248

Yegen C, Aktan AÖ, Doşluoğlu H, Bozkurt Ş, Yalin R, Goksel HA Distribution of axillary lymph nodes in carcinoma of the breast. Turkish J Surg 1991; 7: 221-25. (English abstract.) 2. Doşluoğlu H, Aktan AÖ, Yegen C, Bozkurt Ş, Yalin R, Goksel HA. Axillary nodal status and its impact on survival following radical mastectomy. Turkish J Surg 1992; 8: 45-50. (English abstract.) 3. Aktan AÖ, Gökoz A, Goksel HA. Paget’s disease without a palpable mass in the breast. Br J Surg 1990; 77: 226-27. 1.

Bristol Cancer

Help Centre

SiR,—Dr Kingsley Pillers (June 13, p 1483) notes that among with breast cancer, histological grade III malignancies are

women

frequent in patients aged under 35 than in older patients. There is also ample evidence from recent UK cancer registry datal and from many other UK and US studies over the past 40 years (an early example is citedz) that short-term survival is generally poor for this age-group. I believe this is relevant to the long-running debate. over the report on the Bristol Cancer Help Centre (BCHC), which suggested that women with breast cancer fared worse if they attended the centres3 In that study the BCHC cases were considerably younger on average than the controls. Women under 45 formed 53 % of BCHC cases and only 36% of controls, and presumably the cases included more under-35s than the controls. The Cox regression analysis used (which assumed that rates of relapse or death could be expressed as the product of factors dependent on age, stage of disease, date of diagnosis, and BCHC attendance) apparently allowed only one factor for all women under 45, even though Cox’s method would have allowed the use of a factor that was a function of exact age. The poorer survival of the youngest women would thus inevitably be attributed to BCHC attendance and not to the true cause, their age. Despite all the evidenceChilvers and colleagues deny that breast tumours tend to grow faster in young women.5,6 The hostility to the report among the patients was such that they formed a protest group, which produced a 30-minute television programme and submitted a formal complaint to the Charity Commissioners requesting an independent inquiry. The programme (Cancer Positive, Channel 4) was repeated on July 23, and I think it a good opportunity to ask again if we can find out in more detail what went wrong. We need to know, in particular, the exact age distribution of the under-45 group. I suggest that the raw data should be made available (subject to the agreement of the patients) so that independent statisticians can form their own conclusions. more

been diagnosed as PID), results such as those of Farley et al could have been found even in the absence of a true association if clinicians had suspected that PID risk is especially high immediately after IUD insertion. If there is a true increase in risk of symptomatic PID associated with IUD insertion, this may have little bearing on the issue of risk of conditions such as infertility and ectopic pregnancy that result from lasting tubal damage. Salpingitis and subsequent tubal dysfunction frequently arise in the absence of any symptom of disease. Serological evidence of chlamydial infection in particular has been reported among women with laparoscopic evidence of tubal damage, even in those with no history of PID, at a greater frequency than among women with no tubal diseaseAlso, chlamydial infection has repeatedly been shown to affect the risk of two important sequelae of salpingitis-tubal infertility and ectopic

pregnancy .1,3 It seems that the use of an IUD may predispose to infection with Chlamydia trachomatis; although only a small proportion (13%) of women with serological evidence of previous chlamydial infection reported ever having been diagnosed with PID, chlamydial positivity was more than three times as likely among women who had used

an

IUD than among those who had not,

even

after

adjustment for number of sexual partners and age (Scholes D, et al, unpublished). Although such infections might occur mainly at the time of IUD insertion, many might arise subsequent to insertion: it is recommended that women who are to receive an IUD should be at low risk of having or acquiring a sexually transmitted disease, but we are concerned that if women choose to retain their IUDs for the maximum lifespan of the device (as Farley et al suggest), changes in lifestyle may increase the likelihood of exposure to sexually transmitted agents months or years after insertion. It seems unreasonable to expect that all women will remember or will be reminded by health care professionals to re-evaluate their contraceptive choice before such lifestyle changes. The potential consequences of salpingitis-such as infertility and ectopic pregnancy--can be devastating. Thus, studies that attempt to assess risk of salpingitis and other infectious complications of IUD use should be well controlled and monitor both the occurrence of clinically evident and symptomless disease. Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington 98104, USA

MARY ANNE ROSSING NOEL S. WEISS

W, Rolfs RT, Aral SO. Sexually transmitted diseases, pelvic inflammatory disease, and infertility: an epidemiologic update. Epidemiol Rev 1990; 12: 199-220 2. Patton DL, Moore DE, Spadoni LR, Soules MR, Halbert SA, Wang S-P A 1. Cates

1 Heron Way, Horsham RH13 6DF, UK

K. J. GOODARE

1. Office of Population Censuses & Surveys. OPCS Monitor 1988; MB1 88/1: table 1(b). 2. Goldenberg IS, Bailar JC III, Hayes MA, Lowry R. Female breast cancer: a re-evaluation. Ann Surg 1961; 154: 397-404. 3. Bagenal FS, Easton DF, Harris E, Chilvers CED, McElwain TJ. Survival of patients

with breast cancer attending Bristol Cancer Help Centre. Lancet 1990; 336: 606-10. Johnson AE. Growth rates of breast tumours. Lancet 1992; 339: 59. 5. Chilvers CED, Easton DF, Bagenal FS, Harris E, McElwain TJ. Bristol Cancer Help Centre. Lancet 1990; 336: 1186-88. 6. Chilvers CED, Bagenal F, Harris E. Bristol Cancer Help Centre. Lancet 1991; 338:

4.

