nized approach' has been approved by the Research Department of Boiron Homeopathie SA, one of the largest companies producing homeopathic products in France. The purpose of our study was not to validate or invalidate homeopathy. We assessed the efficacy of a homeopathic treatment frequently used throughout the world to treat patients with plantar warts. It is this approach that was shown not to be efficacious. It is possible that a "constitutional" treatment over several years, such as the one suggested by Jacobs, might cure warts, but would it really be useful? Without treatment, 66% of warts disappear in 2 years.2 Michel Labrecque, MD, MSc Jean Drouin, MD Unite de recherche clinique en medecine familiale Centre hospitalier de l'Universite Laval
Sainte-Foy, Que.
References/References 1. Jouanny J: Therapeutique homeopathique, vol 2, Editions Boiron, Lyons, France, 1985: 499 2. Massing AM, Upstein WI: Natural history of warts. Arch Dermatol 1963; 75: 29-32
Public education about breast cancer I n the June 15, 1992, issue of CMAJ the article "Age as a factor in breast cancer knowledge, attitudes and screening behaviour," by Ms. Zeva Mah and Dr. Heather Bryant (146: 21672174), and the accompanying editorial, "Women and breast cancer: Is it really possible for the public to be well informed?," by Dr. Cornelia J. Baines (ibid: 21472148), bring to our attention important perceptions of patients concerning breast cancer. Mah and Bryant point out that elderly women underestimate NOVEMBER 15, 1992
the risk of breast cancer, and Baines notes the media barrage seemingly directed at young women, which increases their anxiety at a time when their relative risk for breast cancer is low. These authors attest to inadequate public education, reluctance to challenge conflicting opinions that confuse the public and failure to counter unfortunate impressions in advertisements by manufacturers who have a vested interest in mammography. My impressions from working in a diagnostic breast clinic support the conclusions of Mah and Bryant and of Baines. Young women are overly concerned about the risk of breast cancer, whereas postmenopausal women, particularly those aged 70 years or more, consider themselves riskfree. Older women often believe that the risk stops at menopause. They may disregard a significant breast problem because they say they "feel well" or that "the lump doesn't hurt." In contrast, premenopausal women with cyclic breast pain worry about the possible association of their symptoms with cancer. My experience of patients with breast problems developing at different ages was recently published.' I found that many physicians are uncomfortable managing breast problems and that many patients insist on a specialist's opinion, despite reassurance by their family doctor. Mammography is often ordered for women under 40 years in an effort to provide reassurance. In the young this is usually unnecessary and costly. Older patients are more likely to present themselves for screening if encouraged by their
A
A
S
A
A
U
U
physicians.
I support Baines's comments on equipment manufacturers' ad-
vertisements. Their vested interests in mammography and screening are unstated, although a sophisticated public should have little trouble in identifying the bene-
A
Seepage 1620
X L78- 1092 E
fits if mammography were used more widely. Much of the "information" to which people are exposed is not in their best interest. Mah and Bryant are correct when they conclude that "education is needed to increase breast cancer knowledge, promote the Canadian recommendations for early detection of breast cancer and decrease negative beliefs about the disease." Physicians need to keep their knowledge of breast disease current and to take a more active role in public education. Ernest E. Sterns, MD, FRCSC Professor of surgery Queen's University Kingston, Ont.
