1977, British Journal of Radiology, 50, 372-375

Correspondence (The Editors do not hold themselves responsible for opinions expressed by correspondents) THE EDITOR—SIR, SCREENING FOR BREAST CANCER

In the October issue of the Journal on p. 818 the statement is made, "Although the New York experience suggests that women under the age of 50 do not benefit from screening, over half the cancers found in the West London study were in women under 50 years of age". Reference to the report on this study by Chamberlain et al. in the November 22, 1975, Lancet, eight such cancers were found and the statement is made on p. 1027 of that issue, "the large number of cancers detected in women aged 40 to 49 merely reflects the fact that most women attending the clinic were in this age group". The statement in the Journal would thus appear to be meaningless, and one wonders what purpose it was meant to serve. Yours, etc., Walter E. BROWN.

4439 South Birmingham Avenue, Tulsa, Oklahoma 74105.

THE EDITOR—SIR, SCREENING FOR BREAST CANCER

I am grateful to you for bringing Dr. Brown's letter to our attention and I agree that the paragraph is not quite as explicit as it could be. I hope that the following remarks may clarify the problem. Recently there have been recommendations that mammography should be restricted to women over 50 in breast cancer screening programmes. This is based on evidence from the H.I.P. New York Study that the reduction in mortality from breast cancer due to screening was less marked in women under 50, and on the fear of radiation induced cancer from mammography. The most recent figures from the West London Study show that for the 4050 age group 30.7% of the cancers were found by mammography alone and a further 30.7% by clinical examination and mammography. In the New York study 19.4% of cancers in this age group were found by mammography only and 19.4% by clinical examination and mammography. As the lowest case fatality rate occurred in breast cancer cases positive only on mammography, I suspect that the less favourable outlook for the younger age group in the New York Study may be related to the lower proportion of cancers discovered in the under 50s by mammography alone. There has been an improvement in mammography techniques in recent years with the advent of X-ray units and screen/film combinations specifically designed for mammography and we feel that the West London results indicate that more cancers are being found in younger women with the Medichrome film/rare earth screen combination. These techniques minimize the radiation hazard and it should be remembered that no increase in breast carcinoma has yet been demonstrated in female Japanese atomic bomb survivors who received a dose of more than 90 rad, and were over the age of 35 at the time of irradiation. In England and Wales breast cancer is the commonest cause of death in women aged 35-54 and it would be sad if the possible benefits of screening were to be denied to this age group before the latest mammographic techniques are fully evaluated. Yours, etc., J. L. PRICE.

Trefonnen, Little Warren Close, Guildford, Surrey.

THE EDITOR—SIR, THE SMALL BOWEL BARIUM FOLLOW-THROUGH VERSUS JEJEUNAL BIOPSY IN THE DIAGNOSIS OF COELIAC DISEASE

Masterson and Sweeney (1976) recommend a barium follow-through as the initial investigation of patients suspected of having coeliac disease. The age of their patients is not stated; they may well have been adults but I think few paediatricians will agree with their statement. Many screening tests have been advocated in the hope of avoiding jejeunal biopsy but an accurate diagnosis can only be made on histological grounds. The full diagnostic criteria for coeliac disease should be the demonstration of an abnormal small intestinal mucosa by biopsy followed by a histological response to a gluten-free diet and finally the demonstration of a histological relapse following a gluten challenge. Masterson and Sweeney point out that the radiological findings are usually non specific and although a flat jejeunal mucosa is characteristic of coeliac disease there are other conditions in children such as gastroenteritis, cow's milk protein intolerance and giardiasis which may produce the same appearance. For these reasons reinvestigation as outlined above is justified in order to establish the diagnosis of coeliac disease with certainty as this will necessitate a glutenfree diet for life. A jejeunal biopsy can be done as a day case and "costly hospitalization" is not needed and I suggest that it is more simple to perform than a barium follow-through examination. In children it is a safe procedure if the port hole of the capsule is of the correct size. Visakorpi (1970) reports only eight perforations in 4937 biopsies. A biopsy has the further advantage that when indicated the disaccharidase activity of the small intestinal mucosa may be measured and often observations such as immunological studies are possible. Furthermore, during the procedure a sample of duodenal juice may be obtained either for culture or to exclude giardiasis. For these reasons if a child is suspected of having coeliac disease then the initial investigation should be a jejeunal biopsy rather than radiological studies and the diagnosis should not be made or treatment started without this investigation having been performed. Yours etc., P. HUSBAND.

Ashford Hospital, London Road, Ashford, Middlesex, TW15 3AA. REFERENCES MASTERSON, J. B., and SWEENEY, E. C , 1976. The role of

small bowel follow-through examination in the diagnosis of coeliac disease. British Journal of Radiology 49, 660-664. VISAKORPI, J. K., 1970. An international inquiry concerning the diagnostic criteria of coeliac disease. Ada Paediatrica Scandinavica, 59, 463.

THE EDITOR—SIR, BARIUM FOLLOW-THROUGH AS THE INITIAL INVESTIGATION OF PATIENTS SUSPECTED OF HAVING COELIAC DISEASE .

We agree wholeheartedly with the view of Dr. Husband that an accurate diagnosis of coeliac disease can only be made on histological grounds. It was not our contention that barium follow-through examinations should supersede jejunal biopsy in arriving at a definitive diagnosis but rather that because the findings at barium examination correlate

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Screening for breast cancer.

1977, British Journal of Radiology, 50, 372-375 Correspondence (The Editors do not hold themselves responsible for opinions expressed by corresponden...
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