1402.

IUDs and pelvic inflammatory disease SiR,—Dr Farley and colleagues’ findings (March 28, p 785) suggesting that pelvic inflammatory disease (PID) among intrauterine device (IUD) users is most strongly related to the insertion process, should be interpreted with caution. One issue is the lack of a control group of women who did not use an IUD. If a group of women whose first contraceptive method was other than the IUD were followed in a manner similar to the IUD users, they too might have had infections diagnosed more frequently shortly after contact with a health care professional. Such a pattern of occurrence could result because the women had been made aware of the signs and symptoms of pelvic infection at the initial visit, thereby increasing the tendency to recognise and seek care for these symptoms for a brief time. Second, because the clinical diagnosis of PID is not specific (a reviewl reported laparoscopic evidence of tubal involvement in only 60% of patients whose symptoms had

fallopian tube’s response to overt and silent salpmgnis. Obstet Gynecoll989; 73: 622-30. Sherman KJ, Daling JR, Stergachis A, et al. Sexually transmitted diseases and tubal comparison of the

3.

pregnancy. Sex Transm Dis

1. 1990; 17: 115-21.

*** This letter has been shown to Dr Farley and colleagues, whose reply follows.-ED. L. SIR,-Although Dr Rossing and Dr Weiss advocate caution in the interpretation of our results for the pattern of pelvic inflammatory disease (PID) risk among a large cohort of intrauterine device (IUD) users, we doubt the plausibility of their suggestion that the six-fold higher risk seen in the first 20 days after insertion may be the result of an increased reporting rate from recent contact with health care personnel. If their hypothesis is correct we would expect a gradual decline in risk rather than the sudden drop seen after 20 days. Moreover, this striking difference in risk has not, as far as we are aware, been reported for women initiating use of other contraceptive methods, and we found no corresponding increase in the risk of PID around the times of the scheduled follow-up visits. Similarly, with the caution that changes in lifestyle may expose IUD users to increased risk of exposure to sexually transmitted diseases (STDs) many years after insertion, Rossing and Weiss take issue with our suggestion that, in the absence of any desire for change or other contraindications, women continue with the device up to its recommended maximum lifespan. Potential changes in lifestyle are not in our view a contraindication to use

of

an

IUD and all IUD

users are

recommended to have a review of the

regular health checks, which would include

249

COMPARISON OF ASSAYS OF CAPSID-INDETERMINATE SERUM SAMPLES

appropriateness of the method. The lack of any increase in the risk of PID with long-term use of the device suggests that such changes in lifestyle that put women at higher risk of STDs are not a major difficulty among our cohort of almost 23 000 users followed for over 50 000 woman-years. We are aware of the limitations of our results in that we had no measure of the sequelae of the episodes of PID reported in the cohort, but wonder about the costs, practicality, and benefits of monitoring IUD users for not only clinically evident but also symptomless disease. The most important advice to an IUD user, and to all sexually active women irrespective of contraceptive method, is the avoidance of STD and prompt contact with health care personnel if any symptoms suggestive of pelvic infection arise. Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organisation,

P. J. ROWE

1211 Geneva, Switzerland

O. MEIRIK

Health Decisions Inc, Chapel Hill, North Carolina, USA

M. J. ROSENBERG J-H. CHEN

z-

T. M. M. FARLEY

i

*In-house assay with the

NH2-termlnal

part of the recombinant

capsid protein

as

antigen."

Evaluation of anti-HCV capsid indeterminate serum samples SIR,-In hepatitis C virus (HCV) confirmatory testing of blood donors, Follen et all reported a good correlation between recombinant immunoblot assay (RIBA-2) reactivity and polymerase chain reaction (PCR) positivity. However, only a few of the RIBA-2 indeterminate donations reacted with PCR. Different

