This book is the 17th volume in the Basic and Clinical Oncology
series edited by Bruce D. Cheson, MD. Like other volumes in this
series, Expert Consultations in Breast Cancer follows a unique
format and seeks to integrate advances in the basic understanding of
breast cancer with promising new therapies and changing health- care
economics. The integration of these different perspectives provides
both a conceptual and pragmatic framework for clinical decision-making.
The text begins with brief introductory chapters summarizing major
topics, such as natural history, pathology, staging, surgery,
radiation therapy, systemic treatment, and familial breast cancer.
The review of the natural history of breast cancer provides a
particularly important foundation, since virtually all clinical
decisions rest on an accurate estimation of the risk of recurrence.
The radiation therapy chapter provides a well-balanced discussion of
the current controversy surrounding postmastectomy radiation. The
review of inherited breast cancer susceptibility would be useful for
both specialists and primary care physicians.
Although readers desiring a comprehensive review would be better
directed to other texts, these introductory chapters provide a
concise discussion of well-established data. Areas of controversy and
ongoing research are cited, but the tone is generally conservative.
For example, radiation therapy is recommended for all patients with
ductal carcinoma in situ, with little consideration of substantial,
albeit nonrandomized, data suggesting that some patients may be
treated with wide excision alone. Furthermore, sentinel lymph node
dissection is granted no role, while neoadjuvant therapy is
recommended only for patients desiring breast preservation, but
presenting with lesions requiring mastectomydespite the
results from five randomized trials showing equivalent or improved
All texts suffer deficiencies stemming from the delay between initial
writing and publication. For Expert Consultations in Breast
Cancer, this problem is most obvious in the review of medical
therapy for breast cancer, which focuses almost exclusively on the
role of adjuvant treatment, along with useful descriptions of
appropriate strategies based on patient and tumor characteristics.
Important, but recently established, developments in the treatment of
metastatic disease, including the use of bisphosphonates in patients
with lytic bone lesions and the use of trastuzumab (Herceptin) in
patients with HER2-overexpressing tumors, are notably absent.
Part II showcases a series of clinical pathways that guide clinical
decision-making. When describing these pathways, the authors
intentionally avoid recommending specific chemotherapeutic regimens
or surgical procedures, focusing instead on presenting a conceptual
framework for the evaluation and treatment of patients in specific
clinical situations. The pathways strive to be (and succeed in being)
evidence based whenever possible. When evidence is lacking, a
consensus of expert opinion is substituted, and evidence is clearly
distinguished from opinion.
Part IIIthe longest section and perhaps the most unique portion
of this textfeatures a series of case presentations accompanied
by discussions by noted breast cancer experts. The case presentations
follow the format of the pathways, and illustrate their practical
application and usefulness. Additional presentations highlight unique
situations that are not easily addressed within the context of the pathways.
A total of 31 situations cover the evaluation of nonpalpable breast
lesions or nipple discharge, with discussions by radiologists and
surgeons. Suggested plans are well supported and referenced, with
excellent reviews of the diagnostic accuracy of nonsurgical methods.
Eleven presentations review the challenges involved in the treatment
of in situ disease, including incidentally discovered ductal
carcinoma in situ and patients with microinvasive foci.
Several areas of controversy are evident in the 17 presentations that
relate to the local treatment of invasive breast cancer. Specific
situations include the role of a radiation boost to the
tumor bed; the need for axillary dissection in elderly patients with
small, good-prognosis tumors; and the problems involved in
irradiating large, pendulous breasts. Brachytherapy is reviewed as an
alternative to traditional external-beam radiation in one case presentation.
A total of 29 cases review systemic therapy for patients without
overt metastatic disease, and, in keeping with the organization of
the pathways, are segregated into node-negative, node-positive, nodal
status unknown, and locally advanced categories. Here, specific
chemotherapy regimens are recommended (or at least suggested), with
reference to appropriate clinical trials. Consideration of the subtle
differences in patient circumstances, including age, comorbidities,
and patient preference, is an underlying theme of many of the discussions.
The topic of patients with recurrent disease is addressed with 29
case studies; local and systemic recurrences are considered
separately. In general, although specific regimens are avoided,
important distinctions are made between symptomatic and asymptomatic
patients and those with visceral, as opposed to bone or soft-tissue,
disease. Discussions of the utility (or lack thereof) of serum tumor
markers are particularly helpful.
The final cases focus on topics, which, although not exceedingly
rare, do not fit easily into the clinical pathways. Included are
discussions of male breast cancer, Pagets disease, the pregnant
patient, paraneoplastic syndromes, and meningeal carcinomatosis.
Complications of treatment, such as lymphedema and menopausal
symptoms, are also considered.
Much redundancy can be found in the case presentations and
accompanying discussionsat times, with conflicting opinions and
recommendations. Although the editors do offer occasional comments or
additional data for clarity, the disparate opinions may be
disconcerting to the novice reader.
For the experienced clinician, however, these differences may have
quite a contrary effect: They may serve to highlight areas of
controversy and lively debate, providing the more advanced
practitioner access to opinions from some of the leaders in the
field. Furthermore, this section substantiates the need for clinical
judgment and decision-making that integrates the most advanced basic
science and clinical knowledge with the practical constraints of the
clinic and health-care systemexactly the goal the editors set
out to achieve.