Compact Guide to Breast Cancer Medical Treatment Available

Breast Cancer is a unique effort in the world of breast cancer texts: Compact and concise, this 214-page book deals exclusively with breast cancer therapeutics, and strives to accomplish the difficult task of being as current as possible within the limited capabilities of the printed word in a rapidly evolving field. Dr. Seidman has assembled a distinguished group of authors, each of whom was assigned a topic, in the end covering all aspects of the medical oncologic scope of breast cancer treatment in one relatively short text. The book does not address issues of breast cancer epidemiology, screening, prevention, or surgical or radiation treatment-this was not the intent of this publication.

The book is divided into seven chapters organized logically within the field: endocrine therapy as adjuvant treatment, endocrine therapy for advanced disease, adjuvant chemotherapy, chemotherapy for advanced disease, trastuzumab (Herceptin) for both early- and advanced-stage breast cancer, antiangiogenesis treatment for advanced disease, and a closing chapter on targeted therapies. This organization allows for relatively little overlap, with the exception of the final two chapters, where some overlap is unavoidable and does not detract from the overall readability of the text.

While each chapter accomplishes its respective goal with relative ease, there is a subtle uneven quality in those chapters. The first chapter on adjuvant endocrine therapy, written by distinguished authors of impeccable international reputation, provides a proper historical background for adjuvant endocrine therapy, and launches into the difficult task of putting the concept of ovarian ablation into the larger context of breast cancer adjuvant therapy. Keeping in mind that ovarian ablation has not found its way into the routine treatment of early-stage, hormone-receptor–positive breast cancer in premenopausal women in the United States, this foreign-authored chapter reflects an understandable bias toward ovarian ablation as a justifiable alternative to chemotherapy, a concept that has not been accepted easily by oncologists here.

In fact, I would take issue with the statement by these authors, “Furthermore, the combination of GnRH agonists with tamoxifen is superior to CMF alone, but equivalent to CMF plus tamoxifen.” I would submit that this statement remains arguable, and the message that ovarian ablation can be routinely applied with confidence-to the exclusion of adjuvant chemotherapy-remains controversial and a research question. The following discussion of aromatase inhibitors is exhaustive and concise.

The section on endocrine therapy for advanced disease addresses several issues that are too often either poorly understood or, conversely, taken for granted by practitioners: The role (or lack of role) for combined hormonal therapies, the value of tamoxifen after the failure of an aromatase inhibitor, and the potential superiority of aromatase inhibitors in HER2-overexpressing disease are all addressed here, and appropriate conclusions are drawn every time.

The chapters on chemotherapy for early-stage and advanced breast cancer are thorough enough. Unfortunately, the critical discussion of adjuvant chemotherapy suffers from a dearth of tables and figures: The reader with relatively little experience in the literature on adjuvant chemotherapy may find this chapter tough going. The recitation of the results of a large number of clinical trials is difficult enough; a tabular summary would have been helpful to put these many clinical trials into perspective. And although the many clinical trials of adjuvant taxane therapy are all properly addressed here, a tabular summary of those trials, or at least the discussion of a meta-analysis of taxane adjuvant therapy with an accompanying table would have been an enormous help.

The subject of dose-dense therapy, while discussed here in principle, does not get its due, and a more detailed discussion of Cancer and Leukemia Group B (CALGB) trial 9741 would have added strength to this chapter. Finally, the role of the 21-gene assay (Onctotype DX) is recommended as appropriate in patients with “HR-positive, stage I tumors”; perhaps the recommendation should have read “HR-positive, node-negative tumors” for the sake of complete accuracy.

The section on chemotherapy for advanced disease provides a comprehensive summary of the utility of various single agents in the treatment of metastatic breast cancer, the ensuing discussion of combination chemotherapy includes all of the recent randomized clinical trials of taxane-based combinations, but the authors could have rendered an opinion on who should receive combination therapy vs a single agent. There follows a thorough discussion of nab-paclitaxel (Abraxane) therapy (referred to here as ABI-007), but unfortunately, I suspect that this chapter had to go to press before the approval of ixabepilone (Ixempra) in the United States, and thus, this new agent does not receive adequate treatment here.

The two chapters on targeted therapies-one devoted to trastuzumab, and one to antiangiogenesis-represent the greatest strength of the entire text, and add great value to the timeliness and usefulness of the book. The discussion of trastuzumab in the treatment of metastatic breast cancer is exhaustive, and the authors address the question of continuous trastuzumab therapy while changing chemotherapy with appropriate reserve. There follows a superb recitation of all the adjuvant trastuzumab trials and their fundamental differences. This section should almost be required reading for both practitioners and oncologists in training, as it is written with extraordinary clarity and represents the data fairly and without bias.

The following chapter on antiangiogenesis is also outstanding. It begins with a proper elucidation of the mechanisms of angiogenesis, and discusses the evolution of bevacizumab (Avastin) as a therapeutic agent in an appropriately orderly fashion. Given the recent approval of bevacizumab as a therapeutic agent in the treatment of breast cancer in the United States, this summary, as well as the discussion of bevacizumab-related toxicity that follows, are critically important in the education of practitioners and trainees who are relatively unfamiliar with this agent.

The final chapter, which addresses targeted therapies in general, and newer, investigational targeted therapies in particular, is a proper means of bringing the entire text to closure. Although the initial portion of this chapter begins with a daunting summary of the complex pathways that result in the development and progression of cancer, and although the clinician may find this section to be a bit of a challenge, I think perhaps a summary of cancer biology as a means of illustrating the many “targets” available for the development of new therapies is both essential and necessary reading for those committed to this field. A summary of a variety of targeted therapies follows, ranging from monoclonal antibodies to small-molecule tyrosine kinase inhibitors to agents with mechanisms unfamiliar to many of us, and provides basic information regarding each without becoming repetitious or otherwise uninspiring.

This book is actually not a difficult read at all: A concentrated effort can take one through it in a matter of a few days. The book makes no attempt to be encyclopedic; this is not its aim. Although the depth of the information and the exhaustive summaries may not be appropriate for readers at the level of a medical student or resident, any oncology fellow or practitioner, or allied health professional, would find Breast Cancer an easy way to stay current with therapeutic care standards, and could do so with relative ease.

-Kevin R. Fox, MD