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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Yoga is reasonable alternative to physical therapy for lower back pain, say researchers Jacqui Wise. 357:doi 10.1136/bmj.j2964

“The purpose of achieving equanimity through yoga is to diminish suffering” The Yoga Sutras of Patanjali, Aphorism 2, Chapter 2

Chronic back pain is increasingly becoming common especially in younger people and hence an important public health concern. The causes appear to be multi-factorial and observed to be related increasingly to work-related demands, lifestyle, posture, diet, etc. all contributing to chronic physical and psychological stress.

In a country like India which is witnessing rapid urbanization creating a highly competitive, fast-paced and demanding external environment, the youth seem to find themselves helplessly being driven to make maladaptive and irrational choices. This is only maintaining and perpetuating chronic stress related health conditions of which chronic musculo-skeletal pain disorders are increasing. This is an unfortunate trend. With particular reference to chronic pain, there are certain factors that are a pain in the neck uniquely to today’s urban youngster of India and I am sure in several other countries too.

The young Indian lives an artful life having to dodge and dive from commuting to work to managing life on shaky infrastructures full of dangerous defects put to reckless public usage by the many, disorganized mass movements in cities with even more disorganized planning and management and callous unconcern by the high and mighty. As someone wisely said in this rat race, even if you win you are still a rat! Articles like this seem to reassure us there is indeed some light at the end of the rat hole!

It is indeed heartening to read positive original research on yoga in high impact journals like the Annals of Internal Medicine and the BMJ. I am indeed grateful for this. This does have an impact on the modern youth of India who increasingly look to the West for trustworthy health information.

Yoga as a holistic preventive and curative health system is increasingly being reaffirmed and revalidated through several good scientific studies especially coming out of prestigious academic centers in the West. Several of these studies however seem to focus more on the physical aspect of yoga – the asanas or postural exercises and pranayama or breathing techniques. Some recent studies do highlight dhyana or meditation techniques.

Whereas the classical yoga of Patanjali (circa 1500 bce) has eight parts: yama or ethical observances, niyama or hygienic disciplines, asana or adaptability training, pranayama or breath regulation training, pratyahara or sensory-perceptual regulation training, dharana or focused attention training, dhyana or meditation training and samadhi or balanced mind-body state of equanimity. The classical yoga originating from the culture and civilization of the Indian sub-continent several thousand years ago developed as a holistic empowering system of wise living leading to freedom from suffering. The system was practiced widely by all strata of society. But for various reasons the practice became less prevalent over the ages.

All this appears to be changing with a revival of the classical yoga albeit through the physical aspect. With the support of the modern evidence-based medical research showing increasing interest and validating many of the ancient Eastern wisdom practices there seems to be a change in the mind-set from material reductionism to an open and integrative holism. This renaissance is a welcome trend and promises to be a great preventive and public health revolution in the making if the essence of the ancient classical yoga practice is understood and wisely adopted by the many. A heartfelt thank you indeed.

“Know well what leads you forward and what holds you back, and choose the path that leads to wisdom” – the Buddha

References

Büssing, A., Michalsen, A., Khalsa, S. B. S., Telles, S., & Sherman, K. J. (2012). Effects of yoga on mental and physical health: a short summary of reviews. Evidence-Based Complementary and Alternative Medicine, 2012.

Lipton, L. (2008). Using yoga to treat disease: An evidence‐based review. Journal of the American Academy of Physician Assistants, 21(2), 34-41.

Whicher, I. (1998). Yoga and freedom: a reconsideration of Patañjali's classical yoga. Philosophy East and West, 272-322.

Competing interests: No competing interests

10 August 2017
Anand Ramanujapuram
Neuropsychiatrist
Independent Practitioner
Malleswaram, Bengaluru, India
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Re: Loss of fingerprints secondary to palmoplantar erythrodysesthesia in a patient on capecitabine chemotherapy Sara Lightowlers, Rubin Soomal. 351:doi 10.1136/bmj.h6023

We read with great interest the article “Loss of fingerprints secondary to palmoplantar erythrodysaesthesia in a patient on capecitabine chemotherapy” by Lightowlers et al. 1 We would like to congratulate the authors on this publication and thank them for posing a relevant question. The article noted that loss of fingerprints due to palmoplantar erythrodysaesthesia (PPE) will affect daily life, especially on occasions that involve fingerprint recognition. Thus, patients at risk for PPE should be notified of the possibility of fingerprint loss. However, it is worrying that in reality, this issue is often neglected as we perform our duties.

