CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.

Primary treatment in breast cancer SIR, - Messrs Z Rayter and R F Phipps concentrate on the role of primary chemotherapy in reducing the extent of local disease and so permitting more conservative local treatment. ' They pay scant attention to the point that this approach may offer improved survival. The ultimate objective of primary medical treatment must be to improve cure rates and such treatment must therefore be aimed not at local disease but at the microscopic metastases that produce a fatal outcome. As recently indicated by DeVital this requires doses of chemotherapy greater than those used in the Milan study.3 Primary chemotherapy for locally advanced disease by using dose intense regimens with colony stimulating factors and autologous bone marrow transplantation as supportive therapy is being used in America with the intent of cure. Some evidence suggests, however, that reducing the extent of subsequent local treatment may increase the likelihood of local relapse, and in most studies mastectomy is used.4 A recent review suggests that relapse and survival rates are favourable, but judgment must await the results of controlled randomised trials.5 Theoretical reasons exist to support using chemotherapy before local treatment.' Ragaz et al suggest that even the short delay in instituting chemotherapy caused by surgery or radiotherapy may reduce its effectiveness on micrometastatic disease.6 Messrs Rayter and Phipps also only briefly mention the value of leaving the primary tumour in situ to indicate drug response, as first explored by Thomlinson." One of the attractions of primary medical treatment of operable disease is the ability, through observing the behaviour of the primary tumour, to determine sensitivity to antioestrogen therapy and thus its appropriateness for long term use. Our continued experience with managing large operable tumours by antioestrogen therapy or chemotherapy, or both, supports our initial report that statistical analyses of precise measurements are useful for assessing therapeutic efficacy.9" We do not know whether long term treatment of sensitive tumours with antioestrogens can substitute for regimens of intensive chemotherapy, but in view of the great difference in morbidity this must be determined. Another indication for primary medical therapy, which Messrs Rayter and Phipps did not discuss, is the use of tamoxifen for operable disease in elderly women. Not only does this again allow determination of those with responsive disease but continued administration of tamoxifen may make surgery unnecessary. We recently showed the value of immunocytochemical assays of oestrogen receptors in cells obtained by fine needle aspiration in defining a subset of patients in whom this approach is unlikely to succeed."

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We predict that primary medical therapy aimed at cure will become the rule in many patients with palpable invasive breast cancer in whom micrometastases are likely. Local surgery and radiotherapy will become adjuvant treatment, and surgery as the only treatment will be reserved for patients with small in situ and invasive cancers that have been detected by mammography or that are known, on account of their biological characteristics, to have an uncommonly good prognosis. A PATRICK FORREST ELAINE D C ANDERSON UDI CHETTY Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh EH8 9AG I Rayter Z, Phipps RF. Primary medical treatment in breast cancer. BMJ 1991;302:2-3. (5 January.) 2 DeVita VT Jr. Primary chemotherapy can avoid mastectomy but there is more to it than that. J7 Nail Cancer Inst 1990;82: 1522-4. 3 Bonnadonna G. Conceptual and practical advances in the management of breast cancer. J Clin Oncol 1989;7:138-97. 4 Swain SM, Sorace RA, Bagley CS, et al. Neoadjuvant chemotherapy in the combined modality approach of locally advanced non-metastatic breast cancer. Cancer Res 1987;47: 3889-94. 5 Swain SM, Lippman ME. Locally advanced breast cancer. In: Bland KL, Copeland EM, eds. The breast. Philadelphia: Saunders, 1991:843-62. 6 Ragaz J, Baird R, Rebbeck P, Goldie J, Coldman A, Spinelli J. Neoadjuvant (preoperative) chemotherapy for breast cancer. Cancer 1985;56:719-24. 7 Thomlinson RH. Measurement and management of carcinoma of the breast. Clin Radiol 1982;33:481-93. 8 Thomlinson RH. Cancer: the failure of treatment. Brj Radiol 1987;60:735-5 1. 9 Forrest APM, Levack PA, Chetty U, et al. A human tumour model. Lancet 1986;ii:840-2. 10 Anderson EDC, Hawkins RA, Anderson TJ, Leonard RCF, Chetty U, Forrest APM. Primary systemic therapy for operable breast cancer. BrJ7 Cancer (in press). 11 Gaskell DJ, Hawkins RA, Sangster K, Chetty U, Forrest APM. Relationship between immunocytochemical estimation of oestrogen receptors in elderly patients with breast cancer and response to tamoxifen. Lancet 1989;i: 1044-5.

