1393
are high. However, the price of medical medical consultation procedures is low under Japan’s and reimbursement system, physicians therefore tend to of or procedures.14-16 The volume consultations the increase in visits of number Japan is extremely high physician other countries’" with Thus, doctors are compared clinics their in to reluctant open poorly populated areas since time for is patients longer than it is in urban areas. travelling data show that the percentage of private Published to practitioners all practising physicians decreased from 414% to 28-6% in 1980 and 1990, respectively, and that their absolute number also decreased.8 The average age of private practitioners was 59-7 years in 1990 (that of rural practitioners was 60-7), compared with 56-4 years in 1980 (58-3). The ageing of physicians providing primary care has changed in line with that of the rural population of Japan. Both central and local government, together with Japanese medical societies, have attempted to tackle the issue of maldistribution. They have provided scholarships for medical students to work in prefectures where there was a physician shortage; Jichi Medical School trains doctors to work in underprivileged areas; and public clinics and hospitals have been provided for physicians who work in rural practices.’ Our study suggests that these efforts have failed. Japan is no exception to this difficulty.",", Compulsory methods or financial incentives for individual physicians to move are unlikely to be effective. However, several solutions are possible. First, incentives could be provided for groups of physicians, such as medical schools, to contribute to rural practice. Second, the creation of training systems for primary care physicians, together with a favourable payment system for primary care, is necessary. Third, coordination and collaboration between a front-line clinic and supporting hospitals should be reinforced so that single-physician practices would not be isolated professionally and psychologically. These issues require urgent attention since access to health care is an indispensable part of medical practice.
opening
a
clinic or
We thank Ms Kaoru Slnbuta, Ms Chizuko Imai, and Ms Hiromi Kobayashi for data preparation; and Dr Bong-min Yang and Dr Shosaku Nakayama for their comments. The study was supported by a grant-in-aid (No 04770342) from the Japan Ministry of Education, Science, and Culture.
REFERENCES
Ministry of Health and Welfare. Considering the number of physicians: the final report of task force on future supply and demand for physicians. Tokyo: Nihon Iji Shinposha, 1986. 2. Kokumin iryo taisaku taiko (Principles of the national health policy of the Liberal Democratic Party). Jpn Med J 1969; 2347: 103-09. 3. Koku-koritsu ika daigaku 15-kou no zousetsu wo (Another 15 public medical schools will open). Jpn Med J 1972; 2533: 99-100. 4. Kosei Tokei Kyokai. Kokumin eisei no doko (Health state of the nation, annual report). Tokyo: Kosei Tokei Kyokai, 1991. 5. Todaro MP. Economic development of the third world. New York: Longman, 1989: 143-86. 6. Yang BM, Huh J. Physician distribution and health manpower policy in Korea. Asia-Pacific J Public Health 1989; 3: 68-85. 7. Morrow JS. Toward a more normative assessment of maldistribution: the Gini index. Inquiry 1977; 14: 278-92. 8. Ministry of Health and Welfare. Ishi shikaishi yakuzaishi chosa (Survey of physicians, dentists, and pharmacists in 1980 and 1990). Tokyo: Kosei Tokei Kyokai, 1982, 1992. 9. Statistic Bureau, Management and Coordination Agency. 1980 and 1990 population census of Japan. Tokyo: Nihon Tokei Kyokai, 1982, 1992. 10. Newhouse JP, Williams AP, Bennett BW, Schwartz WB. Where have all the doctors gone? JAMA 1982; 247: 2392-96. 11. Newhouse JP. Geographic access to physician services. Ann Rev Public 1.
Health 1990; 11: 207-30. 12. National Institute of Hospital Administration. Kinmui no mirai ni kansuru anketo (The questionnaire survey on the future of salaried
physicians). Report of comprehensive study on primary care. Tokyo: Koseirho, 1990. Kaigyoi taisakuk wo isoge (Urgent measures should be taken for general practitioners). Shakai Hoken Junpo 1992; 1761: 6-10. 14. OECD. Financing and delivering health care: a comparative analysis of OECD countries. Paris: OECD, 1987: 73-74. 15. Iglehart JK. Japan’s medical care system. N Engl J Med 1988; 319: 13. Hamu S.
807-12.
Ikegami N. Japanese health care: low cost through regulated fees. Health Aff 1991; 10: 87-109. 17. Rosenthal M, Butter I, Field MG. The political dynamics of physician manpower policy. Amsterdam: Elsevier, 1990. 18. Frenzen PD. The increasing supply of physicians in US urban and rural areas, 1975 to 1988. Am J Public Health 1991; 81: 1141-47. 16.