Fingerprints are becoming increasingly important in many aspects of public life. Law enforcement officers utilize fingerprints for identity verification and for processing passport and ID card applications; fingerprint recognition is also required to log in to laptops and smart phones and to access safety deposit boxes. In an article published in N Engl J Med in 2015, Yanin et al2 reported a case in which after receiving 3 months of capecitabine and bevacizumab treatment, a stage IV breast cancer patient was refused a wire transfer by a bank due to having unrecognizable fingerprints during the identity verification process. This patient exhibited grade 1 hand-foot syndrome (HFS) during the first cycle of chemotherapy, which worsened during the third cycle of chemotherapy. A PET-CT scan indicated a 50% reduction in lung metastatic activity. After capecitabine treatment was delayed and the patient’s dosage was decreased, no further acute toxicity was observed. However, the patient’s fingerprints faded. The authors stated that the skin reaction associated with HFS may lead to swelling and blisters, which occur in approximately 60% of patients. This adverse reaction is the main cause of fingerprint loss.

A prospective study conducted at the Erasmus Medical Center Cancer Institute3 was published in JAMA Oncology. This investigation demonstrated that capecitabine- and tyrosine kinase inhibitor (TKI)-induced fingerprint loss may not be associated with adverse skin reactions of HFS. This study continued for 7 months and involved the collection of complete fingerprint information from 112 patients; 66 of these patients received capecitabine treatment, and the remaining 46 patients received TKI treatment. Fingerprints were collected from patients before treatment, 6 to 10 weeks after the start of treatment, and after treatment. Changes in fingerprints were accurately captured using a standard fingerprint analysis system. The degree of change in fingerprints was scored from 1-5 points to denote changes from light to severe. The researchers defined 4-5 points as “fingerprint loss” and 1-3 points as “no change in fingerprints”. Additionally, the severity of HFS and hand-foot skin reaction (HFSR) were scored using US National Cancer Institute (NCI) standards. After 8 weeks, fingerprint loss was observed in 9 cases (14%) in the capecitabine group and 1 case (2%) in the TKI group, whereas severe HFS and HFSR were detected in 46 cases (70%) in the capecitabine group and 21 cases (46%) in the TKI group. HFS and HFSR scores did not correspond with fingerprint loss scores; certain patients experienced severe HFS but no changes in fingerprints and vice versa. Thus, it is speculated that fingerprint loss may be a secondary reaction independent of HFS and HFSR. However, there is currently no explanation of the mechanism underlying the occurrence of this type of secondary reaction. Follow-up studies indicated that in the examined context, fingerprint loss was temporary, with fingerprints gradually returning to normal 2-4 weeks following the discontinuation of chemotherapy. The researchers cautioned that although fingerprint loss is regarded as a low-risk side effect, to avoid affecting patients’ daily lives, physicians should notify their patients of this risk prior to chemotherapy!

In the treatment of advanced breast cancer, Jiang and other Chinese experts have proposed the concept of “whole-course management”. This concept is a proposed treatment model based on the characteristics of advanced breast cancer, such as “chronic disease” and “maintenance treatment”. After 6-8 cycles of effective first-line chemotherapy, effective maintenance treatment is administered to delay recurrence; this approach replaces the original treatment model of “cease chemotherapy and await recurrence”. This concept uses the “slow and steady” treatment strategy to achieve the goal of extending survival. Breast cancer treatment is a long-term process in which patient compliance is extremely important. In cases of advanced breast cancer, capecitabine monotherapy has better efficacy than gemcitabine monotherapy or vinorelbine monotherapy. Capecitabine exhibits low haematologic toxicity and cardiotoxicity, is administered orally, is suitable for long-term use, and is the maintenance therapy medication recommended by the Committee of Breast Cancer Society of the Chinese Anti-Cancer Association. 4 Stockler also confirmed that capecitabine monotherapy has high accuracy and safety; thus, capecitabine combination therapy followed by capecitabine maintenance monotherapy (X-based X) is a reasonable choice for the whole-course management treatment model.5 This model includes endocrine therapy and maintenance treatment after effective targeted drug therapy. Capecitabine is a significant chemotherapeutic agent, and its prominence increased after the concept of whole-course management was proposed. In accordance with physicians’ recommendations, the number of capecitabine users and the duration of capecitabine treatment have both increased significantly over time. Do we need to be concerned about fingerprint loss caused by the use of capecitabine? Moreover, advanced-stage patients may require fingerprints for the management of financial affairs. Although the probability of fingerprint loss is low in clinical settings, we often neglect this secondary reaction when obtaining a signature for consent to chemotherapy. However, after it has developed, this reaction could tremendously inconvenience patients in their daily lives. Thus, we believe that irrespective of whether fingerprint loss is associated with HFS, when explaining potential secondary reactions, we should inform patients that fingerprint loss is an independent secondary reaction. In addition, we should urge patients to have their fingerprints collected before the commencement of chemotherapy. In cases involving fingerprint loss, physicians are obliged to provide relevant evidence to relieve their patients’ plight.

