- Email: [email protected]
Hand transplantation follow-up
CORRESPONDENCE
4
5
Noji EK, ed. The public health consequences of disasters. New York: Oxford University Press, 1997: 7–9. Adams V. Doctors for democracy: health professionals in the Nepal revolution. Cambridge: Cambridge University Press, 1998: 3–4.
Hand transplantation follow-up Sir—Our continuing observations of the hand transplant, done Jan 25, 1999, in Louisville, Kentucky, has now reached 2·5 years. After three, early, grade I rejection episodes that were readily controlled, our patient has had no rejection episode for 25 months, while taking immunosuppressive agents and doses identical to those for kidney transplantation. The patient had functional return of high quality, equivalent to the best seen in replantation patients and far better than the function he had had with his prosthesis. He and his family express great satisfaction with the positive impact that hand transplantation has had on his quality of life. We would not support widespread, unmonitored application of this procedure based on our one, favourable experience, or even on a small number of similar outcomes. For the same reason, we would not agree to abandonment of human assessment and return of the procedure to the animal laboratory based on the unfavourable outcome of the first case from Lyon, France, as one team has suggested.1 We advocate continuing to carefully monitor a human series to accumulate sufficient information that allows making a valid assessment scientifically, rather than making judgments from an inadequate number of possibly unrepresentative experiences. Lessons we learned from the hand transplantation experience are the importance of careful preoperative screening and thorough education of patients, including fully informed consent. Careful adherence to these principles resulted in our recipient anticipating and exhibiting exceptional discipline and diligence in his postoperative medication and physical therapy. While we do not judge it appropriate to call a hasty end to an endeavour with such great potential, based on the single, unfavourable Lyon experience, we fully agree that the outcome of hand transplants should be critically assessed on a
1018
continuing basis, and that the risk-tobenefit balance be carefully weighed in each case. *Gordon R Tobin, Darla K Granger, Warren C Breidenbach Divisions of *Plastic, Hand, and Transplantation Surgery, University of Louisville, Louisville, KY 40292, USA 1
Hettiaratchy S, Butler PE, Lee WPA. Lessons from hand transplantations. Lancet 2001; 357: 494–95.
Screening recommendation for women taking tamoxifen Sir—In April, 2001, the Japan Society of Obstetrics and Gynaecology published surveillance recommendations for women taking tamoxifen in their official journal.1 They recommend that women with breast cancer who take tamoxifen should be screened by transvaginal sonography every 6–12 months. When this report was aired in the newspapers in May, 2001, breast cancer physicians’ offices were crowded with tamoxifentreated patients asking for information. Women with breast cancer who take tamoxifen on a long-term basis are at increased risk of developing endometrial cancer. According to the randomised, placebo-controlled National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) breast cancer prevention trial,2 the increased annual risk of developing an endometrial cancer is around two in 1000. Despite the low incidence of endometrial cancer, patients are concerned about developing this disease. Gynaecological surveillance of patients receiving tamoxifen remains an area of concern for practising clinicians. Some researchers advocate routine transvaginal sonography as a useful tool for endometrial screening in symptom-free women who are being treated with tamoxifen. This recommendation for Japanese women is based solely on NSABP-P1. To date, there are few retrospective studies about the risk of endometrial cancer and tamoxifen use for Japanese women. The result of the largest one is negative.3 What is most important is that that report does not discuss adverse effects of screening. A well known difficulty of transvaginal sonography in tamoxifen-treated patients is the high rate of falsepositive findings and an associated increase in invasive procedures, which are mostly not indicated. Two studies
published last year confirm unequivocally that routine screening using transvaginal sonography or biopsy techniques is unnecessary.4,5 The goal of any cancer screening is to detect disease at a preinvasive or early stage to reduce mortality. To date, there is still no evidence that any form of screening for endometrial cancer in tamoxifen-treated patients will accomplish these goals. Women receiving tamoxifen should be informed about the risk and told to contact their gynaecologists immediately in case of bleeding. The Japan Society of Obstetrics and Gynaecology should also revise their screening recommendation. *Hidetaka Kawabata, Takafumi Ueno Department of Surgery, J R Tokyo General Hospital, Tokyo l5l-0053, Japan (e-mail: [email protected]) 1
2
3
4
5
Report of the Oncologic Committee (in Japanese). Nippon Sanfujinnka Gakkaisi 2001; 53: 788–800. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst 1998; 90: 1371–88. Katase K, Sugiyama Y, Hasumi K, et al. The incidence of subsequent endometrial carcinoma with tamoxifen use in patients with primary breast cancer. Cancer 1998; 82: 1698–703. Barakat RR, Gilewski TA, Almadrones L, et al. Meet of adjuvant tamoxifen on the endometrium in women with breast cancer: a prospective study using office endometrial biopsy J Clin Oncol 2000; 18: 3459–63. Gerber B, Krause A, Müller H, et al. Effects of adjuvant tamoxifen on the endometrium in postmenopausal women with breast cancer: a prospective long-term study using transvaginal ultrasound J Clin Oncol 2000; 18: 3464–70.
