Born: May 31, 1944 St. Louis, Missouri
Academic Degrees:
B.A. Rice University Houston, Texas 1967
M.D. Tulane University New Orleans, La. 1971
M.S. Tulane University New Orleans, La. 1971 (Physiology/Immunology
Post Graduate Training:
Internship Surgery San Francisco Gen. Hosp. 1971-1972
Fellowship Immunology & Transplantation Stanford 1972-1973
Residency Surgery St. Joseph Hospital, Houston 1974-1978
Fellowship Surgical Oncology Stehlin Foundation, Houston 1976
Professional Experience:
Private Practice of General Surgery Houston, Texas 1978-1988
Medical Writing/General Practice/Cancer Consultation Houston, Texas 1988-present
Certification:
The American Board of Surgery Diplomate 1980
Societies:
Harris County Medical Society
M. D. Anderson Associates
Texas Medical Association
Publications on the Surgical Treatment of Malignant Disease
Summary of Dr. Evans Contributions to the Medical Literature
I have published over 50 letters-to-the-editor and papers on the subject of cancer. Each is listed and summarized below. Many surgeons have written favorably about my work. "His hypothesis . . . may well be correct." Allen Silberman, UCLA. (ref. 7) ". . . an excellent hypothesis, that if true could explain a large amount of conflicting data." Paul Tartter, Mount Sinai, New York (ref. 9) "The hypothesis advanced by the author is interesting. . . ." Constantine Karakousis, Roswell Park (ref. 23) "I would like to thank Dr. Evans for his insightful comments." Charles Shumate, University of Alabama (ref.49) ". . . a refreshing concept." Ezra Greenspan, Mount Sinai, New York (ref. A) "Your questions reflects a great deal of thought and insight." Warren E. Enker, Memorial Sloan-Kettering Cancer Center, New York (ref. B)
I have asked surgeons to criticize my ideas, but thus far no one has successfully refuted them. (ref. 17, 21, 32) Many surgeons have expressed varying degrees of agreement. (ref. 7,17, 21, 32) Many have seriously misquoted the surgical literature. (ref. 13, 22, 27, 31, 37, 41, 51) These misquotes have erroneously supported the authors' bias toward radical surgery. Some have misrepresented my position. (ref. 21) You will see that one surgeon took 22 months to respond to my letter about his editorial. (ref. 22) He contradicted the conclusion of the NSABP, which I noted. (ref. 27) Another surgeon contradicted his own data. (ref. 25)
I have frequently suggested that investigators need to obtain more information in these areas: the immune status of cancer patients, the size of locally recurrent cancer, and the size of locally recurrent cancer as it compares to the size of the primary lesion. Several investigators have criticized this suggestion, saying there are not sufficient data to verify my hypothesis. (ref. 20, 30, 44). This, of course, is precisely my point.
Several studies published since 1994 have suggested that patients with small tumors (breast cancers or malignant melanoma lesions) may benefit from an elective lymph node dissection when the primary tumor is treated. This is contrary to prevailing ideas. I have suggested that the circulating tumor burden of the recurrence may exceed that of the primary and thus become the cause of tumor spread. (ref. 52,53) No one has refuted my explanation and one surgeon failed to respond to a letter that was accepted for publication by Annals of Surgery in January 1994. (ref. 55) In 1992, I asked this same surgeon if he agreed with my explanation of the paradoxical results of the Guy's Hospital Trials. (ref. 17) He did not reply. In 1993, I asked him again if he agreed with my explanation for the innocent behavior of local recurrence. (ref. 25) Again, he did not reply.
I have frequently suggested that the lessons we have already learned from breast cancer may apply to other malignancies as well. (ref. 15, 22, 23, 25, 28, 30, 33, 34, 35, 36, 38, 39. 40, 42, 43, 52) Thus far, No one has refuted this simple idea.
ARTICLES
1. Stehlin JS Jr, Evans RA, Gutierrez AA, et al. Treatment of carcinoma of the breast. Surg Gynecol Obstet 149:911-922, 1979.
Dr. Stehlin presented his first 81 patients treated with partial mastectomy and radiation therapy. He includes an excellent history of breast-sparing procedures.
