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Management of Patients at High Risk for Breast Cancer

Management of Patients at High Risk for Breast Cancer

Management of Patients at High Risk for Breast
edited by Victor G. Vogel, MD, is designed for all physicians involved in breast
cancer risk assessment and prevention. It does not assume a baseline familiarity
with cancer risk assessment, but rather, endeavors to educate clinicians seeking
to add risk assessment and prevention skills to their clinical capabilities. The
book includes the contributions of 28 authors, comprising people well recognized
in their respective fields and junior authors mainly from the University of
Pittsburgh. The references are current and include several notable papers from

The book contains 16 chapters that progress logically from the epidemiology
and genetics of breast cancer through imaging and risk-reduction strategies.
Chapters on legal, ethical, and psychological issues are also presented. The
book ends with discussions of the cost-effectiveness of screening and risk
reduction as well as population-based strategies for maximizing the effect of
these techniques.

The initial chapters provide a comprehensive review of the epidemiology and
genetics of breast cancer. Some sections of these chapters are probably more
detailed than necessary for the average clinician but offer a wealth of
references. The section in the first chapter on the role of dietary factors in
the etiology of breast cancer is quite applicable clinically and addresses
questions often asked by patients presenting for risk assessment as well as by
those who are generally health-conscious and receive conflicting information
from the lay press. The section takes a detailed look at the data on various
dietary and lifestyle factors while acknowledging the general lack of conclusive
evidence in these areas. The genetics chapter reviews BRCA1 and BRCA2 as well as
several other genetic syndromes associated with breast or ovarian cancer.

The chapter on quantitative risk assessment reviews the various mathematical
models for breast cancer and their validation, applications, strengths, and
limitations. This information is quite useful; many clinicians use the Gail
model but may be less familiar with the models available for those with lobular
carcinoma in situ or an extensive family history of breast cancer. The chapter
also discusses the distinction between relative risk and absolute risk, and the
need to present risk factors to patients in such a way that they both understand
and use the information. The chapter on screening for ovarian cancer also
reviews strategies available for managing patients at genetic risk for ovarian
cancer—not the stated objective of the book, but still a valuable section for
all clinicians involved in managing associated breast cancer risk.

The imaging chapters are particularly well written and concise. They contain
a review of contemporary mammography and ultrasound techniques, as well as a
section on ultrasound- and stereotactic-guided biopsy that describes the
indications, accuracy, and problems associated with each technique. Imaging
strategies are delineated separately for those at high vs normal risk for breast
cancer. The chapter entitled "New Horizons in Breast Imaging" provides
a nice review of the controversies surrounding positron-emission tomography
scanning, sestamibi scintimammography, and breast magnetic resonance imaging,
and outlines the protocols, indications, accuracy, and limitations of each

The chapter on developing a risk-assessment clinic includes several staffing
models and reviews in great detail the function of one such clinic in
particular. It stresses the features of a comprehensive risk-assessment clinic,
including evaluation, education, counseling, screening, and genetic testing.

The next two chapters discuss the data on prophylactic mastectomy and
chemoprevention in high-risk women. A cost-benefit analysis of prophylactic
mastectomy is presented, as well as the various techniques of mastectomy and
reconstruction. The major chemoprevention trials are reviewed, including the
literature on raloxifene (Evista), with a synopsis of the National Surgical
Adjuvant Breast and Bowel Project P-2 trial designed to determine whether
raloxifene is a viable alternative to tamoxifen (Nolvadex) for chemoprevention.


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