- Email: [email protected]
Diet and cancer
678
your views that "limitations of the MEDLINE database
those countries that will have to bear the greatest burden of this disease". Through the Spanish AIDS Society (Sociedad Espanola Interdisciplinaria del SIDA) whose objectives are similar to those of the International AIDS Society, a monthly publication has been produced in Spanish to provide fresh information since 1990. This publication takes the form of an editorial by the director of the publication covering a specific issue, an updating review of a major topic, and eight sections: aetiopathogenic issues (viroimmunological basic research); laboratory diagnosis; clinical issues; therapeutics; epidemiology and prevention; counselling and psychologic aspects; social and ethical aspects; and planning, legislation, and economic issues. Each section records four relevant scientific papers newly published, and translated into Spanish with a comment (350-400 words) provided by an invited expert. 5000 copies of each monthly issue are distributed in Spain. In addition, 200 further copies are distributed to major Latin American Institutions under an agreement with PAHO/WHO.
RAFAEL NÁJERA, Sociedad Española Interdisciplinaria del SIDA, Apartado de Correos, 42 137 Madrid, Spain
Diet and
are
unlikely to account for the patterns of AIDS/HIV research..." and that "there is a clear need to give priority in future AID S research to
Chairman
RAFAEL DE ANDRES, Secretary
1. Elford J, Bor R, Summers P. Research into HIV and AIDS between 1981 and 1990: the epidemic curve. AIDS 1991; 5: 1515-19.
HIV transmission and the law SIR,-C. M. Tomkins of the Medical Defence Union (Aug 29, 543) contends that sections 35, 37, and 38 of the Public Health (Control of Diseases) Act 1984 apply to people with AIDS but not
p
those who are infected with HIV without symptoms. Close examination of the Public Health (Infectious Diseases) Regulations 1985 fails to bear out this claim in respect of section 35.1The 1988 Regulations reinforce the 1985 version in relation to section 35 and HIV seropositivity by specifically not omitting, in subsection (1) (a), the words "... or (ii) though not suffering from such a disease, is carrying an organism that is capable of causing it ..."2 The serotesting of people with learning disability so that those who are seropositive can benefit from prophylactic therapy is beset with difficulties about informed consent. As part of this NHS Trust’s care of its residents we have carefully sought the most reasonable solution. One such was the use of section 35 which allows a magistrate, acting on the recommendation of a registered practitioner nominated by the local authority, to order someone to be serotested " ... in his own interest, or in the interest of his family or in the public interest...". Three nominated practitioners were asked to consider the applicability of section 35 in this unique situation on the basis that identifying seropositivity would benefit the patient. Two expressed grave reservations-perhaps as a result of the notoriety that the use of an order under section 38 attracted in 1985 when a man with AIDS was compulsorily detained in hospital because he was bleeding copiously and trying to discharge himself.3 Few informed commentators doubt that more harm than good would come from extending existing legislation in such a way that a large percentage of the population then perceive themselves to be potentially at risk of compulsory serotesting, with removal to and detention in a hospital. To repeal the current inadequate statutory powers would be far better, as was suggested by the Department of Health in 1989, making maximum use of publicity campaigns to emphasise the reality that everybody’s fate lies in their own hands-that there is no alternative to personal responsibility.
cancer
SIR,-Professor Modan (July 18, p 162) succeeds in pointing out the difficulties for scientists to integrate epidemiological studies, animal experiments, national trends, and biochemical analyses into a coherent recommendation for a healthier, cancer-inhibiting
lifestyle. Modan urges us to expect more benefit from behavioural changes
(tobacco and alcohol misuse), enforcement of anti-pollution legislation, safer insecticides, fewer polychlorinated biphenyls and mercury contaminated fish, less cadmium rich green leafy vegetables, and so on. By contrast, readers need to examine the growing evidence for dietary prevention of colon cancer, stomach and oesophageal cancer, and postmenopausal breast cancer cited by Greenwald1 and Hirayama’s data2 on the effects of salt reduction, refrigeration, and increased vegetable carotenes on the striking decline of gastric cancer in Japan. Dietary carcinogenesis and anticarcinogenesis, as well as pollution carcinogenesis, need to be based on the most appropriate dose-response data for man that are available, irrespective of the long incubation period and multistage aetiology of most cancers that make investigation so difficult. Modan’s thesis would be
more
credible if it
were not cast
in
an
either/or framework (diet versus environmental protection). We can benefit from both
approaches in
a common cause-to
reduce
preventable cancers. Department of Family Medicine, Medical University of South Carolina, Charlston, South Carolina 29425-2217, USA 1. Greenwald P.