2. Evans RA. Host resistance to carcinoma of the breast. South Med J 73:1261-1263, 1980.
This paper states that recurrent cancer after limited (conservative) surgery is not a survival hazard. I suggested that patients resist the implantation of circulating tumor cells with a variety of defense mechanisms. I suggested that: (1) patients have a stable defense threshold throughout life, and (2) patients vary widely in their host resistance thresholds. "For instance, a patient who survives a carcinoma of 2 to 3 cm in diameter arising in one breast without developing distant metastases may be expected to survive the recurrence of a similar volume of tumor in adjacent breast or lymphatic tissue." This is the only uncontested explanation for the innocent behavior of local recurrence following conservative surgery.
3. Evans RA, Bland KI, McMurtrey MJ, Ballantyne AJ. Radionuclide scans not indicated in clinical stage I melanoma. Surg Gynecol Obstet 150:532-534, 1980.
We demonstrated that liver and brain scans were of no use in the evaluation of patients with clinical stage I melanoma. This paper helped to change the evaluation of this disease.
4. Evans RA, Stehlin JS Jr. What risk partial mastectomy? Tex Med 77:4-5, 1981.
We calculated the survival hazard of partial mastectomy to be no more than 1 - 2%. This was verified by the NSABP lumpectomy trial (B-06) which found no survival hazard.
5. Evans RA. Partial mastectomy and radiation therapy. Breast, Dis Breast 10:32-33, 1984. (letter)
I said,"No surgeon, no radiation therapist, and no institution, once having embarked on a program of preservation therapy, has every returned to total removal of the breast." I was incorrect, Geoffrey Keynes, the first modern practitioner of breast-sparing surgery, was the first and only physician to do so. He returned to performing simple mastectomy in 1937 after experiencing a local recurrence rate of about 8% following breast-sparing treatment. It is correct to say that no one returned to radical mastectomy.
6. Evans RA. A hypothesis on breast cancer. Am Coll Surg Bull 72:84, 1987. (letter)
7. Evans RA. Clinical stage I melanoma among patients who presented with lesions of Clark levels deep III through V. Ann Surg 207:484-485, 1988. (letter)
In retrospective studies the survival advantage of elective lymph node dissection (ELND) for malignant melanoma has been exaggerated by relatively advanced nodal disease in patients who require delayed dissection. I commended A. W. Silberman for reporting nodal disease in a quantitative fashion. He said my "hypothesis . . . may well be correct."
8. Evans RA. Lumpectomy and radiation therapy: a question answered. Arch Surg 123:782, 1988. (letter)
9. Evans RA. Natural killer cells and the Guy's Hospital trials. Arch Surg 123:914-915, 1988. (letter)
The Guy's Hospital trials compared radical mastectomy (RM) with partial mastectomy and low dose radiation therapy (PM-XRT). They reported that patients with T1 breast tumors required a RM, but patients with T2 lesions did just as well with PM-XRT. This was the opposite of the practices of most U. S. medical centers. I suggested that many T1 patients died from the large tumor burden of recurrent nodal disease. RM removed the axillary lymph nodes and protected its patients from this threat.
All the patients who survived T2 lesions were immunologically prepared to survive the large volume of recurrent nodal disease. PM-XRT was not a disadvantage because nodal disease could be palpated and removed before it exceeded the tumor burden challenge already posed by the large T2 primary. Paul Tartter called this an "excellent hypothesis, that if true could explain a large amount of conflicting data." There is no other published explanation for these results.
10. Evans RA. Persistence and not recurrence when a tumor appears at the site of resection. Surg 106:578-579, 1989. (letter)
I suggested that local recurrence following limited surgery be called "local persistence," to distinguish it from the local recurrence following radical surgery.
11. Evans RA. Breast cancer: The dilemma of local recurrence. Med Hypotheses 29:151- 153, 1989.
Natural killer (NK) cells appear to destroy circulating tumor cells. NK activities vary widely among individuals, but remain stable throughout life. This is consistent with the hypothesis in ref 2.
12. Evans RA. Preservation surgery for malignant disease: why it works. South Med J 82:1534-1537, 1989.
I expand on the clinical and basic science data which support the role of NK cells in preventing distant metastasis.
