308
dyspepsia, but I must stress that removal of gallstones fied, and especially when symptoms are present.
is
justi-
16 Bialik Street, Ramat-Hasharon,
Y. NivV
Israel
Asian community (albeit a major population at risk) will perpetuate avoidable vitamin-D deficiency in Britain. Fortification of milk and/or butter may therefore be preferable.
Royal National Orthopædic Hospital,
T. C. B. STAMP
London W1
University College Hospital,
A. N. EXTON-SMITH
London WC1
CLASSICAL RICKETS AND OSTEOMALACIA IN BRITAIN
SIR,-Goel et al.’ have again drawn attention to the unacceptable prevalence of rickets among immigrant schoolchildren, especially those of Asian origin. Vitamin-D deficiency in the Asian community is not confined to children, osteomalacia being a serious problem at all ages.2-6 Pietrek et al. selectively fortified chupatty flour (a staple part of the Asian diet) with vitamin D, showed the expected improvement in vitamin-D nutrition which it produced, and advocated the adoption of this public-health measure to eradicate vitamin-D deficiency in "the population that is at risk". Unfortunately, there are other groups who are also at risk from rickets and osteomalacia who do not eat chupatties and who would not be protected by this measure. A small minority of the immigrant children reported by Goel et al. were not Asian. The largest group of all are those old people who have little exposure to sunlight. This group includes the 5% of the elderly population who are in hospital or in other institutions and the other 9-10% of the elderly population at home who are housebound.8 Their relative vitamin-D deficiency9 can also be attributed to diminished dietary intake10 and a possible increase in their physiological requirements for the vitamin." The incidence of osteomalacia may be as high as 4% among elderly women admitted to a geriatric department12 and vitamin-D deficiency may also contribute to femoral-neck frac-
St. Bartholomew’s London EC1
Hospital, A. RICHENS
URINARY CARCINOEMBRYONIC ANTIGEN TO MONITOR EXPOSURE TO URINARY CARCINOGENS
SiR,—The possibility that bladder cancer had an industrial aetiology was first recognised by Rehn’ as a result of epidemiological studies of workers in the German dye industry. At present, it is estimated that about 20% of cases of bladder cancer may have had an industrial setiology due to exposure to agents
such as ot andnaphthylamine and benzidine.l-4 Since raised urinary carcinoembryonic antigen (C.E.A.) levels can be found in patients with bladder cancer,’ a prospective study was instituted to assess whether this could be used to screen "at risk" patients either alone or in conjunction with urinary cytology, as the earlier detection of urothelial tumours is associated with a better prognosis.6 Two industrial employers whose workers had been exposed top naphthylamine, cooperated in the trial. 102 employees were studied over a period of three years, urinary specimens being taken every six months for cytological examination and C.E.A. estimation. The results are shown in the accompanying table. All 5 cases with raised urinary C.E.A. levels had the cliniEXPERIENCE OF C.E.A. MONITORING IN WORKERS EXPOSED TO URINARY
.
