- Email: [email protected]
Confronting Hereditary Breast and Ovarian Cancer
Cancer and Society
Roy Lichtenstein screenprint, Titled, which features his characteristic Ben Day dots in a graphic landscape. These pieces infuse the collection with humour and playfulness, and exemplify the pop art movement’s challenge to presumptions about process and content in fine art. Such progressive works aptly parallel Dana Farber’s ethos of pushing boundaries in medicine and patient care.
The placement of art in healthcare settings is an increasingly conscientious process, as more and more research shows that well selected artworks can enhance a supportive environment and reduce stress. The art (and audio guide) at Yawkey Center are receiving high marks from patients and staff, as well as from art critics, who have noted the exceptional quality of the collection.
The fact that many of the pieces were donated shows a broad commitment to the importance of art in health care. Although the Yawkey Center might be an exceptional model of customising a clinical environment to enhance wellness, every clinic has space on the walls and is a gallery waiting to be curated.
Jill Jouret
Books Confronting Hereditary Breast and Ovarian Cancer The combination of a lay advocate, a clinician with an intimate knowledge of cancer genetics, and a journalist have produced an exceptionally well written and well researched book, providing a great source of information for women with, or at risk for, hereditary breast cancer. Confronting Hereditary Breast and Ovarian Cancer: Identify Your Risk, Understand Your Options, Change Your Destiny would also be a useful read for many clinicians, nurse practitioners, and genetic counsellors who work with patients who are at risk of hereditary cancer. In particular, this book provides useful information for those that carry, or are at risk of carrying, mutations in the high-risk BRCA1 and BRCA2 genes. It presents a well balanced and realistic view of the options open to women with and without cancer—in terms of their treatment and options for prevention and surveillance. Importantly, apart from one or two occasions, the book does not give isolated views that are at odds with published research. A clinician can safely recommend this book without feeling that the publication will act as a scaremonger or as a source of erroneous information for their patients. The book is clearly aimed at the North American market, with regular sections on the issues of medical insurance, access to appropriate clinicians and
screening, and surgical options in North America, which is, in a way, a pity because the lion’s share of the book is certainly very amenable and applicable to women worldwide. The book is well structured, with 18 chapters covering issues such as risk assessment, surgery (including risk-reducing surgery for the breast and ovaries), menopause, chemoprevention, lifestyle issues, and even a chapter for men and their risk associated with BRCA1 and BRCA2. Although criticism seems a little churlish given my overall view of the book, I identified two or three issues that should be highlighted. The book itself is obviously written by women mainly for women and, as such, unsurprisingly has a very female slant. The use of the term “she” for every surgeon, including gynaecological and breast, should at least be introduced rather than assumed, given that in many countries most surgeons are still male. Furthermore, the authors liberally use the term previvor for women at increased risk of breast cancer. This term was invented by the not-for-profit lay advocacy group FORCE (Facing Our Risk of Cancer Empowered) of which one of the authors, Sue Friedman, is a founding member. Although the term is defined early on in the book, many people dipping in and out will have no idea what it means (a glossary would have helped), because previvor is still
www.thelancet.com/oncology Vol 13 September 2012
not a widely recognised way to describe individuals at risk. Indeed, the way the term is derived would mean that virtually every woman is a previvor. Finally, my slight criticism of the lifestyle section is that the authors’ views on the sort of lifestyle to follow slightly overtake the evidence base. For example, clearly, alcohol does increase the risk of breast cancer, but the increased risk is only around 6–7% per unit of alcohol per day, which would mean that for a woman with a 10% lifetime risk of breast cancer, her risk would increase to just 10·7% even if she drank a unit a day, all of her life. On several occasions throughout the book, alcohol is somewhat demonised, and the authors ignore the fact that largescale meta-analyses of alcohol studies have shown that a unit, or even two units, a day is actually associated with increased life expectancy compared with not drinking at all. Indeed, the authors regard drinking a unit a day every day to be “an unwise choice”. The introduction to the chapter on lifestyle choices is very clear about not using isolated studies to justify whether certain lifestyle choices confer risk. Therefore, I was surprised that two recent publications are used to highlight the potential risks of smoking despite the fact that largescale meta-analyses show no overall effect of smoking on breast cancer risk. Certainly, evidence to suggest that
Confronting Hereditary Breast and Ovarian Cancer: Identify Your Risk, Understand Your Options, Change Your Destiny Sue Friedman, Rebecca Sutphen, Kathy Steligo. The Johns Hopkins University Press, 2012. Pp 288, US$18·95. ISBN 978-1421404080
867
Cancer and Society
smoking is an unwise lifestyle choice is abundant, but the data should not be manipulated to show that this is also the case for breast cancer. Having made these criticisms, I have to say that overall the book was of a very high standard, beautifully laid
out, with commentaries from well known experts in cancer genetics and oncology, accompanied by nice layouts in the margins summarising some of the options and data. I would certainly not let my slight criticisms stop me from recommending this
book to any woman who wanted good, detailed knowledge about hereditary breast cancer, and the book is certainly infinitely better than the internet as a source of information on this topic.
