BMJ  2005;330:1025 (30 April), doi:10.1136/bmj.330.7498.1025-a

Letter

Reduction in mortality from breast cancer

Reasons for improved survival are more complex than suggested

EDITOR—Although no supporting data are given, Jones in her editorial proposes that adjuvant treatments with chemotherapy or hormones are more likely than screening to be responsible for reduction in breast cancer mortality.¹ However, the reason(s) for the improved survival is much more complex than suggested.

In the 1970s surgeons felt they "owned" the patient and were usually the only ones who decided which women had anything other than surgery. Nowadays it is accepted that overall management is best decided by a multidisciplinary team and that several people—medical and non-medical—have a crucial role in the management. This very basic change in the overall management of breast and other cancers has been overlooked in the rush to promote the use of adjuvant chemotherapy, although its benefit has been very much over-rated.¹

Additionally the editorial does not give due credit to radiotherapy—there is now evidence that its omission after mastectomy even after chemotherapy or hormones leads to unacceptable local relapse² and that there is an excess mortality (or loss of survival benefit) of 8.6% for women who do not receive radiotherapy after breast conserving surgery.³ As well as the "medical" treatments, much has been accomplished by paramedical services such as psycho-oncology, although the effect is more difficult to quantify.

Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia gmorgan1{at}bigpond.net.au

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Competing interests: None declared.

References

1. Jones AL. Reduction in mortality from breast cancer. BMJ 2005;330: 205-6. (29 January.)[Free Full Text]
2. Morgan G, Ward R, Barton M. The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies. Clin Oncol (R Coll Radiol) 2004;16: 549-60.
3. Taghian A, Jeong JH, Mamounas E, Anderson S, Bryant J, Deutsch M, et al. Patterns of locoregional failure with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five National Surgical Adjuvant Breast and Bowel Project Randomised clinical trials. J Clin Oncol 2004;22: 4247-54.[Abstract/Free Full Text]
4. Vingh-Hung V, Verschraegen C, for the breast-conserving surgery project. Breast-conserving surgery with or without radiotherapy: pooled analysis for risks of ipsilateral breast tumour recurrence and mortality. J Natl Cancer Inst 2004;96: 115-21.[Abstract/Free Full Text]

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Relevant Article

Reduction in mortality from breast cancer

Alison L Jones
BMJ 2005 330: 205-206. [Extract] [Full Text] [PDF]