361
paternal and maternal factors in familial susceptibility. The paternal influence is more likely to involve non-sex-linked genetic factors than environmental factors. One such mechanism could involve genes linked to the major histocompatibility complex (HLA) that influence the immune response, although strong association between breast cancer and HLA has yet been demonstrated.4-7 We suggest that the family reported here might be an example of paternal genetic influence. Further studies on breast cancer and HLA might be more productive if directed at patients and their families where more than one member has been affected by the disease. C. TEASDALE University Department of Surgery, J. F. FORBES Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN. M. BAUM no
HANDICAPPED SCHOOL LEAVERS
SIR,-Your editorial (Jan. 10, p. 77) is a most interesting and stimulating one. Certainly, no one organisation can unite all the agencies that may be required by the young adult. To the formidable list of disciplines you mention, one could add, for example, the Careers Advisory Service, the Employment Medical Advisory Service, and the limbs and appliances
Family tree.
Case 1 In
centres.
(11-4)
June, 1968, the proband,
59-year-old steelworker, noticed a hard painless lump in his left breast. He presented in March, 1969, because the lump was increasing in size. Frozen-section biopsy revealed a spheroidal-cell carcinoma, and a simple mastectomy, with axillary-gland biopsy, was performed. The mastectomy specimen also showed carcinoma, but the glands were free of tumour. He remained well until October, 1975, when he complained of weight loss, epigastric pain, nausea, and vomiting. He sought medical help in January, 1976, and was noted to be cachectic and to have gross ascites. There was no sign of local recurrence
a
of his breast cancer.
Laparotomy revealed gross ascites and a massive gastric carcinoma
invading the mesentery of the small bowel with secondary peritoneal and liver deposits. Histology
Any patient who is to find his or her way through this maze of assistance will need intelligence, courage, and considerable persistence, and have these qualities in excess of the normal population. One of the main difficulties in trying to decide which of the three personal services-health, education, and social services-should be responsible for coordinating help is in trying to determine what are the real needs of the handicapped school leaver and young handicapped adult. A continuation of childhealth services into adult life does not seem to be the answer but I should be most interested to know what others think. Cheshire Area Health Authority, Pepper House, Pepper Row, Chester CH1 1ST. I. CHESHAM
numerous
be well-differentiated adenocarcinoma, there doubt that this was a second primary neobeing plasm. The patient died 4 days postoperatively with bronchopneumonia. Post-mortem examination was not performed.
showed these
to
no reason to
Case 2 (II- 5) The proband’s brother, a retired labourer, presented in 1961 at the age of 70 with a painful ulcer of the left breast which had rapidly enlarged over the preceding month. On examination there was a 4 cm x 5 cm mass in the area of the left breast fixed to both skin and pectorial muscles, and complete destruction of the left nipple by ulceration. There were clinically involved glands in the left axilla, and the chest X-ray revealed a rounded shadow at the base of the right lung. He was treated by orchidectomy and local palliative irradiation, and although he responded initially, he died in February, 1964, with metastatic disease. The proband’s daughter (III-5) was treated by mastectomy for breast cancer in 1959, when she was only 26, and she is currently alive and well. Although the development of breast cancer might have been incidental, it’ is quite possible, in view of the numbers of cancers in the family, that paternal genetic factors influenced her susceptibility. Furthermore, breast cancer is rare in women under 30,’ and familial breast cancer occurs in younger rather than older patients.2 Breast cancer has been shown to occur at 3-4 times the expected rate in both paternal and maternal aunts and grandmothers of patients with breast cancerthus implicating both 1
Birks, D M., Crawford, G. M., Ellison, L. G., Johnstone, F. R. C. Surgery Gyn Obstet 1973, 137, 21. 2 Anderson, D. E. Cancer, 1971, 28, 1500. 3 Macklin, Madge T. J. natn Cancer Inst. 1959, 22, 927.
SiR,—Iwas delighted to read your comments on services for handicapped school leavers. At the request of the D.H.S.S., regional medical officers are collecting information about young people with spina bifida, with a view to providing special centres for their care. This is welcome initiative and should remind us that all handicapped adolescents need this kind of help from a multiplicity of disciplines and professions. You are right to focus attention on the basic need, which is the establishment of follow-up centres. Such centres should provide services comparable to those available to most preschool and school-age children. This may be a matter for joint planning by education, health, and social services, but voluntary effort is traditionally the start of valuable innovation and should be encouraged. The informal approach of self-help a
groups is especially acceptable to many adolescents and may be the link with professional services. If those who are already trained and willing to provide help can be brought together in this way these young people, their families, and their family doctors will receive a valuable service which they often lack at present. Hampshire Area Health Authority, Kings Walk, Silver Hill, Winchester S023 8AF. P. G. WHITFIELD Cordon, A. L., James, D. C. O. Lancet, 1973, ii, 565. Patel, R., Habal, M. B., Wilson, R. E., Birtch, A. G., Moore, F. D. Am. J. Surg. 1972, 124, 31. 6. Takasugi, M., Teresaki, P. I., Henderson, B., Mickey, M. R., Menck, H., Thompson, R. W. Cancer Res. 1973, 33, 648. 7. Svejgaard, A., Platz, P., Ryder, L. P., Nielsen, L. S., Thomsen, M. Transplant Rev. 1975, 22, 3. 4. 5.