1. Lightowlers S, Soomal R, et al. Loss of fingerprints secondary to palmoplantar erythrodysesthesia in a patient on capecitabine chemotherapy. BMJ 2015;351:h6023. doi: https://doi.org/10.1136/bmj.h6023
2. Chavarri-Guerra Y, Soto-Perez-de-Celis E. Images in clinical medicine. Loss of fingerprints. N Engl J Med 2015;372:e22. doi: 10.1056/NEJMicm1409635.
3. Van Doorn L, Veelenturf S, Binkhorst L, Bins S, Mathijssen R. Capecitabine and the Risk of Fingerprint Loss. JAMA Oncol 2017;3:122-123. doi: 10.1001/jamaoncol.2016.2638.
4. Oostendorp LJ, Stalmeier PF, Donders AR, van der Graaf WT, Ottevanger PB. Efficacy and safety of palliative chemotherapy for patients with advanced breast cancer pretreated with anthracyclines and taxanes: a systematic review. Lancet Oncol 2011;12:1053-61. doi: 10.1016/S1470-2045(11)70045-6.
5. Stockler MR, Harvey VJ, Francis PA, Byrne MJ, Ackland SP, Fitzharris B, Van Hazel G, Wilcken NR, Grimison PS, Nowak AK, Gainford MC, Fong A, Paksec L, Sourjina T, Zannino D, Gebski V, Simes RJ, Forbes JF, Coates AS. Capecitabine versus classical cyclophosphamide, methotrexate, and fluorouracil as first-line chemotherapy for advanced breast cancer. J Clin Oncol 2011;29:4498-504. doi: 10.1200/JCO.2010.33.9101

Competing interests: No competing interests

10 August 2017
Bin Zhang
doctor
Xia Zhang, Yajie Gao,Jilai Bian, Jinming Yu
Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
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Re: Consultant triage cuts emergency admissions by a third, report finds Sophie Arie. 358:doi 10.1136/bmj.j3701

The above article throws light on the busiest area of the hospital and the cut down in the duration of hospital stay in emergency services. Although the above study results are from the perspective of surgical emergency admissions, the same also happens with medical emergencies. In a large tertiary care hospital in a northern part of India, a resident doctor does the triage and manages the case overnight and the consultant sees the case next morning and decides regarding the further stay of the patient in the emergency department. A consultant managing the triage area would definitely cut down the duration of hospital stay even in medical emergencies. A study of this kind in the medical emergency department would definitely help in decreasing the morbidity of patients in a resource constrained country like ours.

Competing interests: No competing interests

10 August 2017
mohan kumar h
Senior Resident
ashok kumar pannu
Department of Internal Medicine, Post Graduate Institute of Medical Education and Research
sector 12, chandigarh
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Re: Wanted: clinicians with digital and leadership skills Fiona Godlee. 358:doi 10.1136/bmj.j3382

Perhaps one of the problems in the healthcare system is managerial training. With the passage of time, we have included in the course’s programs leadership and social skills, much needed training if we consider the impact of the leader's attitudes on the health outcomes of the organization. But we need another leap in the courses: that of information management. We need clinical managers with basic knowledge of programming and databases who understand the structure of health care information of a hospital or a health system.

In addition, it would be very interesting that training for managers include other much needed fields: data visualization, ethical and social marketing, collective intelligence and web 2.0, knowledge management and risk and crisis management. In this way, the system would have managers much more prepared for the challenges of this century.

Competing interests: No competing interests

10 August 2017
Miguel Angel Mañez Ortiz
Human Resources Department
Madrid Regional Government Health Service
Madrid (Spain)
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

I did not see specific patient age statistics vs physician age groupings. Wouldn't older patients, whose risk of dying soon was higher, want to see their own older doctors? Lots of uncontrolled variables in this study... I also agree with one of the other comments that a patient who knew the end of their life was near would seek care from an older physician that would tend to be more empathetic with a patient of their own age.

