Textbook of Medical Oncology, 2nd Edition

In this day of encyclopedic oncology texts, frequentlyupdated online reference sites, and literature searches at the click of abutton, is there a place for a basic medical oncology textbook? The secondedition of the Textbook of Medical Oncology, edited by Drs. Cavalli, Hansen, andKaye, is approximately 50% longer than the first edition, due in large part tothe inclusion of newer therapeutic approaches.

The book differs from many other general oncology texts in two ways. First,the information is presented from a medical oncology viewpoint, eschewingdetails of surgical and radiation techniques in favor of a focus on systemictherapy issues. Second, because the editors and many of the contributors areEuropean, studies coordinated by the European Organization for Research andTreatment of Cancer (EORTC) and other regional or national European cooperativegroups figure more prominently in discussions of the evolution of varioustreatments than they do in most US texts.

The text opens with a well-written chapter on the molecular biology of cancerthat uses easy-to-follow text and illustrations to explore topics ranging fromthe somatic mutation theory of cancer through oncogenes, tumor-suppressor genes,signal transduction, and cell-cycle control to the possible role of gene therapyin reversing the malignant phenotype. It features an extremely useful glossaryof molecular biology terms that may be unfamiliar to clinicians. This chapter isfollowed by one on the principles of systemic therapy. Detailed descriptions ofapproved antineoplastics are supplied in an appendix, allowing this chapter tofocus on concepts and to include discussions of novel approaches such astumor-specific immunotherapy, gene therapy, and the identification of newbiologic targets (signal transduction pathways and tumor-induced angiogenesis).

The third chapter is an excellent introduction to clinical trial design andinterpretation. It takes a would-be investigator through the major issuesassociated with designing a study, including the selection of appropriate endpoints, from tumor response and survival through toxicity, impact on quality oflife, and cost-effectiveness analysis. It also addresses timely issues such asthe challenge of choosing appropriate end points for studies of noncytotoxictherapies, the risks of subgroup analysis, and the strengths and weaknesses ofmeta-analysis.

The next 15 chapters address malignancies by organ system, and although theyfocus on the most common cancers affecting that organ system, they also addressmany less common malignancies. In general, the discussions achieve a balancebetween historical and current data to support general treatment recommendationsand important research questions going forward. Extensive bibliographies includemany of the pivotal papers in each area.

Many of the individual chapters are excellent and short enough to be digestedin one sitting, but with sufficient detail to provide a good base of informationfrom which to approach most common clinical situations or to assess newlypresented or published data. One notable exception is the chapter on breastcancer, which presents lists of potential prognostic factors and treatmentoptions without sufficient guidance on the relative value of each. In that samechapter, the author asserts that ductal carcinoma in situ (DCIS) is"usually treated by some form of radical surgery"; in fact,breast-conserving surgery has become the treatment of choice for many women withDCIS.

Given the lead time required to produce a textbook, it is not surprising thatcertain novel therapies—such as the potential of BCR-ABL tyrosine kinaseinhibition in chronic myelogenous leukemia—are mentioned only briefly, if atall. Other omissions are more puzzling—for example, the absence of adiscussion of the influence of BRCA1/BRCA2 mutations on the incidence of ovariancancer, the treatment and screening options available to women identified asbeing at high risk, and the passing mention of interleukin-2 (Proleukin) andbiochemotherapy as systemic therapy for advanced melanoma.

The latter chapters explore a variety of therapeutic issues. A discussion ofthe management of febrile neutropenia includes recommendations for empirictherapy and treatment modifications based on symptoms and other findings.Identification of neutropenic patients whose risk of complications issufficiently low to warrant consideration of outpatient management and the roleof hematopoietic growth factors are also addressed.

The chapter on the long-term side effects of treatment is a worthwhileaddition but should be expanded to include a discusson of the data, or lackthereof, on the risks of long-term cognitive defects. The evaluation of paincontrol, management of the side effects of opioids, alternative routes of opioidadministration, and the use of adjuvant analgesics to enhance the efficacy ofopioids are all addressed in a chapter on pain management.

A chapter on the etiology, recognition, and management of medical oncologyemergencies is also well written but should be expanded to include mention oftreatment-related emergencies, such as hypersensitivity reactions tochemotherapeutic agents and drug extravasation. The chapter on the evaluation ofquality of life in cancer patients is thought-provoking, especially to those whodesign clinical trials. A final chapter on palliative and terminal careencourages clinicians to consider a range of approaches to this aspect of care,including a discussion of physician-assisted suicide and euthanasia.

Although some of the treatment approaches discussed in the various chaptersare being or will be superseded between editions of this text, it generally doesan excellent job of describing basic clinical approaches to the diseases thatchallenge medical oncologists. Unlike many larger oncology texts, these chapterscan be read relatively quickly. For this reason, I would not hesitate torecommend the book to a fellow or resident on a medical oncology rotation.Changes made since the first edition are valuable, but the editors and theircontributing authors must, in future editions, resist the temptation to furtherexpand the text, sacrificing brevity and clarity for added detail. In itscurrent form, the book is a worthwhile acquisition for a physician in trainingor a clinician looking for a more concise medical oncology text.