BRITISH MEDICAL JOURNAL
18 FEBRUARY 1978
443
his health would have suffered and he might Age distribution of zwomen being screened for first time failed to attend, and 74 (group 1, 67; group 2, and of confirmed cases of cancer among them well have lost his job. 7) were not. Of those referred only four It must be understood that the best form (group 1, 3; group 2, 1) were subjected to 1968-July 1977 August-December of life insurance that this man could have biopsy and none of the specimens showed any 1977 taken was to obtain medical advice and help malignancy. A fifth patient included among Age group Percentage Percentage Percentage Percentage the 45 had had a fibroadenoma removed in rather than spend more money on insurance (years) of total of total of total of total premiums. I would therefore like to suggest 1975. Forty-two (group 1, 36; group 2, 6) of screened confirmed screened confirmed cancers cancers (436) that, in order to protect our patients, doctors these patients presented with a swelling (216) (11) should not be expected to disclose any (including inflammatory) or "lump" of the 59 34 35-39 8-3 information about alcohol consumption. This 40-50 breast. In four cases (group 1, 3; group 2, 1) 44-9 53-9 50 51 information must be obtained directly from 51+ a lump could not be confirmed when the 49 16 492 378 the proposers themselves by the insurance patient was seen and in many the "lump" was part of a more generalised nodularity. In a companies. I would like to see the BMA produce a set in women of 39 years or younger I have case not included in the 42 a lump had been of guidelines giving doctors an idea of what decided that, while resources are limited, the removed previously elsewhere, although there they should disclose and what they should not. lower age limit for screening must be raised to was no lump at the time we saw her. TwentyI have already mentioned alcohol and tobacco 40 years, so giving more opportunity for five (group 1, 20; group 2, 5) were complaining consumption, but the same problems apply to screening to older women. It would appear of breast pain or tenderness. Other presenting many other conditions ranging from drug that the effects of public education in medical symptoms included galactorrhoea, inflamabuse to chest pains. In many of these con- matters are not so completely beneficial as matory lesions, skin conditions, pendulous ditions information could be withheld from a some people believe. breasts, unequal breasts, injuries to the breast, doctor for fear of the patient being unable to symptomless fear of breast cancer, unilateral obtain life insurance. If such guidelines could This work is financed by the Women's Cancer breast enlargement and secretion premenstrube produced, then it would go a long way Detection Society, a registered charity, based in ally, embarrassment about small breasts, towards reducing any conflict between the the north-east of England. nipple retraction, and gynaecomastia (inpatients, the insurance companies, and the AGNES M STARK cluding adolescent male mastitis). A large Breast Diagnostic Clinic, doctors. number of the girls were, of course, on the Elizabeth Hospital, T M PICKARD Queen pill, and this probably made them more Gateshead, Tyne and Wear conscious of breast symptoms and the possible Great \Valtham, Chelmsford, Essex l Stark, A M, in Breast Canicer, Trenzds in Research anzd implications of these, as well as in some cases Treatmentt, ed J C Heuson, p 279. New York, Raven contributing to them. Press, 1977. 2Stark, A Xi, Acta Thermnographica, 1976, 1, 33. Thus in two years over 100 girls below the Breast lumps in adolescent girls age of 25 were seen with breast complaints and abnormalities. These covered a wide spectrum SIR,-I have read with interest the opening SIR,-In recent years there has been a great of conditions, but none of them was malignant. statement of your leading article on this increase in interest in cancer of the breast and subject (4 February, p 260), which comments its early diagnosis and in other conditions of D MCCRACKEN on the "steady trickle of frightened young the breast which could be confused with cancer University Health Service, girls" seeking advice about breast problems. or which could predispose to it or precede it. Leeds I thought it would be interesting to conI have found a similar trend in our well sider which breast complaints or breast woman breast screening clinic. The women attending the clinic submit abnormalities arose in a young population. I Carcinoma in a gastroenterostomy themselves for the first visit, the only