cell lung cancer.' Though we agree that surgery remains an optimal treatment for stage I and II disease, radical radiotherapy is of proved benefit in patients with ...
with an established technique. The harsh reality is that doctors who care for patients must, to provide best possible care, make choices between currently available methods. The comment about 15-27% of peripheral new vessels being outside the field of view of the non-mydriatic camera is woefully misleading. Although these figures do indeed appear in the discussion of the quoted paper they represent an opinion not supported by data. The results of that study include only one case of proliferative retinopathy not correctly classified by nonmydriatic photography, it being reported as severe non-proliferative retinopathy. The possibility of missing such new vessels is indeed to be considered, although the risk seems low. The assumption that the new vessels missed by retinal photography reflect a poor sensitivity to fine new vessels is unfounded. Ten of the 12 cases of missed new vessel formation were in eyes identified from the photograph as having advanced diabetic retinopathy but with the new vessels themselves being unrecognisable (shown in table III of the paper). Dr Newsom raises the matter of screening for diabetic retinopathy by ophthalmologists. At least in the Northern region, ophthalmologists are already overstretched by their workload. We would not have created vibration proof devices for cameras had we been able to create ophthalmologists instead. Our data must not be taken to indicate that the non-mydriatic camera is intrinsically excellent. Any tool used badly will give poor results. This is effectively illustrated by a recent small study comparing the performance of physicians peeping through undilated pupils with that of ophthalmologists.' A non-mydriatic camera was used in a small subgroup, and three out of four cases of proliferative retinopathy were missed. Our study has shown that non-mydriatic Polaroid photography is a practical screening technique of value only when used with reasonable care.
Is it not time for us to have more well trained ophthalmologists working in the community as well as in the hospitals so that our diabetic patients can get a decent service? Funduscopy, together with biomicroscopy, could then diagnose retinopathy correctly, and treatment could also be arranged with minimum delay. E M KOHNER
Hammersmith Hospital, London W12 OHS 1 Taylor R, Lovelock L, Tunbridge WMG, et al. Comparison of non-mydriatic retinal photography with ophthalmoscopy in 2159 patients: mobile retinal camera study. BMJ 1990;301: 1243-7. (1 December.)
SIR, - Dr Roy Taylor and colleagues point out that the major problem with diabetic retinopathy remains timely identification of the condition.' We were aware in 1985 that most clinicians looking after diabetic patients were unable to carry out a detailed examination of the retina. For this reason we suggested that optometrists carry out this task. It is probable that the standard of ophthalmoscopic examination by most diabetologists has not improved appreciably since then. Two thirds of diabetic patients attend hospitals infrequently and are therefore unlikely to have the opportunity of an examination with a nonmydriatic fundus camera. In addition, this device fails to pick up sight threatening retinopathy in an unacceptably high proportion of diabetic patients. To compare a poor method of screening with one that is even worse provides little reassurance to those who have shown that other methods of screening are better. The cost of an examination by an optometrist seems to be a small price to pay when weighed against the problems that arise if a person becomes blind as a result of diabetic
retinopathy. J C DEAN-HART Bristol Eye Hospital, Bristol BS l 2LX C j BURNS-COX
ROY TAYLOR
Frenchay Hospital,
Division of Endocrinology, Yale Medical School, New Haven, Connecticut 065 10, United States
Bristol BS 16 ILE
1 Nathan DM, Fogel HA, Godine JE, et al. Role of diabetologist in
1 Taylor R, Lovelock L, Tunbridge WMG, et al. Comparison of non-mydriatic retinal photography with ophthalmoscopy in 2159 patients: mobile retinal camera study. BMJ 1990;301: 1243-7. (1 December.)
evaluating diabetic retinopathy. Diabetes Care 1991;14:26-33.