13. Evans RA. Surviving breast cancer. Stanford Med 7:27, 1990. (letter)
Concerning the NSABP lumpectomy trial, Frank Stockdale stated that "the likely difference in survival between excision alone, excision plus radiation, or mastectomy will be only 10 - 15% . . . ." I pointed out that it was 0% and criticized this prestigious institution for fostering this misconception.
14. Evans RA. Clinical stage I malignant melanoma. J Cancer Res Clin Oncol 116:314, 1990. (letter)
Bieb et al. reported a benefit for ELND in malignant melanoma for males only. I raised the point in ref. 7 above and suggested that males may have returned less regularly for follow-up and may have developed larger nodal recurrences than females. My hypothesis could be confirmed or rejected by reviewing the original data. The authors did not reply.
15. Evans RA. The "Seed and Soil" hypothesis and the decline of radical surgery: a surgeon's opinion. Tex Med 86:85-89, 1990.
I applied the seed-and-soil hypothesis of Paget to explain the innocent behavior of "local persistence." (See ref. 10 above.) To Isaiah Fidler's three principles of the modern seed-and soil hypothesis, I added a fourth. Patients are heterogeneous in their ability to resist the implantation of circulating tumor cells. I suggested that this principle may apply to malignant melanoma and soft tissue sarcoma.
16. Evans RA. Significance of ipsilateral recurrence after lumpectomy. LANCET 338:1402, 1991. (letter)
I pointed out that Bernard Fisher's explanation for the innocent behavior of local recurrence was a "non-sequitur." I also included a brief explanation of my hypothesis. Fisher did not reply. LANCET refused to correct Fisher's error or publish an expanded version of my hypothesis.
17. Evans RA. Survival following locoregional recurrence after breast conservation therapy for breast cancer. Ann Surg 215:91, 1992 (letter)
I asked Charles Balch if he agreed with my explanation of the Guy's Hospital trials, ref. 9. Dr. Stotter replied that patients who develop local recurrence may double their risk of dying. She implied that our views of tumor burden were similar.
18. Evans RA. Survival after local recurrence of soft tissue sarcoma. Br J Surg 79:89, 1992. (letter)
I suggested that investigators should report the size of local recurrences.
19. Evans RA. Cancer in the contralateral breast after radiotherapy for breast cancer. N Engl J Med 327:430, 1992. (letter)
I criticized an article which reported an increased risk of breast cancer among younger women treated with XRT. The article promoted the public perception that radiation therapy was necessary. I suggested that patients be informed that XRT provides no survival benefit. The author replied that his article was not intended to discuss the affect of XRT on survival.
20. Evans RA. Prognostic factors in the treatment of breast cancer. N Engl J Med 327:1317-1318, 1992 (letter)
I suggested that adjuvant therapy trials should measure patient prognostic factors such as NK activity. The authors replied,". . . there are no published studies in breast cancer to verify this hypothesis." That was my point.
21. Evans RA. Brachytherapy enhanced the local control of soft-tissue sarcomas. but failed to enhance survival. Ann Surg 216:614-5, 1992. (letter)
Murray Brennan stated that better local control of soft tissue sarcoma with XRT did not improve survival. Edward Copeland asked,"Why have we not improved survival by reducing local recurrence?" I asked Drs. Brennan and Copeland if they agreed with my hypothesis as presented in reference no. 12. Brennan implied that I do not consider tumor factors to be significant. Paper no. 12 in this C.V. — to which Brennan referred — contains 2 paragraphs on the importance of tumor factors. Brennan relied,"We appreciate Dr. Evans' addressing the issue, but for the moment we would suggest that the failure of local recurrence to predict survival is at least as tumor-dependent as it is host-dependent." This is my point. The present model gives little, if any, significance to host-dependent factors. Copeland did not respond.