CARCINOGENS
tures.13-15 Patients with epilepsy, especially if they reside in instituare another group who suffer relative vitamin-D deficiency,15-17 their disease is multifactorial but hepatic enzyme induction under the influence of anticonvulsant drugs may play an important part. Finally, patients who have had gastrectomies may also develop simple deficiency osteomalacia’* since normal dietary vitamin-D intake may be so borderline’9 that any additional avoidance of fatty foods may be enough to produce vitamin-D deficiency.20 While we agree that public-health measures are overdue, we are anxious that any measures ultimately adopted should help to provide adequate vitamin-D to all those at risk. There is a clear danger that once the decision is made to introduce fortification of food with vitamin D, its unnecessary limitation to the
tions,
M., and others Lancet, 1976, i, 1141. M. G., Pateon, J. P. J., Haase, S., McNichol, G. W., Gardner, M. D., Smith, C. M. Scott. med. J. 1962, 7, 159. 3. Arneil, G. C., Crosbie, J. C. Lancet, 1963, ii, 423. 4. Swan, C. H. J., Cooke, W. T. ibid. 1971, ii, 456. 5. Holmes, A. M., Enoch, B. A., Taylor, J. L., Jones, M. E. Q. Jl Med. 1973, 42, 125. 6. Gupta, M. M., Round, J. M., Stamp, T. C. B. Lancet, 1974, i, 586. 7. Pietrek, J., and others ibid. 1976, i, 1145. 8. Exton-Smith, A. N., Windsor, A. C. M., Stanton, B. R. Nutrition of Housebound Old People. King Edward’s Hospital Fund, London, 1972. 9. Stamp, T. C. B., Haddad, J. G. Jr., Exton-Smith, A. N., Twigg, C. A. Ann. clin. Biochem. (in the press). 10. Exton-Smith, A. N. J. R. Coll. Physns, 1975, 9, 148. 11. Dent, C. E. Proc. R. Soc. Med. 1970, 63, 401. 12. Anderson, I., Campbell, A. E. R., Dunn, A., Runciman, J. B. M. Scott. med. J. 1966, 11, 429. 13 Aaron, J. E., Gallagher, J C., Anderson, J., Stasiak, L., Longton, E. B., Nordin, B. E. C., Nicholson, M. Lancet, 1974, i, 229. 14. Faccini, J. M., Exton-Smith, A. N., Boyde, A. ibid. 1976, i, 1089. 15. Richens, A., Rowe, D. J. F. Br. med. J. 1970, iv, 73. 16. Richens, A., Rowe, D. J. F. ibid. 1971, iv, 684. 17 Stamp, T. C. B., Round, J. M., Rowe, D. J. F., Haddad, J. G. Jr. Br. Med. J. 1972, iv, 9. 18. Morgan, D. B., Paterson, C. R., Pulvertaft, C. N., Woods, C. G., Fourman, 1. 2.
Goel,
K.
Dunnigan,
P. Lancet, 1965, ii, 1089. 19. Stamp, T. C. B , Round, J. M. Nature, 1974, 247, 563. 20. Dent, C. E., Smith, R Q. Jl Med. 1969, 38, 195.
——————————————————————————————————————t——————————————————————!————————————————————
* >35ng/ml
in
males;
> 11 Onglm-l
in
females
cal symptoms of urinary infection at the time the specimens were taken. In no case was there accompanying abnormal cytology. All 17 cases with abnormal cytology have had a full urological assessment, including cystoscopy, but no overt urothelial tumours have been found. These patients remain under observation. In 1 case from the rubber industry, the abnormal cytology may have been accounted for by the finding of urinary calculi. None of the patients with abnormal cytology had a raised urinary c.E.A. level. We conclude, therefore, that urinary C.E.A. levels offer no advantage as a screening method for the detection of urothelial cancers in patients exposed to urinary carcinogens over the established method of urinary cytology and, in fact, may be of less value. A.G.T.
was
in
receipt of a
Department of Urology, Royal Marsden Hospital, London SW3 6JJ
Kingston Hospital, Kingston upon Thames, Surrey Division of Pathology, Institute of Cancer Research, London SW3 6JJ
D.H.S.S.
fellowship. A. G. TURNER H. PALMER M. E. A. POWELL
A. MUNRO NEVILLE
Rehn, L. Archs. klin. Chir. 1895, 50, 588. Anthony, E. M., Thomas, G. M. J. natn. Cancer Inst. 1970, 45, 879. Cole, P., Hoover, R., Friedell, G. H. Cancer, 1972, 29, 1250. Veys, C. A. Br J. ind. Med. 1974, 31, 65. Hall, R. R., Laurence, D. J. R., Darcy, D., Stevens, U., James, R., Roberts, S., Neville, A. M. Br. med. J. 1972, iii, 609. 6. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 1. 2. 3. 4. 5.
dyspepsia, but I must stress that removal of gallstones fied, and especially when symptoms are present.
is
justi-
16 Bialik Street, Ramat-Hasharon,
Y. NivV
Israel
Asian community (albeit a major population at risk) will perpetuate avoidable vitamin-D deficiency in Britain. Fortification of milk and/or butter may therefore be preferable.
