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RECRUITMENT TO MENTAL HANDICAP
362 RECRUITMENT TO MENTAL HANDICAP
SiR,-Dr Spencer’s letter (Feb. 2, p. 174) shows that there are not enough appropriately qualified psychiatrists to work in the field of mental handicap. There may be senior medical officers in the localauthority mental-health services with many of the attributes listed in the editorial (Feb. 2, p. 156), who could give strong support to consultants. They cannot aspire to the top posts for lack of higher qualification and recent hospital experience, but they may be happy to work in a combined community/hospital service at medical-assistant or even senior-medical-officer salary, since some of them foresee their jobs disappearing in the reorganised service.
prepared
Plymouth Nuffield Clinic, Seven Trees, Baring Street, Lipson, Plymouth PL4 8NQ.
N. R. MATHESON.
THE MENOPAUSE AND BREAST CANCER
SiR,-It is well known that the increase in breast-cancer cases with age is interrupted briefly at about the age of the menopause. Clemmesen1 suggested that the interruption resulted from
a
transient decline in
rates
associated with
physiological changes at the menopause. The observed decline is also that expected if the cause were the decrease in the size of the pre-menopausal population. This explanation implied a greater risk of breast cancer for premenopausal women than for post-menopausal women of the same age and was supported by data described below. The numbers of breast cancers, by age, in the United States around 1960 were estimated from mean registration"
for Connecticut in 1960-62 and 1963-65 New York in 1959-61,2 and California in 1960-64.3 The numbers of these breast-cancer cases who would be premenopausal or post-menopausal were estimated for 5-year age-groups from 35-39 years to 55-59 years, using ratios determinedfrom a study of breast-cancer cases in Connecticut during 1960-62. From sizes of the premenopausal and post-menopausal populations in the rates
United States5 incidence-rates were calculated and are shown in the accompanying figure together with the rates for all women. For pre-menopausal women the risk of breast cancer increased steeply with age, without a transient decline in middle life, and was higher than the rate in the general female population at the same age; at 50-54 years the premenopausal rate (1 in 400) was about double and at 55-59 years three times higher than for all women. Correspondingly, the breast-cancer risk for post-menopausal women was lower than for pre-menopausal women of the same age (see figure), agreeing entirely with the lower risk of breast cancer observed amongst women who had had a menopause induced artificially at a relatively early age.B,? Mean age at natural menopause was not 5,8consistently related to marital status, parity, social class, or stature, and did not differ appreciably between countries. It did not seem, therefore, that differences in menopausal age would contribute significantly to the well-known association of breast-cancer rates with the above demographic variables, or to international differences in the rates. Comparing estimates of mean menopausal ages derived at different times the menopause tended to be later in more recent studies. With the predicted steep increase with age of breast-cancer risk for pre-menopausal women, a later menopause would be expected to give a higher breast-cancer rate at around 50 years of age. However, MacMahon and Worcester5 considered that differences in estimates of menopausal ages could have arisen spuriously from methodological errors. Hormone therapy to delay the menopause would be predicted, by the present analysis, to give an increased risk of breast cancer during the time that the menopause was delayed. This possible increase in a risk would need to be balanced against the benefits derived from a delayed menopause. The interest of the present analysis is in the distinct time-courses of carcinogenic development implied for pre-menopausal and post-menopausal women. It is interesting to speculate that for breast tissue there are two types of potentially malignant cells, or two processes of carcinogenic development, one of which requires the physiological conditions of a pre-menopausal woman and Flax et al.° the other a post-menopausal physiology. from their studies of hormone dependence of suggested, breast cancers, that the post-menopausal state may permit the development of androgen-dependent tumours of the breast. Two classes of breast-cancer patient have been recognised in other clinical studies lo,ll and associated with menopausal status. This analysis does not preclude a dependence of the breast-cancer risk of post-menopausal patients on their pre-menopausal history; Trichopoulos et al. found that women with a late menopause had an excess risk of breast cancer in late age. University Department of Social Medicine, Foresterhill, Aberdeen.
Reaiatration-rates of breast
cancer estimated for the United States ( -1960).
GORDON HEMS.
1. Clemmesen, J. Acta path. microbiol. scand. 1965, suppl. 174. 2. Doll, R., Payne, P., Waterhouse, J. A. H. Cancer Incidence in Five Continents, U.I.C.C., Lyons, 1966. 3. Doll, R., Muir, C., Waterhouse, J. A. H. ibid. vol. II, 1970. 4. MacMahon, B. M., List, N. D., Eisenberg, M. in Prognostic Factors in Breast Cancer (edited by A. P. M. Forrest and P. B. Kunkler); p. 56. Edinburgh, 1968. 5. MacMahon, B. M., Worcester, J. Vital and Health Statistics, U.S., 1966, Series 11, no. 19. 6. Feinleib, M. J. natn. Cancer Inst. 1968, 41, 315. 7. Trichopoulos, D., MacMahon, B., Cole, P. ibid. 1972, 48, 605. 8. McKinlay, S., Jeffreys, M., Thompson, B. J. biosoc. Sci. 1972, 4, 161. 9. Flax H., Salih, H., Newton, K. A., Hobbs, J. R. Lancet, 1973, i, 1204. 10. Lilienfeld, A. M. Cancer, 1956, 9, 927. 11. de Waard, F., Baanders van-Halewijn, E. A., Huizinga, J. ibid. 1964, 17, 141.
