Management of Patients at High Risk for Breast Cancer

January 1, 2002

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

Management of Patients at High Risk for BreastCancer,edited by Victor G. Vogel, MD, is designed for all physicians involved in breastcancer risk assessment and prevention. It does not assume a baseline familiaritywith cancer risk assessment, but rather, endeavors to educate clinicians seekingto add risk assessment and prevention skills to their clinical capabilities. Thebook includes the contributions of 28 authors, comprising people well recognizedin their respective fields and junior authors mainly from the University ofPittsburgh. The references are current and include several notable papers from1999.

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

The initial chapters provide a comprehensive review of the epidemiology andgenetics of breast cancer. Some sections of these chapters are probably moredetailed than necessary for the average clinician but offer a wealth ofreferences. The section in the first chapter on the role of dietary factors inthe etiology of breast cancer is quite applicable clinically and addressesquestions often asked by patients presenting for risk assessment as well as bythose who are generally health-conscious and receive conflicting informationfrom the lay press. The section takes a detailed look at the data on variousdietary and lifestyle factors while acknowledging the general lack of conclusiveevidence in these areas. The genetics chapter reviews BRCA1 and BRCA2 as well asseveral other genetic syndromes associated with breast or ovarian cancer.

The chapter on quantitative risk assessment reviews the various mathematicalmodels for breast cancer and their validation, applications, strengths, andlimitations. This information is quite useful; many clinicians use the Gailmodel but may be less familiar with the models available for those with lobularcarcinoma in situ or an extensive family history of breast cancer. The chapteralso discusses the distinction between relative risk and absolute risk, and theneed to present risk factors to patients in such a way that they both understandand use the information. The chapter on screening for ovarian cancer alsoreviews strategies available for managing patients at genetic risk for ovariancancer—not the stated objective of the book, but still a valuable section forall clinicians involved in managing associated breast cancer risk.

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

The chapter on developing a risk-assessment clinic includes several staffingmodels and reviews in great detail the function of one such clinic inparticular. 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 andchemoprevention in high-risk women. A cost-benefit analysis of prophylacticmastectomy is presented, as well as the various techniques of mastectomy andreconstruction. The major chemoprevention trials are reviewed, including theliterature on raloxifene (Evista), with a synopsis of the National SurgicalAdjuvant Breast and Bowel Project P-2 trial designed to determine whetherraloxifene is a viable alternative to tamoxifen (Nolvadex) for chemoprevention.

One of the major strengths of the book is that it covers topics not alwaysreviewed in a medical text, such as the psychological management of patients atdifferent stages of counseling, testing, and risk reduction. In addition, thereis an excellent section on the legal and ethical considerations associated withrisk assessment, including the testing of minors, prenatal testing, andinsurance- and job-related issues.

The sections on cost-effectiveness and population-based strategies attempt topull all this information together into broadly applicable algorithms forpatient management.

In general, the book is well edited and covers the gamut of topics relatingto risk assessment, testing, and management. The average clinician may find somechapters somewhat overinformative, but there is a great deal of information thatwill be helpful to those truly interested in risk management. The book alsoprovides specific suggestions on how this information may be incorporated intoone’s practice.