VIEWPOINT Malignant melanoma excision margins: making a choice The incidence of cutaneous malignant melanoma continues to increase and surgery remains the major treatment. While we wait to find out what is adequate local excision from prospective, randomised trials now in progress, we have to rely on available received wisdom and we need to consider how wise we are. Until the 1970s wide local excision, if possible with 5 cm margins of normal skin, was routine. It is now fashionable to blame W. Sampson Handley, writing in The Lancet in 1907, as the villain behind this tradition.1 In the 19th century malignant melanoma was rare. Because of the poor prognosis, some argued against any surgery2but gradually, and before Handley, an international tradition of wide excision in apparently curable cases developed: "not only remove the disease, but cut away some of the healthy parts" (England, 1857);4 "1st eine Geschwulst scheinbar local, so dass man auf reine Exstirpation rechnen kann, so ist die
Exstirpation vorzunehmen."(Germany, 1887); and "une extirpation aussi large que possible." (France, 1888).3 After his early studies on breast cancer, from which he concluded that it spread mainly by permeation of the surrounding tissues, Handley studied one autopsy of a woman with disseminated malignant melanoma. With no recurrence at the primary site on the right heel, he examined a strip of tissue from the right thigh with multiple metastases. This showed spread of tumour further along the deep fascia than the skin or muscle. From this he concluded that malignant melanoma surgery should include a circular incision through the skin round the tumour "as a rule about an inch from the edge of the tumour... just deep enough to expose the subcutaneous fat ... The
skin, with
a
thin
ADDRESS: Department of Plastic Surgery, St Luke’s Hospital, Bradford, West Yorkshire BD5 0NA, UK (M. J. Timmons, FRCS).
1394
For tumours less than 0-76 mm thick, further 1 cmmargin excision of narrow margin biopsy sites is advocated9 but a 2-3 mm margin excision biopsy appears sufficient. 14 In a prospective, randomised study of malignant melanomas 2 mm thick or less, disease-free and overall survival and the frequency of regional and distant metastases were similar for 1 cm or 3 cm skin margins in 612 cases." 4 patients, all with tumours 1-11 mm or more thick and 1 cm margins, had a local recurrence as the first site of relapse. This is usually cited as the key study showing that 1 cm margins are adequate for melanomas thinner than 1 mm. However, this World Health Organization trial was haunted by the ghosts of Handley and others; the protocol dictated that beyond the 1 cm or 3 cm skin margins an additional 1-2 cm margin of subcutaneous fat down to muscle fascia had to be taken. Only Veronesi and Cascinelli, two members of the WHO Melanoma Group, stress the importance of the additional margin of fat.15 They do not say why. More noteworthy are the similar outcomes of the two treatment groups, making it difficult for surgeons and patients to decide whether or not 3 cm margins for all melanomas 1-2 mm thick are justifiable to reduce the small risk of local
attached layer of subcutaneous fat, is now to be separated from the deeper structures for about two inches in all directions round the skin incision." The tumour, with its margin of skin, deep fat, and fascia, and part of the underlying muscle, were then to be excised. From 1916, wide local excision was suggested by large series in the USA, most notably the 1190 cases reported by Pack and colleagues.5 Pack concluded it could not be definitely stated what margin of normal skin around a malignant melanoma is necessary. By 1934, 3 cm margins were being recommended.6 5 cm margins were in use in the 1940s/ though it is not clear who first thought of them. The principle of wide excision was supported by dermatologists, radiotherapists, and pathologists as well as surgeons. More recent pathological and clinical findings show it is not enough just to base surgery on this traditional
principle.
