Letters to the Editor

LETTERS TO THE EDITOR Dear Sir: In the paper, "The Actual Extent of Mastectomy: A Key to Survival" (Perspectives 30:31 1, 1987), Ferguson states that survival rate comparisons are not appropriate because of uncontrolled variations in clinical staging and then concludes with the statement that "the two studies with significant differences in survival both favored the larger operation." It is contradictory to invalidate survival rate comparisons on the one hand, and then to use them to support radical mastectomy on the other. Moreover, such a contradiction gives no support to the "reasonable assumption" that the "larger operation" is superior. The author is correct in holding that survival rate comparisons are not valid because of uncontrolled variations in clinical staging. They do not express the quality of the method. Therefore, the superior method is not that which achieves the highest rate of survival; it is that which most closely conforms to the principle of treatment. The principle of treatment is ablation of all tumor from the largest amount of tissue at the earliest time with the least risk. Whatever method conforms to this principle will provide the best possible result regardless of the rate of survival. The method cannot be so radical as to impair the recovery of the patient, nor so restricted as to allow recurrence of the cancer in expendable tissue. Between these limits, which are affected by the skill of the si-rgeon, the condition of the patient, and the nature of the tumor lies the best method of therapy. It is conformity to the principle of treatment rather than reasonable assumptions and rates of survival that will give each patient the highest prospect for cure. Chandler Smith 141 Woodcock Court Daytona Beach, Florida 32019 Dear Sir: Professor Smith paraphrases one of my statements and finds it inconsistent with another one that he quotes. The first of these statements indicates that survival dataforpatients in one project cannot reliably be compared with those in anotìier project. Dr. Smith says he agrees with this opinion. The second observation, Permission to reprint a letter printed in this section may be obtained only from the author. Perspectives in Biology and Medicine, 31, 3 ¦ Spring 1988 \ 467 which he quotes, relates specifically to results of controlled trials. The survival differences in question here are between two randomized treatment groups within a single project. These seem to me, and to most investigators, to be more dependable than comparisons that are not formally controlled. I do not think my views are inconsistent. Dr. Smith's opinion that "the superior method is not that which achieves the highest rate ofsurvival" can provide scant comfort to those women who, dying of recurrent cancer, painfully realize that they have not been guided to treatment giving the maximum probability of survival, as determined by controlled trials. Donald J. Ferguson Department of Surgery University of Chicago 468 Letters to the Editor ...