SCREENING FOR BREAST CANCER

1102 LOCAL RECALL SCHEME FOR CERVICAL CYTOLOGY

SIR,—The computer for cervical cytology records at this hospital has been in operation for two years now, and the scheme may be of interest to others. Our computer scheme provides a local cytology recall service to replace the defunct national recall scheme based in Stockport. The computer was paid for by the Gateshead District Health Authority (GDHA) and the Regional Gynaecological Oncology Research Fund, and the hardware, delivery, and commissioning cost 23 000 (the programs are Crown copyright and therefore available at lower than cost price). The GDHA meets the maintenance costs of £ 2476 per annum. The recall scheme evolved through the close cooperation of the cytology laboratory at the regional gynaecological oncology unit and the family practitioner committees in Gateshead, Durham, and South Tyneside Districts. Every patient on the file has a computer number, which begins with the year of birth (eg, the first patient born in 1954 to be registered on the computer has the number 5400001). This permits more accurate statistical analysis of abnormal smears in women screened in a particular age group. A sender code indicates the source of the smear (gynaecologist, general practitioner, wellwoman clinic), and this has been extended to identify patients who have had a particular treatment (eg, laser ablation of cervical invasive neoplasia) so it can also be used to assess treatment results. While the DHSS recommends a 5-yearly recall, we implement, in the light of recent evidence,aa three-yearly recall. The number of patients on file is 46 285. We have recalled women who need annual smears, following treatment to a cervical lesion, but such women are highly motivated to attend. It is not yet possible to give figures for response to true screening recall. The important point is that the Gateshead recall scheme is run by the cytology laboratory and family practitioner committees in combination. It would be very difficult for either to run the scheme on its own. The collecting and filing of information, records, slides, have been reorganised and streamlined, making use of the computer number generated for each individual. Thanks to the computer information about the recall scheme, the current pattern of population screening, the number of unscreened women, and the epidemiology of cervical lesions in this community is available to the laboratory and to general practitioners. A list of patients screened can be shown to a general practitioner who compares this list with his own patient register. Many general practitioners are now carrying out call schemes as well using the recall scheme. Queen Elizabeth Hospital, Gateshead, Tyne and Wear NE9 6SX 1.

ANN K. BROUGH

This experience, although of a small group, confirms my impression that these preclinical, preinvasive breast cancers cannot be ignored. Breast

Diagnostic Unit, Queen Elizabeth Hospital,

AGNES M. STARK

Gateshead NE9 6SX 1. Stark A, et al The screening of well Cancer 1974; 33: 1671-79.

women

for the early detection of breast

cancer

MORE KIDNEY DONORS, GREATER COSTS

SIR,—It seems to be a very reasonable suggestion by Professor Moores (April 20, p 931) that a health authority should be paid DO 000 for each usable kidney generated from its intensive care unit. This would certainly be a good incentive to try to encourage the donation of more kidneys. However, this approach would not save money. Renal transplantation is cheaper than maintenance haemodialysis and leads to a better quality of life but giving new kidneys to patients on haemodialysis will save money only if dialysis units were then closed down, as perhaps they could be if they were providing haemodialysis for every patient with end-stage renal failure. But this is not the case in the UK; after a transplantation a dialysis machine is used by another patient who would otherwise have died. In other words, instead of having one patient being treated for end-stage renal failure we now have two, one with a transplant and one on haemodialysis. Treating two patients must cost more than treating one, so a laudable attempt to save money by generating kidneys for transplantation would result in increased total expenditure. Treating more patients inevitably costs more money, but with increasing efficiency we progressively get greater value for money. For example, treating one patient by transplantation and the other by dialysis costs less than twice the treatment of two by dialysis. This is a policy that any sensible industry would follow and would be encouraged by a hospital or health authority which received an income related to work done and number of patients treated. However, in the National Health Service the income of a health authority is determined by the government and is not related to work done. It is in fact the smallest amount of money that the Treasury can get away with. Moores’ sensible scheme may be in Germany but it will be of no advantage in Britain while strict cash limits remain and while expansion of the health care industry (at least in the public sector) is not allowed. Postgraduate Medical Centre, Royal Infirmary, Blackburn, Lancs BB2 3LR

DAVID S. GRIMES

MacGregor JE, Moss S, Maxwell Parkin D, Day NE. Br Med J (in press) OUT-OF-HOURS CHEMICAL PATHOLOGY

SCREENING FOR BREAST CANCER

SIR,—Your April 13 editorial "over-treatment of some

might

not

raises the

question

of

possible

pre-invasive lesions which, if undetected,

progress to overt breast cancer".

When an in situ lesion is excised, it cannot be proved that it would have become invasive. In 1973, it was suggested to me that half of the women with non-palpable lesions, diagnosed on mammography, should be assigned to a control group-ie, not have a biopsy but kept under observation. My experience of breast screening by that timel made me consider that such a control group would be unethical and I refused. Unfortunately, however, I do have a small "control" group of 17 cases, whose ages range from 36 to 68 and in whom non-palpable cancer was diagnosed by mammography. The findings were typical of in situ lesions. Biopsy was advised but not done for one of several reasons. Eventually, all 17 women presented with clinical breast cancer; 1 had an extensive intraduct cancer, 10 were invasive cancers with negative nodes and 6 were invasive with involved nodes. The time interval varied from 4 to 37 months with an average of 15 months. These 17 cancers constituted 3-9% of the total diagnosed and proved histologically at the breast diagnostic clinic since 1968.

eventually

SIR,—The article from Leeds (April 13, p 859) is misleading. hospital laboratories have an increasing commitment to provide a 24 h service, which has to be paid for by unsatisfactory and Most

outdated on-call arrangements. I accept that modern equipment will enable tests to be done more quickly, more effectively, and possibly more cheaply and closer to the bedside, but I quarrel with the prevailing attitude that doctors and other untrained staff can do this work as effectively as professionally trained laboratory workers can. Superficially, the Leeds General Infirmary approach seems to have achieved some savings but some major contributions to cost have not been measured. Experience in Birmingham has demonstrated that the injection of poorly anticoagulated blood specimens into blood gas analysers results in major blockages which, if not dealt with rapidly, cost a lot to correct. While this is being done the clinical chemistry laboratory is inundated with requests for out-of.hours work and is expected to respond as if it were next door to the intensive therapy or other unit concerned. This results in more paid calls, not less. Laboratories have developed systems to ensure that the results reported are accurate and precise. It could be argued that the quality should be higher out of normal working hours, not lower, because such tests are urgent and will directly affect treatment decisions. The quality of analytical work will often fall at night when