Pathology Handley noted that subcutaneous nodules commonly appeared near the scar after excision of melanotic growths, though this was not so in the necropsy he studied. With few cases available, he used pathology to devise his treatment plan. Noting the similarity between the spread of melanoma and breast cancer he transferred his breast cancer surgical principles to malignant melanoma. Others also used pathology to rationalise treatment. For example, a "field change" of atypical melanocytes or increased numbers of melanocytes was suggested to justify wide excision margins. These changes are now thought to be due to chronic sun 8 exposure alone. Although the full clinical significance of other findings such as micrometastases seen with thick melanomas9 is unclear, modem pathology does throw doubt on wide excision margins. Some even argue that modem pathology justifies narrow margins. Not only is the logic of this suspect, it is also being applied to a vague concept since "narrow margin" is as imprecise as "wide margin". Some pathologists acknowledge observer error in the measurement of melanomas but others assert that if no neoplastic melanocytes are found in excision biopsy margins "no further local surgery is warranted" .10 Clinically this may be true for thin melanomas but it may not be true for thick melanomas, which have more risk oflcoal recurrence." Local recurrences receive little attention in some commentaries, which concentrate on survival rates, there being no clear evidence that increasing excision margins improves survival."’" Here it is again worth comparing malignant melanoma with breast cancer. With both, local recurrence after complete local excision is probably an indicator not a cause of a poor prognosis.lm3 Additional surgery or radiotherapy after complete local excision of breast cancer appear more to reduce local recurrences than to improve overall prognosis13 but are still recommended. Similarly if wider excision can at least reduce local recurrences of malignant melanoma it is reasonable to consider it. Whether or not wider excision does reduce local recurrences and how wide is wide are empirical clinical questions not answerable by histopathology. metastases
Patients
Handley’s idea of measuring excision margins was an important step towards a scientific study of surgery for malignant melanoma. The other important step was measurement
of tumour thickness.
recurrence.
For melanomas more than 2 mm thick, one retrospective study suggested that local recurrence rates are more related to tumour thickness than to excision margins;12 later analysis revealed an increased risk of local recurrence with margins 2 cm or less for melanomas more than 2 mm thick.16 Another retrospective review of tumours 3-1mm or more thick found that margins 1 cm or less were followed by more local recurrences than 2-3 cm margins, while 2-3 cm margins were as effective as 4 cm margins." (2-3 cm is about 1 inch, Handley’s skin margin.) Even 5 cm margins are no guarantee against local recurrence of melanomas more than 2 mm thick.l’ We await the results of a prospective, randomised trial comparing 2 cm and 4 cm margins for 1-4 mm thick melanomas," its conclusions will be diluted by the inclusion of 1 mm tumours, known to have a good prognosis, and by the 4 cm margins which many now consider excessive. Some suggest that excision margins should be decided from traditional observation and palpation; 18 lesions looking like malignant melanomas are excised with 1 cm margins if impalpable, 2 cm if palpable but not nodular, and 5 cm (more recently 3 cm) if nodular. However, although these three groups broadly correspond to microscopic tumour thickness groups, the clinical diagnostic accuracy of exponents of this technique and other experts is less than 100 %. And what do you say to someone who has had a thin melanoma or a less malignant lesion widely excised?
Conclusions Unless
they choose otherwise, patients should have the opportunity to discuss a biopsy result, preferably excisional, before any skin tumour is excised with a margin of more than 1
cm.
"Wide excision" and "narrow excision"
are as
imprecise as "classical physical sign", "significant result", and "large dose of medicine". So, guided by the available, often limited evidence and with various permutations of 1-3 cm margins to choose from, my advice to patients with biopsy-proven malignant melanoma is: (1) if the surgeon and pathologist consider that a tumour less than 0-76 mm thick is completely excised, no further surgery; (2) for 0-76-2 mm thick tumours, further excision of the excision biopsy site or tumour with a 1 cm margin; (3) for tumours more than 2 mm thick, excision with
1395
margin, if anatomically feasible. If a prospective, randomised trial of 1 or 3 cm margins for malignant melanomas more than 2 mm thick becomes accessible, a
3
cm
patients will be advised to be entered into this trial. REFERENCES
pathology of melanotic growths in relation to their operative treatment. Lancet 1907; i: 927-33, 996-1003. 2. Dieterich P. Ein Betrag zur Statistik und klinischen Bedeutung melanotischer Geschwülste. Archiv Klin Chir (Berlin) 1887; 35: 1. Handley WS. The