22. Evans RA. Current management of malignant melanoma. Ann Surg 217:308, 1993. (letter)
In December of 1990, I replied to Donald Morton's August editorial suggesting a 2 - 5 cm margin of excision for malignant melanoma. I said patients should be informed that narrow margins — and local persistence — are of no threat to patient survival, just as in breast cancer. In October, 1992, Morton referred to the analysis of Fisher et al., who concluded that local recurrence is "not a cause of, distant metastases." Morton attempted to quote Fisher and said,". . . local recurrence of breast cancer does (his emphasis) reduce survival time . . ." This was the antithesis of Fisher's conclusion. This dialogue continues in ref. 27. Dr. Morton waited 22 months to reply to this letter. [Published erratum appears in Ann Surg 1993 July; 218(1):108. The date on my letter was corrected from December 6, 1992 to December 6, 1990.]
23. Evans RA. Soft tissue sarcoma: The enigma of local recurrence. J Surg Oncol 53:88-91, 1993.
I applied the hypothesis of local persistence to soft tissue sarcoma. Constantine Karakousis (Roswell Park) said in a editorial reply,"The hypothesis advanced by the author is interesting. . . ."
24. Evans RA. Locally recurrent breast cancer. Surg Gynecol Obstet 177:176-7, 1993. (letter)
Michael Osborne reported the experience of Memorial with patients who developed local recurrence after partial mastectomy and radiation therapy. I asked if the excess mortality was limited to patients whose recurrence tumor exceeded the volume of the primary. He replied,"we have no precise means for measuring tumor volume." The measurement of tumor diameter is a reasonable beginning.
25. Evans RA. The increasing trend toward conservative surgery for malignant melanoma. Ann Surg 218:701-2, 1993. (letter)
Seigler had suggested a 2-cm margin for malignant melanoma. I ask him to clearly state that this is not a minimum "standard of care." He did not. Seigler cited a study by Balch comparing 2-cm and 4-cm margins of excision. Six patients developed local recurrence and five died of metastatic disease. Seigler correctly stated,". . . multiinstitutional randomized trial has provided data confirming a local recurrence rate of 0.8% for patients having 2-cm margins and 1.7% for patients having 4-cm margins." He continued,"These data would suggest that local recurrence in the narrow margin group was slightly higher and did significantly increase patient mortality." This is incorrect. Seigler contradicted his own data! Local recurrence was lower in the narrow margin group.
26. Evans RA. Results of salvage mastectomy for local recurrence after breast-sparing surgery without radiation therapy. Cancer 72:2292, 1993. (letter)
I commended Cajucom et al. for reporting the sizes of recurrences and suggested that the sizes of both the primary and recurrent lesions be compared for each patient. Author Tsangaris said that local recurrence "is not a harbinger of disease, but may indicate a risk for future systemic disease." He seems to understand the NSABP results, but confused "harbinger" with cause. This is a linguistic error.
27. Evans RA. Local recurrence is "not a cause of, distant metastases." Ann Surg 219:106, 1994. (letter)
I said that Morton had reversed the conclusion of the NSABP lumpectomy trial regarding the significance of local recurrence following lumpectomy. Dr. Morton replied,"I do not understand Dr. Evans' logic." I agree.
28. Evans RA. Local recurrence differs from local persistence. Am J Surg 176:622, 1994. (letter)
I suggest that the innocent behavior of promptly treated local recurrence following conservative surgery (local persistence) may apply to soft tissue sarcomas, malignant melanomas, and cancer of the bladder, breast, cervix, head and neck, genitalia, rectum, thyroid, and other organs.
29. Evans RA. Adjuvant systemic therapy and survival after breast cancer. N Engl J Med 331:401, 1994. (letter)
I criticized a Canadian study which concluded that adjuvant chemotherapy was responsible for an increase in the seven-year survival rate of breast cancer patients from 1974 to 1984. The study did not control for tumor size or stage of disease, and did not compare treated to untreated patients.
30. Evans RA. Elective lymph node dissection for clinical stage I malignant melanoma. J Surg Oncol 57:31-2, 1994. (letter)
I suggest that investigators should measure the volume of nodal disease. This tumor burden probably becomes an independent risk factor. Patients with thin lesions may be paradoxically at risk for developing distant metastases from a relatively small nodal recurrence, if those with a weak immune system allow the spread of tumors cells from a small nodal recurrence. Data from the WHO trial could still be reviewed to confirm or refute my suggestions. I also suggested that investigators should attempt to measure to volume of nodal disease.
