Diseases of the breast

Searching National Library of Medicine’s PubMed for the keyword ‘breast’ yields 31 988 new articles between 1996 and 1999. The editors of Diseases of the Breast have taken up the challenge of incorporating the most important and relevant bits of this new knowledge into their second edition; and they have done well. Starting with the excellent chapters on anatomy and development – including its biochemical control – this clinician-oriented book goes straight onto management of disease. The importance of management of benign breast disease cannot be overemphasized. It affects the younger woman and the most important task of the clinician is to reassure the worried young woman without missing the rare sinister pathology. It is well worth noting that although a minority of this group has a cancer, missing it contributes to most lawsuits in the field. Being under the media microscope, it takes courage to reassure these women without practising too much defensive medicine. The algorithms in this chapter are useful, but must be read along with the text, which elaborates on the complexity of the management decisions that cannot be laid down in a simple algorithm. Toe amputation always cures an ingrowing toenail but this is usually not considered the best option. The false-negative rate of a properly conducted triple assessment can be less than 1% and this can save many a women an unnecessary biopsy. We have known the two breast cancer genes BRCA-1 and BRCA-2 for some years, and recent findings indicate that there probably are many more less penetrant genes that are yet to be identified. Public knowledge of these genes has forced the profession to devise ways to tackle the difficult and delicate issue of managing the worried well. Experts in the field have shared their wisdom at great length, covering these new areas in detail. There are separate and well written chapters on chemoprevention and prophylactic mastectomy. In addition, the non-genetic risks of breast cancer – which are probably modifiable – are discussed. The complex discussion on balancing the risks and benefits of mutilating interventions in high-risk individuals is well presented. The section on natural history of breast cancer has explored the radical conceptual changes in the last century, including the Halstedian concept of orderly spread of breast cancer, Fisher’s view of pre-clinical systemic spread, and the combination/spectrum of these two concepts. The recent publication of the Danish radiotherapy trials, which suggested that in certain groups of women post-mastectomy radiotherapy may actually improve survival in patients receiving chemotherapy, contradicts the cumulated evidence from randomized trials, that has been presented in the Oxford overview several times, that nuances of local treatment do not have a great impact on survival. We were hoping that there would be some enlightening discussion on this paradox – but perhaps this is not a place for novel ideas. The pathogenesis – genetic and endocrine – of breast cancer, and the various types of pathology, are very well covered in separate chapters. The local treatment options of in situ and invasive breast cancer are described very well and so also are special situations like locally advanced breast cancer, pregnancy and cancer, male breast cancer, lymphoedema and occult primary with axillary metastasis. The sensitive topics like treatment of in situ cancer, evaluation of patients after primary therapy, breast reconstruction and psychosocial aspects are discussed in detail. In this book, metastatic disease is presented in great detail and takes up nearly a third of the book. There is a full discussion about the pros and cons of follow-up after active treatment is completed and several clinical, economic and psychological issues are well addressed. The standard treatments as well as newer methods of treatment of metastasis have been dealt with extensively. The clinical appearance of distant metastasis many years after treatment of primary tumour has remained a mystery despite all advances in the molecular and clinical research. Intense research about growth factors, angiogenesis, apoptosis and the host–metastasis equilibrium is now reaching the bedside. These newer and complex developments are covered in a lucid manner in the book. Detailed overviews of novel treatment modalities using angiogenesis as a therapeutic target, immunotherapy and biologic as are presented in individual chapters. The section on breast imaging covers the latest advances in image-guided biopsy techniques. These techniques, especially the vacuum-assisted core biopsy (Mammotome) have brought great change in diagnostic work-up of patients with non-palpable breast lesions, avoiding a surgical biopsy in most cases. The excellent chapter on screening includes a section on ‘risk-based’ screening guidelines, which unfortunately usually have to be based on expert opinion only. A discussion on the risks of screening and therefore what an informed consent for screening should include is sadly lacking. This is particularly relevant today, with very sensitive imaging technology that has started uncovering more and more ‘pseudodisease’ that may never have manifested in the woman’s lifetime. Physical breast examination should have received more coverage, since this may be the only feasible intervention in developing countries and may have the advantage of being able to identify only the potentially fatal cancers. There are four useful chapters on research methods, techniques of molecular biology and of conducting clinical trials, and assessment of quality of life and cost-effectiveness. In addition, medicolegal issues have a chapter devoted to them. Diseases of the Breast provides extensive coverage of the whole spectrum of issues in breast cancer, with special emphasis on management, while not losing sight of the basic science and patient-related factors. The extensive referencing of every chapter appears to be editorial policy and many of the classic studies should be very useful, as should be the management summaries at the end of relevant chapters. Colour illustrations, especially for some inflammatory conditions, reconstructive procedures and