Keynote address:
cancer
STAN SCHUMAN DAN LACKLAND
prevention. J Natl Cancer Inst Monogr 1992;
12: 37-43. 2. Hirayama T. Lifestyle and cancer: from epidemiological evidence to public behavior change to mortality reduction of target cancers J Natl Cancer Inst Monogr 1992; 12: 37-43.
to
Leavesden, Horizon NHS Trust. Abbots Langley, Herts WD5 0NU, UK
PETER HALL
(Infectious Diseases) Regulations 1985. London: HM Stationery (SI 1985 no 434)). 2. The Public Health (Infectious Diseases) Regulations 1988. London: HM Stationery Office, 1988 (SI 1988 no 1546). 3. Dyer C. Detaining patients with AIDS. BMJ 1985, 29: 1102-03 1. The Public Health
Office,
1985
High
versus
low dose ovarian
cisplatin
in
epithelial
cancer
SIR,-Professor Kaye and colleagues (Aug 8, p 329) report a randomised study of two doses of cisplatin (50 and 100 mg(m2). Although their results may exaggerate the treatment effect due to the early closure of the trial, when considered together with those of other trials, we believe that they provide a persuasive argument for investigating further the relation between total dose and treatment effect. The results of the advanced ovarian cancer overview’ along with those of the CAP/CP overview (cyclophosphamide+ doxorubicin+cisplatin vs cyclophosphamide + cisplatin)2 led the members of the Advanced Ovarian Cancer Trialists Group to suggest that, when cisplatin is used at 50-60 mg/m2, platinum in combination is probably better than platinum as a single agent in the treatment of advanced disease (when used at the same dose in the two arms), and that CAP is possibly the better of the combinations available. It is, however, unclear whether the improvement in long-term survival with combination platinum-based therapy is attributable to the use of other cytotoxics (for example, doxorubicin and cyclophosphamide) or to the higher total dose of cytotoxic drugs in the combination arm. As Kaye et al point out, a price is paid in terms of toxicity for the observed improvement in survival, both by patients receiving high-dose cisplatin and those receiving CAP. To explore the issue of toxicity further, we reviewed the reports of the randomised studies that have compared CAP and CP.1 Three of the four studies identified reported results on toxicity3-6 (table). Although the comparison of factors such as toxicity is valid within an individual trial, difficulty in achieving heterogeneity should always discourage reviewers from comparing results across trials. Such comparisons can be useful, however, when trying to obtain an overall impression of relative differences. Both haematological and non-haematological toxicity did not differ significantly between the arms of any of the trials in which they were reported. The Gruppo Interregionale Cooperativo Oncologico Ginelogicia4 trialists reported an increase in haematological toxicity for patients on CAP; however, this trial did not adjust the dose of cyclophosphamide in CP to balance for the addition of doxorubicin to CAP. The
your views that "limitations of the MEDLINE database
those countries that will have to bear the greatest burden of this disease". Through the Spanish AIDS Society (Sociedad Espanola Interdisciplinaria del SIDA) whose objectives are similar to those of the International AIDS Society, a monthly publication has been produced in Spanish to provide fresh information since 1990. This publication takes the form of an editorial by the director of the publication covering a specific issue, an updating review of a major topic, and eight sections: aetiopathogenic issues (viroimmunological basic research); laboratory diagnosis; clinical issues; therapeutics; epidemiology and prevention; counselling and psychologic aspects; social and ethical aspects; and planning, legislation, and economic issues. Each section records four relevant scientific papers newly published, and translated into Spanish with a comment (350-400 words) provided by an invited expert. 5000 copies of each monthly issue are distributed in Spain. In addition, 200 further copies are distributed to major Latin American Institutions under an agreement with PAHO/WHO.
RAFAEL NÁJERA, Sociedad Española Interdisciplinaria del SIDA, Apartado de Correos, 42 137 Madrid, Spain
Diet and
are
unlikely to account for the patterns of AIDS/HIV research..." and that "there is a clear need to give priority in future AID S research to
Chairman
RAFAEL DE ANDRES, Secretary
1. Elford J, Bor R, Summers P. Research into HIV and AIDS between 1981 and 1990: the epidemic curve. AIDS 1991; 5: 1515-19.
HIV transmission and the law SIR,-C. M. Tomkins of the Medical Defence Union (Aug 29, 543) contends that sections 35, 37, and 38 of the Public Health (Control of Diseases) Act 1984 apply to people with AIDS but not
p
those who are infected with HIV without symptoms. Close examination of the Public Health (Infectious Diseases) Regulations 1985 fails to bear out this claim in respect of section 35.1The 1988 Regulations reinforce the 1985 version in relation to section 35 and HIV seropositivity by specifically not omitting, in subsection (1) (a), the words "... or (ii) though not suffering from such a disease, is carrying an organism that is capable of causing it ..."2 The serotesting of people with learning disability so that those who are seropositive can benefit from prophylactic therapy is beset with difficulties about informed consent. As part of this NHS Trust’s care of its residents we have carefully sought the most reasonable solution. One such was the use of section 35 which allows a magistrate, acting on the recommendation of a registered practitioner nominated by the local authority, to order someone to be serotested " ... in his own interest, or in the interest of his family or in the public interest...". Three nominated practitioners were asked to consider the applicability of section 35 in this unique situation on the basis that identifying seropositivity would benefit the patient. Two expressed grave reservations-perhaps as a result of the notoriety that the use of an order under section 38 attracted in 1985 when a man with AIDS was compulsorily detained in hospital because he was bleeding copiously and trying to discharge himself.3 Few informed commentators doubt that more harm than good would come from extending existing legislation in such a way that a large percentage of the population then perceive themselves to be potentially at risk of compulsory serotesting, with removal to and detention in a hospital. To repeal the current inadequate statutory powers would be far better, as was suggested by the Department of Health in 1989, making maximum use of publicity campaigns to emphasise the reality that everybody’s fate lies in their own hands-that there is no alternative to personal responsibility.