Gareth Evans
Breast Cancer and the Environment
xx
Breast Cancer and the Environment: A Life Course Approach Institute of Medicine of The National Acadamies, The National Academies Press, 2012. Pp 180. £28·00. ISBN 978-0309220699
Over the past 25 years, intense efforts have done little to identify how environmental factors could cause breast cancer. Research has sadly stalled despite enormous efforts by advocates, government, and scientists. That failure, and the fact that most breast cancer risk factors are still unknown, no doubt stimulated the commissioning of this impressive book. Similar information is available in fairly recent comments and reviews, but this volume sounds a strong call for expanded research on environment and breast cancer. The main obstacle encountered by researchers is how to uncover links between external environment and cancer through biological mechanisms. This work endorses a concept whereby environment affects mammary biology over the life course. Windows of susceptibility in relation to environment and breast cancer have been discussed and liberally funded since the 1990s, so the question is really how to better elucidate that concept. This volume reassesses that framework, although it does not reshape its direction. However, some
compelling recommendations are made that are most welcome. Paving the way to those conclusions are teaching moments, including comprehensive epidemiology and exposure science that will be useful, serving as a key reference in the field. Known risk factors are described in great detail, including radiation and hormones. As usual, and less appealing, environment is broadly defined to include lifestyle factors such as obesity and physical activity, without linking them to external exposures. Advocates, including myself, are most interested in exogenous-chemical and physical insults. The complex assortment of breast tumours might be responsive to toxins at different times during their initiation and progression. Environment itself is equally complex. Frustration remains for solving the blinding array of potential links that confronts us. The final chapter is well crafted and provocative (which we need), with 13 action items. The key recommendation is to reduce wellknown risks, but also to avoid less well recognised carcinogenic exposures
(radiation, occupational chemicals, potent carcinogens, and hormonally active personal exposures). This firm position represents substantial progress toward prevention. It states the obvious but it adds some new dimensions. Most importantly, it codifies our long-held suspicion that environmental factors contribute to breast cancer. Consensus documents such as this by their nature might not greatly improve knowledge, but their influence can be enormous in terms of guiding policy and research funding priorities. Thus, welcome news is that we must continue discovery of mechanisms while following the precautionary principle by promoting elimination of known or highly suspect risk factors for breast cancer. Richard Doll, who appreciated environmental links to cancer, said in 1975 that “We have clues to the causation of [breast cancer], and…we should learn how to prevent [it] before long.” How long? 40 years hasn’t been enough, but the door is still open.
Mary S Wolff
Voices from the front: September “Hey…you”, she said as she answered the phone. It was our greeting. I had taken over her care 3 years earlier when her first oncologist had left just as she was diagnosed with metastasis from her breast cancer. We forged a bond under difficult circumstances. She and her husband were a determined and loving couple who fought her cancer fully, yet never stopped raising their young children and living in their community. Now, she was home with hospice and I was calling to check in before going home to my own young family. She died before I could see her again. But, from time to time, she still greets me with that same inflection.
David M Mastrianni
868
www.thelancet.com/oncology Vol 13 September 2012
Roy Lichtenstein screenprint, Titled, which features his characteristic Ben Day dots in a graphic landscape. These pieces infuse the collection with humour and playfulness, and exemplify the pop art movement’s challenge to presumptions about process and content in fine art. Such progressive works aptly parallel Dana Farber’s ethos of pushing boundaries in medicine and patient care.
The placement of art in healthcare settings is an increasingly conscientious process, as more and more research shows that well selected artworks can enhance a supportive environment and reduce stress. The art (and audio guide) at Yawkey Center are receiving high marks from patients and staff, as well as from art critics, who have noted the exceptional quality of the collection.
The fact that many of the pieces were donated shows a broad commitment to the importance of art in health care. Although the Yawkey Center might be an exceptional model of customising a clinical environment to enhance wellness, every clinic has space on the walls and is a gallery waiting to be curated.
