Expert Consultations in Breast Cancer: Critical Pathways and Clinical Decision Making

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 mastectomy”—despite the results from five randomized trials showing equivalent or improved overall survival.

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 III—the longest section and perhaps the most unique portion of this text—features 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, Paget’s 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 discussions—at 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 system—exactly the goal the editors set out to achieve.