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RECURRENCE OF RECTAL CANCER IN PATIENTS MANAGED BY STAPLED ANASTOMOSIS
462 RECURRENCE OF RECTAL CANCER IN PATIENTS MANAGED BY STAPLED ANASTOMOSIS
SIR,-The letter from Mr Johnson
and Mr Celestin
(July 28,
p 219) is a timely warning that the efficacy of restorative rectal resection for cancer needs to be kept constantly under review. I have just completed a survey of 220 cases, consecutive and unselected, of
restorative rectal resection in a seven-year period; the full details will be published elsewhere. My policy was to use restorative resection whenever it seemed to give a very good chance of complete clearance of the growth. Abdominoperineal excision was done in only 1 out of 10 cases where the growth lay within 15 cm of the anal skin. yardstick for comparison has been the 1963 report by Morson et al on 1763 cases of rectal cancer treated by total rectal excision. In that series 80% of pelvic recurrences were detected within 2 years of the operation. In my smaller series 87 operation survivors have been followed up for at least 2 years or until pelvic recurrence. Morson et al found a pelvic recurrence rate of 205/1796 (11.4%). The pelvic recurrence rate in my series was 13/87 (15%). This difference is not significant. Admittedly the follow-up has been short, but this may be offset by the fact that the presence of a functioning anus makes the symptoms of recurrence appear earlier and its diagnosis easier than in cases where the rectum has been completely removed. The series was of all cases, including those in which the operation was thought at the time not to be "curative". In every case the rectal stump was irrigated with cytotoxic solution before division of the bowel. The stapler makes the operation easier and quicker but did not, in my hands, have any effect on the suture line leak rate. The latter was favourably influenced by the routine use of antimicrobial prophylaxis-54% before and 32% after its introduction (radiological measurement). Neither of these advances is likely, to have influenced the incidence of recurrent cancer. These results suggest that the tremendous boon of avoiding a colostomy can be offered to most patients with rectal cancer, without compromising the chance of cure.
My
unfortunately,
16 Maid’s Causeway, Cambridge CB5 8DA
R. E. B. TAGART
1. Morson
BC, Vaughan EG, Bussey HJR. Pelvic recurrence after excision of rectum for carcinoma. Br Med J 1963; ii: 13-18.
SCREENING FOR BREAST CANCER
SIR,-In trials comparing treatment for breast or any other cancer the survival time is the interval between first treatment and death. In early breast cancer treatment usually begins after the definitive diagnosis, and the intervals treatment-to-death and diagnosis-todeath will be much the same. In a randomised trial, any difference in survival will be due to deaths occurring later in one of the groups. However, with screening the diagnosis-to-death interval may be prolonged because of later death and/or earlier diagnosis, and the crucial question is whether earlier diagnosis really postpones death. Have the two case-control analyses of screening programmes in the Netherlands (June 2, pp 1222 and 1224) shown such an effect? Both of these studies took as "cases" patients who had been diagnosed as having breast cancer after they had been offered mammography, and who subsequently died of the disease. In Nijmegen, women aged 35-69 were first offered screening from Jan 1, 1975, onwards, and women aged 70 + were offered screening from 1977 onwards. The acceptance rate for the 35-69 age group in the first round of screening (1975-76) was almost 85%, but in the 70 + group (in 1977-78) it was only 34-5%. In Utrecht, screening began in 1974, being offeredto women aged 50-64 at that time. The acceptance rate was 72%. As "controls", women born in the same year were selected, there being 5 controls for each case in Nijmegen and 3 controls per case in Utrecht. Of the 46 Nijmegen cases, 26 (57%) had accepted screening, but 162 (70 - 4%) of their 230 controls had been screened. In Utrecht, only 9 (20%) of the 46 cases but 59 (42-8%) of 138 controls had been screened. Clearly, screening had been done much less often in the cases than the controls, and this difference was on the border of significance at the 5% level in Nijmegen and was
definitely significant in Utrecht. Does this mean that screening is delaying or preventing death from breast cancer in these cities? The deaths analysed had to have occurred in 1975-81, so the maximum survival of any case is 7 years in Nijmegen and 8 years in Utrecht (ie, a case diagnosed just after the start of the screening programme and dying late in 1981). Year of death is not presented in the Nijmegen report, but almost half the Utrecht cases had died by 1979 - a maximum survival (if they had been diagnosed in 1974) of66 years. These cases are therefore early deaths from breast cancer, cases with a short interval between diagnosis and death. Since screening will tend to make diagnosis occur "earlier" than otherwise (eg, self-examination prompting a woman to seek medical advice), it would be expected that many more patients whose cancer has been detected by screening will have longer diagnosis-to-death times than patients whose cancer has been detected by feeling a lump in the breast. Therefore, if patients with short diagnosis-todeath times are chosen for study (as these two papers have done), one would expect a deficit of cases diagnosed by screening, and the shorter the diagnosis-to-death interval the greater this deficit should be.
