In the randomised TARGIT-A trial, risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy was non-inferior to whole-breast external beam radiotherapy, for local recurrence. In the long-term, no difference was found in any breast cancer outcome, whereas there were fewer deaths from non-breast-cancer causes. TARGIT-IORT should be included in pre-operative consultations with eligible patients.
OBJECTIVES--To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon9s opinion or the patient9s choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial. DESIGN--Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer. SETTING--12 District general hospitals, three London teaching hospitals, and four private hospitals. PATIENTS--269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons. INTERVENTIONS--Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon9s stated preferences for managing early breast cancer. MAIN OUTCOME MEASURES--Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery. RESULTS--Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.) CONCLUSIONS--There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.
# Impact of mammographic screening is not clear {#article-title-2} EDITOR—We should all rejoice that there has been an improvement in survival and reduction in mortality for carcinoma of the breast, but Richards et al in their paper perpetuate the myth that this is related to the breast screening programme.1 The periods for comparison were 1981-5 and 1986-90. The Forrest report on mammographic screening was published in 1986,2 the first screening centres were established in 1988, and the country was not covered by the programme until 1990. Even the greatest zealots for mammographic screening would not expect an impact on mortality until 1997. The fall in mortality could therefore be attributed only to improvements in treatment, and it is relevant to note that the first overview of the trials of adjuvant systemic treatment were published in 1985.3 The only support for the assertion that the reduction in mortality can be attributed to the breast screening programme was a personal communication from S M Moss. Many people are of the opinion that mammographic screening is saving thousands of lives, but opinion alone does not provide sufficient data to support a publication in a prestigious journal such as the BMJ . 1. 1.↵1. Richards MA, 2. Stockton D, 3. Babb P, 4. Coleman MP . How many deaths have been avoided through improvements in cancer survival? BMJ 2000;320:895–898. (1 April.) [OpenUrl][1][Abstract/FREE Full Text][2] 2. 2.↵1. Forrest P . Breast cancer screening: Report to the Health Ministers of England, Wales, Scotland and Northern Ireland. London: HMSO, 1986. 3. 3.↵1. Early Breast Cancer Trialists Collaborative Group . Effects of adjuvant tamoxifen and of cytotoxics on mortality in early breast cancer: an overview of 61 randomised trials amongst 28,896 women. N Engl J Med 1988;319:1681–1692. [OpenUrl][3][PubMed][4][Web of Science][5] # Diagnostic practice in the United States is different {#article-title-5} EDITOR—Richards et al seem to have made inferences about "deaths avoided" using data on five year survival.1 This measure is, however, powerfully affected by diagnostic practice and is not a reliable indicator of mortality.2 In the United States the problem is best exemplified by prostate cancer. Five year survival has increased from about 40% in the 1950s to about 95% currently.3 Although it is tempting to conclude that we Americans have made major medical advances (and left the United Kingdom in the dust), the truth is that this largely reflects our diagnostic practice. As we aggressively seek and find early stage (and often innocuous) tumours, … [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft.stitle%253DBMJ%26rft.issn%253D0007-1447%26rft.aulast%253DRichards%26rft.auinit1%253DM%2BA%26rft.volume%253D320%26rft.issue%253D7239%26rft.spage%253D895%26rft.epage%253D898%26rft.atitle%253DHow%2Bmany%2Bdeaths%2Bhave%2Bbeen%2Bavoided%2Bthrough%2Bimprovements%2Bin%2Bcancer%2Bsurvival%253F%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.320.7239.895%26rft_id%253Dinfo%253Apmid%252F10741993%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bmj&resid=320/7239/895&atom=%2Fbmj%2F321%2F7274%2F1470.2.atom [3]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.volume%253D319%26rft.issue%253D26%26rft.spage%253D1681%26rft.epage%253D1692%26rft.atitle%253DEffects%2Bof%2Badjuvant%2Btamoxifen%2Band%2Bof%2Bcytotoxic%2Btherapy%2Bon%2Bmortality%2Bin%2Bearly%2Bbreast%2Bcancer.%2BAn%2Boverview%2Bof%2B61%2Brandomized%2Btrials%2Bamong%2B28%252C896%2Bwomen.%2BEarly%2BBreast%2BCancer%2BTrialists%2527%2BCollaborative%2BGroup%26rft_id%253Dinfo%253Apmid%252F3205265%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/external-ref?access_num=3205265&link_type=MED&atom=%2Fbmj%2F321%2F7274%2F1470.2.atom [5]: /lookup/external-ref?access_num=A1988R516200001&link_type=ISI
Ramifications of screening for breast cancerSee Research p 689 in 4 cancers detected by mammography are pseudocancersEditor-In this issue Zackrisson et al report on follow-up data from the Malmö mammographic screening trial and conclude that the rate of overdiagnosis of breast cancer was 10%. 1 They do not, however, calculate the risk we believe is most relevant to women considering mammography: What is the chance that a screen detected cancer represents overdiagnosis?After 15 years of follow-up, there were 1320 diagnosed in the screened group and 1205 in the control group (table 1).The excess detection of 115 cancers associated with screening led to their conclusion of an overdiagnosis rate of 10% (115/1205).However, because the intervention had stopped 15 years earlier and yet breast cancer cases continue to accumulate in both groups, the approach understates the risk of overdiagnosis.A more relevant denominator is the number of cancers found in the screened group at the end of the trial-741 (table 2).This addresses the question: Were I found to have cancer after being randomised to screening, how likely is it to represent overdiagnosis?As shown in the figure, using this denominator the risk of overdiagnosis is 15% (115/741).However, many of the cancers detected in the screened group are not detected by screening.They are instead clinically detected (either during the interval between screening examinations or among nonattenders).The most relevant denominator is the number of screen detected cancers found at the end of the trial.This addresses the question: Were I found to have cancer by a mammogram, how likely is it to represent overdiagnosis?Although this denominator is not reported by Zackrisson et al, the original BMJ article describing Malmö reported that 64% of the cancers detected in the screened group were detected by screening mammography. 2Thus one can deduce that the number of screen detected cancers at the end of the trial was about 475.As shown in the figure, using this denominator the risk of overdiagnosis is 24% (115/475).
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