289-320. 3. Boulay M. Du prognostic des tumeurs mélaniques. Arch Gén Méd 1888; 2: 157-81. 4. Norris W. Eight cases of melanosis, with pathological and therapeutical remarks on that disease. London: Longman, Brown, Green, Longmans and Roberts, 1857. 5. Pack GT, Gerber DM, Scharnagel IM. End results in the treatment of malignant melanoma: a report of 1190 cases. Ann Surg 1952; 136: 905-11. 6. Butterworth T, Klauder JV. Malignant melanomas arising in moles: report of fifty cases. JAMA 1934; 102: 739-45. 7. Raven RW. The properties and surgical problems of malignant melanoma. Ann R Coll Surg Engl 1950; 6: 28-55. 8. Fallowfield ME, Cook MG. Epidermal melanocytes adjacent to melanoma and the field change effect. Histopathology 1990; 17: 397-400. 9. Kelly JW, Sagebiel RW, Calderon W, Murillo L, Dakin RL, Blois MS. The frequency of local recurrence and microsatellites as a guide to
reexcision margins for cutaneous malignant melanoma. Ann Surg 1984; 200: 759-63. 10. Ackerman AB, Scheiner AM. How wide and deep is wide and deep enough? Hum Pathol 1983; 14: 743-44. 11. Ames FC, Balch CM, Reintgen D. Local recurrences and their managment. In: Balch CM, Houghton AN, Milton GW, Sober AJ, Soong S-j, eds. Cutaneous melanoma, 2nd ed. Philadelphia: Lippincott, 1992: 287-94. 12. Cascinelli N, van der Esch EP, Breslow A, Morabito A, Bufalino R. Stage I melanoma of the skin: the problem of resection margins. Eur J Cancer 1980; 16: 1079-85. 13. Fisher B, Anderson S, Fisher ER, Redmond C, Wickerham DL, Wolmark N, et al. Significance of ipsilateral breast tumour recurrence after lumpectomy. Lancet 1991; 338: 327-31. 14. Evans J, McCann BG. A new protocol for the treatment of stage I cutaneous malignant melanoma; interim results of the first 806 patients treated. Br J Plast Surg 1990; 43: 426-30. 15. Veronesi U, Cascinelli N. Narrow excision (1-cm margin): a safe procedure for thin cutaneous melanoma. Arch Surg 1991; 126: 438-41. 16. Rampen F. Melanoma of the skin: the problem of resection margins. Eur J Cancer 1981; 17: 589-90. 17. Griffiths RW, Briggs JC. Incidence of locally metastatic ("recurrent") cutaneous malignant melanoma following conventional wide margin excisional surgery for invasive clinical stage I tumours: importance of maximal primary tumour thickness. Br J Surg 1986; 73: 349-53. 18. Taylor BA, Hughes LE. A policy of selective excision for primary cutaneous malignant melanoma. Eur J Surg Oncol 1985; 11: 7-13. 19. Grin CM, Kopf AW, Welkovich B, Bart RS, Levenstein MJ. Accuracy in the clinical diagnosis of malignant melanoma. Arch Dermatol 1990; 126: 763-66.
BOOKSHELF Bright Air,
Brilliant Fire: On the Matter of the
Mind Gerald Edelman. Harmondsworth:
Penguin.
1992.
Pp
280.
20.ISBN 0-713990961. It is difficult for mere mortals such as myself to criticise Nobel Prize winners like Edelman, especially when we are told that he is the new Darwin. I had the same troubles with J. C. Eccles when he joined Popper to venture into the complex fields of philosophy, psychology, neurology, physiology, and religious belief, very much as Edelman is doing in this book. I did not feel happy with Eccles and Popper, and I do not feel happy with Edelman. His main purpose is to explain the nature of mind and consciousness but, as he points out, it is imposible to give an explanation of one’s own consciousness in terms satisfactory to oneselfthe original claim is drawing cheques on a non-existent bank account. What Edelman tries to do, with some success, is to draw on the neurosciences to suggest a way in which consciousness arose as a phenotype at some point during the evolution of the species. In fact, he posits two kinds of consciousness: primary and higher-order consciousness. But his account is burdened with possibilities rather than scientific proof, as when he notes that "it seems likely that an animal with primary consciousness would have the ability to generalize its learning abilities across many more cues more quickly than an animal without it". Possibly, but this is an absolutely vital aspect of the theory and cannot be left
relevant to his theory. Similarly, most psychologists will be surprised to find the ancient figure of Freud being resurrected as if he had any scientific contribution to make in this debate; there is no mention of the hundreds of empirical studies disproving his version of "the unconscious", so well summarised in Kline’s Fact and Fantasy in Freudian Theory. When will people learn that what is new in Freud’s theory is not true, and what is true is not new. There is much of interest in Edehnan’s book, and he is wise in his discussion of aspects properly belonging to his field of neuroscience. But in philosophy and psychology, I am not happy. If Homer can nod, so can Nobel Prize winners. Excursions into alien territories can be costly, and this enterprise is no exception. Interesting: yes. The new Darwin: no! Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK
Darwin’s Influence Sciences
H.
on
J. EYSENCK
Freud: A Tale of Two
Lucille B. Ritvo. London: Yale University Press. 1992. Pp 267.