So, these two studies have shown results which can only be interpreted to mean that patients who have short diagnosis-to-death times are unlikely to have had their breast cancer diagnosed by screening. Screened patients will be likely to have longer diagnosisto-death intervals, but this does not necessarily mean that death is being delayed too-ie, in addition to diagnosis being made earlier. A curious feature of the results is that screening was accepted in fewer of the controls than in the whole population offered screening in these two cities-70-4% of the controls, compared with an acceptance rate for the 35-69 age group in Nijmegen of nearly 85% (but only 34 - 5% in the 70 + group), and only 42 - 8% of the Utrecht controls compared with an overall acceptance rate of 72%. The agespecific acceptance rates presented in the Nijmegen paper suggest strongly that low acceptance of screening is a feature of older age, but the Utrecht paper does not present data enabling this to be corroborated for that study. So, we can add that these two studies have considered in the main older patients with short intervals from diagnosis to death. Once more then we have findings which do not answer the fundamental question-does screening merely prolong the diagnosis-to-death interval by making diagnosis earlier and not by delaying death? If all screening did was just this, one would always expect patients with longer diagnosis-to-death intervals to have been diagnosed by screening, and patients with shorter interval not to have been so diagnosed. There really is no alternative to a randomised study if screening is to be properly assessed. Case-control analyses, unfortunately, can be very difficult to understand. These two studies seem to suggest great benefit from the use of mammography on all women over the age of 35 or 40, but close scrutiny shows that the results are artifacts of case selection. Case-control studies might seem to be impressive alternatives to randomised studies, but they are not. King’s College School of and Dentistry,
Medicine
M. BAUM
London SE5
Charing Cross Hospital London W68RF
Medical School,
K. D. MACRAE
INTRADUCTAL BREAST CANCER
SIR,-Intraduct carcinoma of the breast represents a small fraction of breast disease, and its importance lies in the potential for surgical cure in the face of likely malignant progression.’ As emphasised by your July 7 editorial, the great difficulty lies in diagnosis of the preinvasive phase. In the absence of a reliable screening method, most clinicians have to depend on three modes of clinical presentation-an associated breast lump; Paget’s disease of the nipple (surprisingly ignored in the editorial); and nipple discharge (which need not necessarily be bloodstained). The importance of the last two must not be forgotten. I have reviewed the histological reports of 2667 breast biopsies under the care of one consultant between 1967 and 1983 and
SIR,-The letter from Mr Johnson
and Mr Celestin
(July 28,
p 219) is a timely warning that the efficacy of restorative rectal resection for cancer needs to be kept constantly under review. I have just completed a survey of 220 cases, consecutive and unselected, of
restorative rectal resection in a seven-year period; the full details will be published elsewhere. My policy was to use restorative resection whenever it seemed to give a very good chance of complete clearance of the growth. Abdominoperineal excision was done in only 1 out of 10 cases where the growth lay within 15 cm of the anal skin. yardstick for comparison has been the 1963 report by Morson et al on 1763 cases of rectal cancer treated by total rectal excision. In that series 80% of pelvic recurrences were detected within 2 years of the operation. In my smaller series 87 operation survivors have been followed up for at least 2 years or until pelvic recurrence. Morson et al found a pelvic recurrence rate of 205/1796 (11.4%). The pelvic recurrence rate in my series was 13/87 (15%). This difference is not significant. Admittedly the follow-up has been short, but this may be offset by the fact that the presence of a functioning anus makes the symptoms of recurrence appear earlier and its diagnosis easier than in cases where the rectum has been completely removed. The series was of all cases, including those in which the operation was thought at the time not to be "curative". In every case the rectal stump was irrigated with cytotoxic solution before division of the bowel. The stapler makes the operation easier and quicker but did not, in my hands, have any effect on the suture line leak rate. The latter was favourably influenced by the routine use of antimicrobial prophylaxis-54% before and 32% after its introduction (radiological measurement). Neither of these advances is likely, to have influenced the incidence of recurrent cancer. These results suggest that the tremendous boon of avoiding a colostomy can be offered to most patients with rectal cancer, without compromising the chance of cure.
My
unfortunately,
16 Maid’s Causeway, Cambridge CB5 8DA
R. E. B. TAGART
1. Morson
BC, Vaughan EG, Bussey HJR. Pelvic recurrence after excision of rectum for carcinoma. Br Med J 1963; ii: 13-18.