paternal and maternal factors in familial susceptibility. The paternal influence is more likely to involve non-sex-linked genetic factors than environmental factors. One such mechanism could involve genes linked to the major histocompatibility complex (HLA) that influence the immune response, although strong association between breast cancer and HLA has yet been demonstrated.4-7 We suggest that the family reported here might be an example of paternal genetic influence. Further studies on breast cancer and HLA might be more productive if directed at patients and their families where more than one member has been affected by the disease. C. TEASDALE University Department of Surgery, J. F. FORBES Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN. M. BAUM no
HANDICAPPED SCHOOL LEAVERS
SIR,-Your editorial (Jan. 10, p. 77) is a most interesting and stimulating one. Certainly, no one organisation can unite all the agencies that may be required by the young adult. To the formidable list of disciplines you mention, one could add, for example, the Careers Advisory Service, the Employment Medical Advisory Service, and the limbs and appliances
Family tree.
Case 1 In
centres.
(11-4)
June, 1968, the proband,
59-year-old steelworker, noticed a hard painless lump in his left breast. He presented in March, 1969, because the lump was increasing in size. Frozen-section biopsy revealed a spheroidal-cell carcinoma, and a simple mastectomy, with axillary-gland biopsy, was performed. The mastectomy specimen also showed carcinoma, but the glands were free of tumour. He remained well until October, 1975, when he complained of weight loss, epigastric pain, nausea, and vomiting. He sought medical help in January, 1976, and was noted to be cachectic and to have gross ascites. There was no sign of local recurrence
a
of his breast cancer.
Laparotomy revealed gross ascites and a massive gastric carcinoma
invading the mesentery of the small bowel with secondary peritoneal and liver deposits. Histology
Any patient who is to find his or her way through this maze of assistance will need intelligence, courage, and considerable persistence, and have these qualities in excess of the normal population. One of the main difficulties in trying to decide which of the three personal services-health, education, and social services-should be responsible for coordinating help is in trying to determine what are the real needs of the handicapped school leaver and young handicapped adult. A continuation of childhealth services into adult life does not seem to be the answer but I should be most interested to know what others think. Cheshire Area Health Authority, Pepper House, Pepper Row, Chester CH1 1ST. I. CHESHAM
numerous
be well-differentiated adenocarcinoma, there doubt that this was a second primary neobeing plasm. The patient died 4 days postoperatively with bronchopneumonia. Post-mortem examination was not performed.
showed these
to
no reason to
Case 2 (II- 5) The proband’s brother, a retired labourer, presented in 1961 at the age of 70 with a painful ulcer of the left breast which had rapidly enlarged over the preceding month. On examination there was a 4 cm x 5 cm mass in the area of the left breast fixed to both skin and pectorial muscles, and complete destruction of the left nipple by ulceration. There were clinically involved glands in the left axilla, and the chest X-ray revealed a rounded shadow at the base of the right lung. He was treated by orchidectomy and local palliative irradiation, and although he responded initially, he died in February, 1964, with metastatic disease. The proband’s daughter (III-5) was treated by mastectomy for breast cancer in 1959, when she was only 26, and she is currently alive and well. Although the development of breast cancer might have been incidental, it’ is quite possible, in view of the numbers of cancers in the family, that paternal genetic factors influenced her susceptibility. Furthermore, breast cancer is rare in women under 30,’ and familial breast cancer occurs in younger rather than older patients.2 Breast cancer has been shown to occur at 3-4 times the expected rate in both paternal and maternal aunts and grandmothers of patients with breast cancerthus implicating both 1
Birks, D M., Crawford, G. M., Ellison, L. G., Johnstone, F. R. C. Surgery Gyn Obstet 1973, 137, 21. 2 Anderson, D. E. Cancer, 1971, 28, 1500. 3 Macklin, Madge T. J. natn Cancer Inst. 1959, 22, 927.
SiR,—Iwas delighted to read your comments on services for handicapped school leavers. At the request of the D.H.S.S., regional medical officers are collecting information about young people with spina bifida, with a view to providing special centres for their care. This is welcome initiative and should remind us that all handicapped adolescents need this kind of help from a multiplicity of disciplines and professions. You are right to focus attention on the basic need, which is the establishment of follow-up centres. Such centres should provide services comparable to those available to most preschool and school-age children. This may be a matter for joint planning by education, health, and social services, but voluntary effort is traditionally the start of valuable innovation and should be encouraged. The informal approach of self-help a
groups is especially acceptable to many adolescents and may be the link with professional services. If those who are already trained and willing to provide help can be brought together in this way these young people, their families, and their family doctors will receive a valuable service which they often lack at present. Hampshire Area Health Authority, Kings Walk, Silver Hill, Winchester S023 8AF. P. G. WHITFIELD Cordon, A. L., James, D. C. O. Lancet, 1973, ii, 565. Patel, R., Habal, M. B., Wilson, R. E., Birtch, A. G., Moore, F. D. Am. J. Surg. 1972, 124, 31. 6. Takasugi, M., Teresaki, P. I., Henderson, B., Mickey, M. R., Menck, H., Thompson, R. W. Cancer Res. 1973, 33, 648. 7. Svejgaard, A., Platz, P., Ryder, L. P., Nielsen, L. S., Thomsen, M. Transplant Rev. 1975, 22, 3. 4. 5.