28. ISBN 0-300052626. Nobel laureate Gerald Edelman has dedicated his
recent
As a psychologist I am not happy with much of what Edelman writes about movements such as behaviourism. He discusses Watson’s and Skinner’s excesses, which are quite atypical of the main developments in laboratory animal
Bright Air, Brilliant Fire: On the Matter of the Mind (reviewed above) to both Darwin and Freud. By so doing, he pinpoints the widespread conviction that it is they who constitute the key figures in the shaping of today’s scientific views on man or, at least, man’s self-image in modem culture. Inevitably, the question arises: how were they
Clearly, Edelman is unaware of what modem psychology is really about, although much that is going on is
linked? What and how much did Freud get from Darwin? More speculatively, would Darwin have given his blessing
hanging as "likely".
research.
are high. However, the price of medical medical consultation procedures is low under Japan’s and reimbursement system, physicians therefore tend to of or procedures.14-16 The volume consultations the increase in visits of number Japan is extremely high physician other countries’" with Thus, doctors are compared clinics their in to reluctant open poorly populated areas since time for is patients longer than it is in urban areas. travelling data show that the percentage of private Published to practitioners all practising physicians decreased from 414% to 28-6% in 1980 and 1990, respectively, and that their absolute number also decreased.8 The average age of private practitioners was 59-7 years in 1990 (that of rural practitioners was 60-7), compared with 56-4 years in 1980 (58-3). The ageing of physicians providing primary care has changed in line with that of the rural population of Japan. Both central and local government, together with Japanese medical societies, have attempted to tackle the issue of maldistribution. They have provided scholarships for medical students to work in prefectures where there was a physician shortage; Jichi Medical School trains doctors to work in underprivileged areas; and public clinics and hospitals have been provided for physicians who work in rural practices.’ Our study suggests that these efforts have failed. Japan is no exception to this difficulty.",", Compulsory methods or financial incentives for individual physicians to move are unlikely to be effective. However, several solutions are possible. First, incentives could be provided for groups of physicians, such as medical schools, to contribute to rural practice. Second, the creation of training systems for primary care physicians, together with a favourable payment system for primary care, is necessary. Third, coordination and collaboration between a front-line clinic and supporting hospitals should be reinforced so that single-physician practices would not be isolated professionally and psychologically. These issues require urgent attention since access to health care is an indispensable part of medical practice.
opening
a
clinic or
We thank Ms Kaoru Slnbuta, Ms Chizuko Imai, and Ms Hiromi Kobayashi for data preparation; and Dr Bong-min Yang and Dr Shosaku Nakayama for their comments. The study was supported by a grant-in-aid (No 04770342) from the Japan Ministry of Education, Science, and Culture.
REFERENCES
Ministry of Health and Welfare. Considering the number of physicians: the final report of task force on future supply and demand for physicians. Tokyo: Nihon Iji Shinposha, 1986. 2. Kokumin iryo taisaku taiko (Principles of the national health policy of the Liberal Democratic Party). Jpn Med J 1969; 2347: 103-09. 3. Koku-koritsu ika daigaku 15-kou no zousetsu wo (Another 15 public medical schools will open). Jpn Med J 1972; 2533: 99-100. 4. Kosei Tokei Kyokai. Kokumin eisei no doko (Health state of the nation, annual report). Tokyo: Kosei Tokei Kyokai, 1991. 5. Todaro MP. Economic development of the third world. New York: Longman, 1989: 143-86. 6. Yang BM, Huh J. Physician distribution and health manpower policy in Korea. Asia-Pacific J Public Health 1989; 3: 68-85. 7. Morrow JS. Toward a more normative assessment of maldistribution: the Gini index. Inquiry 1977; 14: 278-92. 8. Ministry of Health and Welfare. Ishi shikaishi yakuzaishi chosa (Survey of physicians, dentists, and pharmacists in 1980 and 1990). Tokyo: Kosei Tokei Kyokai, 1982, 1992. 9. Statistic Bureau, Management and Coordination Agency. 1980 and 1990 population census of Japan. Tokyo: Nihon Tokei Kyokai, 1982, 1992. 10. Newhouse JP, Williams AP, Bennett BW, Schwartz WB. Where have all the doctors gone? JAMA 1982; 247: 2392-96. 11. Newhouse JP. Geographic access to physician services. Ann Rev Public 1.
