CORRESPONDENCE
1 Veronesi U, Maisonneuve P, Sacchini V, that HRT was not a factor for
et al. Tamoxifen for breast cancer among
hysterectomised women. Lancet 2002; 359:
1122–24.
2 Fisher B, Constantino JP, Wickerman DL,
et al. Tamoxifen for prevention of breast
cancer: report of the National Surgical
Adjuvant Breast and Bowel Project P-I
study. J Natl Cancer Inst 1998; 90: 1371–88.
3 Veronesi U, Maisonneuve P, Costa A, et al,
for the Italian Tamoxifen Study Group.
Prevention of breast cancer with tamoxifen:
preliminary findings from the Italian
randomised trial among hysterectomised
women. Lancet 1998; 352: 93–97.
4 Rosen PP, Groshen S, Kinne D, et al.
Factors influencing prognosis in node
negative breast carcinoma: analysis of 767
TINOMO patients with long term follow
up. J Clin Oncol 1993; 11: 2090–100.
5 Fisher B, Dignam J, Wolmark N, et al.
Tamoxifen and chemotherapy for lymph
node negative oestrogen receptor positive
breast cancer. J Natl Cancer Inst 1997; 89:
1673–82.
Authors’ reply
Sir—In our and the NSAB-P1 trial,
there is a reduced risk of breast cancer
in the group receiving tamoxifen,
although the reduction is significant in
the NSAB-P1 trial but not in our trial.
An overview analysis of the available
intervention trials would show that
the outcomes are similar in magnitude
but differ in CI for the effect.
A more important issue surrounds
the comment that some of the
differences between the two studies
could be related to the high rate of
attrition in our study. This issue was
initially raised by Kathleen Pritchard1
who underlined that there were clearly
difficulties with adherence in our
preliminary analysis. Similarly, Fisher
and colleagues, whom Benson cites,
noted that non-adherence rates were
appreciable in the European trials.
We have previously reviewed the
data of the three studies in which the
same criteria were used to define
drop-out: the number of discontin-
uations for reasons other than major
events, including women lost to
follow-up, divided by the total
number of women included in the
analysis.2 With application of these
criteria, 36% of patients stopped
prematurely in Powles and colleagues’
study,3 29% in the NSAB-P1, and
21% in our preliminary analysis.
Differences in drop-out rates are not
the cause of differences in findings
between studies. Additionally,
tamoxifen cannot be considered as a
population-based prevention agent
without taking into account the large
non-adherence rate observed in all
three studies.
As we noted in our report, findings
on HRT must be interpreted with
caution for several reasons, mainly
THE LANCET • Vol 360 • November 30, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
workers to encourage patients to
randomisation. Benson seems to have
misread our findings. We stated that
our results suggest that the use of
HRT increases the risk of breast
cancer and that tamoxifen use in
women using HRT seems to reduce
the risk of breast cancer to that of
non-users of HRT.
We are interested in Benson’s
proposal that, in premenopausal
women with oestrogen deprivation
due to chemotherapy, HRT plus
tamoxifen might keep to a minimum
breast-cancer risk and improve
adverse effects of oestrogen
deprivation on the cardiovascular
system and bones. He suggests this
regimen’s use in women with good
prognosis and expected long-term
survival. However, women with good
prognosis do not generally undergo
chemotherapy, and there is not
sufficient evidence that administration
of oestrogens to women treated for a
breast carcinoma does not increase
the risk of metastatic potential at the
disease. Certainly the hypothesis
deserves to be discussed and tested in
a clinical setting.
U Veronesi, P Maisonneuve, N Rotmensz,
*P Boyle
Divisions of Senology, and *Epidemiology and
Biostatistics, European Institute of Oncology,
Via Ripamonti 435, 20141 Milan, Italy
(e-mail: peter.boyle@ieo.it)
1 Pritchard KI. Is tamoxifen effective in
prevention of breast cancer? Lancet 1998;
352: 80–81.
2 Veronesi U, Maisonneuve P, Costa A,
Rotmensz N, Boyle P. Drop-outs in
tamoxifen prevention trials. Lancet 1999;
353: 244.
3 Powles T, Eeles R, Ashley S, et al. Interim
analysis of the incidence of breast cancer in
the Royal Marsden Hospital Tamoxifen
randomised chemoprevention trial. Lancet
1998; 352: 98–101.
Dietary effect on blood
pressure
Sir—Jeyanthi John and co-workers
(June 8, p 1969)1 describe a sustained
improvement in fruit and vegetable
intake with a specific community-
based dietary intervention in a
southern England population.
Biomarkers confirmed the self-
reported increase and showed a
beneficial effect on blood pressure
and plasma antioxidant status.
Clearly an effective strategy for
dietary modification in the general
population would be a major step
towards achieving some of the
Government’s targets in public
health. It is tempting to try the
approach used by John and co-
take the recommended five portions
of fruit and vegetables per day.
However, participants who agreed to
take part in the study were defined as
being less materially deprived
than non-respondents. Indeed, the
investigators acknowledge that their
study group had a higher
socioeconomic class than the UK
average.
Socioeconomic status and material
deprivation could impact on the study
group’s willingness to alter habitual
dietary intakes. If there was a high
proportion of well-motivated individ-
uals in the study group, the
intervention would have a greater
likelihood of success. Moreover, in
their education materials, John and
co-workers quite rightly address
potential barriers to change in dietary
habit (cost, eating out, and catering
for children). The barriers to change
frequently described by those in lower
socioeconomic groups2 may differ
notably from those addressed in the
study. Thus, whether these results
could be replicated in lower
socioeconomic groups, in which the
rate of cancer, coronary heart disease,
and strokes is highest, remains
unclear.
We are investigating methods for
promoting dietary changes in relation
to the prevention of colorectal cancer.
After detailed interviews, our
preliminary findings show that in a
typical Scottish cohort of 50 people,
48% do not know why fruit
and vegetables are beneficial to
health, 54% are unaware of how
many portions should be eaten
each day, and 62% are unclear as to
what constitutes a portion. In
addition, 70% thought their diet
was already healthy. In John and
co-workers’ study the mean baseline
fruit and vegetable intake was
3·4 portions per day. In Scotland,
48% of the population eat fresh
fruit once a week or less and 41% eat
green vegetables once a week or less.3
This absence of recognition that
dietary improvement is needed, has
been cited by others as a barrier to
change.4
John and co-workers should be
applauded for outlining a strategy that
improves fruit and vegetable intake
and has a beneficial physiological
effect. However, it must be
established whether the intervention
used would be as effective in lower
socioeconomic groups. Moreover, if
the risk of coronary heart disease and
cancers is to be reduced, much more
effort is required to find methods of
making the public aware of their
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