With respect to the news article by Newman (1), there are clinical issues regarding the biology of colonic neoplasms that should be considered when evaluating the study of screening by colonoscopy reported by Lieberman et al. (2). In an editorial, Podolsky (3) correctly observed that the study by Lieberman et al. did not demonstrate that screen by colonoscopy enhanced survival. Colon cancers exhibit extreme biologic diversity, and the probability of metastasis, which is directly related to survival, is completely independent of the size of the cancers (4,5). Neoplasms of the colorectum exhibit enormous variance in growth rates, with many growing so slowly that they accumulate over time as the colon ages (6). This variance in growth rates can lead to length bias sampling and leadtime bias in assessing prognosis. The only valid assessment of what is in the aging colon is an autopsy study (7). Autopsy studies have consistently shown dissimilarity between the distributions of cancers and the benign polyps that are more frequently detected by colonoscopy. The great number of benign polyps with respect to the small number of cancers found at autopsy supports a very low probability of a benign polyp becoming a cancer. Lessfrequent villous adenomas may become cancerous with increasing size (>2 cm). Only a controlled clinical trial for screening strategies will establish that survival can be enhanced by colonoscopic screening.

Cancers of the anus, whether keratinizing squamous, nonkeratinizing, clear-cell, or melanoma, are infrequent neoplasms. Small keratinizing (<4 cm2) with no deep invasion can be controlled by local excision or laser ablation, but larger ones may be treated by chemoirradiation, restricting abdominoperineal resection to recurrences. Neither melanomas nor clear-cell cancers are curable, and local control is the surgical objective. Prophylactic groin dissection is not required but, for enlarged nodes or in the presence of a positive sentinel node biopsy, may be curative in many cases and palliative in all.

A review of the history, indications, basic technique, end results, and complications of exenterative surgery for pelvic neoplasms is provided. The authors discuss their broad personal experience with the operation. Much of this experience evolved from work at Barnes Hospital and the Ellis Fischel State Cancer Hospital. The techniques are applicable to advanced neoplasms of the cervix uteri, scrotum, urinary bladder, and other, less frequent neoplasms still confined to the pelvis. J. Surg. Oncol. 1999;72:102–104. © 1999 Wiley‐Liss, Inc.

The strategy of therapy for any neoplasm is determined to a significant degree by the biological characteristics of the neoplasm. The ones benefited most by surgical ablation are the cancers that grow locally but never metastasize. The second group is composed of neoplasms with exceedingly slow growth rates permitting long periods of symptom-free survival before recidivation. Many such cancers occur in pelvic structures requiring understanding of the nature of the cancers and then techniques necessary for their resection. The review provides an introduction to some of the relevant biological considerations. (C) 1999 Wiley-Liss, Inc.

Journal of Surgical OncologyVolume 71, Issue 4 p. 248-248 Letter to the Editor Rates of growth of human cancers: Clinical relevance John S. Spratt MD, FACS, Corresponding Author John S. Spratt MD, FACS jsspra@ulkyvm.louisville.edu University of Louisville Health Sciences Center, Division of Surgical Oncology, Louisville, KentuckyUniversity of Louisville Health Sciences Center, Division of Surgical Oncology, 529 South Jackson St., Louisville, KY 40202-1671Search for more papers by this author John S. Spratt MD, FACS, Corresponding Author John S. Spratt MD, FACS jsspra@ulkyvm.louisville.edu University of Louisville Health Sciences Center, Division of Surgical Oncology, Louisville, KentuckyUniversity of Louisville Health Sciences Center, Division of Surgical Oncology, 529 South Jackson St., Louisville, KY 40202-1671Search for more papers by this author First published: 03 August 1999 https://doi.org/10.1002/(SICI)1096-9098(199908)71:4<248::AID-JSO9>3.0.CO;2-EAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume71, Issue4August 1999Pages 248-248 RelatedInformation

BACKGROUND:Mammography is less effective for women aged 40-49 years than for older women, which has led to a call for research to improve the performance of screening mammography for younger women. One factor that may influence the performance of mammography is breast density. Younger women have greater mammographic breast density on average, and increased breast density increases the likelihood of false-negative and false-positive mammograms. We investigated whether breast density varies according to time in a woman's menstrual cycle. METHODS:Premenopausal women aged 40-49 years who were not on exogenous hormones and who had a screening mammogram at a large health maintenance organization during 1996 were studied (n = 2591). Time in the menstrual cycle was based on the woman's self-reported last menstrual bleeding and usual cycle length. RESULTS:A smaller proportion of women had "extremely dense" breasts during the follicular phase of their menstrual cycle (24% for week 1 and 23% for week 2) than during the luteal phase (28% for both weeks 3 and 4) (two-sided P = .04 for the difference in breast density between the phases, adjusted for body mass index). The relationship was stronger for women whose body mass index was less than or equal to the median (two-sided P<.01), the group who have the greatest breast density. CONCLUSIONS/IMPLICATIONS:These findings are consistent with previous evidence suggesting that scheduling a woman's mammogram during the follicular phase (first and second week) of her menstrual cycle instead of during the luteal phase (third and fourth week) may improve the accuracy of mammography for premenopausal women in their forties. Breast tissue is less radiographically dense in the follicular phase than in the luteal phase.

