- Email: [email protected]
Removal of basal-cell carcinoma of the face
Reflection and Reaction
support the state prerogative, evidenced in propaganda praising manliness and strength, to care for the young and strong. Such an outlook is evident, not only in radiation therapy, but throughout the Russian healthcare system. Many diagnostic and therapeutic measures indicated for patients with cancer are not covered by medical insurance. NN Blokhin Cancer Research Centre, the leading oncological institution in our country, is notorious for charging patients through official and unofficial means for treatments and services: bribes are not only accepted, but often demanded from patients or their relatives. Among staff, an impolite and haughty attitude towards patients has become a habit. Living conditions in retirement homes and hospices
are also far from optimum: wards have too many beds, no privacy, and rude personnel who command elderly patients as if they were recruits in the army. It is no surprise that, apart from some beggars, there are almost no people in rocking chairs in Moscow’s streets. Where are they, sitting at home? New Russia, young, manly, and increasingly rich, does not care much about the weak and disabled. Sergei V Jargin Peoples’ Friendship University of Russia, Moscow, Russia [email protected] The author declared no conflicts of interest. 1
Moving at the speed of light. Lancet Oncol 2008; 9: 1019.
Removal of basal-cell carcinoma of the face We read with interest the study by Mosterd and colleagues1 in a previous issue of The Lancet Oncology, which compared outcomes of patients with basalcell carcinoma (BCC) undergoing Mohs’ micrographic surgery (MMS) versus those of patients who underwent surgical excision. Although this study represents a good starting point for a prospective, randomised, controlled trial addressing this issue, there have been several concerns regarding its design.2 We would like to share three further concerns. First, although the same patients were included in the earlier (30-month) study and the present (5-year) study,1,3 the number of BCCs reported at 30 months’ follow-up are different between the two studies. For example, for patients with primary BCC who were assigned to receive MMS, there were 38 dropouts reported in the first study (24 died, 9 for other reasons, and 5 for unknown reasons) with 160 patients remaining. The present report lists 37 drop-outs (25 died, 10 other reasons, and 2 recurrences) leaving a total of 161 patients. The discrepancy might be a result of clarification of the reasons for drop-out, however we would like to know the cause for these differences as it could affect the consistency of data in the study series. Could the authors explain this difference, including any changes in the method of follow-up, between the two studies? Second, tumours showing perineural invasion are regarded as more aggressive and have a higher rate www.thelancet.com/oncology Vol 10 January 2009
of recurrence than those without perineural invasion. Perineural inflammation, perineural tumour invasion, or both, were present in 6·7% of patients with BCC with both aggressive and non-aggressive histological subtypes treated with MMS.4 Therefore, an assessment of perineural invasion in determining risk factors for recurrence is important. Clinicians would need to know if a clear margin without perineural tumour or inflammation was obtained in each patient in this study. Third, some epidemiological and clinical features of skin cancer are different between light-skinned and darkskinned ethnic groups. For example, the incidence of BCC in white people is higher than that in black people. A black patient who presents with a BCC has a higher possibility of having basal-cell naevus syndrome, which might disturb the diagnosis of recurrence of carcinoma.5 The Netherlands is an ethnically diverse country with a non-white population of more than 2 million (12·7% of overall population). However, the investigators didn’t provide any data on the ethnic structure of patients in this study. Lei Wang*, Delin Lei, Yimin Zhao Department of Oral and Maxillofacial Surgery (LW, DL), and Department of Prothodontics (YZ), Fourth Military Medical University, School of Stomatology, 145 West Chang Le Road, Xi’an 710032, China [email protected] The authors declared no conflicts of interest.
9
Reflection and Reaction
1
2 3
4 If you would like to respond to an article published in The Lancet Oncology, please submit your correspondence online at: http://ees.elsevier. com/thelancetoncology
5
Mosterd K, Krekels GAM, Nieman FHM, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years‘ follow-up. Lancet Oncology 2008; 9: 1149–56. Feldman S, Pearce DJ, Williford PM. Surgical decision making for basal-cell carcinoma of the face. Lancet Oncology 2008; 9: 1119–20. Smeets NWJ, Krekels GAM, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004; 364: 1766–72. Ratner D, Lowe L, Johnson TM, et al. Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery. Cancer 2000; 88: 1605–13. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol 2006; 55: 741–60.
Author’s reply Wang and Lei question the consistency of the data presented in both studies published by our group. The explanation of the inconsistency in the number of BCCs included in each group is indeed partly due to clarification of the reasons for some patient dropouts. However, it is also explained by the fact that some patients were lost to follow-up after 30 months, and were therefore unable to visit our department at that time, but returned into follow-up when they visited our department after a
longer period. There was no difference in the method of follow-up between our first and second publications. Regarding the second question raised, we agree that perineural tumour invasion is an important risk factor. We emphasise that in our study all margins were thoroughly searched for residual (perineural) tumour. Although we did no assessment of perineural invasion as a risk factor in all tumours, this might be considered in future prospective randomised controlled trials. Finally, although the Netherlands is indeed an ethnically diverse country, the patients included in our study were people with Fitzpatrick skin type I (11%), II (44%), III (35%), and IV (10%). No patients with darker skin types (V or VI) were included. K Mosterd*, N Kelleners-Smeets Department of Dermatology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, Netherlands [email protected] The authors declared no conflicts of interest.
