A Biopsy Review

While the "Standard Operating Procedures" article on sentinel lymph node biopsy ["Even an Uneventful Surgery Involves Choices and Risks," Feb. 4] was informative, we would like to clarify several statements that may be confusing to breast cancer patients and their families.

As noted in the article, the procedure is a method of selectively removing the first draining lymph node in the underarm area, the theory behind it being that breast cancer spreads to lymph nodes in an orderly fashion. Sentinel lymph node biopsy is an alternative to the standard level I and II axillary dissection, and carries a lower risk of arm swelling or other symptoms. It is also associated, as noted, with about a 5 percent false negative rate. It is not an alternative to lumpectomy or mastectomy, but rather an additional procedure that gives information to help guide therapy recommendations.

Treatment for breast cancer may be divided into local (breast) treatment -- such as lumpectomy with radiation therapy, or mastectomy -- and systemic (body) treatment.The information obtained from the sentinel lymph node biopsy is actually most helpful in determining systemic therapy recommendations. When lymph node involvement with cancer is found, it helps doctors determine what the risk may be of cancer cells elsewhere (outside the breast and lymph node area). This may lead to a recommendation for chemotherapy to try to prevent these other cells from growing. While the presence of tumor in the lymph nodes is associated witha lower cure rate, it has nothing to do with whether a woman may have a lumpectomy and radiation therapy rather than a mastectomy; the cure rate is unchanged by the choice of local therapy.

Stella Hetelekidis, M.D.

Susan M. Pierce, M.D.

Department of Radiation Oncology

Inova Fairfax Hospital

Falls Church

Editor's note: While an information box accompanying the story makes clear that sentinel node biopsy is a refinement to complete axillary lymph node dissection, the language at the top of the main story describing the procedure as "a less invasive alternative to mastectomy" is incorrect or at least misleading.

The story by J.B. Orenstein does little to realistically educate the public about the complexities of breast cancer.

The author did not explain the role lymph nodes play in breast cancer staging, or clearly relate the impact that cancer-positive nodes might have in determining the usefulness of other types of post-operative treatments. A significant number of women with positive nodes can still be cured of their disease, but one gets no inkling of this from the way the information is presented.

Women who undergo sentinel node dissection at the time of their lumpectomy do not have to be more vigilant when it comes to ongoing cancer surveillance. There is no evidence that women who have had fewer nodes removed must have additional mammograms over those required for any woman who has had breast conservation.

Also, it is the rare patient who would need plastic surgery after breast conservation. Indeed, the whole point of "lumpectomy" is to remove the cancer while trying to preserve a cosmetically acceptable breast.

Apart from these medical issues, this article does nothing to command the respect that meticulous breast surgery deserves. It seems that the author is looking for gratuitous drama, contradicting himself in the description of the operating room procedure as "lacking drama," yet playing up the patient's future of "always living in the shadow" of her disease. One needs only to print the words "breast cancer," and you can be sure of catching almost every woman's eye and garnering her undivided attention without the need of boldface type and catchy headlines.

Lastly, it is offensive to use such words as "jiggling," "carving out," "Big Mac" and "voodoo" in describing this patient and her cancer operation.

Stephanie Akbari MD

The Center for Breast Health

McLean

Virginia Chiantella MD FACS

Leesburg

Editor's note: It is the author's belief, as well as ours, that readers are well served by a candid, rather than idealized, description of a surgery many regard with fear. The author writes:

"I stand by the notion that revealing the inner workings of a typical procedure ultimately helps those patients undergoing it, and maybe even helps the surgeons better appreciate a patient's anxieties and sense of unknown."

Because the article didn't aim to be exhaustive in scope, it did not include a report on how to stage cancer or some of the other omissions cited.

The Price Was Wrong

We would like to point out a gross inaccuracy in "A New Choice for Treating ADHD" [Feb. 4].

You indicate that a spokesperson from CVS said that a month's supply of once-daily Adderall XR{reg} can cost $188. In fact, the retail cost of 30 Adderall XR{reg} capsules is around $88, depending on the pharmacy markup. In addition, a month's supply of Adderall{reg} (the original short-acting version) should cost closer to $90, rather than $120 as mentioned in the article.

Douglas Zink

Associate Director, ADHD Products

Shire US Inc.

Newport, Ky.

Editor's note: The cost information came from CVS, but our prices incorrectly assumed twice-daily dosing for Adderal XR, accounting for the disparity.

Bern, Baby, Bern

The dog pictured in "Blood Hounds 'Volunteer' Without Even a Bow-Ow" [Feb. 4] is a Bernese Mountain Dog, named after the area around Bern, Switerland. The breed is not from Burma. Bernese are an old, cold-weather-loving working dog breed, that purportedly kept Roman soldiers warm in Helvetia (ancient Switzerland).

Mary Singh and another "Bear"

Potomac

Bear's roots are in the mountains of Switzerland, not Burma.