PURPOSE: Changing emphasis on educating generalist physicians prompted us to survey practicing primary care physicians to determine their perception of the lecture content and clinical skills required of students in our third-year surgical clerkship.METHODS: A 72-item questionnaire was developed. Respondents were asked to evaluate the relative importance of lecture topics and clinical skills on a 5-point Likert-type scale. Respondents were also asked about their medical practice and demographic information. primary care physicians were randomly selected from among those registered in our state's medical association.RESULTS: Nearly 70% of physicians in the sample responded. Although there were significant differences in responses among the primary care physicians surveyed, virtually all indicated that faculty should teach pathways in surgical management with emphasis on when to refer the patient to a surgeon.CONCLUSIONS: The changing health care climate necessitates a closer examination of undergraduate surgical curricula with attention to the educational needs of the generalist physician. (C) 1997 by Excerpta Medica, Inc.

The Physician and Home Health Care, John S. Spratt, M.D. and Rhonda L. Hawley, B.S. Systems Approach to Home Health Care, Robert E. Hoye, Ph.D. and M. Therese Dalton, R.N., M.P.A. Respiratory Therapy/DME, Dan K. Robinson Venous Access Ports, Michael J. Edwards, M.D. and Scott W. Taber, M.D. IV Antibiotic Therapy, Hiram C. Polk, Jr., M.D. and Anna K. Huang, M.D. Pain Management, Benjamin M. Rigor, Sr., M.D. Chemotherapy, Terence J. Hadley, M.D. Nutrition, Paul Mangino, R.Ph. and Paula Zelle Rehabilitative Therapy, David R. Watkins, M.D. and Joanne Berryman, R.N. Home Care of Communicative Disorders, David R. Cunningham, Ph.D. and Barbara M. Baker, Ph.D. An Overview of Hospice Home Care, Barbara Head, R.N., C.R.N.H., A.C.S.W. The Role of the Social Worker in Home Care, Bibhuti K. Sar, Ph.D. and Iris Phillips, M.S.S.W. Legal Aspects of Home Health Care, Brian K. Brake, J.D. Total Quality Management in Home Health Care, Vanita Bellen, B.S., B.Comm., M.H.S. Pediatric Home Care, Sofia M. Franco, M.D. Pediatric Pulmonary Disease, Nemr S. Eid, M.D. Home Health Care of Chronically/Terminally Ill Child, Salvatore J. Bertolone, M.D. Home Care of Radiation Patient, William J. Spanos, Jr., M.D. Home Care of Head and Neck Patient, David S. Robinson, M.D. Mental Health in Home Health Care, Danielle Turns, M.D. Oral Health Management in Chronically Ill Patients, Margaret Hill, D.M.D. and Regan L. Moore, D.D.S., M.S.D. Home Care of the Cardiac Patient, Albert G. Goldin, M.D. Index

Journal of Surgical OncologyVolume 63, Issue 2 p. 71-76 What are the benefits and costs of screening mammograms on Kentucky women aged 40–49? John S. Spratt MSPH, MD, Corresponding Author John S. Spratt MSPH, MD Department of Surgery, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, KentuckyUniversity of Louisville School of Medicine, James Graham Brown Cancer Center, 529 South Jackson Street, Louisville, KY 40292Search for more papers by this authorBeverly M. Gaines MD, Beverly M. Gaines MD Kentucky Health Policy Board, Frankfort, Kentucky, Louisville, KentuckySearch for more papers by this authorW. Steve Aaron MD, W. Steve Aaron MD Kentucky Health Policy Board, Frankfort, Kentucky, Louisville, KentuckySearch for more papers by this authorPatricia Cerrito PhD, Patricia Cerrito PhD Department of Mathematics, University of Louisville, Louisville, KentuckySearch for more papers by this author John S. Spratt MSPH, MD, Corresponding Author John S. Spratt MSPH, MD Department of Surgery, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, KentuckyUniversity of Louisville School of Medicine, James Graham Brown Cancer Center, 529 South Jackson Street, Louisville, KY 40292Search for more papers by this authorBeverly M. Gaines MD, Beverly M. Gaines MD Kentucky Health Policy Board, Frankfort, Kentucky, Louisville, KentuckySearch for more papers by this authorW. Steve Aaron MD, W. Steve Aaron MD Kentucky Health Policy Board, Frankfort, Kentucky, Louisville, KentuckySearch for more papers by this authorPatricia Cerrito PhD, Patricia Cerrito PhD Department of Mathematics, University of Louisville, Louisville, KentuckySearch for more papers by this author First published: October 1996 https://doi.org/10.1002/(SICI)1096-9098(199610)63:2<71::AID-JSO1>3.0.CO;2-LAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume63, Issue2October 1996Pages 71-76 RelatedInformation