SCREENING FOR BREAST CANCER
SIR,-In trials comparing treatment for breast or any other cancer the survival time is the interval between first treatment and death. In early breast cancer treatment usually begins after the definitive diagnosis, and the intervals treatment-to-death and diagnosis-todeath will be much the same. In a randomised trial, any difference in survival will be due to deaths occurring later in one of the groups. However, with screening the diagnosis-to-death interval may be prolonged because of later death and/or earlier diagnosis, and the crucial question is whether earlier diagnosis really postpones death. Have the two case-control analyses of screening programmes in the Netherlands (June 2, pp 1222 and 1224) shown such an effect? Both of these studies took as "cases" patients who had been diagnosed as having breast cancer after they had been offered mammography, and who subsequently died of the disease. In Nijmegen, women aged 35-69 were first offered screening from Jan 1, 1975, onwards, and women aged 70 + were offered screening from 1977 onwards. The acceptance rate for the 35-69 age group in the first round of screening (1975-76) was almost 85%, but in the 70 + group (in 1977-78) it was only 34-5%. In Utrecht, screening began in 1974, being offeredto women aged 50-64 at that time. The acceptance rate was 72%. As "controls", women born in the same year were selected, there being 5 controls for each case in Nijmegen and 3 controls per case in Utrecht. Of the 46 Nijmegen cases, 26 (57%) had accepted screening, but 162 (70 - 4%) of their 230 controls had been screened. In Utrecht, only 9 (20%) of the 46 cases but 59 (42-8%) of 138 controls had been screened. Clearly, screening had been done much less often in the cases than the controls, and this difference was on the border of significance at the 5% level in Nijmegen and was
definitely significant in Utrecht. Does this mean that screening is delaying or preventing death from breast cancer in these cities? The deaths analysed had to have occurred in 1975-81, so the maximum survival of any case is 7 years in Nijmegen and 8 years in Utrecht (ie, a case diagnosed just after the start of the screening programme and dying late in 1981). Year of death is not presented in the Nijmegen report, but almost half the Utrecht cases had died by 1979 - a maximum survival (if they had been diagnosed in 1974) of66 years. These cases are therefore early deaths from breast cancer, cases with a short interval between diagnosis and death. Since screening will tend to make diagnosis occur "earlier" than otherwise (eg, self-examination prompting a woman to seek medical advice), it would be expected that many more patients whose cancer has been detected by screening will have longer diagnosis-to-death times than patients whose cancer has been detected by feeling a lump in the breast. Therefore, if patients with short diagnosis-todeath times are chosen for study (as these two papers have done), one would expect a deficit of cases diagnosed by screening, and the shorter the diagnosis-to-death interval the greater this deficit should be.
So, these two studies have shown results which can only be interpreted to mean that patients who have short diagnosis-to-death times are unlikely to have had their breast cancer diagnosed by screening. Screened patients will be likely to have longer diagnosisto-death intervals, but this does not necessarily mean that death is being delayed too-ie, in addition to diagnosis being made earlier. A curious feature of the results is that screening was accepted in fewer of the controls than in the whole population offered screening in these two cities-70-4% of the controls, compared with an acceptance rate for the 35-69 age group in Nijmegen of nearly 85% (but only 34 - 5% in the 70 + group), and only 42 - 8% of the Utrecht controls compared with an overall acceptance rate of 72%. The agespecific acceptance rates presented in the Nijmegen paper suggest strongly that low acceptance of screening is a feature of older age, but the Utrecht paper does not present data enabling this to be corroborated for that study. So, we can add that these two studies have considered in the main older patients with short intervals from diagnosis to death. Once more then we have findings which do not answer the fundamental question-does screening merely prolong the diagnosis-to-death interval by making diagnosis earlier and not by delaying death? If all screening did was just this, one would always expect patients with longer diagnosis-to-death intervals to have been diagnosed by screening, and patients with shorter interval not to have been so diagnosed. There really is no alternative to a randomised study if screening is to be properly assessed. Case-control analyses, unfortunately, can be very difficult to understand. These two studies seem to suggest great benefit from the use of mammography on all women over the age of 35 or 40, but close scrutiny shows that the results are artifacts of case selection. Case-control studies might seem to be impressive alternatives to randomised studies, but they are not. King’s College School of and Dentistry,
Medicine
M. BAUM
London SE5
Charing Cross Hospital London W68RF
Medical School,
K. D. MACRAE
INTRADUCTAL BREAST CANCER
SIR,-Intraduct carcinoma of the breast represents a small fraction of breast disease, and its importance lies in the potential for surgical cure in the face of likely malignant progression.’ As emphasised by your July 7 editorial, the great difficulty lies in diagnosis of the preinvasive phase. In the absence of a reliable screening method, most clinicians have to depend on three modes of clinical presentation-an associated breast lump; Paget’s disease of the nipple (surprisingly ignored in the editorial); and nipple discharge (which need not necessarily be bloodstained). The importance of the last two must not be forgotten. I have reviewed the histological reports of 2667 breast biopsies under the care of one consultant between 1967 and 1983 and