Competing interests: No competing interests

10 August 2017
Scott J. Andrea
retired
Pasadena, TX 77505
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Re: Global climate is warming rapidly, US draft report warns Michael McCarthy. 358:doi 10.1136/bmj.j3824

Nuclear power plants emit virtually no greenhouse gases in comparison to coal, oil or gas. The global development of nuclear energy must be managed by a powerful international executive based in the most developed parts of the world. It would prevent the spreading of nuclear technologies to unstable regions, where wars and terrorism are not excluded. It would also permit construction of nuclear power plants in optimally suitable places, disregarding national borders, considering all socio-political, geological and other preconditions, quality of working, etc.

In this way, nuclear accidents like in Japan (2011), caused by the formidable earthquake and tsunami, or in Chernobyl (1986), favored by disregard for written instructions, would be prevented. Natural energy sources like solar, geothermal, wind, hydroelectric power will make a contribution, but their share in the global energy balance is too small to substitute for nuclear power. It can be illustrated by the figures of the world total primary energy supply (2014): fossil fuel (coal, oil, natural gas) - 81.7%, biofuels and waste - 10%, nuclear - 4.8, hydro - 2.4, others -1.2%.

More details and references: Jargin SV. Nuclear Facilities and Nuclear Weapons as a Guarantee of Peace. J Def Manag 2016;6: 146. Available at https://www.researchgate.net/publication/303051342_Nuclear_facilities_an...

Competing interests: No competing interests

09 August 2017
Sergei Jargin
Medical reviewer
Clementovski per 6-82
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Re: Enhancing the usability of systematic reviews by improving the consideration and description of interventions Toby J Lasserson, David I Tovey, Ken Stein, Katy Sutcliffe, et al. 358:doi 10.1136/bmj.j2998

This guidance from Hoffmann and colleagues for reporting interventions in systematic reviews is widely applicable and likely to be useful to many readers.

Previously, we developed a tool that could be used in conjunction with this guidance.

The Oxford Implementation Index (OII) helps systematic reviewers address intervention (1) design, (2) delivery, (3) uptake, and (4) context.

Within trials, interventions may not be implemented exactly as intended. Thus, it is important to distinguish what was intended (i.e., in the trial protocol) from what actually happened (i.e., what providers and participants did in practice). Across trials, implementation may be a source of heterogeneity (e.g., for complex interventions), so reviewers should consider how differences in design, delivery, or uptake might affect the overall results. Finally, the context in which interventions are implemented might affect their comparative effectiveness or generalizability. Systematic reviewers should consider contextual similarities and differences across trials, and they should identify to whom and under what circumstances the results of systematic reviews might apply.

OII provides a framework that can be used in conjunction with the new guidance from Hoffmann and colleagues to help systematic reviewers address intervention implementation in their protocols, extract intervention details, incorporate intervention characteristics in analyses, and compare interventions across trials.

Evan Mayo-Wilson
Sean Grant
Paul Montgomery

Montgomery P, Underhill K, Operario D, Gardner F, Mayo-Wilson E (2013). The Oxford Implementation Index: A new tool for incorporating implementation data into systematic reviews and meta-analyses. J Clin Epidemiol 66(8): 874-882. DOI: 10.1016/j.jclinepi.2013.03.006

Competing interests: No competing interests

09 August 2017
Evan Mayo-Wilson
Assistant Scientist
Sean Grant (RAND), Paul Montgomery (University of Birmingham)
Johns Hopkins Bloomberg School of Public Health
615 North Wolfe Street, E6036
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Re: Many vaccines have tiny amounts of inorganic matter, investigation finds Jacqui Wise. 356:doi 10.1136/bmj.j596

Concerns re vaccine safety

Noel Thomas concludes in his response:

'...Those of us who have been members of the BMA for half a century wish to dismiss from our minds any suggestion that the BMJ, a respected journal of medical record, has been influenced by any such considerations, in not reporting the recent case of a senior scientist and whistle blower, at the CDC, in the USA. He alleges, with documentation to support his case, that the CDC attempted to destroy evidence of an association between MMR vaccines and autism. The alleged cover up lasted for 14 years...'