Neuro-oncology: a call for papers To submit a manuscript to The Lancet Oncology visit http://ees.elsevier.com/ thelancetoncology To submit a manuscript to The Lancet Neurology visit http:// ees.elsevier.com/ thelancetneurology
10
Despite considerable research and the introduction of new therapies, long-term positive outcomes for patients with brain tumours are rare, and most patients experience a recurrence or progression of their cancer irrespective of the intervention. Consequently, mortality is high and many patients have neurological morbidity during the course of their disease. The Lancet Oncology and The Lancet Neurology are therefore issuing a joint call for papers that address cancers of the CNS. We are specifically interested in the results of randomised controlled trials and other original clinical studies that will have a profound effect on clinical practice, or on the fundamental understanding of tumour or CNS biology, or on the management of neurological sequelae. Accepted papers will be published in either The Lancet Oncology or The Lancet Neurology, and publication will coincide with the quadrennial meeting of the World Federation of Neuro-oncology and 6th meeting of the Asian Society for Neuro-oncology (WFNO/ASNO), to be held in Yokohama, Japan, on May 11–14, 2009. We are especially interested in research that will be presented at this conference, but we will also consider other suitable articles. If your submission describes, in part or wholly,
a study accepted for presentation at the WFNO/ASNO meeting, please let us know the precise details of the type of presentation (such as poster or oral presentation), including dates and times, so that publication can be scheduled to comply with WFNO/ASNO embargo policies. Articles can be submitted via either The Lancet Oncology’s or The Lancet Neurology’s online submission services, but all authors must clearly state in the covering letter that their submission is in response to the TLO/TLN call for papers. The closing date for this call for papers is March 13, 2009. David Collingridge, Helen Frankish The Lancet Oncology (DC), The Lancet Neurology (HF), London NW1 7BY, UK
Erratum Kubota K, Kawahara M, Ogawara M, et al. Vinorelbine plus gemcitabine followed by docetaxel versus carboplatin plus paclitaxel in patients with advanced non-small-cell lung cancer: a randomised, open-label, phase III study. Lancet Oncol 2008; 9: 1135–42. In this Article, the HR for overall survival in table 2 should have read: “0·996 (0·78–1·27)”.
www.thelancet.com/oncology Vol 10 January 2009
support the state prerogative, evidenced in propaganda praising manliness and strength, to care for the young and strong. Such an outlook is evident, not only in radiation therapy, but throughout the Russian healthcare system. Many diagnostic and therapeutic measures indicated for patients with cancer are not covered by medical insurance. NN Blokhin Cancer Research Centre, the leading oncological institution in our country, is notorious for charging patients through official and unofficial means for treatments and services: bribes are not only accepted, but often demanded from patients or their relatives. Among staff, an impolite and haughty attitude towards patients has become a habit. Living conditions in retirement homes and hospices
are also far from optimum: wards have too many beds, no privacy, and rude personnel who command elderly patients as if they were recruits in the army. It is no surprise that, apart from some beggars, there are almost no people in rocking chairs in Moscow’s streets. Where are they, sitting at home? New Russia, young, manly, and increasingly rich, does not care much about the weak and disabled. Sergei V Jargin Peoples’ Friendship University of Russia, Moscow, Russia [email protected] The author declared no conflicts of interest. 1
Moving at the speed of light. Lancet Oncol 2008; 9: 1019.
Removal of basal-cell carcinoma of the face We read with interest the study by Mosterd and colleagues1 in a previous issue of The Lancet Oncology, which compared outcomes of patients with basalcell carcinoma (BCC) undergoing Mohs’ micrographic surgery (MMS) versus those of patients who underwent surgical excision. Although this study represents a good starting point for a prospective, randomised, controlled trial addressing this issue, there have been several concerns regarding its design.2 We would like to share three further concerns. First, although the same patients were included in the earlier (30-month) study and the present (5-year) study,1,3 the number of BCCs reported at 30 months’ follow-up are different between the two studies. For example, for patients with primary BCC who were assigned to receive MMS, there were 38 dropouts reported in the first study (24 died, 9 for other reasons, and 5 for unknown reasons) with 160 patients remaining. The present report lists 37 drop-outs (25 died, 10 other reasons, and 2 recurrences) leaving a total of 161 patients. The discrepancy might be a result of clarification of the reasons for drop-out, however we would like to know the cause for these differences as it could affect the consistency of data in the study series. Could the authors explain this difference, including any changes in the method of follow-up, between the two studies? Second, tumours showing perineural invasion are regarded as more aggressive and have a higher rate www.thelancet.com/oncology Vol 10 January 2009
of recurrence than those without perineural invasion. Perineural inflammation, perineural tumour invasion, or both, were present in 6·7% of patients with BCC with both aggressive and non-aggressive histological subtypes treated with MMS.4 Therefore, an assessment of perineural invasion in determining risk factors for recurrence is important. Clinicians would need to know if a clear margin without perineural tumour or inflammation was obtained in each patient in this study. Third, some epidemiological and clinical features of skin cancer are different between light-skinned and darkskinned ethnic groups. For example, the incidence of BCC in white people is higher than that in black people. A black patient who presents with a BCC has a higher possibility of having basal-cell naevus syndrome, which might disturb the diagnosis of recurrence of carcinoma.5 The Netherlands is an ethnically diverse country with a non-white population of more than 2 million (12·7% of overall population). However, the investigators didn’t provide any data on the ethnic structure of patients in this study. Lei Wang*, Delin Lei, Yimin Zhao Department of Oral and Maxillofacial Surgery (LW, DL), and Department of Prothodontics (YZ), Fourth Military Medical University, School of Stomatology, 145 West Chang Le Road, Xi’an 710032, China [email protected] The authors declared no conflicts of interest.