Health 1990; 11: 207-30. 12. National Institute of Hospital Administration. Kinmui no mirai ni kansuru anketo (The questionnaire survey on the future of salaried
physicians). Report of comprehensive study on primary care. Tokyo: Koseirho, 1990. Kaigyoi taisakuk wo isoge (Urgent measures should be taken for general practitioners). Shakai Hoken Junpo 1992; 1761: 6-10. 14. OECD. Financing and delivering health care: a comparative analysis of OECD countries. Paris: OECD, 1987: 73-74. 15. Iglehart JK. Japan’s medical care system. N Engl J Med 1988; 319: 13. Hamu S.
807-12.
Ikegami N. Japanese health care: low cost through regulated fees. Health Aff 1991; 10: 87-109. 17. Rosenthal M, Butter I, Field MG. The political dynamics of physician manpower policy. Amsterdam: Elsevier, 1990. 18. Frenzen PD. The increasing supply of physicians in US urban and rural areas, 1975 to 1988. Am J Public Health 1991; 81: 1141-47. 16.
VIEWPOINT Malignant melanoma excision margins: making a choice The incidence of cutaneous malignant melanoma continues to increase and surgery remains the major treatment. While we wait to find out what is adequate local excision from prospective, randomised trials now in progress, we have to rely on available received wisdom and we need to consider how wise we are. Until the 1970s wide local excision, if possible with 5 cm margins of normal skin, was routine. It is now fashionable to blame W. Sampson Handley, writing in The Lancet in 1907, as the villain behind this tradition.1 In the 19th century malignant melanoma was rare. Because of the poor prognosis, some argued against any surgery2but gradually, and before Handley, an international tradition of wide excision in apparently curable cases developed: "not only remove the disease, but cut away some of the healthy parts" (England, 1857);4 "1st eine Geschwulst scheinbar local, so dass man auf reine Exstirpation rechnen kann, so ist die
Exstirpation vorzunehmen."(Germany, 1887); and "une extirpation aussi large que possible." (France, 1888).3 After his early studies on breast cancer, from which he concluded that it spread mainly by permeation of the surrounding tissues, Handley studied one autopsy of a woman with disseminated malignant melanoma. With no recurrence at the primary site on the right heel, he examined a strip of tissue from the right thigh with multiple metastases. This showed spread of tumour further along the deep fascia than the skin or muscle. From this he concluded that malignant melanoma surgery should include a circular incision through the skin round the tumour "as a rule about an inch from the edge of the tumour... just deep enough to expose the subcutaneous fat ... The
skin, with
a
thin
ADDRESS: Department of Plastic Surgery, St Luke’s Hospital, Bradford, West Yorkshire BD5 0NA, UK (M. J. Timmons, FRCS).
1394
For tumours less than 0-76 mm thick, further 1 cmmargin excision of narrow margin biopsy sites is advocated9 but a 2-3 mm margin excision biopsy appears sufficient. 14 In a prospective, randomised study of malignant melanomas 2 mm thick or less, disease-free and overall survival and the frequency of regional and distant metastases were similar for 1 cm or 3 cm skin margins in 612 cases." 4 patients, all with tumours 1-11 mm or more thick and 1 cm margins, had a local recurrence as the first site of relapse. This is usually cited as the key study showing that 1 cm margins are adequate for melanomas thinner than 1 mm. However, this World Health Organization trial was haunted by the ghosts of Handley and others; the protocol dictated that beyond the 1 cm or 3 cm skin margins an additional 1-2 cm margin of subcutaneous fat down to muscle fascia had to be taken. Only Veronesi and Cascinelli, two members of the WHO Melanoma Group, stress the importance of the additional margin of fat.15 They do not say why. More noteworthy are the similar outcomes of the two treatment groups, making it difficult for surgeons and patients to decide whether or not 3 cm margins for all melanomas 1-2 mm thick are justifiable to reduce the small risk of local
attached layer of subcutaneous fat, is now to be separated from the deeper structures for about two inches in all directions round the skin incision." The tumour, with its margin of skin, deep fat, and fascia, and part of the underlying muscle, were then to be excised. From 1916, wide local excision was suggested by large series in the USA, most notably the 1190 cases reported by Pack and colleagues.5 Pack concluded it could not be definitely stated what margin of normal skin around a malignant melanoma is necessary. By 1934, 3 cm margins were being recommended.6 5 cm margins were in use in the 1940s/ though it is not clear who first thought of them. The principle of wide excision was supported by dermatologists, radiotherapists, and pathologists as well as surgeons. More recent pathological and clinical findings show it is not enough just to base surgery on this traditional
principle.