limits at looked at the records of every person attending stoma this stage having been the availability of the University Health Service between appointments and age of the women-that is, 1 January 1976 and 1 January 1978 who either SIR,-In their report of a case of adenoat least 35 years. The waiting list is opened at came with a specific breast complaint or who, squamous carcinoma occurring in a gastrospecified intervals and the first 150 applicants on routine examination for another purpose, enterostomy stoma (21 January, p 151) Drs are accepted. Forty to fifty applications per was found to have a breast abnormality Rose Buchanan and M J Sworn claim that week are refused between these specified sufficient to warrant inclusion in the diagnosis "even when a gastroenterostomy has been dates. From this self-selected group high-risk or diagnoses following the consultation. The performed only a minority [of gastric carwomen are abstracted for annual review on the numbers are accurate in that a diagnostic card cinomas] have been restricted to the stoma grounds of personal and family history and the index was kept and when the day's consulta- itself." Reported series of gastric carcinoma results of the initial screening by clinical tions were reviewed for record purposes I occurring many years after surgery for benign examination, thermography, and mammo- marked each case to be included on the conditions all document the area of the graphy.1 2The aim of the clinic is to screen a diagnostic card. The investigation was not anastomosis as being the commonest site for cohort of high-risk women at annual intervals, prospective (but for the same reason perhaps carcinoma to occur. This seems to be the case so few appointments have been available for more informative) in that my colleagues did whether the previous surgery has been partial not know what information I was collecting gastrectomyl-3 or just gastroenterostomy new entrants in recent years. Significant trends have appeared in the self- and did not take this into account when alone.4-6 S M JONES selection ovrer the years. In 1968 31 %, were in making their notes. There are approximately University Department of Surgery, the high-risk group; by 1976 this figure was 6500 patients, of whom just over a third are Bristol Infirmary, 620/. It is assumed that this increase in the women, registered with the University Health Bristol Royal are self-selection of high-risk groups is due to Service for NHS purposes, and these 1977, 2, 467. almost all students-staff are not eligible ISchrumpf, E, et al, Latncet, public education. 2Pack, F T, and Banner, R L, Suirgery, 1958, 44, 1024. Until mid-1977 there was a satisfactory except for a very few resident in an official 3Bushkin, F L, Major Probleims inl Clizical Suirgery, 1976, 20, 106. spread of ages in the self-selected group, as capacity in a hall of residence. 4 Morgenstern, L, Yamakawa, T, and Seltzer, D, The number of patients included on the shown in the accompanying table, which also Amnerican 3'ournal of Suirgery, 1973, 125, 29. E, Acta Pathologica et Microbiologica indicates the percentage of total cancers diagnostic card with the criteria laid down 5 Hammar, Scandintavica, section A, 1976, 84, 495. according to age group. In the second half of was 128. Of these 107 (group 1) were born in 6 Kobayashi, S, Prolla, J C, and Kirsner, B J, American J7ournal of Digestive Diseases, 1970, 15, 905. 1977, however, there has been a marked 1952 or later (and were 25 years of age or two years) change in the age groups of women seen for younger at the mid-point of the the first time at the breast screening clinic (see and 13 (group 2) between 1952 and 1947 (and table). Questioning these women indicates were between 25 and 30 years at the mid- Yawning in pharyngeal obstruction that various articles in the media have caused point of the two years). Eight patients were undue concern in the younger women, who older and were excluded from those in the SIR,-After observing two infants in the early stages of choking, I wish to draw attention to are swamping the clinic at the expense of the figures now given. Of the 120 patients (group 1, 107; group 2, yawning as a symptom of pharyngeal impacolder women. No cancers were found in the 13), 13 (group 1, 12; group 2, 1) were males. tion. under-40 age group. In the first infant, aged 11 months, an acute In spite of the fact that 72°' of all the Forty-five (group 1, 39; group 2, 6) were registered breast cancers in this region occur referred for a second opinion, although one episode of obstruction occurred immediately