Reference 1. Stems EE: Age-related breast diagnosis. Can JSurg 1992; 35: 41-45
The excellent editorial on women and breast cancer by Dr. Baines covers many of the key issues, among them the continuing debate over the screening of women under 50 years of age. There is no sound scientific evidence to support mammographic screening in women under 50 years of age, and the preliminary reports from the Canadian National Breast Screening Study (NBSS) suggested a higher rate of death in women aged 40 to 49 years who had undergone mammography and physical examination than in women who had undergone only a single physical breast examination.' Women in this age group may have a false sense of security after mammography has given a negative result, and they need to be reminded that such a result does not eliminate the possibility of cancer.2 They should inform their physician of any changes in their breasts even if the results of recent mammography and physical examination were normal.2 Evidence of benefit requires a -
For prescribing information see page 1589
comparison of rates of death in screened and unscreened populations, and the present data reveal, at best, no evidence of benefit in women under 50 years of age.3 Only a randomized controlledstudy in a large population is likely to provide unequivocal data to resolve this problem;4 there should perhaps be a moratorium on all mammography for symptom-free women in this age group outside randomized controlled tri-
als.' Timothy Johnstone, MB, BS, DPH Deputy medical health officer Capital Regional District Victoria, BC
References 1. Breast cancer screening in women under 50 [E]. Lancet 1991; 337: 15751576 2. Kopans DB: Breast screening in women under 50 [C]. Lancet 1991; 338: 447 3. Wright CJ: Breast screening [C]. Lancet 1992; 340: 122 4. Canadian study of breast screening under 50. Lancet 1992; 339: 1473-1474
Neither of the two recent articles about breast cancer was devoted to methods of early detection, and neither was concerned with the causes and prevention of this disease. The only patient with carcinoma of the breast whom I saw in Kenya during my 3-year period as a physician in district hospitals was an African woman with a fungating carcinoma. I recall that she was nulliparous. In the maternity wards there, newly delivered mothers always had abundant milk in their breasts. The breasts usually shrivelled up at the "change of life" after years of use. On a recent visit to Baffin Island I stayed in Iqualik (Frobisher Bay) at the house of a Canadian, originally from Denmark, who had an Inuit wife. He told me that cancer of the breast did not occur in the women there, although lung cancer was common in Inuit men. Inuit
women breast-feed their infants. Are we in the Western world paying enough attention to the decline of breast-feeding? Dr. B.P. Harris Brighton, England
[Dr. Bryant and Ms. Mah reply.]
Dr. Sterns highlights one of the key points in our article: as the risk of breast cancer increases with age, women's perception of their susceptibility declines. We concur with Sterns that women and physicians need to be educated on the importance of age as the principal risk factor for breast cancer. The Screen Test: the Alberta Program for the Early Detection of Breast Cancer is now distinguishing high-risk factors from others noted on a woman's premammography questionnaire when communicating the results to her physician. Age over 50 years, birth in North America or northwestern Europe and family history of breast cancer in two or more first-degree relatives are identified to the physician as high-risk factors.' Other more commonly elicited but less important factors - nulliparity, advanced age at birth of first child and family history of breast cancer in one first-degree relative are listed as other risk factors. We hope to sensitize physicians to the concept that other risk factors are not as critical as a woman's age: physicians in North America should still consider a woman over 50 years of age to be at high risk for breast cancer despite lack of family history of the disease or other characteristics. We also support Dr. Johnstone's assertion that mammography, although proven beneficial for women over 50 years of age, has not been proven beneficial for women under 50 years of age.2 Johnstone notes that women aged 40 to 49 years should be reminded that negative screening results do CAN MED ASSOC J 1992; 147 (10)
1411
Sainte-Foy, Que.
References/References 1. Jouanny J: Therapeutique homeopathique, vol 2, Editions Boiron, Lyons, France, 1985: 499 2. Massing AM, Upstein WI: Natural history of warts. Arch Dermatol 1963; 75: 29-32
Public education about breast cancer I n the June 15, 1992, issue of CMAJ the article "Age as a factor in breast cancer knowledge, attitudes and screening behaviour," by Ms. Zeva Mah and Dr. Heather Bryant (146: 21672174), and the accompanying editorial, "Women and breast cancer: Is it really possible for the public to be well informed?," by Dr. Cornelia J. Baines (ibid: 21472148), bring to our attention important perceptions of patients concerning breast cancer. Mah and Bryant point out that elderly women underestimate NOVEMBER 15, 1992
the risk of breast cancer, and Baines notes the media barrage seemingly directed at young women, which increases their anxiety at a time when their relative risk for breast cancer is low. These authors attest to inadequate public education, reluctance to challenge conflicting opinions that confuse the public and failure to counter unfortunate impressions in advertisements by manufacturers who have a vested interest in mammography. My impressions from working in a diagnostic breast clinic support the conclusions of Mah and Bryant and of Baines. Young women are overly concerned about the risk of breast cancer, whereas postmenopausal women, particularly those aged 70 years or more, consider themselves riskfree. Older women often believe that the risk stops at menopause. They may disregard a significant breast problem because they say they "feel well" or that "the lump doesn't hurt." In contrast, premenopausal women with cyclic breast pain worry about the possible association of their symptoms with cancer. My experience of patients with breast problems developing at different ages was recently published.' I found that many physicians are uncomfortable managing breast problems and that many patients insist on a specialist's opinion, despite reassurance by their family doctor. Mammography is often ordered for women under 40 years in an effort to provide reassurance. In the young this is usually unnecessary and costly. Older patients are more likely to present themselves for screening if encouraged by their
A
A
S
A
A
U
U
physicians.
