available, and at this stage you can draft your letter to unsuccessful applicants. Craft such letters so as to enrage the rejected. Do not refer to any specific inadequacies in their applications, but designate them as non-compliant, and attach a huge bulleted list of items (none checked) which individually may (or may not) have been the reason for rejection. Include among them a statement that the application may be more relevant to another of the organisation’s funding schemes (but check first that this scheme is now closed). Surprising to some, no doubt, this pantomime of events is not drawn from my long-term dealings with the officialdom of grant-awarding bodies. Rather, it is based solely on the experience of having sought funding from the aforesaid NEAT programme (http://www.doh.gov.uk/research/ neat.htm). I am unlikely to be alone in my opinion that this scheme has been abjectly managed. Of a total of 293 applications submitted, 90% have been rejected at the outline stage. The Department of Health needs urgently to review its procedures if NEAT (whose future, I understand, is now under review) is to be established as a recurrent source of funding. Merrick Moseley Academic Unit of Ophthalmology, Imperial College School of Medicine, Western Eye Hospital, London NW1 5YE, UK (e-mail: [email protected])
DEPARTMENT OF ERROR Venous thromboembolism among new users of different oral contraceptives—In this research letter by R M C Herings and colleagues (July 10, p 127), the incidence rates of deep-vein thrombosis among first-year users of third and second generation oral contraceptives should have been 13.1/10 000 person-years and 4.7/10 000 person-years, respectively. In the table the heading for the category "Absence of disease" should have read "Absence of chronic disease", and the "yes" values should be 17/21 291 and 1/16 426 for third and second generation contraceptives, respecively Long-term low-molecular-mass heparin in unstable coronary-artery disease—In this Article by the FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC II) Investigators (Aug 28, p 701), in table 1, leftventricular ejection fraction should have been <45%, in table 4, row four should have been headed age >65 years, and for figures 4 and 5, the figure titles should have been swapped.
THE LANCET • Vol 354 • October 23, 1999
Delays in diagnosis in breast cancer Sir—Your correspondents on the delay in diagnosis in breast cancer (June 19, p 2154)1 address the question as to whether there was any discrepancy between the studies by Michael Richards (April 3, p 1119)2 a n d Richard Sainsbury (April 3, p 1132)3 and their colleagues and what the effect of them should be on policy in breast cancer referral. The A u d i o Journal of Oncology (1999, vol 7, no 3) carried an interview with Richards, but did not mention the work of Sainsbury and colleagues, clearly conveying a message that delay was deleterious. Neither study may be a fair comment on contemporary practice. The patients on whom both studies are based include many who were treated before the era of systemic adjuvant therapy. Treatment for these patients would be surgery and radiotherapy except for patients who presented with metastases. Adjuvant hormonal therapy with tamoxifen became common practice during the second half of Sainsbury and colleagues’ study. However, adjuvant chemotherapy, which was initially used only in the treatment of premenopausal women with lymph-node involvement, was received by only 51% of patients who were included in their study in 1991.4 The treatment studied in their patients, therefore, is not likely to delay death by affecting the onset of metastatic disease. A study of the order in which adjuvant chemotherapy and radiotherapy is received by patients 5 has indicated that patients for whom chemotherapy is delayed have a worse outcome than patients who receive chemotherapy before radiotherapy. This difference depends on the development of metastatic disease. If the difference in timing of a few weeks generates a measurable difference in outcome then we expect that delays of this magnitude or greater due to delays in presentation or in the provision of service would also have an effect on outcome. Future studies should therefore be population based, to exclude selection bias, but the study participants should all be residents of the catchment area of a service provider that functions in accordance with current practice. S M Crawford Oncology Department, Airedale General Hospital, Keighley BD20 6TD, UK 1
Benson EA; Nosarti C, et al; Patel R, Richards MA, et al; Bentzen SM, et al.