SIR,-Dr Roy Taylor and colleagues state that non-mydriatic retinal photography is at least as good as funduscopy in detecting new vessels and better in detecting maculopathy in diabetic patients.' They made the serious mistake of assuming that a doctor, by being a doctor, automatically knows how to use an ophthalmoscope and how to diagnose "clinically significant" retinal lesions. The conclusions on the value of the nonmydriatic camera are not valid because, although three observers compared their readings of retinal photographs, no effort was made to ensure that ophthalmoscopy was similarly comparable between doctors. Furthermore, reading of photographs was done by consultants while a considerable number of patients were seen by less experienced junior doctors. In Glasgow physicians are allowed to screen for diabetic retinopathy only once they have been trained by ophthalmologists in the diabetic eye clinic-why not in Newcastle? We are told that one in 10 referrals by general practitioners is to eye departments, yet ophthalmology is given hardly any time in our medical schools. Compared with our colleagues in Europe, we are woefully poor in our ophthalmic services to patients. There are no ophthalmologists in the community and we expect optometrists, general practitioners, and junior doctors to diagnose diabetic retinopathy, often without specialised training or even dilatation of the pupil. '
176
Management of lung cancer SIR,-Dr Stephen G Spiro suggests that radical radiotherapy is of no value in treatipg non-small cell lung cancer.' Though we agree that surgery remains an optimal treatment for stage I and II disease, radical radiotherapy is of proved benefit in patients with potentially operable disease who are medically unfit for operation, are too old, refuse surgery, or have limited disease that is technically inoperable. Radical radiotherapy has a a poor reputation because most published data relate to its use in inoperable advanced disease. In early disease five year survival rates of 20% to 25% are commonly quoted.2 In an elderly group of patients found to have stage I disease after modern investigative procedures, including computed tomography, the five year survival rate was 15% in patients treated by radiotherapy and 26% in comparable patients treated by surgery: a non-significant difference.3 We therefore perform a full investigation to determine the disease stage, and if patients show localised disease we offer potentially curative radical radiotherapy. Unfortunately, few such patients are currently referred for treatment-in particular, we see few patients with asymptomatic localised lesions found while they were being investigated for coincidental illness. For inoperable disease the use of novel fractionation regimens such as CHART (continuous hyper-
fractionated accelerated radiotherapy) is proving interesting in terms of both local control and overall survival: survival at two years was 42% compared with 12% in historical controls. This regimen is currently being assessed in a multicentre trial.4 We agree that radiotherapy is also excellent palliative treatment. Medical Research Council trials showed that a two fraction regimen resulted in equivalent toxicity and efficacy when compared with a two week course of treatment (one standard treatment in Europe).5 The overall prognosis from lung cancer is poor. Only small improvements are likely from optimising usage of current treatments. New approaches and drugs are urgently required to make a genuine impact on the appalling morbidity and mortality from this common disease. S J FALK A LAMONT N M BLEEHEN Addenbrooke's Hospital, Cambridge 1 Spiro S. Management of lung cancer. BMJ7 1990;301:1287-8. (8 December.) 2 Haffty BG. Is radiation therapy a viable altemative to surgery in early stage lung cancer? Intl Radiat Oncol Biol Phys 1990;19: 2234. 3 Noordijk EM, Poest Clement E, Hermans J, Wever AMJ, Leer JWH. Radiotherapy as an alternative to surgery in elderly patients with resectable lung cancer. Radiother Oncol 1988;13: 83-9. 4 United Kingdom Coordinating Committee for Cancer Research Subcommittee for the Management of Lung Cancer. Third bulletin. London: UKCCCR, 1989:8-9. 5 Bleehen NM, Fayers PM, Girling DJ. Controlled trial of palliative radiotherapy given in two fractions or conventially fractionated for inoperable NSCLC. [Abstract.] Lung Cancer
1988;4:A144.
SIR,-We share Dr Stephen G Spiro's view that radiotherapy provides excellent palliation of the distressing symptoms caused by intrathoracic disease. ' The optimal fractionation of radiotherapy for symptomatic relief of primary lung cancer is, however, unclear. The trial to which he refers relates to the management of bone metastases in patients with a wide variety of primary tumours.2 The- fractionation of radiotherapy for the palliation of intrathoracic lung cancer is the subject of several trials. Preliminary results of two MRC trials have been reported (N M Beehan et al, first international consensus workshop on radiation therapy in the treatment of metastatic and locally advanced cancer, Washington, DC, 1990). Thefirst trial showed similar symptomatic benefit from either two 8-5 Gy treatments given a week apart or a course of 30 Gy given as 10 daily fractions. The second showed that single 10 Gy treatment seems to be as effective as the regimen using two fractions. Patients with better performance were, however, excluded from the second trial, and it is therefore not possible to conclude for all patients that a single treatment is as effective as a longer course. A current trial in Edinburgh compares the benefit of a short course of palliative radiotherapy comprising 30 Gy in 10 fractions over two weeks with a single 10 Gy treatment for locally advanced disease. Stratification by performance status before randomisation will allow accurate comparison of these two treatments not only in patients with a very poor prognosis but also in those with a longer life expectancy. Until the results of this and other studies are available the optimal radiotherapeutic schedule remains uncertain. C G KELLY M N GAZE
Radiation Oncology Unit, Western General Hospital, Edinburgh EH4 2XU 1 Spiro SG. Management of lung cancer. BMJ 1990;301:1287-8. (8 December.) 2 Price P, Hoskin PJ, Easton D, Austin D, Palmer SG, Yarnold JR. Prospective randomised trial of single and multifraction radiotherapy schedules in the treatment of painful bony metastases. Radiother Oncol 1986;6:247-55.
BMJ VOLUME 302
19 JANUARY 1991
