Breast Cancer – A Guide to Detection and Multidisciplinary Therapy

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Details:

MH Torosian (ed)
Published by Humana Press (2002)
ISBN: 0-86903-839-4. 342 pages plus index.
RRP: US$125.00


There are probably too many textbooks on breast cancer, and I have been involved relatively recently in two. I may, therefore, be prejudiced, but this is one that probably adds little to the sum of our knowledge on the subject. Furthermore, while the authors almost achieve an adequate description of improving the reader’s knowledge of the detection of breast cancer, they singularly fail to give any credence to the philosophy that therapy is directed or decided in a multidisciplinary way. And while it is expansive though not always accurate on therapy, this book makes no pretence of discussing and advocating care of patients.

In his foreword Robert Young MD describes the book’s great strength as its multidisciplinary format. However, I recognise only compartments of treatment, some excellently presented (chapter seven on breast reconstruction) while others repeat, often with no consistency, what is described before or later. Thus in chapter four (clinical classification), sentinel node biopsy is noted as a technique whose role remains to be determined, but in the next chapter on breast conserving surgery the indications for its use are clearly defined and extolled.

In another example, locally advanced disease is covered in breast conserving surgery (chapter five) and the subsequent one on mastectomy. While chapter six sticks to mastectomy, the previous one on breast conserving surgery strays frequently on to more ablative surgery.  Parts of the early chapters on imaging and diagnostic techniques are repeated in later sections. One is left wondering if the editor did any work. Repetition and omission abound mixed with inconsistency and inaccuracy.

The authors of chapter eight on radiotherapy wax eloquently and at length on the absolute indication for radiotherapy when high dose, marrow-ablative chemotherapy regimes are indicated – and this in 2002. (Indeed, a whole chapter is devoted to such chemotherapy later in the section addressing controversies.) The same authors throw in pedantic statements like “bolus is used every other day… but daily bolus or a boost to the scar is not needed” for post-mastectomy radiotherapy: no evidence, no justification.

The radiation oncologists discuss systemic therapy and the management of locally advanced disease as if hormone therapy, the elderly and the frail do not exist. The exception is radiotherapy for bone metastases, where several excellent randomised trials are ignored and single fractions of palliative radiotherapy are reserved for such sick and old patients in preference to more protracted and more costly and longer but no more effective fractionation regimes. And they ignore the most significant cause of radionecrotic rib fractures: a high dose per fraction. They need also to ask themselves why they have such a high rate of pneumonitis at 5%.

It is also amazing that in an eight page chapter on surgery for metastatic disease, there is not one mention of orthopaedic intervention but whole pages about excision of lung and liver metastases. When did you last request that?

This book omits entirely any thought towards the psychosocial support of patients and their families. The breast care nurse is not mentioned. Breast screening is reduced to a paragraph – but the chapter on imaging is otherwise excellent. Palliative care beyond palliative radiation or systemic therapy or unusual surgical interventions is not featured.

There is no clear discussion or use of staging systems, yet there is the usual recommendation for over-investigation at diagnosis, contrary to ASCO guidelines. In fact, it is as though guidelines and evidence do not exist – only local policies or habits seem to prevail, and they are not cross-referenced to the references tagged on to each chapter.

The special clinical situations of six chapters on T0N1-2 disease, cancer in pregnancy and breast lymphomas or sarcomas are good. The final section of another five chapters on current controversies and research – on breast conservation without radiotherapy, high dose chemotherapy, managing the IMC and the misnamed “immunotherapy and gene therapy” – is also interesting and easy to read. But why, in 2002, is the anti HER-2/neu monoclonal antibody reduced to one paragraph and not even named, yet adoptive immunotherapy warrants seven pages?

Most regrettable of all in this disorganised, compartmentalised and poorly edited book is the lack of any indication that anyone has a clue about or an involvement with multidisciplinary care.

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