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Therapy of breast disease: experts' overview
Breast Cancer Research volume 7, Article number: 59 (2005)
Advanced Therapy of Breast Disease 'is designed to provide a concise, current, and comprehensive survey of advanced concepts in the management of both benign and malignant disease of the breast. It is not intended to be a comprehensive review, but rather a unique collection of expert opinions...'. These are the aims set forth in the preface and I must say that the book does exactly what it says on the cover.
The book provides a flavour of the change that is occurring in approaches to breast cancer management, from 'kill to cure' to prevention and long-term management as a chronic disease. The contributors and the chapter topics have been chosen carefully, although I would have liked a chapter dedicated to the natural history of breast cancer. In keeping with the title, though, there are sections dedicated to the therapy of almost every aspect of breast disease.
The evaluation and treatment of benign breast diseases covers in detail common problems such as mastalgia. Recent advances such as ductoscopy and percutaneous management of fibroadenoma are touched on. The description of high-throughput protein analysis of nipple aspiration fluid includes a table of exciting results that spans two pages. The level of HER2/neu in nipple aspiration fluid can be as much as 50 times the concurrent serum level. Comparing the expression profiles in the two breasts of a patient with unilateral cancer allows an excellent control for the identification of useful markers for the prevention and treatment of breast cancer in general, and nipple discharge in particular.
The quantitative assessment of genetic risk of breast cancer and the various aspects of its management – from counselling to bilateral prophylactic mastectomy – is well covered. The epidemiological and psychological aspects as well as important surgical nuances are mentioned. For example, the photos of the double opposing tab flap nipple reconstruction are very instructive.
There is a chapter on screening mammography, although with nominal regard to recently publicised doubts about its true efficacy. This is not the place to argue about it, but it is a shame that only one side of the argument is included. Irrespective of whether screening with mammography is beneficial or harmful, it seems that it is here to stay and we can only inform women about its fine balance between benefit and harm. Breast self examination has a chapter dedicated to it, if only to fare a polite goodbye.
The book includes a chapter on the latest version of the TNM/AJCC staging. In practice the use of detailed TNM staging mainly enables an audit of cases rather than the planning of appropriate treatment. For the latter purpose many other factors come into play. These are discussed in detail in individual chapters on chemotherapy and hormonal agents. In this computer age, software such as Adjuvant! http://www.adjuvantonline.com can offer a quantitative basis for decisions about adjuvant therapy rather than only the subjective 'feel' that is provided by the other prognostic indices. I was surprised that this is mentioned only in the chapter 'Breast cancer in older women' in the 'Special presentations' section. Perhaps in the next edition the current popularity of this method will be reflected and it will be covered in more detail in the main adjuvant therapy section.
There is a chapter on preoperative systemic therapy that discusses the role of chemotherapy before operation, but there is no mention of preoperative hormone therapy, which is rapidly gaining popularity and is even more relevant as there are increasing numbers of older women with breast cancer who are more likely to be dependent on oestrogen. It is mentioned only as a small paragraph in the chapter 'Feasibility of breast conservation therapy'.
A chapter explains very well the importance of radiotherapy in local treatment of early-stage breast cancer and briefly mentions partial breast irradiation. This particular chapter was perhaps written before the intraoperative radiotherapy trials such as ELIOT and TARGIT were initiated in the year 2000.
Management of locally advanced breast cancer and of systemic disease is dealt with in separate sections, with chapters dedicated to individual issues such as bone metastases and brain metastases. A section describes special cases that, in addition to the usual, include cancer in the augmented breast or recurrence in a reconstructed breast.
Follow-up care is discussed in a large section, and reiterates in a clear chapter how intensive follow-up does not serve any purpose: 'It seems clear that patients want to be seen and evaluated by their physician (although this may not be true for English patients, as opposed to American), but bone scans, chest roentgenograms, and serum chemistry determinations are not medically necessary, do not improve survival, and may decrease quality of life.'
The section on future directions gives a small glimpse of the future, with chapters such as molecular targeted therapy and molecular profiling.
There is an accompanying CD that I found very useful. The CD is easy to navigate and chapters are arranged in PDF file format. However, there is no facility to search across the whole book, unless one creates a PDF catalogue with Adobe Acrobat. Such a facility (a 'search the book' button) could be perhaps included in the next edition.
Flicking through the book I found that it was easy to find something of interest throughout the book. For example, one would notice something that one had recently heard about and then find an in-depth analysis about it in the chapter, although sometimes this was not completely balanced. On the whole this book would be a useful addition to the desk of a busy surgeon or oncologist who wishes to freshen up his or her understanding of breast diseases.
Carl Zeiss manufactures Intrabeam that is being tested for intraoperative radiotherapy in the TARGIT trial, mentioned in this report. Carl Zeiss has funded some of JSV's travel to steering committee meetings of Targit.
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Cite this article
Vaidya, J.S. Therapy of breast disease: experts' overview. Breast Cancer Res 7, 59 (2005) doi:10.1186/bcr1000
- Breast Cancer
- Breast Disease
- Benign Breast Disease
- Prophylactic Mastectomy
- Augmented Breast