SiR,-Dr Spencer’s letter (Feb. 2, p. 174) shows that there are not enough appropriately qualified psychiatrists to work in the field of mental handicap. There may be senior medical officers in the localauthority mental-health services with many of the attributes listed in the editorial (Feb. 2, p. 156), who could give strong support to consultants. They cannot aspire to the top posts for lack of higher qualification and recent hospital experience, but they may be happy to work in a combined community/hospital service at medical-assistant or even senior-medical-officer salary, since some of them foresee their jobs disappearing in the reorganised service.
prepared
Plymouth Nuffield Clinic, Seven Trees, Baring Street, Lipson, Plymouth PL4 8NQ.
N. R. MATHESON.
THE MENOPAUSE AND BREAST CANCER
SiR,-It is well known that the increase in breast-cancer cases with age is interrupted briefly at about the age of the menopause. Clemmesen1 suggested that the interruption resulted from
a
transient decline in
rates
associated with
physiological changes at the menopause. The observed decline is also that expected if the cause were the decrease in the size of the pre-menopausal population. This explanation implied a greater risk of breast cancer for premenopausal women than for post-menopausal women of the same age and was supported by data described below. The numbers of breast cancers, by age, in the United States around 1960 were estimated from mean registration"
for Connecticut in 1960-62 and 1963-65 New York in 1959-61,2 and California in 1960-64.3 The numbers of these breast-cancer cases who would be premenopausal or post-menopausal were estimated for 5-year age-groups from 35-39 years to 55-59 years, using ratios determinedfrom a study of breast-cancer cases in Connecticut during 1960-62. From sizes of the premenopausal and post-menopausal populations in the rates
United States5 incidence-rates were calculated and are shown in the accompanying figure together with the rates for all women. For pre-menopausal women the risk of breast cancer increased steeply with age, without a transient decline in middle life, and was higher than the rate in the general female population at the same age; at 50-54 years the premenopausal rate (1 in 400) was about double and at 55-59 years three times higher than for all women. Correspondingly, the breast-cancer risk for post-menopausal women was lower than for pre-menopausal women of the same age (see figure), agreeing entirely with the lower risk of breast cancer observed amongst women who had had a menopause induced artificially at a relatively early age.B,? Mean age at natural menopause was not 5,8consistently related to marital status, parity, social class, or stature, and did not differ appreciably between countries. It did not seem, therefore, that differences in menopausal age would contribute significantly to the well-known association of breast-cancer rates with the above demographic variables, or to international differences in the rates. Comparing estimates of mean menopausal ages derived at different times the menopause tended to be later in more recent studies. With the predicted steep increase with age of breast-cancer risk for pre-menopausal women, a later menopause would be expected to give a higher breast-cancer rate at around 50 years of age. However, MacMahon and Worcester5 considered that differences in estimates of menopausal ages could have arisen spuriously from methodological errors. Hormone therapy to delay the menopause would be predicted, by the present analysis, to give an increased risk of breast cancer during the time that the menopause was delayed. This possible increase in a risk would need to be balanced against the benefits derived from a delayed menopause. The interest of the present analysis is in the distinct time-courses of carcinogenic development implied for pre-menopausal and post-menopausal women. It is interesting to speculate that for breast tissue there are two types of potentially malignant cells, or two processes of carcinogenic development, one of which requires the physiological conditions of a pre-menopausal woman and Flax et al.° the other a post-menopausal physiology. from their studies of hormone dependence of suggested, breast cancers, that the post-menopausal state may permit the development of androgen-dependent tumours of the breast. Two classes of breast-cancer patient have been recognised in other clinical studies lo,ll and associated with menopausal status. This analysis does not preclude a dependence of the breast-cancer risk of post-menopausal patients on their pre-menopausal history; Trichopoulos et al. found that women with a late menopause had an excess risk of breast cancer in late age. University Department of Social Medicine, Foresterhill, Aberdeen.
Reaiatration-rates of breast
cancer estimated for the United States ( -1960).
GORDON HEMS.
1. Clemmesen, J. Acta path. microbiol. scand. 1965, suppl. 174. 2. Doll, R., Payne, P., Waterhouse, J. A. H. Cancer Incidence in Five Continents, U.I.C.C., Lyons, 1966. 3. Doll, R., Muir, C., Waterhouse, J. A. H. ibid. vol. II, 1970. 4. MacMahon, B. M., List, N. D., Eisenberg, M. in Prognostic Factors in Breast Cancer (edited by A. P. M. Forrest and P. B. Kunkler); p. 56. Edinburgh, 1968. 5. MacMahon, B. M., Worcester, J. Vital and Health Statistics, U.S., 1966, Series 11, no. 19. 6. Feinleib, M. J. natn. Cancer Inst. 1968, 41, 315. 7. Trichopoulos, D., MacMahon, B., Cole, P. ibid. 1972, 48, 605. 8. McKinlay, S., Jeffreys, M., Thompson, B. J. biosoc. Sci. 1972, 4, 161. 9. Flax H., Salih, H., Newton, K. A., Hobbs, J. R. Lancet, 1973, i, 1204. 10. Lilienfeld, A. M. Cancer, 1956, 9, 927. 11. de Waard, F., Baanders van-Halewijn, E. A., Huizinga, J. ibid. 1964, 17, 141.