Reduction in mortality from breast cancer

Although no supporting data is given,the editorial (BMJ
28th January) suggests that adjuvant treatments with
chemotherapy or hormones are more likely than
screening to be responsible for reduction in breast
cancer mortality,

However, the reason(s) for the improved survival is
much more complex than suggested.

In the 1970's surgeons felt they 'owned' the patient and
they were usually the only ones who decided which
women had anything other than surgery. Nowadays
there is an acceptance that overall management is best
decided by a multidisciplinary team and that a number
of persons - medical and non-medical - have a vital 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).

The editorial also fails to give due credit to radiotherapy
where there is now evidence that its omission
post-mastectomy even after chemotherapy or
hormones leads to unacceptable local relapse (2) 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 para-medical services such as
psycho-oncology, although the effect is more difficult to
quantify.

(1) 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
- 560.

(2) Taghian A, Jeong J-H, Mamounas E 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 - 4254.

(3) 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 -121.

Competing interests:
None declared