It is true that the Priory Hospitals Group is the largest provider of private psychiatric care in Britain. The authors fail to make it clear, however, that this group is the "encouraging exception"2 that they refer to. Thus the exception becomes the rule. Following the example set by the Priory group there is reason to be optimistic that private psychiatric hospitals in the United Kingdom will take a different approach to their American counterparts. Responsibilities to research and training are taken seriously. A recently held Priory Fellows Day, devoted entirely to projects associated with this hospital and attended by 120 psychiatrists, provides further evidence. In arguing that private care is elitist the authors again overlook the fact that 71 NHS patients have been successfully cared for in the Priory Hospital over the past three years. These were very disturbed patients who would otherwise have been admitted to a locked ward. They were mostly patients of social class V from the deprived inner city area in which Professor Marks and Dr Thornicroft work. Surely the future lies in close cooperation between the private, academic, and NHS sectors. To achieve this we need to be fair minded, not prejudiced. JOHN COBB
investigations because "the endoscopic yield from the investigation of x-ray negative dyspepsia after a double contrast barium meal is minimal."' This is not hearsay or anecdotal wisdom but medical audit of the very best sort-that is, clinicians from different specialties coming together to test their tests. But audit has little value if we do not learn from the results and make the changes to our practice that are appropriate to those results. An editorial written by gastroenterologists advising general practitioners on the appropriate sequence of hospital investigations that totally ignores the results of relevant audit suggests that some doctors will continue to remain locked within their own particular fields of expertise, playing with their own particular toys, unable or unwilling to argue the case for (or against) a sensible permutation of the skills and techniques that are available for us to use together in order to help our patients. It may well be proper for the profession to challenge many of the NHS reforms,' which are being imposed in a seemingly cavalier fashion. But the future looks really inauspicious if doctors are equally cavalier and ignore the one item regarded as a progressive step forward. M A SAMPSON C RECORD Northwick Park Hospital,
Middlesex HAl 3UJ
Priory Hospital, London SW15 5JJ
I .Brown C, Rees WDW. Dyspepsia in general practice. Br MedJ
I Marks 1, TIhornicroft G. Private inpatient psychiatric care. BrMedJ 1990;300:892. (7 April.) 2 Kelly D. Private sector psychiatric services. Bulletin of the Royal College of Psvchiatri'ss 1989;13:199.
Dyspepsia in general practice SIR,-Drs C Brown and W D W Rees in their recent editorial on dyspepsia in general practice point out that the referral rate for upper gastrointestinal endoscopy has outstripped the resources available and has led to long waiting lists.' They suggest that the answer is to treat all patients, except those with a history suggestive of gastric malignancy, with antacids or H2 receptor antagonists for four to six weeks before considering investigation with endoscopy. They singularly fail to suggest, or even to bother to discuss, the alternative method of investigation-namely, the double contrast barium meal. An estimated 400 000 double contrast barium meal investigations are carried out in England and Wales each year2; the examination is comparable in accuracy with endoscopy,' except in the diagnosis of fine mucosal inflammation. Moreover, modern barium radiology is better than endoscopy at showing some aspects of function, hiatal hernias, and extrinsic mass lesions, and it also provides a permanent record4; furthermore, it is safe-mortality from endoscopy varies between one in 5000 and one in 13 Oo."6 Endoscopy is an observer dependent investigation that does not provide a permanent record and that may well miss serious lesions such as carcinoma of the stomach," and even with careful biopsy of gastric lesions it can still result in misleading benign results on histological examination.' But the omissions in the editorial have unintentionally highlighted a contemporary medicopolitical issue, and the omens are not promising. The one aspect of the government's proposals for reforming the NHS that has been warmly welcomed by doctors has been the importance and emphasis placed on audit.' There have been few prospective surveys in the United Kingdom comparing the findings on double contrast barium radiology with those on skilled endoscopy. Salter, a gastroenterologist, carried out such a survey and concluded that endoscopy should usually assume third rather than second place in the sequence of
BMJ
VOLUME
300
28
APRIL
1990
1990;300:829-30. (31 March.) 2 Simpkins KC. What use is barium? Clin Radiol 1988;39:469-73. 3 Salter RH. X-ray negative dyspepsia. BrMedj 1977;ii:235-6. 4 Cotton PB, Shorvon IlJ. Analysis of endoscopy and radiographin the diagnosis, follow-up and treatment of peptic ulcer disease. Clinics in Gastroenterology 1984;13:383-403. 5 Schiller KFR, Prout BJ. Hazard of endoscopy. In: Schiller KFR, Salmon PR, eds. Modern topics in gastrointestinal endoscopy. London: Heinemann Medical, 1976:147-65. 6 Dawson J, Cockel R. Oesophageal perforation at fibreoptic gastroscopy. BrMedj 1981;283:583.