Pathology Handley noted that subcutaneous nodules commonly appeared near the scar after excision of melanotic growths, though this was not so in the necropsy he studied. With few cases available, he used pathology to devise his treatment plan. Noting the similarity between the spread of melanoma and breast cancer he transferred his breast cancer surgical principles to malignant melanoma. Others also used pathology to rationalise treatment. For example, a "field change" of atypical melanocytes or increased numbers of melanocytes was suggested to justify wide excision margins. These changes are now thought to be due to chronic sun 8 exposure alone. Although the full clinical significance of other findings such as micrometastases seen with thick melanomas9 is unclear, modem pathology does throw doubt on wide excision margins. Some even argue that modem pathology justifies narrow margins. Not only is the logic of this suspect, it is also being applied to a vague concept since "narrow margin" is as imprecise as "wide margin". Some pathologists acknowledge observer error in the measurement of melanomas but others assert that if no neoplastic melanocytes are found in excision biopsy margins "no further local surgery is warranted" .10 Clinically this may be true for thin melanomas but it may not be true for thick melanomas, which have more risk oflcoal recurrence." Local recurrences receive little attention in some commentaries, which concentrate on survival rates, there being no clear evidence that increasing excision margins improves survival."’" Here it is again worth comparing malignant melanoma with breast cancer. With both, local recurrence after complete local excision is probably an indicator not a cause of a poor prognosis.lm3 Additional surgery or radiotherapy after complete local excision of breast cancer appear more to reduce local recurrences than to improve overall prognosis13 but are still recommended. Similarly if wider excision can at least reduce local recurrences of malignant melanoma it is reasonable to consider it. Whether or not wider excision does reduce local recurrences and how wide is wide are empirical clinical questions not answerable by histopathology. metastases
Patients
Handley’s idea of measuring excision margins was an important step towards a scientific study of surgery for malignant melanoma. The other important step was measurement
of tumour thickness.
recurrence.
For melanomas more than 2 mm thick, one retrospective study suggested that local recurrence rates are more related to tumour thickness than to excision margins;12 later analysis revealed an increased risk of local recurrence with margins 2 cm or less for melanomas more than 2 mm thick.16 Another retrospective review of tumours 3-1mm or more thick found that margins 1 cm or less were followed by more local recurrences than 2-3 cm margins, while 2-3 cm margins were as effective as 4 cm margins." (2-3 cm is about 1 inch, Handley’s skin margin.) Even 5 cm margins are no guarantee against local recurrence of melanomas more than 2 mm thick.l’ We await the results of a prospective, randomised trial comparing 2 cm and 4 cm margins for 1-4 mm thick melanomas," its conclusions will be diluted by the inclusion of 1 mm tumours, known to have a good prognosis, and by the 4 cm margins which many now consider excessive. Some suggest that excision margins should be decided from traditional observation and palpation; 18 lesions looking like malignant melanomas are excised with 1 cm margins if impalpable, 2 cm if palpable but not nodular, and 5 cm (more recently 3 cm) if nodular. However, although these three groups broadly correspond to microscopic tumour thickness groups, the clinical diagnostic accuracy of exponents of this technique and other experts is less than 100 %. And what do you say to someone who has had a thin melanoma or a less malignant lesion widely excised?
Conclusions Unless
they choose otherwise, patients should have the opportunity to discuss a biopsy result, preferably excisional, before any skin tumour is excised with a margin of more than 1
cm.