DEPARTMENT OF ERROR Glucosamine sulphate and osteoarthritis—In this Correspondence letter by Jean Yves Reginster and colleagues (May 19, p 1618), the second sentence of the third paragraph should have read: “Nevertheless we can confirm that, although this effect was beyond the goals of our study, the effect on symptoms developed early”. Thyroid function tests—In this Correspondence letter by P B S Fowler (June 23, p 2057), the penultimate sentence of the third paragraph should have read: “Serum thyrotropin concentration, if raised, confirms that the thyroxine replacement dose is inadequate but a suppressed concentration does not necessarily show that the dose is too high”. Serious adverse events associated with yellow fever 17DD vaccine in Brazil: a report of two cases—In this Article by Pedro F C Vasconcelos and colleagues (July 14, p 91), the 13th author’s name should have been “Priscila M O Papaiordanou”.
THE LANCET • Vol 358 • September 22, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
4
5
Noji EK, ed. The public health consequences of disasters. New York: Oxford University Press, 1997: 7–9. Adams V. Doctors for democracy: health professionals in the Nepal revolution. Cambridge: Cambridge University Press, 1998: 3–4.
Hand transplantation follow-up Sir—Our continuing observations of the hand transplant, done Jan 25, 1999, in Louisville, Kentucky, has now reached 2·5 years. After three, early, grade I rejection episodes that were readily controlled, our patient has had no rejection episode for 25 months, while taking immunosuppressive agents and doses identical to those for kidney transplantation. The patient had functional return of high quality, equivalent to the best seen in replantation patients and far better than the function he had had with his prosthesis. He and his family express great satisfaction with the positive impact that hand transplantation has had on his quality of life. We would not support widespread, unmonitored application of this procedure based on our one, favourable experience, or even on a small number of similar outcomes. For the same reason, we would not agree to abandonment of human assessment and return of the procedure to the animal laboratory based on the unfavourable outcome of the first case from Lyon, France, as one team has suggested.1 We advocate continuing to carefully monitor a human series to accumulate sufficient information that allows making a valid assessment scientifically, rather than making judgments from an inadequate number of possibly unrepresentative experiences. Lessons we learned from the hand transplantation experience are the importance of careful preoperative screening and thorough education of patients, including fully informed consent. Careful adherence to these principles resulted in our recipient anticipating and exhibiting exceptional discipline and diligence in his postoperative medication and physical therapy. While we do not judge it appropriate to call a hasty end to an endeavour with such great potential, based on the single, unfavourable Lyon experience, we fully agree that the outcome of hand transplants should be critically assessed on a
1018
continuing basis, and that the risk-tobenefit balance be carefully weighed in each case. *Gordon R Tobin, Darla K Granger, Warren C Breidenbach Divisions of *Plastic, Hand, and Transplantation Surgery, University of Louisville, Louisville, KY 40292, USA 1
Hettiaratchy S, Butler PE, Lee WPA. Lessons from hand transplantations. Lancet 2001; 357: 494–95.