This time period is of crucial interest as 14 years ago, in 2003, there was a UK multi-party MMR class action involving 1400 children that was just six months away from being put before the High Court where the details of individual cases would at long last be scrutinised. However, 'the Legal Services Commission withdrew public funding on the grounds that the litigation was likely to fail. It said that medical research had failed to provide a conclusive link with the MMR vaccine and the symptoms experienced by the children, notably autism.'(1)

Mr Justice Keith: 'stressed that it was the funding issues, rather than the merits of the case, which had driven the decision not to allow claims to proceed. "It is NOT because the court thinks that the claims have no merit. Although this litigation has been going on for many years, the question whether the claims have merit has never been addressed by the court,"...' (1)

If the US CDC's scientists had published their work as it was originally produced, according to the senior scientist and whistleblower William W Thompson, PhD, I believe this could have had an important impact not only on the UK class action but also a 5000-case vaccine-damage multi-party action in the US. (3)

And, who knows? If any of the UK cases had been successful the burden of providing long-term care packages for vaccine-damaged individuals could have been met by the pharmaceutical manufacturers rather than the NHS continuing care budget and the DWP disability benefits system paid for by tax-payers.

(1) http://www.ft.com/cms/s/0/4fb0e88a-1625-11dc-a7ce-000b5df10621.html?ft_s...

(2) http://legislature.vermont.gov/assets/Documents/2016/WorkGroups/House%20...

(3) http://www.uscfc.uscourts.gov/autism-decisions-and-background-information

Competing interests: Mother of MMR vaccine-damaged son

09 August 2017
Jackie Fletcher
Carer
JABS
Warrington, Cheshire
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Re: Pharmaceutical companies’ policies on access to trial data, results, and methods: audit study Igho Onakpoya, Ian Bushfield, Liam Smeeth, et al. 358:doi 10.1136/bmj.j3334

RE: Pharmaceutical companies’ policies on access to trial data, results, and methods: audit study (BMJ 2017;358:j3334; doi: 10.1136/bmj.j3334)

Dear Editor:

We read with great interest the article titled “Pharmaceutical companies’ policies on access to trial data, results, and methods: audit study,” by Ben Goldacre, published in The BMJ on 26 July 2017. The International Society for Medical Publication Professionals (ISMPP), a not-for-profit professional society with over 1,500 members involved in the publication of medical research, would like to thank Goldacre and colleagues on the first global industry analysis of the policies of pharmaceutical companies related to transparency of clinical trials.

While variations were noted in the 42 company policies reviewed as part of the audit, it was constructive to find that a majority of the companies had policies that commit to the registration of all trials, availability of summary results, sharing of clinical study reports (CSRs), and availability of individual patient data (IPD) from clinical trials on request. In fact, over 90% of the top 23 pharmaceutical companies in the audit had policies that met all four of these transparency commitments.

With regards to the audit study’s findings related to the commitment to submit all trial results to an academic journal within 12 months of trial completion, the timeframes for manuscript submission in current guidelines [1,2] recommend the following:
• For licensed products, manuscripts should be submitted within 12 months (or 18 months at the latest) of study completion.
• For investigational products, manuscripts should be submitted within 12 months (or 18 months at the latest) of product approval or within 18 months of product discontinuation.

These guidelines, along with the usual timeframes needed for manuscript development, including managing challenges associated with data analysis/verification and coordination of author input [3], may be reflected in the audit study’s findings on the timing for manuscript submissions in the pharmaceutical companies’ policies. Recent clinical trial transparency regulations from the European Medicines Agency (EMA) and the US National Institutes of Health (NIH) [4-6], plus new data sharing requirements from the International Committee of Medical Journal Editors (ICMJE) [7], are likely to evolve the guidelines on timeframes for manuscript submission and, in turn, the policies of pharmaceutical companies.

Finally, we agree on the need to also look at transparency actions and policies by academic journals, academic institutions, and non-commercial sponsors as a basis of understanding trial transparency across all entities, not just pharmaceutical companies.