7 Fraser (GM, Earnshaw PM. The double contrast barium meal: a correlation with endoscopy. Clin Radiol 1983;34:121-31. 8 Farini R, Farinati F, Cardin F, cl al. Evidence of gastric carcinoma during follow up of apparently benign gastric ulcer. Gut 1983;24:A486. 9 Secretaries of State for Health, Wales, Northern Ireland,. and Scotland. Working for patients. London: HMSO, 1989.
(Cmnd 555.)
Node negative breast cancer SIR, -After 15 years of work on prognostic factors in breast cancer it is saddening to read in the regular review article by Drs S M O'Reilly and M A Richards that accurate identification of a subgroup of patients with a very good prognosis "is difficult"; also that "further research is needed in the ability of known prognostic factors to select such groups."' We refer to several publications from our unit. In 1982 we advanced an index that combined lymph node stage, histological grade, and tumour size as accurately identifying a group with a very good prognosis.2 In 1987 we confirmed our index 1.0-
> 080 0
.00. co E
34
,
,0 6X06-
5-01
0.2
0-0. 0
50 34e -
-7.0
8 10 12 14 16 Years Survival curves for 1000 women with operable breast cancer by prognostic index 2
4
6
Actuarial survival at 15 years of women with operable breast cancer Actuarial Index 21-34 >3 4-5-0 >5 0
Percentage of women
survival (%)
26 46 27
79 50 18
(the Nottingham prognostic index), which had been based on a retrospective study of 387 patients, with a prospective study of 320 patients.' The index was shown to give highly reproducible results in the estimation of prognosis. Analysis of the index in the first 1000 consecutive patients presenting to our unit between 1973 and 1989 with operable breast cancer (tumour size 5 0 have a very poor survival chance at five years; are likely to have poorly differentiated, oestrogen receptor negative tumours; and seem to be candidates for adjuvant
cytotoxic treatment. Lymph node stage and tumour size are time dependent factors. Histological grading is the best method of providing a biological factor for a prognostic index and has consistently scored better in our series than all of the other factors we have tested4: DNA index,' S phase fraction, oestrogen receptor,6 epidural growth factor receptor,7 c-Erb B2 (C Lovekin et al, unpublished work), C-myc,8 Helix pomatia,9 and epithelial mucin antibody. '0 As these factors are related to grade they do not further refine the index once grade has been incorporated. Our final message is to Drs O'Reilly and Richards and to the authors of similar papers to their review (for example, the National Cancer Institute clinical alert) ": there are published indices that give excellent prognostic discriminationWhy not use them? R W BLAMEY C W ELSTON I 0 ELLIS D A L MORGAN J L HAYBITTLE
Citv Hospital, Nottingham I O'Reilly SM, Richards MA. Node negative breast cancer. BrMedJ 1990;300:346-8. (10 February.) 2 Haybittle JL, Blamey RW, Elston CW, Johnson J, Doyle Pj, Campbell FC. A prognostic index in primary breast cancer. Brj Cancer 1982;45:361-6. 3 Todd JH, Dowle C, Williams MR, et al. Confirmation of a prognostic index in primary breast cancer. Br J Cancer 1987;56:295-9. 4 Elston CW. Grading of invasive carcinoma of the breast. In: Page DL, Anderson TJ. Diagnostic histopathology of the breast. Edinburgh: Churchill Livingstone, 1987:300-l 1. 5 Dowle CS, Owainati A, Robins A, et al. Prognostic significance of the DNA content of human breast cancer. Br J Surg 1987;74: 133-6. 6 Williams MR, Todd JH, Ellis 10, et al. Oestrogen receptors in primary and advanced breast cancer: an eight year review of 704 cases. BrJ' Cancer 1987;55:67-73. 7 Lewis S, Locker A, Todd JH, et al. Epidural growth factor receptor expression in human breast carcinoma. J Clin Pathol (in press). 8 Locker AP, Dowle CS, Ellis 10, et al. C-myc oncogene prodttct expression and prognosis in operable breast cancer. BrJ Cancer 1989;60:669-72.
