Bland K, Copeland E: The Breast, 3rd edition. London, Saunders; 2003. 1628 pp.
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KeywordsTamoxifen Anastrozole Fulvestrant Porphyria Post Mastectomy Radiotherapy
ductal carcinoma in situ
The Breast is a huge two-volume textbook that boldly claims to cover the comprehensive management of breast disorders. So, does it perform as well as Google for questions and problems that crop up during a working week? Most of us gloss over the small print in training, but in clinical practice small print is often important. The larger the textbook, the better it should be on small print topics.
A query from one of the breast care nurses: "A patient wants to switch from tamoxifen to anastrozole because she says that tamoxifen has ruined her singing voice. Is that possible? If so, would anastrozole be any better?". Out comes the two volumes with a reassuring thump. But the section on tamoxifen toxicity turns out to be disappointingly short. There is no mention of tamoxifen's effect on the voice, perhaps a forgivable omission. But other important side effects are not dealt with well. For example, there is a brief and vague paragraph on tamoxifen eye toxicity, which certainly isn't an obscure topic: breast oncologists refer patients for slit lamp examination all the time.
Later in the same week there is another rarity: a patient with acute porphyria and newly diagnosed oestrogen receptor-positive breast cancer. The director of the European Porphyria Centre turns out to be extremely helpful in advising on drug choices by phone. He is also a steroid biochemist with a detailed interest in sex hormones and the exact effects of selective aromatase inhibition on each part of the pathway, including possible differential effects on estradiol versus estrone. Here, the chapter on endocrine therapy of breast cancer was outstandingly helpful; it is well written with clear diagrams on the site and mechanism of action of aromatase inhibitors, and includes an excellent summary of the evidence underlying the endocrine treatment of advanced disease (although it was odd to read that "one of the clear advantages of fulvestrant" is that it can only be given through deep intramuscular injections "since this ensures compliance"; few patients would agree with this).
How did the textbook perform with more commonly encountered problems? At our protocol review meeting the question of thresholds for giving radiotherapy (RT) after breast conserving therapy for ductal carcinoma in situ (DCIS) comes up yet again. In common with oncologists around the world, we have had ongoing difficulties in deciding which patients need to be given RT and which can be treated with excision alone. The textbook deals with this eccentrically. Mel Silverstein is given a long chapter to make the case for the modified Van Nuys Prognostic Index (VNPI), a widely used system devised by Silverstein, which incorporates lesion size, patient age, surgical margins and lesion grade to stratify patients into different management groups. The VNPI system has been widely adopted by surgical oncologists, but has aroused controversy. It is good to see the system so well laid out and explained, and there are some excellent clinical vignettes (which would be useful for resident board exam teaching). Although Silverstein is meticulous in presenting the alternate view from the National Surgical Adjuvant Breast and Bowel Project (NSABP, a clinical trials cooperative group supported by the National Cancer Institute) triallists that radiotherapy should usually be given for all DCIS lesions after a local excision, the textbook is heavily biased towards the Van Nuys approach. It seems a questionable editorial decision to give the main DCIS chapter to one of the protagonists in an ongoing and occasionally acrimonious debate. This whole area of breast oncology urgently needs a magisterial overview from an independent contributor, similar to the remarkable review that so decisively sorted out thresholds for post mastectomy radiotherapy (which was in a similar state of chaos a few years ago). Perhaps Abe Recht could step up to the plate for the next edition.
The week ends with a heated debate at our tumour board on the role of chemotherapy for lower risk older patients with endocrine responsive disease. Afterwards, the textbook comes out again. It has an excellent chapter on the adjuvant systemic therapy of breast cancer, reviewing exactly this problem in some detail. The authors are moderate in their interpretation of the evidence. It is refreshingly clear from this chapter that not all medical oncologists in North America are blindly following NIH Consensus recommendations.
Incidentally, it was very surprising that the textbook barely mentions the NIH Consensus statement, with no mention of St Gallen. In terms of its impact on clinical practice, the NIH Consensus statement is probably the most influential single publication in breast cancer over the past 10 years. It has resulted in a huge expansion in the number of patients receiving chemotherapy, and probably an increase in the inappropriate use of chemotherapy by under-informed (or unscrupulous) cancer physicians, since it can be used to justify chemotherapy for virtually all patients. The NIH Consensus statement wasn't based on a true consensus since it led to a deep schism in the medical oncology community. Within a few months, seven of the expert witnesses from the NIH meeting had reconvened in St Gallen to form their own panel. They drafted an alternative Consensus, which differs markedly from the NIH. This has had considerable influence in Europe. Future editions of the textbook might therefore include a chapter on decision-making, which could review the Consensus statements and the controversies behind them, together with the recent advent of hugely popular decision support programs such as 'Adjuvant!', which is now in use worldwide, and has become a major influence in consultations. This development is also not mentioned at all in the textbook. These are major omissions. Also, perhaps some contributors from outside the USA might be invited for future editions (currently only one of the 146 authors is international).
Should you buy this book? On balance, yes, if you are physician with a substantial breast practice. Even today, with the internet in virtually every room of the hospital, it is reassuring to have some heavyweight textbooks to fall back on, and despite its faults, this book has a reasonable number of excellent chapters. It complements existing multi-author textbooks (such as Harris) very well.