Royal National Orthopædic Hospital,
T. C. B. STAMP
London W1
University College Hospital,
A. N. EXTON-SMITH
London WC1
CLASSICAL RICKETS AND OSTEOMALACIA IN BRITAIN
SIR,-Goel et al.’ have again drawn attention to the unacceptable prevalence of rickets among immigrant schoolchildren, especially those of Asian origin. Vitamin-D deficiency in the Asian community is not confined to children, osteomalacia being a serious problem at all ages.2-6 Pietrek et al. selectively fortified chupatty flour (a staple part of the Asian diet) with vitamin D, showed the expected improvement in vitamin-D nutrition which it produced, and advocated the adoption of this public-health measure to eradicate vitamin-D deficiency in "the population that is at risk". Unfortunately, there are other groups who are also at risk from rickets and osteomalacia who do not eat chupatties and who would not be protected by this measure. A small minority of the immigrant children reported by Goel et al. were not Asian. The largest group of all are those old people who have little exposure to sunlight. This group includes the 5% of the elderly population who are in hospital or in other institutions and the other 9-10% of the elderly population at home who are housebound.8 Their relative vitamin-D deficiency9 can also be attributed to diminished dietary intake10 and a possible increase in their physiological requirements for the vitamin." The incidence of osteomalacia may be as high as 4% among elderly women admitted to a geriatric department12 and vitamin-D deficiency may also contribute to femoral-neck frac-
St. Bartholomew’s London EC1
Hospital, A. RICHENS
URINARY CARCINOEMBRYONIC ANTIGEN TO MONITOR EXPOSURE TO URINARY CARCINOGENS
SiR,—The possibility that bladder cancer had an industrial aetiology was first recognised by Rehn’ as a result of epidemiological studies of workers in the German dye industry. At present, it is estimated that about 20% of cases of bladder cancer may have had an industrial setiology due to exposure to agents
such as ot andnaphthylamine and benzidine.l-4 Since raised urinary carcinoembryonic antigen (C.E.A.) levels can be found in patients with bladder cancer,’ a prospective study was instituted to assess whether this could be used to screen "at risk" patients either alone or in conjunction with urinary cytology, as the earlier detection of urothelial tumours is associated with a better prognosis.6 Two industrial employers whose workers had been exposed top naphthylamine, cooperated in the trial. 102 employees were studied over a period of three years, urinary specimens being taken every six months for cytological examination and C.E.A. estimation. The results are shown in the accompanying table. All 5 cases with raised urinary C.E.A. levels had the cliniEXPERIENCE OF C.E.A. MONITORING IN WORKERS EXPOSED TO URINARY
.
