Breast cancer treatment outside teaching hospitals The letter by Drs Boyle and Bell on this subject’ contains several non-sequiturs which invalidate their conclusions. In the first place, a distinction has to be made between the overall management of cancer patients and the delivery of relatively simple chemotherapy as a component of that treatment, chemotherapy which, for many patients, is a simple office procedure, and thus appropriately delivered in clinics in regional centres. There is no statistically valid evidence that breast cancer is a curable disease. In fact, there is an extensive body ofliterature to the As a generalisation, the observed mortality at ten pears is more than twice the expected mortality. The contribution of systemic therapies to the modest reduction in the odds of death reported in the recent Overview4 falls far short of that required if we are to talk of the cure of breast cancer. Drs Boyle and Bell would do well to consider the goals of therapy when treatment is palliative. Median survival is an inappropriate measure of treatment efficacy when death is predictable. Before embarking on (expensive) palliative treatment, all costs must be counted, most particularly, from the patient’s standpoint. Here, the chief criterion is that the course of the disease should be less distressing than it would have been had the patient been left alone. Drs Boyle and Bell know perfectly well that the biology of ovarian and breast cancer are totally different, yet they seek to compare the two. Patient survival in ovarian cancer is heavily dependent on the quality of the primary surgery (as exemplified in the article they q u ~ t e )which ,~ in turn depends on where the surgery is performed: surgical treatment in specialised units translates directly into improved survival.5 Similarly, survival advantages have been described for a number of other malignancies, including cancers of the cervix,’ head and neck,’ and oesophagus,’ when treated (by different modalities) in specialised units. This is quite different to breast cancer, where it is well established that the extent of locoregional therapy does not affect survival? It is perhaps, then, not surprising that their data fail to demonstrate a difference in outcome between teaching and non-teaching w hospitals. M. J. McKAY, National Health and Medical Research Council Postgraduate Scholar, Department of Medical Oncology and Palliative Care, A. 0. LANGLANDS, Chairman and Director, Division of Radiation Oncology, Westmead Hospital, Sydney, NSW. References 1. Boyle I;M,Bell DR. Breast cancer treatment outside teaching hospitals. Ausi NZ J Med 1992; 22: 309-10. 2. Langlands AO, Pocock SJ, Kerr GR. Br Med J 1979; 2: 1247-51.

702

Aust NZ J Med 1992; 22

LE, Wallgren A. Cancer 1985; 55: 658-65. Early Breast Cancer Trialists’Collaborative Group. Systemic treatment of early breast cancer. Lancet 1992; 339: 1-15, 71-85. 5. Gillis CR, Hole DJ, Still RM, Davis J, Kaye SB. Medical audit, cancer registration, and survival in ovarian cancer. Lancet 1991; 337: 61 1-2. 6. Fisher B, Bauer M, Margolese R er al. Five year results of a randomised clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312: 665-73. 7. McKay MJ, Langlands AO. The American ‘Patterns of Care’ Study: a model for the assessment of the quality of patient care in radiation oncology. Australas Radio1 1990; 34: 306-11. 8. Earlam R. Oesophageal carcinoma in North East Thames region, 1981: Medical audit using hospital activity analysis data. Br Med J 1984; 288: 1892-4. 3. Rutqvist

4.

REPLY The conclusions of our paper were that: 1. Multimodality therapy for breast cancer, which may include chemotherapy given on site and referral for radiotherapy, can be coordinated through peripheral clinics under the supervision of visiting oncologists without compromising survival. 2. That treatment on site reduces costs and disruption to patients, enhancing the ‘palliativeness’ of palliative therapy as well as cost-effectiveness of adjuvant therapy. Attention was specificallydrawn to the fact that these results do not necessarily extrapolate to ovarian cancer. Whilst accepting that survival in metastatic disease is not generally improved by systemic therapy, there remains the possibility that it might be reduced if injudicious and poorly supported therapy is administered. The similar survival curves are reassuring on this point, and length ofsurvival is ofinterest to those of us for whom no dispensation from the inevitability of death has been arranged. It is unnecessarily nihilistic to imply that systemic therapy has no impact on survival in the adjuvant setting. Both groups in our study fare as well as the treatment group in the Overview,‘ and better than the control group quoted. For these patients also the availability of therapy close to home reduces the impact of a diagnosis of breast cancer, but if such therapy was likely to lead to inferior outcomes, the patients would not be satisfied.

F. M. BOYLE, Oncology Registrar, D. R. BELL, Medical Oncologist, Department of Clinical Oncology, Royal North Shore Hospital, Sydney, NSW. Reference 1. Early Breast Cancer Trialists’Collaborative Group. Systemic treatment of early breast cancer. Lancet 1992; 339: 1-15, 71-85.

LETTERS AND CASE REPORTS