Book Review

Challenges in Breast Cancer

N Engl J Med 2000; 342:1298-1299April 27, 2000

Article

Challenges in Breast Cancer
Edited by Ian S. Fentiman. 268 pp., illustrated. Malden, Mass., Blackwell Science, 1999. $139.95. ISBN: 0-632-05242-2

Challenges in Breast Cancer is a welcome addition to the literature about this increasingly complex subject. A series of essays by experts from Europe and North America, it is not another textbook covering the entire field. The discussions of the biology, diagnosis, and local and systemic treatment of breast cancer reflect the personal opinions of each author. These opinions are supported by up-to-date information and excellent references. The excitement engendered by research in such areas as angiogenesis and gene mutations relevant to breast cancer percolates through the book.

The book is not intended to be encyclopedic. For example, there is no mention of the monoclonal antibody trastuzumab (Herceptin), which has changed the management of many cases of metastatic breast cancer. There is, however, a very comprehensive chapter on tamoxifen by Dr. V.C. Jordan, in which he reviews the use of the drug to improve the cure rate among women with operable breast cancer. He also covers the recent clinical trials showing the benefit of tamoxifen in reducing the risk of breast cancer. The discussion of the “tamoxifen wars,” sparked by the recruiting efforts of the prevention trial in the United States and the interpretation of the American results in the light of the absence of confirmatory results from a European trial, is fascinating reading.

The perspective of British physicians practicing in a national health system differs from the American perspective. In one chapter, a British author proposes that all breast cancer care be centered in the hands of specialists skilled in all aspects of breast surgery. In another chapter, it is urged that a system of familial-breast-cancer clinics be funded by the National Health Service. Elsewhere is a description of a single British national protocol to test the validity of the sentinel-node biopsy. Such sweeping proposals would not survive in the decentralized American system of health care delivery.

Challenges in Breast Cancer prepares the practitioner to deal with the many questions that patients ask: “If I have a lumpectomy, must I have radiation therapy?” “Can I have a sentinel-node biopsy instead of an axillary lymph-node dissection?” “Is there benefit to having surgery at a certain time in the menstrual cycle?” “What is the benefit of chemotherapy after surgery? Should I have the chemotherapy before surgery?” “Should I take tamoxifen? I understand it causes uterine cancer and blood clots.” “My hot flashes are terrible — can't I take estrogen?” “What diet do you recommend and can I drink alcohol?” “How will I be followed? How often should I have mammograms, blood tests, and scans?” “Should my daughters be tested for the breast cancer gene?”

The authors force us to think carefully before giving perfunctory replies to such common questions. The British surgeon C. Saunders entitles his chapter, “Is it safe to give [hormone-replacement therapy] to women who have been diagnosed with breast cancer?” “Of course not,” we might answer automatically. After all, the Physicians' Desk Reference carries a warning against giving estrogen to a woman with a history of breast cancer. What should the physician do, then, with the woman who is suffering from acute estrogen withdrawal after chemotherapy or after the cessation of long-standing hormone-replacement therapy? Although this book does not provide the answers, the discussion about this question and similar controversial issues by sympathetic experts will help clinicians as they use their best judgment to individualize their recommendations.

Anne Moore, M.D.
New York Presbyterian Hospital, New York, NY 10021