interpretations for this finding have been proposed: infections with divergent variants of HCV or sequential loss of antibodies from apparently recovering individuals.2,3 Boudart and colleagues,4 however, showed that most c22 RIBA-2 indeterminate blood donors are not implicated in early anti-HCV seroconversion. Because such reactions were also negative with new screening tests, they hoped that these samples were showing false c22 positives or true c22 positives not implicated in hepatitis transmission. In our confirmation studies we also found a large number of capsid-indeterminate samples (only reactive with the so-called structural antigen in the Abbott Supplemental Assay) (Wanmans L, et al, unpublished). To evaluate this reaction pattern we have investigated a series of 36 capsid-indeterminate samples in more detail. These samples were selected on the basis of a strong serological reaction (ratio 4-0) in an attempt to focus on specificity-based differences between assays. Different screening assays (Abbott HCV EIA second generation, Ortho HCV ELISA second generation, Sanofi-Pasteur Monolisa anti-HCV, UBI HCV EIA) were evaluated in relation to established and newly developed immunoblot assays (Chiron RIBA HCV second generation, Chiron RIBA HCV SIA prototype, Innogenetics INNO-LIA Ab) and PCR.5 With a combination of the immunoblot assays the 36 capsidindeterminate serum samples could be divided into three groups: 5 reactive sera (1 serum was reactive on c33 and c22 in the RIBA-2, were c22 indeterminate in the RIBA-2 but reactive against c100[p] and c22[p] in the RIBA-SIA, and 5 sera were reactive against several capsid-peptides in the INNO-LIA), indeterminate sera (reactive against c22 in the RIBA-2 and against c22[p] in the RIBA-SIA but only against one capsid-peptide in the INNOLIA) ; and non-reactive sera (9 sera were non-reactive in the RIBA-2 and for 13 sera c22-reactivity in the RIBA-2 could not be confirmed in the RIBA-SIA nor in the INNO-LIA) (table). The established screening assays (Abbott, Ortho) detected nearly all positive serum samples, whereas the new screening assays (Monolisa, UBI) almost exclusively detected the 14 that were positive in the newly developed immunoblot assays. The same samples were also detected with our Ag520 EIA. Moreover, PCR-positive samples were found only among the 11 immunoblotreactive samples. In a control series of 81 serum samples in which the reaction on the structural antigen was confirmed by a reaction on the non-structural antigen in the Abbott Supplemental Assay, this peculiar reaction pattern on immunoblots was not seen, and all sera

were positive in the different screening assays and in the Ag250 EIA. From these data we conclude that by the introduction of new screening and confirmation protocols the difficulty of capsidindeterminate sera has been largely solved. Some of these samples can unequivocally be classified as reactive. However, in accord with those of Boudart et al,4our data suggest that most capsidindeterminate reactions in blood donor screening are attributable to a false-positive reaction with the capsid antigen in established

screening assays.

Belgian Red Cross Blood Transfusion Centre, 3000 Leuven, Belgium

H. CLAEYS A. VOLKAERTS H. VERHAERT H. DE BEENHOUWER C. VERMYLEN

1. Follett EAC, Dow BC, McOrnish F, et al. HCV confirmatory testing of blood donors. Lancet 1991; 338: 1024. 2. Chan SW, Simmonds F, McOrnish F, et al. Serological responses to infection with three different types of hepatitis C virus. Lancet 1991; 338: 1391. 3. Allain JP, Rankin MC, Kuhns MC, McNamara A. Clinical importance of HCV confirmatory testing in blood donors. Lancet 1992; 339: 1171-72. 4. Boudart D, Lucas JC, Adjou C, Muller JY. HCV confirmatory testing of blood donors. Lancet 1992; 339: 372. 5. De Beenhouwer H, Verhaert H, Claeys H, Vermylen C. Confirmation of HCV positive blood donors by immunoblotting and PCR. Vox Sang (in press). 6. Claeys H, Volckaerts A, De Beenhouwer H, Vermylen C. Association of hepatitis C virus carrier state with the occurrence of hepatitis C virus core antibodies. J Med Virol 1992; 36: 259-64.

Detection of HCV in seronegative donors with raised ALT SiR,—Dr Sugitani and colleagues (April 25, p 1018) note the difficulty of detecting antibodies to HCV with various tests on serum samples from donors with raised alanine aminotransferase (ALT) and HCV detectable by PCR. Among 108 samples with ALT higher than 100 IU/1, a subset of 19 had HCV RNA demonstrable by two separate PCR assays. However, anti-HCV reactivity was demonstrable only in 13 specimens. In a similar study of 101 donors with ALT exceeding 68 IU/1, our group found that 11 were HCV RNA positive, by use of PCR primer pairs from the NS3 region; all 11 were anti-HCV (C 100-3) reactive. We are now investigating the prevalence of HCV viraemia in plasma units rejected for transfusion because of ALT elevation (above 45 IU/1) but seronegative for all routinely screened viral markers. We used a highly sensitive hemi-nested reverse transcription PCR (RT-PCR) assay with primers from the 5’-non-coding region of HCV that can reliably amplify 10 molecules of in-vitro-transcribed HCV RNA (Ulrich P, et al, unpublished results). Pools of plasma from 4 donors (2-5 ml per donor) were screened for HCV RNA by RT-PCR. For any reactive