"Wide excision" and "narrow excision"
are as
imprecise as "classical physical sign", "significant result", and "large dose of medicine". So, guided by the available, often limited evidence and with various permutations of 1-3 cm margins to choose from, my advice to patients with biopsy-proven malignant melanoma is: (1) if the surgeon and pathologist consider that a tumour less than 0-76 mm thick is completely excised, no further surgery; (2) for 0-76-2 mm thick tumours, further excision of the excision biopsy site or tumour with a 1 cm margin; (3) for tumours more than 2 mm thick, excision with
1395
margin, if anatomically feasible. If a prospective, randomised trial of 1 or 3 cm margins for malignant melanomas more than 2 mm thick becomes accessible, a
3
cm
patients will be advised to be entered into this trial. REFERENCES
pathology of melanotic growths in relation to their operative treatment. Lancet 1907; i: 927-33, 996-1003. 2. Dieterich P. Ein Betrag zur Statistik und klinischen Bedeutung melanotischer Geschwülste. Archiv Klin Chir (Berlin) 1887; 35: 1. Handley WS. The
289-320. 3. Boulay M. Du prognostic des tumeurs mélaniques. Arch Gén Méd 1888; 2: 157-81. 4. Norris W. Eight cases of melanosis, with pathological and therapeutical remarks on that disease. London: Longman, Brown, Green, Longmans and Roberts, 1857. 5. Pack GT, Gerber DM, Scharnagel IM. End results in the treatment of malignant melanoma: a report of 1190 cases. Ann Surg 1952; 136: 905-11. 6. Butterworth T, Klauder JV. Malignant melanomas arising in moles: report of fifty cases. JAMA 1934; 102: 739-45. 7. Raven RW. The properties and surgical problems of malignant melanoma. Ann R Coll Surg Engl 1950; 6: 28-55. 8. Fallowfield ME, Cook MG. Epidermal melanocytes adjacent to melanoma and the field change effect. Histopathology 1990; 17: 397-400. 9. Kelly JW, Sagebiel RW, Calderon W, Murillo L, Dakin RL, Blois MS. The frequency of local recurrence and microsatellites as a guide to
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BOOKSHELF Bright Air,
Brilliant Fire: On the Matter of the
Mind Gerald Edelman. Harmondsworth:
Penguin.
1992.
Pp
280.
20.ISBN 0-713990961. It is difficult for mere mortals such as myself to criticise Nobel Prize winners like Edelman, especially when we are told that he is the new Darwin. I had the same troubles with J. C. Eccles when he joined Popper to venture into the complex fields of philosophy, psychology, neurology, physiology, and religious belief, very much as Edelman is doing in this book. I did not feel happy with Eccles and Popper, and I do not feel happy with Edelman. His main purpose is to explain the nature of mind and consciousness but, as he points out, it is imposible to give an explanation of one’s own consciousness in terms satisfactory to oneselfthe original claim is drawing cheques on a non-existent bank account. What Edelman tries to do, with some success, is to draw on the neurosciences to suggest a way in which consciousness arose as a phenotype at some point during the evolution of the species. In fact, he posits two kinds of consciousness: primary and higher-order consciousness. But his account is burdened with possibilities rather than scientific proof, as when he notes that "it seems likely that an animal with primary consciousness would have the ability to generalize its learning abilities across many more cues more quickly than an animal without it". Possibly, but this is an absolutely vital aspect of the theory and cannot be left
relevant to his theory. Similarly, most psychologists will be surprised to find the ancient figure of Freud being resurrected as if he had any scientific contribution to make in this debate; there is no mention of the hundreds of empirical studies disproving his version of "the unconscious", so well summarised in Kline’s Fact and Fantasy in Freudian Theory. When will people learn that what is new in Freud’s theory is not true, and what is true is not new. There is much of interest in Edehnan’s book, and he is wise in his discussion of aspects properly belonging to his field of neuroscience. But in philosophy and psychology, I am not happy. If Homer can nod, so can Nobel Prize winners. Excursions into alien territories can be costly, and this enterprise is no exception. Interesting: yes. The new Darwin: no! Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK
Darwin’s Influence Sciences
H.
on
J. EYSENCK
Freud: A Tale of Two
Lucille B. Ritvo. London: Yale University Press. 1992. Pp 267.
28. ISBN 0-300052626. Nobel laureate Gerald Edelman has dedicated his
recent
As a psychologist I am not happy with much of what Edelman writes about movements such as behaviourism. He discusses Watson’s and Skinner’s excesses, which are quite atypical of the main developments in laboratory animal
Bright Air, Brilliant Fire: On the Matter of the Mind (reviewed above) to both Darwin and Freud. By so doing, he pinpoints the widespread conviction that it is they who constitute the key figures in the shaping of today’s scientific views on man or, at least, man’s self-image in modem culture. Inevitably, the question arises: how were they
Clearly, Edelman is unaware of what modem psychology is really about, although much that is going on is
linked? What and how much did Freud get from Darwin? More speculatively, would Darwin have given his blessing
hanging as "likely".
research.