cancer
SIR,-Professor Modan (July 18, p 162) succeeds in pointing out the difficulties for scientists to integrate epidemiological studies, animal experiments, national trends, and biochemical analyses into a coherent recommendation for a healthier, cancer-inhibiting
lifestyle. Modan urges us to expect more benefit from behavioural changes
(tobacco and alcohol misuse), enforcement of anti-pollution legislation, safer insecticides, fewer polychlorinated biphenyls and mercury contaminated fish, less cadmium rich green leafy vegetables, and so on. By contrast, readers need to examine the growing evidence for dietary prevention of colon cancer, stomach and oesophageal cancer, and postmenopausal breast cancer cited by Greenwald1 and Hirayama’s data2 on the effects of salt reduction, refrigeration, and increased vegetable carotenes on the striking decline of gastric cancer in Japan. Dietary carcinogenesis and anticarcinogenesis, as well as pollution carcinogenesis, need to be based on the most appropriate dose-response data for man that are available, irrespective of the long incubation period and multistage aetiology of most cancers that make investigation so difficult. Modan’s thesis would be
more
credible if it
were not cast
in
an
either/or framework (diet versus environmental protection). We can benefit from both
approaches in
a common cause-to
reduce
preventable cancers. Department of Family Medicine, Medical University of South Carolina, Charlston, South Carolina 29425-2217, USA 1. Greenwald P.
Keynote address:
cancer
STAN SCHUMAN DAN LACKLAND
prevention. J Natl Cancer Inst Monogr 1992;
12: 37-43. 2. Hirayama T. Lifestyle and cancer: from epidemiological evidence to public behavior change to mortality reduction of target cancers J Natl Cancer Inst Monogr 1992; 12: 37-43.
to
Leavesden, Horizon NHS Trust. Abbots Langley, Herts WD5 0NU, UK
PETER HALL
(Infectious Diseases) Regulations 1985. London: HM Stationery (SI 1985 no 434)). 2. The Public Health (Infectious Diseases) Regulations 1988. London: HM Stationery Office, 1988 (SI 1988 no 1546). 3. Dyer C. Detaining patients with AIDS. BMJ 1985, 29: 1102-03 1. The Public Health
Office,
1985
High
versus
low dose ovarian
cisplatin
in
epithelial
cancer
SIR,-Professor Kaye and colleagues (Aug 8, p 329) report a randomised study of two doses of cisplatin (50 and 100 mg(m2). Although their results may exaggerate the treatment effect due to the early closure of the trial, when considered together with those of other trials, we believe that they provide a persuasive argument for investigating further the relation between total dose and treatment effect. The results of the advanced ovarian cancer overview’ along with those of the CAP/CP overview (cyclophosphamide+ doxorubicin+cisplatin vs cyclophosphamide + cisplatin)2 led the members of the Advanced Ovarian Cancer Trialists Group to suggest that, when cisplatin is used at 50-60 mg/m2, platinum in combination is probably better than platinum as a single agent in the treatment of advanced disease (when used at the same dose in the two arms), and that CAP is possibly the better of the combinations available. It is, however, unclear whether the improvement in long-term survival with combination platinum-based therapy is attributable to the use of other cytotoxics (for example, doxorubicin and cyclophosphamide) or to the higher total dose of cytotoxic drugs in the combination arm. As Kaye et al point out, a price is paid in terms of toxicity for the observed improvement in survival, both by patients receiving high-dose cisplatin and those receiving CAP. To explore the issue of toxicity further, we reviewed the reports of the randomised studies that have compared CAP and CP.1 Three of the four studies identified reported results on toxicity3-6 (table). Although the comparison of factors such as toxicity is valid within an individual trial, difficulty in achieving heterogeneity should always discourage reviewers from comparing results across trials. Such comparisons can be useful, however, when trying to obtain an overall impression of relative differences. Both haematological and non-haematological toxicity did not differ significantly between the arms of any of the trials in which they were reported. The Gruppo Interregionale Cooperativo Oncologico Ginelogicia4 trialists reported an increase in haematological toxicity for patients on CAP; however, this trial did not adjust the dose of cyclophosphamide in CP to balance for the addition of doxorubicin to CAP. The