1478
2
3
4 5
Delay in diagnosis in breast cancer. Lancet 1999; 353: 2154–56. Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. The influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999; 353: 1119–26. Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet 1999; 353: 1132–35. Crawford SM. Breast cancer: have we lost our way? Lancet 1993; 341: 771. Recht A, Come SE, Henderson IC, et al. The sequencing of chemotherapy and radiation therapy after conservative surgery for early-stage breast cancer. N Engl J Med 1996; 334: 1356–61.
Naff not NEAT Sir—Imagine you are a senior administrator charged with implementing a new, government-funded programme of biomedical research. How might you set about this task? First, think up a suitably catchy acronym, and if you can work in a weak pun, so much the better. A creditable example is the UK Department of Health’s NEAT (New and Emerging Applications of Technology) programme. Next, draw up a set of guidelines for applicants. Since this is a new scheme, its remit should appear to be much broader than it actually is to ensure that the scheme does not founder at the outset. Do not provide any examples of the type of applications you seek to encourage; instead include a gamut of vague descriptors such as strategic, applied, and generalisable outputs, but throw in a few meaningless caveats like not pump priming or trouble shooting (you should not seem too desperate to part with tax-payers’ money). Guidance notes should also include selection criteria. However, do not commit yourself; adopt the banal—eg, state that applications must be of good scientific quality. Make a sly attempt to curry favour with potential applicants by first inviting only outline applications of, say, three sides, but confound this request by asking for, within these constraints, details of background, proposed methodology, outcome, methods for dissemination and implementation, innovation, relevance, value, costeffectiveness, references, and biographical details of all co-applicants. Do not forget to include copious advice notes replete with patronising minutiae. As an example, the phrase—please ensure that all the pages are stapled together in the correct order—is hard to beat. Be aware that the applicant, having submitted only an outline, will be expecting a rapid decision as to his or
her progress to the next stage. Disabuse them of this reasonable assumption; an outline submitted in March can be sat upon until, say, late September, and a further nice touch here is not to inform the applicants of this arrangement until 2 months after their initial submission. With any luck, in view of the parlous state of UK academic funding, you will be inundated with applications quite in excess of the resources available, and at this stage you can draft your letter to unsuccessful applicants. Craft such letters so as to enrage the rejected. Do not refer to any specific inadequacies in their applications, but designate them as non-compliant, and attach a huge bulleted list of items (none checked) which individually may (or may not) have been the reason for rejection. Include among them a statement that the application may be more relevant to another of the organisation’s funding schemes (but check first that this scheme is now closed). Surprising to some, no doubt, this pantomime of events is not drawn from my long-term dealings with the officialdom of grant-awarding bodies. Rather, it is based solely on the experience of having sought funding from the aforesaid NEAT programme (http://www.doh.gov.uk/research/ neat.htm). I am unlikely to be alone in my opinion that this scheme has been abjectly managed. Of a total of 293 applications submitted, 90% have been rejected at the outline stage. The Department of Health needs urgently to review its procedures if NEAT (whose future, I understand, is now under review) is to be established as a recurrent source of funding. Merrick Moseley Academic Unit of Ophthalmology, Imperial College School of Medicine, Western Eye Hospital, London NW1 5YE, UK (e-mail: [email protected])
DEPARTMENT OF ERROR Venous thromboembolism among new users of different oral contraceptives—In this research letter by R M C Herings and colleagues (July 10, p 127), the incidence rates of deep-vein thrombosis among first-year users of third and second generation oral contraceptives should have been 13.1/10 000 person-years and 4.7/10 000 person-years, respectively. In the table the heading for the category "Absence of disease" should have read "Absence of chronic disease", and the "yes" values should be 17/21 291 and 1/16 426 for third and second generation contraceptives, respecively Long-term low-molecular-mass heparin in unstable coronary-artery disease—In this Article by the FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC II) Investigators (Aug 28, p 701), in table 1, leftventricular ejection fraction should have been <45%, in table 4, row four should have been headed age >65 years, and for figures 4 and 5, the figure titles should have been swapped.
THE LANCET • Vol 354 • October 23, 1999