How sick the baby?
Authors: C Watkins
Journal: BMJ (1991)

benefits.''3When the data from all published trials of intraportal treatment are combined they show an overall reduction in the odds of death of 26%.'4 Whereas some of the trials of intraportal fluorouracil showed a reduction in the incidence of liver metastases" 1 ' others showed no such reduction,'2 15 and the effect of this treatment might be systemic rather than a local effect on liver metastases.'2The perioperative approach to adjuvant chemotherapy does have the considerable advantage of a very short treatment period lasting only a few days -compared with one year of treatment in the intergroup studies.7The United Kingdom Coordinating Committee for Cancer Research is currently conducting AXIS, a new trial to attempt to confirm or refute the value of this approach, and this study will be crucial in determining the future of intraportal administration of fluorouracil.Where do we go from here?The clear statement from the National Cancer Institute that adjuvant chemotherapy is now standard practice in stage C carcinoma of the colon and that ''no treatment" controls are no longer justifiable has resulted in most doctors in the United States using fluorouracil and levamisole.16 17 The attitude ofEuropean oncologists, however, is much more variable.8 9Though most are now more optimistic in their attitude to adjuvant therapy for cancer of the colon, many believe that studies have not yet established that the reduction in mortality with systemic chemotherapy outweighs the toxicity and inconvenience ofthe treatment and consider that trials should still include an untreated control arm.What is clear is that the pessimistic attitude to adjuvant therapy for cancer of the colon -common in the past -can no longer be justified.The recent intergroup trials from the United States were rigorous, and on the basis of these studies many clinicians in Britain are likely to conclude that those patients with stage C cancer of the colon who are treated outside a clinical trial should be offered adjuvant therapy as used in the intergroup studies.Much remains to be done-as the consensus report made clear.Newer treatments (such as the combination of fluorouracil with folinic acid, which has shown substantial activity in advanced cancer of the colon) should be tested as adjuvant therapy.The places of levamisole in combination with fluorouracil and of short perioperative infusions of fluorouracil into the portal vein need to be defined.Though it seems unlikely that the effect of adjuvant therapy in stage B cancer of the colon should be qualitatively different from that in stage C, the number of events and the follow up are not yet sufficient for any conclusions to be drawn from the published studies to date.Recent reports of adjuvant therapy in rectal cancer now suggest a degree of benefit similar to that in the colon cancer studies.20The priority must now be to enter many more suitable patients with cancer of the colon into randomised trials of adjuvant therapy.Patients who are eligible for clinical trials should be encouraged to take part in such studies.Only by this means will progress be made.Individual doctors will have to judge whether or not they think a "no treatment" control arm is still justifiable, and patients will need to be informed of the issues before they are treated or offered randomisation.