Letters

Optimum treatment for young women with breast cancer needs to be determined

EDITORThe paper by Kroman et al on factors influencing the effect of age on prognosis in breast cancer has important implications for service delivery,¹ increased amounts of chemotherapy being required for young women. The authors imply that only women at high risk received adjuvant chemotherapy. In all, 36.3% of their 867 patients under 35 were in the low risk group, an excess mortality being associated with not receiving chemotherapy.

We used the Yorkshire Cancer Registry (now part of the Northern and Yorkshire Cancer Registration and Information Service) to investigate the uptake of chemotherapy in this group of patients over the 15 years from 1980 to 1994 and determine its effect on survival.

Only 304 (19.8%) of the 1534 patients under 35 received adjuvant chemotherapy. Their overall five year survival rate was 60% (95% confidence interval 54.8 to 65.8) compared with 63% (60.6 to 66.0) in those who did not receive chemotherapy. When 41 patients who presented with overt metastatic disease were excluded from the analysis the five year survival rates increased to 63% and 64% respectively. The paper from Denmark does not give five year survival rates, so we cannot compare data.

We found no significant improvement in survival for those receiving chemotherapy in either the individual time cohorts or the group as a whole. A Wilcoxon (Breslow) test for equality of survivor functions showed no significant differences between the groups receiving chemotherapy and those who did not (P=0.31). The rate of chemotherapy use in this age group increased from 8% in 1980-4 to 17% in 1985-9 and 32% in 1990-4.

Reasons for the lower use of chemotherapy in Yorkshire over this time may be related to the comparative lack of surgical specialisation and lack of non-surgical oncology. The Danish patients were all included in trials in which chemotherapy was used. We previously found large variations in the use of chemotherapy and radiotherapy in Yorkshire,² all patients with breast cancer population receiving suboptimal treatment.³ Chemotherapy may have been given only to those under 35 with conventionally poor prognostic features, so no overall effect of treatment would be seen.

With the end of high dose chemotherapy as an evidence based option the optimum type of chemotherapy for this group of patients needs defining.

Richard Sainsbury, consultant surgeon. 
Huddersfield Royal Infirmary, Huddersfield HD3 3EA jrcs{at}compuserve.com

Bob Haward, professor of cancer studies. 
University of Leeds, Leeds LS2 9JT