Book Review

Gastrointestinal Cancers: Biology, diagnosis, and therapy

N Engl J Med 1996; 334:199-200January 18, 1996

Article

Gastrointestinal Cancers: Biology, diagnosis, and therapy
Edited by Anil K. Rustgi. 663 pp., illustrated. Philadelphia, Lippincott–Raven, 1995. $169. ISBN: 0-7817-0276-3

For many years the treatment of cancers of the gastrointestinal tract has remained static. The advances in the past decade have occurred for the most part not because of new drugs, new surgical techniques, or new forms of radiotherapy. Instead, response rates have improved because of earlier diagnosis and the selection of subgroups of patients likely to benefit from more intensive therapy that combines the various available methods of treatment. More than ever, a multidisciplinary approach to the management of gastrointestinal cancer has been needed. This is especially so in the case of metastatic or recurrent disease, when standard treatment is no longer an option or has failed. Choosing the subgroup of the population that is likely to benefit from a given treatment remains the challenge. It is therefore refreshing to find a practical, systematic approach to the problem of gastrointestinal cancers that emphasizes biology and management.

This multiauthored book was written predominantly by experts from the United States. It begins with useful overviews of the embryology, biochemistry, and molecular genetics (covering both oncogenes and tumor-suppressor genes) of the gastrointestinal tract. Subsequent sections deal with individual anatomical parts of the tract, including the esophagus, stomach, colon, liver, and pancreas. Premalignant disorders, such as Barrett's esophagus, colonic polyposis syndromes, and inflammatory bowel disease, are usefully reviewed in separate chapters. Chapters are also devoted to AIDS-related cancers of the gastrointestinal tract and to stromal and neuroendocrine tumors. The book examines in detail the clinical, pathological, and biologic presentation of relevant cancers. Treatment is discussed according to discipline: medical oncology, radiation oncology, and surgery. The book concludes with three chapters that look to the future of molecular diagnosis, gene therapy, and immunotherapy. Despite the number of authors, there is a unity of style that makes the book readable throughout.

This work is reasonably comprehensive. It covers the basic-science aspects particularly well, in addition to matters of diagnosis, staging, and treatment. The role of imaging is discussed and illustrated with very good radiographs. The causes of morbidity and mortality from disease and therapy are presented. There are good summaries of published series; if nothing else, they document how treatment has changed. Surgical procedures are illustrated and explained effectively; variations in technique are discussed together with their strengths and weaknesses. For those of us who rarely step inside an operating suite, this part of the book is very worthwhile. Overall, the book is remarkably up to date, and extensive references ensure that topics can be pursued.

The discussions of screening for esophageal and colonic cancers, a difficult and sometimes controversial area, include the theoretical and practical difficulties with the implementation of such programs, but this coverage is rather brief. In addition, the epidemiology of the major cancers is outlined but not addressed comprehensively. Unfortunately, there is no discussion of the cost effectiveness of either investigation or treatment.

There are other shortcomings. A noteworthy one is that quality-of-life data are presented only for patients who have undergone esophagectomy. The treatment options outlined often have substantial morbidity and not inconsequential mortality, yet little attention is paid here to the potential burdens placed on patients. The role of tumor-modifying treatments to palliate patients is addressed only with regard to esophageal, gastric, and pancreatic cancers. For a work that deals so extensively with incurable diseases, whose course often cannot be modified, symptom control is almost totally ignored.

Despite these limitations, this book achieves its goals overall and provides a comprehensive and in-depth account that includes the relevant basic-science and clinical aspects of gastrointestinal cancers. It will be useful as a reference work for students and a valuable book for gastroenterologists, surgeons specializing in the gastrointestinal tract, and oncologists to acquire.

D.C. Currow, B.Med., M.B., B.S.
N.J. Talley, M.D., Ph.D.
University of Sydney, Penrith, NSW 2751, Australia