Editorial

Breast cancer: old and new debates

Todays Lancet features a two-part Series on breast cancer ahead of the San Antonio Breast Cancer Symposium (Dec 610). The rst paper discusses whether MRI, which is used to screen women at increased risk of breast cancer because it oers more sensitive detection than mammography, improves patient outcomes. Among the dierent clinical settings in which MRI is used, Monica Morrow and colleagues conclude that the strongest evidence for MRI screening is in women at increased risk of breast cancer because of their genetic risk or family history. However, the authors note that further studies are needed to assess the benet in other high-risk groups, such as women with lobular carcinoma in situ. The second paper in the Series reviews gene expression proling in breast cancer, which has changed the way in which clinicians perceive the disease. For example, oestrogen-receptor (ER) positive and negative cancers are dierent diseases, both clinically and molecularly. Disease prognosis in women with ER-positive disease can be predicted by the expression of genes related to proliferation, and the clinical value of molecular signatures based on this premise is currently being tested in trials. While potential advances in breast cancer prognostics and diagnostics are being investigated, an old controversy continues. A letter in todays issue defends the health benets of population-based mammographic screening, which has come under recent attack by what the authors call an anti-screening campaign. Prospective randomised trials have shown that mammographic screening reduces breast cancer mortality. Breast screening programmes have been widely accepted as a proven, eective, population-based intervention. Yet an increasing number of researchers continue to raise concerns about overdiagnosis and the relative benet versus harm. This controversy has led England to set up an inquiry into the evidence supporting breast cancer screening. The results of this review, expected in early 2012, will be important, and not only for the UK. They must resolve distractions from the growing challenge of providing eective diagnosis and treatment for women with breast cancer. The Lancet

Science Photo Library

See Series pages 1804 and 1812 See Correspondence page 1775

For more on the UK review of breast cancer screening see http://www.cancerscreening.nhs. uk/breastscreen/news/037.html

CRASH-2 goes viral

In 2010, the CRASH-2 collaborators announced the results of a multinational randomised trial of tranexamic acid versus placebo in adult trauma patients with signicant bleeding. When given within 8 h of injury, tranexamic acid signicantly reduced the risk of all-cause mortality by about a tenth and death due to bleeding by about a sixth, with no increased risk of thromboembolic side-eects. A cost-eectiveness analysis showed that tranexamic acid could save 372 life-years per 1000 trauma patients in a low-income country such as Tanzania, 315 per 1000 in a middle-income country such as India, and 755 per 1000 in a high-income country such as the UK, at a cost per lifeyear saved of US$48, $66, and $64, respectively. Despite these compelling ndings, an audit of UK hospitals in 2011 showed that, of 412 trauma patients who were ill enough to need a blood transfusion and therefore be eligible for tranexamic acid treatment, only 12 (3%) received the drug. The implementation rate in low-income and middleincome countries could well be lower still. The CRASH-2 trial results were published in this journal, widely reported in the international media, and presented at many trauma and intensive care conferences. How else could researchers reach out to practising clinicians and make them aware of this lifesaving treatment? An enterprising idea that the CRASH-2 team rolls out today involves an adaptation of the concept of viral marketingie, a compelling video that internet users pass on to their online contacts. Drawing on the elements that tend to increase sharing (humour, surprise, emotion), the collaborators made a stop-motion animation in which a clay trauma victim, blood squirting heartily from a gaping hole in his abdomen, happily avoids imminent exsanguination by means of a timely injection. The video ends with an invitation to view the CRASH-2 trial results. The discordant juxtaposition of cartoon-like character and death at its messiest will no doubt appeal to the South Park generation. But will it impress them to the extent that it changes their practice? If branded pens and sticky notes can boost prescription of blockbuster drugs (and we know that they can), there is every hope that a much greater reward can be reaped by patients whose doctors view this animation. The Lancet
www.thelancet.com Vol 378 November 19, 2011
London School of Hygiene & Tropical Medicine/Hywel P Roberts

See Online for webvideo

For the video and other trial materials in Spanish, Portuguese, Chinese, Russian, and Japanese see http://crash2. lshtm.ac.uk/ For the CRASH-2 trial and associated Lancet content see http://www.thelancet.com/ crash-2-2010 For the cost-eectiveness analysis of CRASH-2 data see PLoS One 2011; 6: e18987. DOI:10.1371/journal. pone.0018987

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