Editor Gerald Murphy summarized the comments of several reviewers. They suggested that pathologists may be reluctant to measure the volume of nodal metastases "without some compelling documentation that it might be clinically useful." The compelling documentation is presented ref. 35, a paper which this journal had previously rejected for publication.
31. Evans RA. Review and current perspectives of cutaneous malignant melanoma. J Am Coll Surg 179:764-767, 1994. (letter)
I criticized this review article from M.D. Anderson which cited a paper by Aitken et al. which endorsed wide margins of excision. These authors later concluded,"Our study shows that a policy of conservative surgery did not adversely affect local recurrence." This retraction was not mentioned. I also criticized the ELND studies of Balch for the reasons mentioned above.
32. Evans RA. Prognosis of patients with bilateral carcinoma of the breast. J Am Coll Surg 180:126-7, 1994. (letter)
I asked if the investigators had compared the sizes of each patient's recurrent tumor to the size of her primary. They were unable support or refute my hypothesis with their data, but agreed that a patient's prognosis is primarily determined by the size of the largest tumor.
33. Evans RA. Narrow margins of excision do not decrease survival. Surg 117:115, 1995. (letter)
I said that narrow margins of excision do not reduce survival. Wider margins should not be a "standard of care." Some patients with a weak immune defense and thin lesions may risk tumor dissemination from positive nodal disease.
34. Evans RA. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 221:203, 1995 (letter)
I commended Paty et al. for being among the first to suggest that as with breast cancer, isolated local recurrence following conservative surgery may not be a hazard to survival.
35. Evans RA. Elective lymph node dissection for malignant melanoma: the tumor burden of nodal disease. Anticancer Res 15:575-80, 1995.
All available data support the point made in ref no. 7. The efficacy of ELND has been exaggerated by retrospective studies which generally fail to carefully measure the volume of nodal disease or report the follow-up frequency of the of the patients. Many patients died because nodal disease was allowed to grow to volume which exceed the volume of the primary tumor and the patient's defense threshold. I suggest that in current trials the volume of nodal disease be measured as precisely as possible. The follow-up practices of both surviving and dying patients should also be recorded. In the WHO ELND study the variations among centers may have related to these two factors and not genetic variation among the patients. Clinical trials now in progress may fail to resolve the role of ELND unless more accurate measurements are made.
It is theoretically possible that some patients with thin lesions are at greater risk for tumor spread. Those with a low defense threshold may kill tumors cells circulating from a thin primary, but develop distant metastases from a nonpalpable nodal disease. This is analogous to the paradoxical results of the Guy's Hospital trials described in reference 9 above.
36. Evans RA. Elective lymph node dissection (ELND) for malignant melanoma. Ann Surg 221:435-6, 1995. (letter)
I commended Slingluff et al. for being among the first to question ELND based upon a retrospective trial. They found a possible survival advantage for patients with thin lesions, which I suggested may be real.
37. Evans RA. Treatment of breast cancer. Ann Surg 221:436-7, 1995. (letter)
I criticized a review article by Eberlein from Harvard for misquoting local recurrence rates in patients treated with partial mastectomy and no radiation therapy. He said that two studies has reported the same high 40% recurrence rate found by the NSABP. This was wrong. The studies he quoted had actually reported recurrence rates of 9% and 10.2%.
38. Evans RA. RE: Discussion of expectant management of prostate cancer. J Urol 153:1954-5, 1995. (letter)
Dr. Gary Miller quoted the 1929 observation of Dr. Stanley Reiman,"ultimately if the surgeon leaves cancer in the patient then the patient is going to die, and if the surgeon takes the cancer out then the patient will live." I cited the NSABP conclusion that local recurrence is a "marker for risk of, not a cause of, distant metastases." I asked,"Can localized prostate cancer be treated with limited surgery?" Miller mentioned a randomized trial of radiation therapy and encouraged early detection.
39. Evans RA. Making the Right Choice: Treatment Options in Cancer Surgery, Avery Publishing Group, Garden City Park, New York (1995).