18 FEBRUARY 1978
443
his health would have suffered and he might Age distribution of zwomen being screened for first time failed to attend, and 74 (group 1, 67; group 2, and of confirmed cases of cancer among them well have lost his job. 7) were not. Of those referred only four It must be understood that the best form (group 1, 3; group 2, 1) were subjected to 1968-July 1977 August-December of life insurance that this man could have biopsy and none of the specimens showed any 1977 taken was to obtain medical advice and help malignancy. A fifth patient included among Age group Percentage Percentage Percentage Percentage the 45 had had a fibroadenoma removed in rather than spend more money on insurance (years) of total of total of total of total premiums. I would therefore like to suggest 1975. Forty-two (group 1, 36; group 2, 6) of screened confirmed screened confirmed cancers cancers (436) that, in order to protect our patients, doctors these patients presented with a swelling (216) (11) should not be expected to disclose any (including inflammatory) or "lump" of the 59 34 35-39 8-3 information about alcohol consumption. This 40-50 breast. In four cases (group 1, 3; group 2, 1) 44-9 53-9 50 51 information must be obtained directly from 51+ a lump could not be confirmed when the 49 16 492 378 the proposers themselves by the insurance patient was seen and in many the "lump" was part of a more generalised nodularity. In a companies. I would like to see the BMA produce a set in women of 39 years or younger I have case not included in the 42 a lump had been of guidelines giving doctors an idea of what decided that, while resources are limited, the removed previously elsewhere, although there they should disclose and what they should not. lower age limit for screening must be raised to was no lump at the time we saw her. TwentyI have already mentioned alcohol and tobacco 40 years, so giving more opportunity for five (group 1, 20; group 2, 5) were complaining consumption, but the same problems apply to screening to older women. It would appear of breast pain or tenderness. Other presenting many other conditions ranging from drug that the effects of public education in medical symptoms included galactorrhoea, inflamabuse to chest pains. In many of these con- matters are not so completely beneficial as matory lesions, skin conditions, pendulous ditions information could be withheld from a some people believe. breasts, unequal breasts, injuries to the breast, doctor for fear of the patient being unable to symptomless fear of breast cancer, unilateral obtain life insurance. If such guidelines could This work is financed by the Women's Cancer breast enlargement and secretion premenstrube produced, then it would go a long way Detection Society, a registered charity, based in ally, embarrassment about small breasts, towards reducing any conflict between the the north-east of England. nipple retraction, and gynaecomastia (inpatients, the insurance companies, and the AGNES M STARK cluding adolescent male mastitis). A large Breast Diagnostic Clinic, doctors. number of the girls were, of course, on the Elizabeth Hospital, T M PICKARD Queen pill, and this probably made them more Gateshead, Tyne and Wear conscious of breast symptoms and the possible Great \Valtham, Chelmsford, Essex l Stark, A M, in Breast Canicer, Trenzds in Research anzd implications of these, as well as in some cases Treatmentt, ed J C Heuson, p 279. New York, Raven contributing to them. Press, 1977. 2Stark, A Xi, Acta Thermnographica, 1976, 1, 33. Thus in two years over 100 girls below the Breast lumps in adolescent girls age of 25 were seen with breast complaints and abnormalities. These covered a wide spectrum SIR,-I have read with interest the opening SIR,-In recent years there has been a great of conditions, but none of them was malignant. statement of your leading article on this increase in interest in cancer of the breast and subject (4 February, p 260), which comments its early diagnosis and in other conditions of D MCCRACKEN on the "steady trickle of frightened young the breast which could be confused with cancer University Health Service, girls" seeking advice about breast problems. or which could predispose to it or precede it. Leeds I thought it would be interesting to conI have found a similar trend in our well sider which breast complaints or breast woman breast screening clinic. The women attending the clinic submit abnormalities arose in a young population. I Carcinoma in a gastroenterostomy themselves for the first visit, the only limits at