Management of Patients at High Risk for Breast Cancer, 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 1999.
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 cancernot 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 technique.
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(Drug information 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(Drug information on tamoxifen) (Nolvadex) for chemoprevention.