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Reply to Counterpoint
Histologic Grade as a Prognostic
Factor in Breast Carcinoma—Reply
Nicholas E. Roberti,
Retired Private Practice Radiation Oncologist, Oceanside, California.
See editorial counterpoint on pages 1703–5,
and referenced original article on pages 1708–
16, this issue.
Address for reprints: Nicholas E. Roberti, M.D.,
58 St. Malo Beach, Oceanside, CA 92054.
Received June 27, 1997; accepted July 9, 1997.
lthough I welcome efforts to go beyond the current TNM practice
of considering only anatomic extent variables in the assessment
of the prognosis of breast carcinoma, Drs. Burke and Henson1 fail to
appropriately address the practical clinical problem of the potential
use of grade as a prognostic indicator and guide to treatment within
the TNM framework. That tumor size and lymph node status outweigh
grade alone is not in question, nor is it at all surprising that combining
size and grade, as they have done, demonstrates little additional statistical effect for the inclusion of grade. However, that information is
irrelevant to the problem of selecting treatment for individual patients, because it makes no attempt to stratify by tumor size and then
examine grade for each T classification. Virtually all of the material I
have presented supports the position that grade is a usable prognostic
indicator in this clinical context. Furthermore, this position has been
validated by Dr. Henson’s own findings in previously published analyses of Surveillance, Epidemiology, and End Results (SEER) data.
Carter2, with Dr. Henson as a coauthor, examined SEER cases for
the relation between tumor size and lymph node status and noted
‘‘Within the group, however, are subsets that have increasing or decreasing survival experiences for the same tumor size and node status.’’ In a subsequent report, Henson et al.3 clearly demonstrated that
within each T category, grade is related to survival, for both lymph
node negative and positive patients. TNM system Stage IV cases also
were analyzed. Contrary to the editorial, these had been graded in
approximately the same proportion as the entire group, 27.0% as
opposed to the overall 24.8%. The 5- and 10-year prognostic indices
of Henson et al. demonstrated a consistent survival advantage for
patients with Grade 1 disease, including those patients with Stage IV
disease. They stated ‘‘Histologic grade, when used in conjunction with
stage of disease, can improve the prediction of outcome. Our results
also indicate that a prognostic index can be created for breast cancer
using a combination of stage of disease and histologic grade.’’
The current editorial analysis finds that grade adds nothing to
the predictive value of new molecular genetic factors. Omitted is any
statement of whether the reverse is true. It remains unclear what, if
anything, the new factors add to the prognostic value of grade.
The TNM system is simple to use and easy to understand. It is
an excellent tool for subset identification and for communication
among clinicians, and is a great aid in patient education. The TNM
nomenclature has proven its clinical value and will not be discarded
q 1997 American Cancer Society
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10-08-97 14:20:02
W: Cancer
lightly. Drs. Burke and Henson offer no means of
translating their computer experience to the individual
patient decision-making process, and they grossly exaggerate the complexity of adding grade to the TNM
system. The potential utility of grade is to identify patients who are at a greater or lesser risk of failure than
suggested by the system with its current limitations.
Using only three grades, as suggested by Henson et
al.3, which is an approach such as that used staging
for prostate carcinoma, should suffice.
Finally, for decades it has been recognized that an
unacceptable number of Stage I patients eventually
die of their disease. From the former practice of withholding adjuvant treatment from all these patients un-
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10-08-97 14:20:02
til they recurred to the now common practice of treating many or all patients without further attempts to
identify those for whom such treatment may or may
not be appropriate, grade continues to be largely ignored despite decades of evidence of its prognostic
Burke HB, Henson DE. Histologic grade as a prognostic factor in breast carcinoma. Cancer 1997;80:1703–5.
Carter CL, Allen CE, Henson DE. Relation of tumor size,
lymph node status and survival in 24,740 breast cancer
cases. Cancer 1989;63:181–7.
Henson DE, Ries L, Freedman LS, Carriega M. Relationship
among outcome, stage of disease, and histologic grade for
22,616 cases of breast cancer. Cancer 1991;68:2142–9.
W: Cancer
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