looked at the records of every person attending stoma this stage having been the availability of the University Health Service between appointments and age of the women-that is, 1 January 1976 and 1 January 1978 who either SIR,-In their report of a case of adenoat least 35 years. The waiting list is opened at came with a specific breast complaint or who, squamous carcinoma occurring in a gastrospecified intervals and the first 150 applicants on routine examination for another purpose, enterostomy stoma (21 January, p 151) Drs are accepted. Forty to fifty applications per was found to have a breast abnormality Rose Buchanan and M J Sworn claim that week are refused between these specified sufficient to warrant inclusion in the diagnosis "even when a gastroenterostomy has been dates. From this self-selected group high-risk or diagnoses following the consultation. The performed only a minority [of gastric carwomen are abstracted for annual review on the numbers are accurate in that a diagnostic card cinomas] have been restricted to the stoma grounds of personal and family history and the index was kept and when the day's consulta- itself." Reported series of gastric carcinoma results of the initial screening by clinical tions were reviewed for record purposes I occurring many years after surgery for benign examination, thermography, and mammo- marked each case to be included on the conditions all document the area of the graphy.1 2The aim of the clinic is to screen a diagnostic card. The investigation was not anastomosis as being the commonest site for cohort of high-risk women at annual intervals, prospective (but for the same reason perhaps carcinoma to occur. This seems to be the case so few appointments have been available for more informative) in that my colleagues did whether the previous surgery has been partial not know what information I was collecting gastrectomyl-3 or just gastroenterostomy new entrants in recent years. Significant trends have appeared in the self- and did not take this into account when alone.4-6 S M JONES selection ovrer the years. In 1968 31 %, were in making their notes. There are approximately University Department of Surgery, the high-risk group; by 1976 this figure was 6500 patients, of whom just over a third are Bristol Infirmary, 620/. It is assumed that this increase in the women, registered with the University Health Bristol Royal are self-selection of high-risk groups is due to Service for NHS purposes, and these 1977, 2, 467. almost all students-staff are not eligible ISchrumpf, E, et al, Latncet, public education. 2Pack, F T, and Banner, R L, Suirgery, 1958, 44, 1024. Until mid-1977 there was a satisfactory except for a very few resident in an official 3Bushkin, F L, Major Probleims inl Clizical Suirgery, 1976, 20, 106. spread of ages in the self-selected group, as capacity in a hall of residence. 4 Morgenstern, L, Yamakawa, T, and Seltzer, D, The number of patients included on the shown in the accompanying table, which also Amnerican 3'ournal of Suirgery, 1973, 125, 29. E, Acta Pathologica et Microbiologica indicates the percentage of total cancers diagnostic card with the criteria laid down 5 Hammar, Scandintavica, section A, 1976, 84, 495. according to age group. In the second half of was 128. Of these 107 (group 1) were born in 6 Kobayashi, S, Prolla, J C, and Kirsner, B J, American J7ournal of Digestive Diseases, 1970, 15, 905. 1977, however, there has been a marked 1952 or later (and were 25 years of age or two years) change in the age groups of women seen for younger at the mid-point of the the first time at the breast screening clinic (see and 13 (group 2) between 1952 and 1947 (and table). Questioning these women indicates were between 25 and 30 years at the mid- Yawning in pharyngeal obstruction that various articles in the media have caused point of the two years). Eight patients were undue concern in the younger women, who older and were excluded from those in the SIR,-After observing two infants in the early stages of choking, I wish to draw attention to are swamping the clinic at the expense of the figures now given. Of the 120 patients (group 1, 107; group 2, yawning as a symptom of pharyngeal impacolder women. No cancers were found in the 13), 13 (group 1, 12; group 2, 1) were males. tion. under-40 age group. In the first infant, aged 11 months, an acute In spite of the fact that 72°' of all the Forty-five (group 1, 39; group 2, 6) were registered breast cancers in this region occur referred for a second opinion, although one episode of obstruction occurred immediately