Sincerely,

Al Weigel
President and CEO, International Society for Medical Publication Professionals (ISMPP)

References

1. Battisti WP, Wager E, Baltzer L, Bridges D, Cairns A, Carswell CI, et al. Good Publication Practice for Communicating Company-Sponsored Medical Research: GPP3. Ann Intern Med. 2015;163:461-464; doi:10.7326/M15-0288.
2. International Federation of Pharmaceutical Manufacturers & Associations; European Federation of Pharmaceutical Industries and Associations; Japan Pharmaceutical Manufacturers Association; Pharmaceutical Research and Manufacturers of America. Joint position on the publication of clinical trial results in the scientific literature. 10 June 2010. Accessed at www.ifpma.org/resource-centre/new-industry-position-requires-submission-... on 2 August 2017.
3. Mooney LA, Fay L. Cross-sectional study of Pfizer-sponsored clinical trials: assessment of time to publication and publication history. BMJ Open 2016;6: e012362; doi:10.1136/bmjopen-2016-012362.
4. EU no 536/2014. https://ec.europa.eu/health/human-use/clinical-trials/regulation_en#ct4. Accessed 7 August 2017.
5. EMA Policy 0070. http://www.ema.europa.eu/ema/index.jsp?curl=pages/special_topics/general.... Accessed 7 August 2017.
6. US NIH Final Rule. https://prsinfo.clinicaltrials.gov/. Accessed 7 August 2017.
7. Taichman DB, Sahni P, Pinborg A, et al. Data Sharing Statements for Clinical Trials: A Requirement of the International Committee of Medical Journal Editors. Ann Intern Med 2017; doi:10.7326/M17-1028.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I previously worked for several pharmaceutical companies on medical publication teams, and currently serve as President and CEO of ISMPP. ISMPP is a not-for-profit professional society that is largely comprised of members from the pharmaceutical and medical communications profession, with funding derived from medical publications-related programs and memberships. Review and input was received by some ISMPP staff and the ISMPP Board of Trustees.

09 August 2017
Al Weigel
President and CEO
International Society for Medical Publication Professionals (ISMPP)
520 White Plains Road, Suite 500, Tarrytown, NY 10591, USA
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Re: Reduced radiotherapy is as effective as whole breast treatment for early breast cancer, study finds Susan Mayor. 358:doi 10.1136/bmj.j3759

Richard Lehman, in his BMJ Journal Review 7th August 2017 [1] comments on the report of the IMPORT LOW trial of partial breast radiotherapy [2], the subject also of Susan Mayor`s News item. [3] He draws attention to the fact that “trials of intra-operative local radiotherapy and a whole reclassification of the subtypes of `early breast cancer` have occurred since the trial began.” He, putting himself in the shoes of affected patients, opines that “If somebody could come up with a shared decision tool for patients, I would commend them as a genius, but also defy them to keep it up to date.”

Participants in both the IMPORT LOW Trial and the TARGIT-A trial of intra-operative radiotherapy [4] will have included women with non-invasive types of `early breast cancers` which would not have progressed, posing no threat to their lives. The sharp fall in the “local cancer relapse rate after breast conservation surgery followed by radiotherapy in many countries is influenced by patient age and clinicopathological factors.” that authors of the IMPORT LOW trial report, [2] could also have been affected by this factor. Either treatment for these women would constitute unnecessary overtreatment.

How indeed can we come up with a decision aid [1] for citizens and patients today when thorough work in producing `evidence` [2][4] is based on such shifting foundations, progressive re-classifications and understanding of `early breast cancer` and over-diagnosis? Certainly a `moving target` that defies finding the bulls eye. A move in the right direction would be to encourage citizens and patients to ask more questions: `What will happen if I do nothing?`; `What are the alternatives?`; `What might be the consequences?` [5]

[1] Richard Lehman Journal Review. BMJ 7th August 2017 Is less more for low-risk breast cancer? http://blogs.bmj.com/bmj/2017/08/07/richard-lehmans-journal-review-7-aug...

[2] Coles CE, Griffin CL, Kirby AM, et al. Partial breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5 year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet 2017. doi:10.1016/S0140-6736(17)31145-5.

[3] Susan Mayor. Reduced radiotherapy is as effective as whole breast treatment for early breast cancer, study finds. BMJ 2017;358:j3759 http://www.bmj.com/content/358/bmj.j3759

[4] Vaidya, JS, Wenz, F, Bulsara, M..., and on behalf of the TARGIT trialists' group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014; 383: 603-613

[5] Evans I, Thornton H, Chalmers I, Glasziou P. Testing treatments: better research for better healthcare – Second Edition. Pinter and Martin, London. 2011. ISBN 978-1-905177-48-6 Page 168: An Action Plan. Free download from www.testingtreatments.org/the-book/

Competing interests: No competing interests

09 August 2017
Hazel Thornton
Honorary Visiting Fellow, Department of Health Sciences
N/A
University of Leicester
"Saionara", 31 Regent Street, Rowhedge, Colchester CO5 7EA
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