Just as much confusion and ignorance surrounds what has been referred to in medicalese as adjuvant (just in case) therapies which are used after surgery to prevent cancer from recurring.

These include hormonal therapy with drugs like tamoxifen, an oestrogen agonist, which acts against the body's production of oestrogen, a factor in the growth of some types of breast cancer. There is also chemotherapy, orally or by injection, often used to shrink the cancer first so the breast may remain intact; radiotherapy, which employs an x-ray machine or other types of radiation, including the temporary insertion into the body of radioactive isotopes; and ovarian ablation, a medical euphemism for what amounts to castration ("inactivating" or removing the ovaries) by surgery, radiotherapy or drugs. The rationale here is that by wiping out the ovaries, you prevent the source of oestrogen, which helps to grow the cancer. Ovarian ablation is mainly used on premenopausal women, which means that after the trauma of cancer and surgery some young women also face either an early menopause or indefinite use of hormone replacement therapy, which itself appears to cause breast cancer.

Most of these adjuvant methods are used in conjunction with breast conserving surgery, although tamoxifen is sometimes used alone for women over 50 with early breast cancer.

As with most new medical "advances" tamoxifen was hailed as a breakthrough with very little examination of its long term effects. This followed a study by the Imperial Cancer Research Fund's Cancer Studies Unit at Oxford, which analyzed the results of 133 different breast cancer treatment studies on 75,000 women worldwide. They found that for post menopausal women tamoxifen would prevent the recurrence of cancer in the other breast by 39 per cent. The study also found that tamoxifen helped to avoid recurrence primarily for the first four years after breast cancer but would nearly double a woman's chances of survival for 10 years, and that long term tamoxifen (between two and five years) is "significantly more effective" than shorter regimens.

Several other surprise findings included the fact that chemotherapy for six months could produce the same results as therapy of a year or more. The study also found that ovarian ablation reduced the annual death rate by about one quarter, causing one editorial in The Lancet (11 January 1992) to call for ablation as a "alternative to chemotherapy" in premenopausal women.

In all of this enthusiasm, what haven't been communicated to the public are the considerable, potentially fatal, side effects of tamoxifen. Because the drug is often recommended to be taken for five to 10 years many questions have been raised about its effect upon bone mineral density, cholesterol levels, hormone secretion and the potential to develop other sorts of cancers in places besides the breast.

First of all, we still don't know conclusively whether it works. In a Viewpoint in The Lancet (7 November 1992), Adriane Fugh-Berman of the National Women's Health Network in Washington, DC, and Professor Samuel Epstein of the University of Illinois School of Public Health, an outspoken critic of cancer treatment, pointed out that in the massive Oxford study a "statistically significant reduction in contralateral [other breast] tumours in patients with breast cancer was found in only three of eight studies."

Increasing numbers of endometrial cancer cases have been reported in postmenopausal women who have received tamoxifen for breast cancer. Drs Epstein and Fugh-Berman point out in The Lancet article mentioned above that tamoxifen increases the risk of endometrial cancer about five fold. Tamoxifen patients also experience abnormal vaginal bleeding, hyperplasia (excessive cell formation), polyps and endometriosis (BMJ, 26 October 1991).