Book Review

Breast Cancer: Controversies in Management

N Engl J Med 1994; 331:1534December 1, 1994

Article

Breast Cancer: Controversies in Management
Edited by Leslie Wise and Houston Johnson, Jr. 592 pp. Armonk, N.Y., Futura, 1994. $105. ISBN: 0-87993-562-6

The detection and treatment of breast cancer have spawned much controversy, as evidenced by dissimilarities in practices among countries and over time. This book consists of 49 short chapters, almost essays, on selected topics by 61 contributors from Canada, England, Italy, Scotland, and -- primarily -- the United States. It begins with a long section of seven chapters chronicling the history of the acquisition of knowledge about breast cancer and the theories and philosophies that have led to today's controversies.

The book includes another long section of seven chapters on mastectomy versus breast conservation. Five chapters deal with systemic adjuvant chemotherapy; there are four on the value of mammographic screening; four on the management of advanced breast cancer; three on axillary dissection; and two chapters each on the necessity of radiation after breast conservation, the appropriate intraductal therapy to conserve breast tissue, the place of prophylactic mastectomy, racial and ethnic differences in breast-cancer patterns, and the role of immunologic evaluation for patients with breast cancer. Chapters are also given over to such topics as lobular carcinoma in situ, pregnancy-associated breast cancer, breast reconstruction, and the costs of treatment.

A notable feature of the book is the international group of expert authors (though, arguably, French authors should have been included as well). The effect is necessarily somewhat disjointed; the authors evidently followed the editors' instructions, cited in the preface, to “use their personal experience and understanding of the literature to construct their contributions.” The editors state, “It was more important that each author create for the reader a cogent understanding of the rationale of his views and data to support the author's position rather than be encyclopedic on the topic.”

The format of each chapter varies; one chapter incorporates case histories, some shape the text as a lecture, many use comprehensive tables of results from various reported series, and some include figures illustrating survival analyses of their own series. The length varies from less than 5 pages to 20 pages or more. Some diversity is to be expected, however, because of the varied subject material. The starting point often differs among chapters on the same topic, but this is advantageous since outlining the background would be repetitious. On the other hand, the facts and circumstances leading up to the current controversy may not be delineated adequately for medical students or residents.

Of the 49 chapters, only 10 are not by practicing surgeons. There are two chapters by pathologists, five by medical oncologists, one by a radiation oncologist, one by a radiologist, and one by a psychologist. For example, of the five chapters on systemic adjuvant therapy, four are by surgeons; of the four chapters on the role of mammography, three are by practicing or retired surgeons. The chapters are convincing, insightful, and well written. The perspective is mainly surgical. This book will be valuable for practicing surgeons and radiation therapists who wish to delve into controversial issues, as well as for others interested in the thoughtful surgical outlook and analysis.

Jeanne Petrek, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10021