This book is a guide to understanding and using limited surgery in the treatment of cancer. Written for the lay public, its thesis is supported by considering the history of cancer surgery, the biologic behavior of cancer and the patient's own defenses against the spread of cancer cells. The book focuses on areas where aggressive surgery and radiation are often the most detrimental: cancer of the bladder, breast, cervix, genitals, prostate, and rectum; also included are the soft tissue sarcomas and malignant melanoma, which can occur in various parts of the body.
40. Evans RA. Salvage prostatectomy following radiation therapy. J Urol 154:537-8,1995. (letter)
Rogers et al. from Baylor reported on the survival of forty patients who developed recurrent prostate cancer following radiation therapy. The actuarial cancer specific five-year survival among these patient was 95% following salvage surgery. Among patients with early disease — disease confined to the gland or the immediate vicinity — there was no progression of disease in 82%. I compared these results to similar experience with breast cancer dating back many decades and suggested that the radical prostatectomy may soon go the way to the radical mastectomy. The authors did not reply.
41. Evans RA. Adjuvant chemotherapy in breast cancer. N Engl J Med 333;596-7, 1995. (letter)
Henderson said,"Local failure is a particularly difficult consequence of therapy for most patients because it is readily apparent and is thus a constant reminder that the tumor is no longer curable." This is incorrect. Responding to my letter he acknowledged his error:"If the new cancer is of the same stage or a lower one than the original cancer the patient's prognosis remains largely unchanged."
42. Evans RA. Radical hysterectomy for recurrent cancer of the cervix following radiation therapy. Gynecol Oncol 59:162-3,1995. (letter)
Surgeons at M. D. Anderson Hospital reported a 90% five-year survival among patients treated with salvage hysterectomy for recurrence cancer of 2 cm or less following radiation therapy. I compared this to similar results for cancer of the breast reported in the 1970's. I suggested that these data support the wider use of fertility-sparing surgery in the initial treatment of this disease.
43. Evans RA. Primary vaginal melanoma. Gynecol Oncol 59:164-5,1995. (letter)
The authors had treated only eight patients and had failed to correct for the stage of disease. I criticized the authors and editorial staff for their obvious bias in favor of radical surgery.
44. Evans RA. Recurrent breast cancer. Ann Surg 222:687-8,1995. (letter)
In the September 1993 issue, Cady et al. of Harvard suggested that selected patients with very small tumor primary lesions may be treated without axillary dissection or radiation therapy. They reported four patients who developed disturbing local recurrences. I suggested that recurrent breast cancers be measured and compared to the size of the primary lesion. Cady said he could not address the issues that I raised "in terms of the comparative bulk of metastatic versus primary disease." He said I was getting into an area of "believe and not data." Of course, there are no data, because few investigators have collected it.
45. Evans RA. Malignant melanoma: primary surgical management (excision and node dissection) based upon pathology and staging. Cancer 76:2384-5, 1995.(letter)
I repeated that no reliable study hand ever reported that narrow margins of excision adversely affect survival. I cited two studies suggesting that some patients with thin lesions may benefit from ELND, because nodal disease may easily exceed the tumor burden of the primary lesion. Harris replied by citing a more recent study by Coates et al. Using much of the same data Balch had used to support the benefit of ELND, Coates et al. found no benefit. (My letters on the Coates' study were both rejected for publication by the Journal of the American College of Surgeons.)
46. Evans RA. Primary soft tissue sarcoma of the extremities in adults. Brit J Surg 1996; 83:422. (letter)
I ask Karakousis if he agreed with my explanation for the innocence of local persistence. He said,"The truth probably lies in considering the relationship of the host and the tumour. . .. "
47. Evans RA. Routine axillary dissection for carcinoma of the breast. J Am Coll Surg 1996; 182:277-8. (letter)
The authors suggested that axillary dissection may have a therapeutic value. They cited studies which failed to included patients with an untreated axilla.
48. Evans RA. The tumor burden of locally recurrent breast cancer is a neglected prognostic factor. Am J Surg 1996;171:445-8.
I summarized the data which suggest that locally recurrent breast cancer only becomes a risk to survival when it exceeds the volume of the primary tumor. I suggest the investigators should accurately report the size and grade of recurrent disease and compare it to the size and grade of the primary. I discusses the NSABP's two unsuccessful attempts to explain the innocence of local recurrence.