Screening recommendation for women taking tamoxifen Sir—In April, 2001, the Japan Society of Obstetrics and Gynaecology published surveillance recommendations for women taking tamoxifen in their official journal.1 They recommend that women with breast cancer who take tamoxifen should be screened by transvaginal sonography every 6–12 months. When this report was aired in the newspapers in May, 2001, breast cancer physicians’ offices were crowded with tamoxifentreated patients asking for information. Women with breast cancer who take tamoxifen on a long-term basis are at increased risk of developing endometrial cancer. According to the randomised, placebo-controlled National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) breast cancer prevention trial,2 the increased annual risk of developing an endometrial cancer is around two in 1000. Despite the low incidence of endometrial cancer, patients are concerned about developing this disease. Gynaecological surveillance of patients receiving tamoxifen remains an area of concern for practising clinicians. Some researchers advocate routine transvaginal sonography as a useful tool for endometrial screening in symptom-free women who are being treated with tamoxifen. This recommendation for Japanese women is based solely on NSABP-P1. To date, there are few retrospective studies about the risk of endometrial cancer and tamoxifen use for Japanese women. The result of the largest one is negative.3 What is most important is that that report does not discuss adverse effects of screening. A well known difficulty of transvaginal sonography in tamoxifen-treated patients is the high rate of falsepositive findings and an associated increase in invasive procedures, which are mostly not indicated. Two studies
published last year confirm unequivocally that routine screening using transvaginal sonography or biopsy techniques is unnecessary.4,5 The goal of any cancer screening is to detect disease at a preinvasive or early stage to reduce mortality. To date, there is still no evidence that any form of screening for endometrial cancer in tamoxifen-treated patients will accomplish these goals. Women receiving tamoxifen should be informed about the risk and told to contact their gynaecologists immediately in case of bleeding. The Japan Society of Obstetrics and Gynaecology should also revise their screening recommendation. *Hidetaka Kawabata, Takafumi Ueno Department of Surgery, J R Tokyo General Hospital, Tokyo l5l-0053, Japan (e-mail: [email protected]) 1
2
3
4
5
Report of the Oncologic Committee (in Japanese). Nippon Sanfujinnka Gakkaisi 2001; 53: 788–800. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst 1998; 90: 1371–88. Katase K, Sugiyama Y, Hasumi K, et al. The incidence of subsequent endometrial carcinoma with tamoxifen use in patients with primary breast cancer. Cancer 1998; 82: 1698–703. Barakat RR, Gilewski TA, Almadrones L, et al. Meet of adjuvant tamoxifen on the endometrium in women with breast cancer: a prospective study using office endometrial biopsy J Clin Oncol 2000; 18: 3459–63. Gerber B, Krause A, Müller H, et al. Effects of adjuvant tamoxifen on the endometrium in postmenopausal women with breast cancer: a prospective long-term study using transvaginal ultrasound J Clin Oncol 2000; 18: 3464–70.
DEPARTMENT OF ERROR Glucosamine sulphate and osteoarthritis—In this Correspondence letter by Jean Yves Reginster and colleagues (May 19, p 1618), the second sentence of the third paragraph should have read: “Nevertheless we can confirm that, although this effect was beyond the goals of our study, the effect on symptoms developed early”. Thyroid function tests—In this Correspondence letter by P B S Fowler (June 23, p 2057), the penultimate sentence of the third paragraph should have read: “Serum thyrotropin concentration, if raised, confirms that the thyroxine replacement dose is inadequate but a suppressed concentration does not necessarily show that the dose is too high”. Serious adverse events associated with yellow fever 17DD vaccine in Brazil: a report of two cases—In this Article by Pedro F C Vasconcelos and colleagues (July 14, p 91), the 13th author’s name should have been “Priscila M O Papaiordanou”.
THE LANCET • Vol 358 • September 22, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.