Mammography Tribute to Dr. Frank Adair

To the Editor:

After reviewing your July/August issue onthe Breast Cancer Detection Demonstration Project (Ca 32:194—225, 1982), aspecific problem has arisen that I have noidea how to answer.

I have a 38-year-old female patient withbilateral breast cancer in remission. Shehas three teenage daughters—ages 13, 15,and 17. She has asked when and if mammography should begin and how often. Iunderstand that examination of the breastswill need to be performed yearly in womenin such a high-risk category. However,when should mammography be started onteenagers with such family history?

David Litowsky, M.D.Houston, Texas

Dr. Philip Strax's Reply:

Reassurance should be given to the threeteenage daughters that their mother's experience does not mean that they will develop breast cancer. It does mean that theirrisk is higher than that of other womenwithout the positive family history and that,therefore, it behooves them to be extracareful in following suggested precautions.

The girls should each be taught breastself-examination on a one-to-one basis andencouraged to follow through on a regularmonthly basis.

Clinical examination on an annual basis by a physician is indicated for reassurance as@wel1as for checkup.

Manirnography should be started on anannual basis at age 35. If any questionablefindings or symptoms develop before thisage, mammography may be helpful at thattime.

Philip Strax, M.D.DirectorGuttman InstituteNew York, New York

To the Editor:

I would like to tell you how much I enjoyedyour personal tribute to Frank E. Adair,M.D. (Ca 32:238—241, 1982). He wascertainly one of the most outstanding people I knew during the time we were atMemorial (Sloan-Kettering Cancer Center)together. I still remember “¿�Pappy―swinging the mop in the O.R. between cases.

It is very fining that this tribute waspaid to him in the issue of Ca devoted tobreast diseases and breast éancers.

John 1. P. Cudmore, M.D.San Diego Tumor InstituteSan Diego,California

To the Editor:

Thank you for such a fine tribute to FrankAdair. I know that he would have beengreatly appreciative of the quality of thetribute, and the respect and affection itclearly demonstrated.

Charles D. Sherman, Jr., M.D.Clinical Professor of SurgeryUniversity of RochesterDirector of Surgical OncologyHighland HospitalRochester, New York

GestationalTrophoblasticNeopiasiaTo the Editor:

I was interested to read Dr. Greentree'scomments (Ca 32: 191—192, 1982) relative to the incidence of gestational trophoblastic neoplasia he found while inpractice in the Orient, since my own experience of practice in the Philippines reveals some interesting statistical anomalies.

Dr. Greentree, while in practice in threedifferent areas of the Orient, encounteredno cases of molar tumors, whereas the pub

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lished statistics, as quoted by Dr. Hammond in his excellent review (Ca 31:322—332, 1981) and cited in his reply to Dr.Greentree, indicated a twofold to threefoldor greater increase in incidence rates overrates witnessed in the West.

During a three-year assignment to ClarkAir Force Base in Pampanga, Philippines,I encountered three cases of gestational trophoblastic neoplasia out of a total of 3,600deliveries. One of these occurred in a Caucasian, and two, in Orientals. The femalepatient population at Clark Air Force Baseis about two thirds Oriental and one thirdCaucasian. Thus, the rate in Orientals andCaucasians was the same, and the overallrate was 0.08 percent.

However, during this same time, whilebeing a volunteer consultant at San Fernando General Hospital, a Philippine provincial hospital within a few miles fromClark Air Force Base, I found that the incidence of this condition was one in 200births. The patient population at this hospital is totally Oriental. The general population from which the Oriental patients atboth hospitals is drawn, is about the same.

It would appear that the incidence ofgestational trophoblastic neoplasia at theClark Air Force Base hospital is approximately equal to that in the United States,while similar patients at San Fernando showa fivefold to tenfold increase over westernrates. The Oriental patients at Clark aremarried to Caucasian or black Air Forcepersonnel and enjoy a higher standard ofliving than the San Fernando patients,which may be a contributing factor to thelower incidence. Dr. Hammond has pointedout that socioeconomic factors cannot satisfactorily account for regional incidencevariations. Since the only other factor separating the two populations is the race ofthe husband, perhaps a sex-linked factortransmitted by the husband accounts for thelower incidence when the husband is nonOriental.

Another possible factor involved ingeographical variations in the Orient couldbe either altitude or mean temperature. Thegoldmine mentioned by Dr. Greentree liesat a higher elevation, and has a lower meantemperature than San Fernando. Manchu

ria, where he also practiced, would havea lower mean temperature, as would Korea. Similar correlation with temperaturehas been found for geographical variationfor Burkitt's lymphoma in Central Africa,and I have observed a correlation betweenaltitude (and temperature) and the incidence of leprosy in Cebu, Philippines.

I hope other physicians practicing inthe Orient may be able to expand on theseobservations.

Christopher J. Von Dippe, M.D.Assistant Clinical ProfessorDepartment of Obstetrics-GynecologyUniversity of CaliforniaSchool of MedicineLos Angeles, California

Cancer Risks ofMedical Treatment

To the Editor:

In “¿�CancerRisks of Medical Treatment―(Ca 32 :258—279, 1982) Dr. David Schottenfeld asserts that phenacetin-containinganalgesics can cause chronic interstitial nephritis and transitional cell carcinomas ofthe renal pelvis and bladder. The focusappears to have been on “¿�phenacetin.―Itmight have better been on “¿�analgesics.―

For years many of us, including me,may have perpetuated a myth about phenacetin while missing the true villain or villains in this story. Phenacetin has receiveda bum rap because of guilt by associationaccording to an extensive review on thesubject by L.F. Prescott (University Department of Therapeutics and ClinicalPharmacology, The Royal Infirmary,Edinburgh) who lists 593 references in anarticle entitled “¿�AnalgesicNephropathy: AReassessment of the Role of Phenacetinand Other Analgesics―(Drugs 23:75—149,1982).

Prescott states, “¿�Analgesicnephropathy is more likely to be caused by aspirin,pyrazolones, and other acidic anti-inflammatory analgesics rather than by phenacetin itself, and the common belief that

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