49. Evans RA. Melanoma recurrence surveillance: Patient or physician based? Ann Surg 1996;223:445-6. (letter)
I suggested that investigators should report the volume of recurrent disease and compare it to the volume of the primary. I had already made this point regarding breast cancer to two of the authors, Urist and Maddox. Shumate called my comments "insightful."
50. Evans RA. RE: EDITORIAL COMMENTS: TAKING ON PROSTATE CANCER (P.C. Walsh) J Urol 1997; 156:1518- 48 (letter)
Dr. Walsh criticized Andy's Grove Fortune magazine article in which Mr. Grove described his decision to have interstitial radiotherapy for his prostate cancer. I pointed out the faults in Dr. Walsh's criticism.
51. Evans RA. Radiation therapy and chemotherapy in high-risk beast cancer. N Engl J Med 1998; 338:331. (letter)
Hellman said, ". . . local recurrence often leads to distant metastases that are likely eventually to decrease overall survival." I said that I was surprised that Hellman would write such a misleading statement and more surprised that the journal would publish it. Hellman referred to the NSABP B-06 trial. The major papers on that trial have all been published in the NEJM. The NEJM has previously published a similar erroneous statement, which I corrected. (See ref. 41.)
52. Evans RA. Predictors of axillary lymph node metastases in patients with T1 breast carcinoma. Cancer 1998; 82:613-4. (letter)
An article and two editorials in CANCER suggested that selected patients with small breast cancers could prudently forego axillary dissection. I pointed out that a small number of patients with small lesions may develop nodal recurrences which are larger and which may shed a larger number of tumor cells into the circulation than the primary. These patients may develop distant disease from the recurrences. There is evidence from studies of both breast cancer and melanoma to support this conclusion.
53. Evans RA. Recent advances in the care of the patient with malignant melanoma. Ann Surg 1998; 227:607-8. (letter)
I offered an explanation for the benefit of ELND for patients with thin lesions. See ref. 52. In their reply authors Reintgen and Ross suggest that I have not considered the importance of the immune system in patients with cancer, concluding,"Nothing is life, including the metastatic event, is so simple." My letter included a reference to my 1980 paper,"Host resistance to carcinoma of the breast," ref. 2 above.
54. Evans RA. Treatment for head and neck cancer. N Engl J Med 1998; 339:1330-1. (letter)
Complications of all sorts occurred in greater numbers of patients treated with chemotherapy. The paper exaggerated the benefit and minimized the complications associated with aggressive treatment.
55. Evans RA. Margins of excision for malignant melanoma. Ann Surg 1995. (letter) (accepted)
I said that narrow margins of excision had never been shown to compromise survival and asked Balch to accept my explanation or provide an alternative. I also suggested that investigators measure the tumor burden of nodal disease for reasons discussed above in reference 30. This letter was accepted for publication in January 1994. The authors have not replied.
PUBLICATIONS UNRELATED TO CANCER
56. Evans RA. Pathology Slide Syllabus, Houston, 1970.
57. Evans RA, Pisano JC, DiLuzio NR. Evaluation of Serum Opsonin Depletion in the Induction of the Primary Immune Response. J Reticuloendothelial Soc 7:629-630, 1970. (abstract)
58. Evans RA. Antigen-Induced Immunosuppression in Allotransplantation: The Role of Immunological Tolerance and Enhancement. (Thesis for M.S. Degree, Tulane University) 1971.
59. Evans RA. Prolonged Graft Survival by the Treatment of Neonates with Donor Antigen. Tex Rep Biol Med 20:388, 1971. (abstract)
60. Evans RA. Bethune's China. JAMA 244:1095, 1980.
61. Baer PE, Evans, RA, Friedman LC, Harper RG, Robbins HT. Follow-up Psycho-Social Status after Two Types of Gastroplasty. Clinical Nutrition 1:157-162, 1986.
62. Evans RA. The Surgical Treatment of Morbid Obesity-A Patient Guide, Houston, 1987.
63. Evans RA. Sleep Apnea and Surgery for Morbid Obesity. Texas Med 84:7-8, 1988.
The Texas Cancer Center gratefully welcomes contributions from all those 