1137
investigations because "the endoscopic yield from the investigation of x-ray negative dyspepsia after a double contrast barium meal is minimal."' This is not hearsay or anecdotal wisdom but medical audit of the very best sort-that is, clinicians from different specialties coming together to test their tests. But audit has little value if we do not learn from the results and make the changes to our practice that are appropriate to those results. An editorial written by gastroenterologists advising general practitioners on the appropriate sequence of hospital investigations that totally ignores the results of relevant audit suggests that some doctors will continue to remain locked within their own particular fields of expertise, playing with their own particular toys, unable or unwilling to argue the case for (or against) a sensible permutation of the skills and techniques that are available for us to use together in order to help our patients. It may well be proper for the profession to challenge many of the NHS reforms,' which are being imposed in a seemingly cavalier fashion. But the future looks really inauspicious if doctors are equally cavalier and ignore the one item regarded as a progressive step forward. M A SAMPSON C RECORD Northwick Park Hospital,
Middlesex HAl 3UJ
Priory Hospital, London SW15 5JJ
I .Brown C, Rees WDW. Dyspepsia in general practice. Br MedJ
I Marks 1, TIhornicroft G. Private inpatient psychiatric care. BrMedJ 1990;300:892. (7 April.) 2 Kelly D. Private sector psychiatric services. Bulletin of the Royal College of Psvchiatri'ss 1989;13:199.
Dyspepsia in general practice SIR,-Drs C Brown and W D W Rees in their recent editorial on dyspepsia in general practice point out that the referral rate for upper gastrointestinal endoscopy has outstripped the resources available and has led to long waiting lists.' They suggest that the answer is to treat all patients, except those with a history suggestive of gastric malignancy, with antacids or H2 receptor antagonists for four to six weeks before considering investigation with endoscopy. They singularly fail to suggest, or even to bother to discuss, the alternative method of investigation-namely, the double contrast barium meal. An estimated 400 000 double contrast barium meal investigations are carried out in England and Wales each year2; the examination is comparable in accuracy with endoscopy,' except in the diagnosis of fine mucosal inflammation. Moreover, modern barium radiology is better than endoscopy at showing some aspects of function, hiatal hernias, and extrinsic mass lesions, and it also provides a permanent record4; furthermore, it is safe-mortality from endoscopy varies between one in 5000 and one in 13 Oo."6 Endoscopy is an observer dependent investigation that does not provide a permanent record and that may well miss serious lesions such as carcinoma of the stomach," and even with careful biopsy of gastric lesions it can still result in misleading benign results on histological examination.' But the omissions in the editorial have unintentionally highlighted a contemporary medicopolitical issue, and the omens are not promising. The one aspect of the government's proposals for reforming the NHS that has been warmly welcomed by doctors has been the importance and emphasis placed on audit.' There have been few prospective surveys in the United Kingdom comparing the findings on double contrast barium radiology with those on skilled endoscopy. Salter, a gastroenterologist, carried out such a survey and concluded that endoscopy should usually assume third rather than second place in the sequence of
BMJ
VOLUME
300
28
APRIL
1990
1990;300:829-30. (31 March.) 2 Simpkins KC. What use is barium? Clin Radiol 1988;39:469-73. 3 Salter RH. X-ray negative dyspepsia. BrMedj 1977;ii:235-6. 4 Cotton PB, Shorvon IlJ. Analysis of endoscopy and radiographin the diagnosis, follow-up and treatment of peptic ulcer disease. Clinics in Gastroenterology 1984;13:383-403. 5 Schiller KFR, Prout BJ. Hazard of endoscopy. In: Schiller KFR, Salmon PR, eds. Modern topics in gastrointestinal endoscopy. London: Heinemann Medical, 1976:147-65. 6 Dawson J, Cockel R. Oesophageal perforation at fibreoptic gastroscopy. BrMedj 1981;283:583.