Part I of this study [Spratt JS, Meyer JS, Spratt JA: J Surg Oncol 60:137-146, 1995] reviewed the early reports of investigators, predominantly mathematical biologists and statisticians considering the mathematical laws that would describe the growth of a neoplasm. Included were cytokinetic measurements of the mitotic index, thymidine labeling index, bromodeoxy-uridine labeling index, and the relation of these indices to the potential tumor volume doubling time. The actual doubling time of benign and malignant colonic neoplasms were reported. This second part provides the cumulative observations on the actual doubling times of pulmonary metastases, primary pulmonary cancers, skeletal sarcomas, melanomas, a chemodectoma, tumors of maxillary antrum, testicular cancers, prostate cancer, and the relation between the accumulation of multiple primary cancers and growth rates. The most complete data set is for breast cancer concluding that the cancer growth curve is a decelerating curve with great natural variance. Understanding of the rates of growth of human cancers is essential for understanding the spectrum of cancer behavior observed clinically.

The purpose of this article is to consolidate data collected from a variety of sources that have permitted calculations of the rates of growth of human neoplasms. These sources include Fischel State Cancer Hospital (Columbia, MO); Mallinckrodt Institute of Radiology, (St. Louis, MO); Roentgen Diagnostic Institute, Allmanna Sjukhuset (Malmo, Sweden); University of Louisville (Louisville, Kentucky); University of Heidelberg (Heidelberg, Germany); and St. Luke's Hospital (St. Louis, MO). Included in the data are laboratory measurements of cell replication rates. All gross measurements were made either on imaging studies or with a centimeter scale for surface or palpable neoplasms. Data have been reported for breast and pulmonary cancers and metastases of many types, melanomas, skeletal sarcomas, benign and malignant colonic neoplasms, and isolated cases of less frequent neoplasms. Related cytokinetic measurements by tritriated thymidine labelling, bromodeoxyuridine labelling, S‐phase fraction from DNA flow cytometric analysis, and mitotic indices are discussed. The various mathematical formulae applicable to the analysis of the collected data and the determination of rates and patterns of growth are included. Also considered are the clinical implications of these data and the importance of ever better knowledge on the cytokinetics of human cancer. Prior studies on the evolution of insight into this field are cited and discussed. The authors conclude that a more accurate quantification of the growth rates of human cancer is essential for understanding the biological variance of human cancers seen clinically. © 1995 Wiley‐Liss, Inc.

We tested the hypothesis that learning objectives could be used to evaluate course and instructor effectiveness. Ninety-seven third-year medical students who had their surgical clerkship or their medical clerkship as their first clinical rotation were compared. The surgery clerks received 171 urologic learning objectives. Students taking the surgical clerkship had significantly higher postclerkship recognition of the learning objectives than did medical clerkship students. One year later, these students were again surveyed to determine whether they still knew the correct response to the learning objective. The follow-up survey showed that 50% of the students recognized objectives covered in five of the eight urology lectures, while the other lectures were not effective. Students who recognized the objective on the postclerkship evaluation were more likely to think the objective had been taught on this follow-up survey. These data suggest that learning objectives are useful for evaluating course and instructor effectiveness.

Journal of Surgical OncologyVolume 59, Issue 3 p. 143-146 Article Decisions, interventions, outcomes, and cost in cancer control Dr. John S. Spratt MSPH MD, FACS, Corresponding Author Dr. John S. Spratt MSPH MD, FACS James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky; and F. Edward Hebert School of Medicine, Uniformed Services University for the Health Sciences, Bethesda, MarylandDepartment of Surgery, School of Medicine, University of Louisville, Louisville, KY 40292Search for more papers by this author Dr. John S. Spratt MSPH MD, FACS, Corresponding Author Dr. John S. Spratt MSPH MD, FACS James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky; and F. Edward Hebert School of Medicine, Uniformed Services University for the Health Sciences, Bethesda, MarylandDepartment of Surgery, School of Medicine, University of Louisville, Louisville, KY 40292Search for more papers by this author First published: July 1995 https://doi.org/10.1002/jso.2930590302Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume59, Issue3July 1995Pages 143-146 RelatedInformation

This article reviews the biologic variance in the lethality and rates of growth of human breast cancers and the clinical paradoxes these variances produce. The paradoxes themselves deviated from contemporary dogma on breast cancer control When alleged deviations from dogma occur in breast cancer interventions, medical negligent suits may arise because the biologic realities responsible for the paradoxes determine the outcome.