Book Review

Breast Cancer Management: Application of Evidence to Patient Care

N Engl J Med 2001; 344:614-615February 22, 2001

Article

Breast Cancer Management: Application of Evidence to Patient Care
Edited by Jean-Marc Nabholtz, Katia Tonkin, Matti S. Aapro, and Aman U. Buzdar. 569 pp. London, Martin Dunitz, 2000. $135. ISBN: 1-85317-915-9

No area of medicine is as driven by evidence of the effectiveness (or lack of effectiveness) of treatment as medical oncology. Breast Cancer Management deals with evidence accrued from clinical trials of the prevention and treatment of breast cancer. The book was organized by the Academic Global Virtual Group — a sign of the new wave of international collaboration in breast-cancer research. The Breast Cancer International Research Group has held two conferences in Edmonton, Alberta, Canada. The premise of the group is that those conducting research on breast cancer must use global strategies and have a commitment to high-quality data and high patient accrual. The group has completed one trial, which accrued 1500 patients in 12 months; this rate of accrual is a substantial improvement over that of standard clinical trials.

The stated target audience for this book includes surgical, radiation, and medical oncologists, and it will indeed be an excellent reference book for those specialists. However, several sections of the book could be valuable for any physician who cares for patients with breast cancer.

The early chapters of the book review the history of evidence-based medicine and define the clinical-practice guidelines according to the levels of evidence. Level I evidence is based on results from large randomized, controlled trials. Level II evidence is obtained from at least one well-designed experimental study or a randomized study with a high false positive rate, a high false negative rate, or both (low power). Level III evidence is obtained from well-designed quasi-experimental studies, such as matched case–control series. Level IV evidence is obtained from well-designed nonexperimental studies, such as comparative studies and case studies. Level V evidence comes from case reports and clinical examples. The authors attempt to review most of the important breast-cancer trials performed worldwide. They present a balanced view, with emphasis on some of the limitations of existing data that necessitate additional trials, and provide clear, concise reviews of clinical trials and the weight of evidence concerning the efficacy and toxicity of treatments.

Because of the “virtual” nature of this collaborative effort, there is some redundancy of topics. There are, for example, three chapters on bone marrow transplantation for the treatment of breast cancer; unfortunately, the Bezwoda trial of this treatment, which has since been discredited as a scientific fraud, is included in two of these chapters. The Bezwoda debacle highlights the responsibility of medical researchers to verify the quality and integrity of data, which will require more than “virtual collaboration”: there is still a need for old-fashioned audits.

The standard treatment methods of surgery, radiation therapy, and chemotherapy are discussed in great detail, again according to the levels of evidence. Other chapters cover recent topics from molecular medicine, the cost effectiveness of care, biologic-response modifiers, and the increasing use of the Internet by patients and physicians. One helpful feature in many of the review chapters is a table summarizing the types of treatment and the strength of the evidence supporting each treatment. For example, the table summarizing surgery after primary chemotherapy for breast cancer is excellent.

Recognized leaders in surgery, radiation therapy, medical oncology, and basic science have collaborated to make this book an excellent review of past, present, and potential future treatments for breast cancer. Indeed, if their hope for speedier international trials comes to fruition, the book will soon be outdated.

Judith Salmon Kaur, M.D.
Mayo Clinic, Rochester, MN 55905