Axillary dissection in primary breast cancer SIR,-Mr P J O'Dwyer points out that morbidity after axillary node clearance is considerable,' and it has been found that only about 10% of women with non-palpable lesions have axillary node disease.2 Impalable breast cancer is now diagnosed by using stereotactic fine needle aspiration, and thus no histological diagnosis is available before surgery. As some patients will turn out to have non-invasive breast cancer, it would be inappropriate during an operation to excise abnormalities found on mammography to perform axillary node clearance; it would, however, seem logical to perform axillary node sampling, a procedure that Mr O'Dwyer acknowledges can give an accurate assessment of axillary lymph node disease.' Those 80-90% of

patients who are axillary node negative can then have radiotherapy limited to the breast and so avoid the unnecessary morbidity associated with axillary radiotherapy or axillary node clearance. All patients with breast cancer were once treated with a standard operation. As we have learnt more about the biology of breast cancer, so we now tend to treat patients on a selective basis. We believe that the same is likely to be true of the treatment of the axilla in breast cancer, and we are participating in a prospective assessment of morbidity after axillary node sampling and axillary node clearance in patients treated either conservatively or by mastectomy. Studies such as these should determine which patients will be best treated by axillary node sampling and which by axillary node clearance. Until data from such studies are available the views expressed in recent articles on this subject remain personal.45 J MICHAEL DIXON U CHETTY

Royal Infirmary, Edinburgh EH3 9YW I O'Dwyer PJ. Axillary dissection in primary breast cancer. BMJ 1991;302:360-1. (16 February.) 2 Anderson TJ, Alexander F, Chetty U, et al. Comparative pathology of prevalent and incidence cancers detected by breast screening. Lancet 1986;i:5 19-22. 3 Steele RJC, Forrest APM, Gibson T, et al. The efficacy of lower axillary sampling in obtaining lymph node status in breast cancer: a controlled randomised trial. BrJSurg 1985;72:368-9. 4 Ball ABS, Waters R, Thomas JM. Formal axillary dissection. BrJ3 Hosp Med 1990;44:396-8. 5 Fentiman IS, Mansel RE. The axilla: not a no go area. Lancet

1991;337:221-3.

SIR,-Mr P J O'Dwyer's editorial' and an article by Fentiman and Mansell show that some surgeons are needlessly confused. Research shows that in terms of survival there is nothing to choose between more conservative and more radical methods of treating primary breast cancer.35 Moreover, in terms of morbidity axillary dissection or irradiation, or both, proved harmful to some patients. It took nearly half a century for this message to be appreciated by most surgeons in Britain.6 Women with breast cancer thus began to benefit from more kindly care without detriment to their survival and with less morbidity. It was inevitable that, with the introduction of new supplementary methods of treatment, surgeons and other oncologists would develop a fresh interest in classifying their patients for the purposes of more selective chemotherapy. Methods used include tumour grading and lymphocytic reaction, tests ofhormone dependency, and axillary (or even mediastinal) node sampling. And what is the motivation for all this? Largely to avoid chemotherapeutic harm to those patients thought to have an inherently good prognosis, thus confining the treatment to those who are supposedly more threatened. Sadly, many of these new weapons damage the natural immunity of some patients.

BMJ VOLUME 302

9 MARCH 1991

Primary treatment in breast cancer.

CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on...
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