CARCINOGENS
tures.13-15 Patients with epilepsy, especially if they reside in instituare another group who suffer relative vitamin-D deficiency,15-17 their disease is multifactorial but hepatic enzyme induction under the influence of anticonvulsant drugs may play an important part. Finally, patients who have had gastrectomies may also develop simple deficiency osteomalacia’* since normal dietary vitamin-D intake may be so borderline’9 that any additional avoidance of fatty foods may be enough to produce vitamin-D deficiency.20 While we agree that public-health measures are overdue, we are anxious that any measures ultimately adopted should help to provide adequate vitamin-D to all those at risk. There is a clear danger that once the decision is made to introduce fortification of food with vitamin D, its unnecessary limitation to the
tions,
M., and others Lancet, 1976, i, 1141. M. G., Pateon, J. P. J., Haase, S., McNichol, G. W., Gardner, M. D., Smith, C. M. Scott. med. J. 1962, 7, 159. 3. Arneil, G. C., Crosbie, J. C. Lancet, 1963, ii, 423. 4. Swan, C. H. J., Cooke, W. T. ibid. 1971, ii, 456. 5. Holmes, A. M., Enoch, B. A., Taylor, J. L., Jones, M. E. Q. Jl Med. 1973, 42, 125. 6. Gupta, M. M., Round, J. M., Stamp, T. C. B. Lancet, 1974, i, 586. 7. Pietrek, J., and others ibid. 1976, i, 1145. 8. Exton-Smith, A. N., Windsor, A. C. M., Stanton, B. R. Nutrition of Housebound Old People. King Edward’s Hospital Fund, London, 1972. 9. Stamp, T. C. B., Haddad, J. G. Jr., Exton-Smith, A. N., Twigg, C. A. Ann. clin. Biochem. (in the press). 10. Exton-Smith, A. N. J. R. Coll. Physns, 1975, 9, 148. 11. Dent, C. E. Proc. R. Soc. Med. 1970, 63, 401. 12. Anderson, I., Campbell, A. E. R., Dunn, A., Runciman, J. B. M. Scott. med. J. 1966, 11, 429. 13 Aaron, J. E., Gallagher, J C., Anderson, J., Stasiak, L., Longton, E. B., Nordin, B. E. C., Nicholson, M. Lancet, 1974, i, 229. 14. Faccini, J. M., Exton-Smith, A. N., Boyde, A. ibid. 1976, i, 1089. 15. Richens, A., Rowe, D. J. F. Br. med. J. 1970, iv, 73. 16. Richens, A., Rowe, D. J. F. ibid. 1971, iv, 684. 17 Stamp, T. C. B., Round, J. M., Rowe, D. J. F., Haddad, J. G. Jr. Br. Med. J. 1972, iv, 9. 18. Morgan, D. B., Paterson, C. R., Pulvertaft, C. N., Woods, C. G., Fourman, 1. 2.
Goel,
K.
Dunnigan,
P. Lancet, 1965, ii, 1089. 19. Stamp, T. C. B , Round, J. M. Nature, 1974, 247, 563. 20. Dent, C. E., Smith, R Q. Jl Med. 1969, 38, 195.
——————————————————————————————————————t——————————————————————!————————————————————
* >35ng/ml
in
males;
> 11 Onglm-l
in
females
cal symptoms of urinary infection at the time the specimens were taken. In no case was there accompanying abnormal cytology. All 17 cases with abnormal cytology have had a full urological assessment, including cystoscopy, but no overt urothelial tumours have been found. These patients remain under observation. In 1 case from the rubber industry, the abnormal cytology may have been accounted for by the finding of urinary calculi. None of the patients with abnormal cytology had a raised urinary c.E.A. level. We conclude, therefore, that urinary C.E.A. levels offer no advantage as a screening method for the detection of urothelial cancers in patients exposed to urinary carcinogens over the established method of urinary cytology and, in fact, may be of less value. A.G.T.
was
in
receipt of a
Department of Urology, Royal Marsden Hospital, London SW3 6JJ
Kingston Hospital, Kingston upon Thames, Surrey Division of Pathology, Institute of Cancer Research, London SW3 6JJ
D.H.S.S.
fellowship. A. G. TURNER H. PALMER M. E. A. POWELL
A. MUNRO NEVILLE
Rehn, L. Archs. klin. Chir. 1895, 50, 588. Anthony, E. M., Thomas, G. M. J. natn. Cancer Inst. 1970, 45, 879. Cole, P., Hoover, R., Friedell, G. H. Cancer, 1972, 29, 1250. Veys, C. A. Br J. ind. Med. 1974, 31, 65. Hall, R. R., Laurence, D. J. R., Darcy, D., Stevens, U., James, R., Roberts, S., Neville, A. M. Br. med. J. 1972, iii, 609. 6. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 1. 2. 3. 4. 5.
