Cigar and pipe smoking and the heart.
Authors: R Mulcahy
Journal: BMJ (1985)

galaxy of complications.Cytotoxic drugs have immediate side effects such as nausea and vomiting, phlebitis, alopecia, neuropathy, and late complications seen in the form of second malignancy some years after successful control of Hodgkin's disease.6Several drugs, such as etoposide and methotrexate, are being advocated in first line treatment to lessen these effects, and several trials are attempting to find the minimum amount of chemotherapy compatible with the maximum response rate.Radiotherapy is not without its problems either, particu- larly in children.Serious disturbance of growth and interfer- ence with the development of the endocrine and reproductive organs are of great concern in young patients-whose prognosis is better than that of adults.7 Furthermore, the addition of radiotherapy to chemotherapy further increases the risk of secondary malignancy in both child and adult.Not surprisingly, therefore, paediatricians have been experi- menting with smaller radiotherapy fields and lower doses in children with limited disease.An article describing long term survival of children treated for Hodgkin's disease in Britain appeared recently in the Archives of Disease in Childhood.8The report spanned the period 1974-82 and included 80 children.The complete remission rate of these patients was 95% and their actuarial five year survival 94%.The relapse free survival was 82%, with a median follow up of 4 8 years.An encouraging feature of this report is the tendency to give chemotherapy to children with earlier stages of disease in order to avoid staging laparotomy and extended field radiation.The reduc- tion in these fields and doses of x rays prevented stunting of growth, hypothyroidism, and hypoplasia of breasts in pubertal girls.Substituting chlorambucil for nitrogen mustard lessened acute nausea and vomiting but it seems unlikely to prevent secondary tumours or disturbances of fertility.In the same vein the Amsterdam Working Party for Childhood Tumours treated nine patients in stages I and II with tumours smaller than 4 cm with six MOPP cycles without radiotherapy (H Behrendt, B Van Bunningen, paper given at second international conference on malignant lym- phoma, Lugano, Switzerland, 1984).All are in sustained complete remission with a median follow up of five years.Nine further patients with larger tumours were given the same drugs, sandwiched round local radiation of 25 Gy (2500 rads).Only one child relapsed (outside the irradiated area) after 26 months, and he died of progressive disease.The remainder are free of disease with a follow up of 22-72 (median 50) months.These two reports show how successful chemotherapy can be in children with very early stages of Hodgkin's disease.The omission of staging laparotomy is therefore logical, and radiotherapy may reasonably be reduced or omitted.Problems of potential overtreatment of patients remain, however, and efforts need to be continued to remove potential carcinogenic substances from chemotherapy regimens.Despite the astonishing success of the past 21 years small groups of patients may be identified who will fare less well.Young girls with bulky mediastinal masses are one such group, and at the other end of the age range treatment in patients over 60 still has a 60% failure rate.New therapeutic regimens must be developed for these high risk patients, and further clinical trials of multidisciplinary treatment (now the accepted norm) are mandatory.Tackling Hodgkin's disease in such a fashion has paid rich dividends.The lessons of the past two decades have provided oncology with an excellent model which is now being successfully applied to other forms of solid tumour.We hope that the next 21 years will see the control with multimodality treatment of the "big three" cancers-breast, lung, and colon.