9
Reflection and Reaction
1
2 3
4 If you would like to respond to an article published in The Lancet Oncology, please submit your correspondence online at: http://ees.elsevier. com/thelancetoncology
5
Mosterd K, Krekels GAM, Nieman FHM, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years‘ follow-up. Lancet Oncology 2008; 9: 1149–56. Feldman S, Pearce DJ, Williford PM. Surgical decision making for basal-cell carcinoma of the face. Lancet Oncology 2008; 9: 1119–20. Smeets NWJ, Krekels GAM, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004; 364: 1766–72. Ratner D, Lowe L, Johnson TM, et al. Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery. Cancer 2000; 88: 1605–13. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol 2006; 55: 741–60.
Author’s reply Wang and Lei question the consistency of the data presented in both studies published by our group. The explanation of the inconsistency in the number of BCCs included in each group is indeed partly due to clarification of the reasons for some patient dropouts. However, it is also explained by the fact that some patients were lost to follow-up after 30 months, and were therefore unable to visit our department at that time, but returned into follow-up when they visited our department after a
longer period. There was no difference in the method of follow-up between our first and second publications. Regarding the second question raised, we agree that perineural tumour invasion is an important risk factor. We emphasise that in our study all margins were thoroughly searched for residual (perineural) tumour. Although we did no assessment of perineural invasion as a risk factor in all tumours, this might be considered in future prospective randomised controlled trials. Finally, although the Netherlands is indeed an ethnically diverse country, the patients included in our study were people with Fitzpatrick skin type I (11%), II (44%), III (35%), and IV (10%). No patients with darker skin types (V or VI) were included. K Mosterd*, N Kelleners-Smeets Department of Dermatology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, Netherlands [email protected] The authors declared no conflicts of interest.
Neuro-oncology: a call for papers To submit a manuscript to The Lancet Oncology visit http://ees.elsevier.com/ thelancetoncology To submit a manuscript to The Lancet Neurology visit http:// ees.elsevier.com/ thelancetneurology
10
Despite considerable research and the introduction of new therapies, long-term positive outcomes for patients with brain tumours are rare, and most patients experience a recurrence or progression of their cancer irrespective of the intervention. Consequently, mortality is high and many patients have neurological morbidity during the course of their disease. The Lancet Oncology and The Lancet Neurology are therefore issuing a joint call for papers that address cancers of the CNS. We are specifically interested in the results of randomised controlled trials and other original clinical studies that will have a profound effect on clinical practice, or on the fundamental understanding of tumour or CNS biology, or on the management of neurological sequelae. Accepted papers will be published in either The Lancet Oncology or The Lancet Neurology, and publication will coincide with the quadrennial meeting of the World Federation of Neuro-oncology and 6th meeting of the Asian Society for Neuro-oncology (WFNO/ASNO), to be held in Yokohama, Japan, on May 11–14, 2009. We are especially interested in research that will be presented at this conference, but we will also consider other suitable articles. If your submission describes, in part or wholly,
a study accepted for presentation at the WFNO/ASNO meeting, please let us know the precise details of the type of presentation (such as poster or oral presentation), including dates and times, so that publication can be scheduled to comply with WFNO/ASNO embargo policies. Articles can be submitted via either The Lancet Oncology’s or The Lancet Neurology’s online submission services, but all authors must clearly state in the covering letter that their submission is in response to the TLO/TLN call for papers. The closing date for this call for papers is March 13, 2009. David Collingridge, Helen Frankish The Lancet Oncology (DC), The Lancet Neurology (HF), London NW1 7BY, UK
Erratum Kubota K, Kawahara M, Ogawara M, et al. Vinorelbine plus gemcitabine followed by docetaxel versus carboplatin plus paclitaxel in patients with advanced non-small-cell lung cancer: a randomised, open-label, phase III study. Lancet Oncol 2008; 9: 1135–42. In this Article, the HR for overall survival in table 2 should have read: “0·996 (0·78–1·27)”.
www.thelancet.com/oncology Vol 10 January 2009