I support Baines's comments on equipment manufacturers' ad-
vertisements. Their vested interests in mammography and screening are unstated, although a sophisticated public should have little trouble in identifying the bene-
A
Seepage 1620
X L78- 1092 E
fits if mammography were used more widely. Much of the "information" to which people are exposed is not in their best interest. Mah and Bryant are correct when they conclude that "education is needed to increase breast cancer knowledge, promote the Canadian recommendations for early detection of breast cancer and decrease negative beliefs about the disease." Physicians need to keep their knowledge of breast disease current and to take a more active role in public education. Ernest E. Sterns, MD, FRCSC Professor of surgery Queen's University Kingston, Ont.
Reference 1. Stems EE: Age-related breast diagnosis. Can JSurg 1992; 35: 41-45
The excellent editorial on women and breast cancer by Dr. Baines covers many of the key issues, among them the continuing debate over the screening of women under 50 years of age. There is no sound scientific evidence to support mammographic screening in women under 50 years of age, and the preliminary reports from the Canadian National Breast Screening Study (NBSS) suggested a higher rate of death in women aged 40 to 49 years who had undergone mammography and physical examination than in women who had undergone only a single physical breast examination.' Women in this age group may have a false sense of security after mammography has given a negative result, and they need to be reminded that such a result does not eliminate the possibility of cancer.2 They should inform their physician of any changes in their breasts even if the results of recent mammography and physical examination were normal.2 Evidence of benefit requires a -
For prescribing information see page 1589
comparison of rates of death in screened and unscreened populations, and the present data reveal, at best, no evidence of benefit in women under 50 years of age.3 Only a randomized controlledstudy in a large population is likely to provide unequivocal data to resolve this problem;4 there should perhaps be a moratorium on all mammography for symptom-free women in this age group outside randomized controlled tri-
als.' Timothy Johnstone, MB, BS, DPH Deputy medical health officer Capital Regional District Victoria, BC
References 1. Breast cancer screening in women under 50 [E]. Lancet 1991; 337: 15751576 2. Kopans DB: Breast screening in women under 50 [C]. Lancet 1991; 338: 447 3. Wright CJ: Breast screening [C]. Lancet 1992; 340: 122 4. Canadian study of breast screening under 50. Lancet 1992; 339: 1473-1474
Neither of the two recent articles about breast cancer was devoted to methods of early detection, and neither was concerned with the causes and prevention of this disease. The only patient with carcinoma of the breast whom I saw in Kenya during my 3-year period as a physician in district hospitals was an African woman with a fungating carcinoma. I recall that she was nulliparous. In the maternity wards there, newly delivered mothers always had abundant milk in their breasts. The breasts usually shrivelled up at the "change of life" after years of use. On a recent visit to Baffin Island I stayed in Iqualik (Frobisher Bay) at the house of a Canadian, originally from Denmark, who had an Inuit wife. He told me that cancer of the breast did not occur in the women there, although lung cancer was common in Inuit men. Inuit
women breast-feed their infants. Are we in the Western world paying enough attention to the decline of breast-feeding? Dr. B.P. Harris Brighton, England
[Dr. Bryant and Ms. Mah reply.]
Dr. Sterns highlights one of the key points in our article: as the risk of breast cancer increases with age, women's perception of their susceptibility declines. We concur with Sterns that women and physicians need to be educated on the importance of age as the principal risk factor for breast cancer. The Screen Test: the Alberta Program for the Early Detection of Breast Cancer is now distinguishing high-risk factors from others noted on a woman's premammography questionnaire when communicating the results to her physician. Age over 50 years, birth in North America or northwestern Europe and family history of breast cancer in two or more first-degree relatives are identified to the physician as high-risk factors.' Other more commonly elicited but less important factors - nulliparity, advanced age at birth of first child and family history of breast cancer in one first-degree relative are listed as other risk factors. We hope to sensitize physicians to the concept that other risk factors are not as critical as a woman's age: physicians in North America should still consider a woman over 50 years of age to be at high risk for breast cancer despite lack of family history of the disease or other characteristics. We also support Dr. Johnstone's assertion that mammography, although proven beneficial for women over 50 years of age, has not been proven beneficial for women under 50 years of age.2 Johnstone notes that women aged 40 to 49 years should be reminded that negative screening results do CAN MED ASSOC J 1992; 147 (10)
1411
