October 17, 2002
Breast-Conserving Surgery versus Radical Mastectomy for Early Breast Cancer
Beginning in 1973, the value of radical mastectomy in early breast cancer was compared with that of limited surgery plus local postoperative radiotherapy in a randomized trial at the Milan Cancer Institute in Italy. After a median follow-up of 20 years, the overall survival in the two groups was virtually identical. The efficacy of the Halsted radical mastectomy was accepted as axiomatic for 80 years, although the validity of this assumption was never subjected to a rigorous scientific test. This report demonstrates clearly that the extent of local surgical treatment is not decisive in the outcome of breast cancer. (See also the report by Fisher et al. on 20 years of follow-up of women who underwent lumpectomy in a North American multi-institutional study, page 1233.)
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20-Year Follow-up of a Trial Comparing Total Mastectomy with Lumpectomy
In 1985, Fisher and colleagues reported the results of a randomized trial of the surgical treatment of early breast cancer. Five years after surgery, there were no differences in survival among women who had undergone total mastectomy, those who underwent lumpectomy, and those who underwent lumpectomy plus postoperative radiation therapy. Now, the same group reports 20-year follow-up data on 1851 women in that study. The results are the same: total mastectomy offers no advantage. The original study contributed to a major shift in the treatment of early breast cancer and improved quality of life for countless women with the disease. This long-term follow-up study should strengthen confidence in the efficacy of lumpectomy for eligible women with early breast cancer. (See also the report by Veronesi et al. of a 20-year follow-up of women who had breast-conserving surgery in Milan, Italy, page 1227.)
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Public Use of Automated External Defibrillators
This observational study describes the early experience after the installation of readily accessible automated external defibrillators throughout passenger terminals at three Chicago airports. Over a two-year period, 18 patients had ventricular fibrillation, 11 of whom were successfully resuscitated. The majority of rescuers were good Samaritans, acting voluntarily. In 6 of the 11 cases, the rescuers had no previous training in the use of automated external defibrillators, although 3 had medical degrees. Ten patients (56 percent) were alive and neurologically intact at one year. Bystanders without a duty to act and without prior training in the use of automated external defibrillators can use these devices successfully to save lives. Since passengers at O'Hare Airport include many health professionals, confirmation of these results in different settings is needed before they can be generalized.
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Special Article in the Patient Safety Series: Fatigue among Clinicians and the Safety of Patients
Clinicians, especially physicians in training, often work long hours and get inadequate sleep. The implications of fatigue among clinicians for the quality of medical care have not been adequately studied, but sleep deprivation is likely to cause medical errors. This article reviews the effect of fatigue on performance, as well as current policies regulating residents' hours of work and options for new regulations governing residency shifts. The authors argue that reform is needed because the long work hours of clinicians adversely affect the quality of health care.
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Current Concepts: Renal Dysfunction Complicating the Treatment of Hypertension
In patients with hypertension and renal insufficiency, there is often an increase in the serum creatinine concentration as the blood pressure is lowered. Physicians may respond by reducing antihypertensive treatment. However, as this review explains, the decline in renal function is hemodynamic in origin and is due to changes in renal autoregulation. Such an increase in creatinine should be recognized as a sign that the intraglomerular pressure has been successfully reduced, and the physician should continue antihypertensive treatment.
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