7 Fraser (GM, Earnshaw PM. The double contrast barium meal: a correlation with endoscopy. Clin Radiol 1983;34:121-31. 8 Farini R, Farinati F, Cardin F, cl al. Evidence of gastric carcinoma during follow up of apparently benign gastric ulcer. Gut 1983;24:A486. 9 Secretaries of State for Health, Wales, Northern Ireland,. and Scotland. Working for patients. London: HMSO, 1989.
(Cmnd 555.)
Node negative breast cancer SIR, -After 15 years of work on prognostic factors in breast cancer it is saddening to read in the regular review article by Drs S M O'Reilly and M A Richards that accurate identification of a subgroup of patients with a very good prognosis "is difficult"; also that "further research is needed in the ability of known prognostic factors to select such groups."' We refer to several publications from our unit. In 1982 we advanced an index that combined lymph node stage, histological grade, and tumour size as accurately identifying a group with a very good prognosis.2 In 1987 we confirmed our index 1.0-
> 080 0
.00. co E
34
,
,0 6X06-
5-01
0.2
0-0. 0
50 34e -
-7.0
8 10 12 14 16 Years Survival curves for 1000 women with operable breast cancer by prognostic index 2
4
6
Actuarial survival at 15 years of women with operable breast cancer Actuarial Index 21-34 >3 4-5-0 >5 0
Percentage of women
survival (%)
26 46 27
79 50 18
(the Nottingham prognostic index), which had been based on a retrospective study of 387 patients, with a prospective study of 320 patients.' The index was shown to give highly reproducible results in the estimation of prognosis. Analysis of the index in the first 1000 consecutive patients presenting to our unit between 1973 and 1989 with operable breast cancer (tumour size 5 0 have a very poor survival chance at five years; are likely to have poorly differentiated, oestrogen receptor negative tumours; and seem to be candidates for adjuvant
cytotoxic treatment. Lymph node stage and tumour size are time dependent factors. Histological grading is the best method of providing a biological factor for a prognostic index and has consistently scored better in our series than all of the other factors we have tested4: DNA index,' S phase fraction, oestrogen receptor,6 epidural growth factor receptor,7 c-Erb B2 (C Lovekin et al, unpublished work), C-myc,8 Helix pomatia,9 and epithelial mucin antibody. '0 As these factors are related to grade they do not further refine the index once grade has been incorporated. Our final message is to Drs O'Reilly and Richards and to the authors of similar papers to their review (for example, the National Cancer Institute clinical alert) ": there are published indices that give excellent prognostic discriminationWhy not use them? R W BLAMEY C W ELSTON I 0 ELLIS D A L MORGAN J L HAYBITTLE
Citv Hospital, Nottingham I O'Reilly SM, Richards MA. Node negative breast cancer. BrMedJ 1990;300:346-8. (10 February.) 2 Haybittle JL, Blamey RW, Elston CW, Johnson J, Doyle Pj, Campbell FC. A prognostic index in primary breast cancer. Brj Cancer 1982;45:361-6. 3 Todd JH, Dowle C, Williams MR, et al. Confirmation of a prognostic index in primary breast cancer. Br J Cancer 1987;56:295-9. 4 Elston CW. Grading of invasive carcinoma of the breast. In: Page DL, Anderson TJ. Diagnostic histopathology of the breast. Edinburgh: Churchill Livingstone, 1987:300-l 1. 5 Dowle CS, Owainati A, Robins A, et al. Prognostic significance of the DNA content of human breast cancer. Br J Surg 1987;74: 133-6. 6 Williams MR, Todd JH, Ellis 10, et al. Oestrogen receptors in primary and advanced breast cancer: an eight year review of 704 cases. BrJ' Cancer 1987;55:67-73. 7 Lewis S, Locker A, Todd JH, et al. Epidural growth factor receptor expression in human breast carcinoma. J Clin Pathol (in press). 8 Locker AP, Dowle CS, Ellis 10, et al. C-myc oncogene prodttct expression and prognosis in operable breast cancer. BrJ Cancer 1989;60:669-72.
1137