Jill Jouret
Books Confronting Hereditary Breast and Ovarian Cancer The combination of a lay advocate, a clinician with an intimate knowledge of cancer genetics, and a journalist have produced an exceptionally well written and well researched book, providing a great source of information for women with, or at risk for, hereditary breast cancer. Confronting Hereditary Breast and Ovarian Cancer: Identify Your Risk, Understand Your Options, Change Your Destiny would also be a useful read for many clinicians, nurse practitioners, and genetic counsellors who work with patients who are at risk of hereditary cancer. In particular, this book provides useful information for those that carry, or are at risk of carrying, mutations in the high-risk BRCA1 and BRCA2 genes. It presents a well balanced and realistic view of the options open to women with and without cancer—in terms of their treatment and options for prevention and surveillance. Importantly, apart from one or two occasions, the book does not give isolated views that are at odds with published research. A clinician can safely recommend this book without feeling that the publication will act as a scaremonger or as a source of erroneous information for their patients. The book is clearly aimed at the North American market, with regular sections on the issues of medical insurance, access to appropriate clinicians and
screening, and surgical options in North America, which is, in a way, a pity because the lion’s share of the book is certainly very amenable and applicable to women worldwide. The book is well structured, with 18 chapters covering issues such as risk assessment, surgery (including risk-reducing surgery for the breast and ovaries), menopause, chemoprevention, lifestyle issues, and even a chapter for men and their risk associated with BRCA1 and BRCA2. Although criticism seems a little churlish given my overall view of the book, I identified two or three issues that should be highlighted. The book itself is obviously written by women mainly for women and, as such, unsurprisingly has a very female slant. The use of the term “she” for every surgeon, including gynaecological and breast, should at least be introduced rather than assumed, given that in many countries most surgeons are still male. Furthermore, the authors liberally use the term previvor for women at increased risk of breast cancer. This term was invented by the not-for-profit lay advocacy group FORCE (Facing Our Risk of Cancer Empowered) of which one of the authors, Sue Friedman, is a founding member. Although the term is defined early on in the book, many people dipping in and out will have no idea what it means (a glossary would have helped), because previvor is still
www.thelancet.com/oncology Vol 13 September 2012
not a widely recognised way to describe individuals at risk. Indeed, the way the term is derived would mean that virtually every woman is a previvor. Finally, my slight criticism of the lifestyle section is that the authors’ views on the sort of lifestyle to follow slightly overtake the evidence base. For example, clearly, alcohol does increase the risk of breast cancer, but the increased risk is only around 6–7% per unit of alcohol per day, which would mean that for a woman with a 10% lifetime risk of breast cancer, her risk would increase to just 10·7% even if she drank a unit a day, all of her life. On several occasions throughout the book, alcohol is somewhat demonised, and the authors ignore the fact that largescale meta-analyses of alcohol studies have shown that a unit, or even two units, a day is actually associated with increased life expectancy compared with not drinking at all. Indeed, the authors regard drinking a unit a day every day to be “an unwise choice”. The introduction to the chapter on lifestyle choices is very clear about not using isolated studies to justify whether certain lifestyle choices confer risk. Therefore, I was surprised that two recent publications are used to highlight the potential risks of smoking despite the fact that largescale meta-analyses show no overall effect of smoking on breast cancer risk. Certainly, evidence to suggest that
Confronting Hereditary Breast and Ovarian Cancer: Identify Your Risk, Understand Your Options, Change Your Destiny Sue Friedman, Rebecca Sutphen, Kathy Steligo. The Johns Hopkins University Press, 2012. Pp 288, US$18·95. ISBN 978-1421404080
867
Cancer and Society
smoking is an unwise lifestyle choice is abundant, but the data should not be manipulated to show that this is also the case for breast cancer. Having made these criticisms, I have to say that overall the book was of a very high standard, beautifully laid
out, with commentaries from well known experts in cancer genetics and oncology, accompanied by nice layouts in the margins summarising some of the options and data. I would certainly not let my slight criticisms stop me from recommending this
book to any woman who wanted good, detailed knowledge about hereditary breast cancer, and the book is certainly infinitely better than the internet as a source of information on this topic.
Gareth Evans
Breast Cancer and the Environment
xx
Breast Cancer and the Environment: A Life Course Approach Institute of Medicine of The National Acadamies, The National Academies Press, 2012. Pp 180. £28·00. ISBN 978-0309220699
Over the past 25 years, intense efforts have done little to identify how environmental factors could cause breast cancer. Research has sadly stalled despite enormous efforts by advocates, government, and scientists. That failure, and the fact that most breast cancer risk factors are still unknown, no doubt stimulated the commissioning of this impressive book. Similar information is available in fairly recent comments and reviews, but this volume sounds a strong call for expanded research on environment and breast cancer. The main obstacle encountered by researchers is how to uncover links between external environment and cancer through biological mechanisms. This work endorses a concept whereby environment affects mammary biology over the life course. Windows of susceptibility in relation to environment and breast cancer have been discussed and liberally funded since the 1990s, so the question is really how to better elucidate that concept. This volume reassesses that framework, although it does not reshape its direction. However, some
compelling recommendations are made that are most welcome. Paving the way to those conclusions are teaching moments, including comprehensive epidemiology and exposure science that will be useful, serving as a key reference in the field. Known risk factors are described in great detail, including radiation and hormones. As usual, and less appealing, environment is broadly defined to include lifestyle factors such as obesity and physical activity, without linking them to external exposures. Advocates, including myself, are most interested in exogenous-chemical and physical insults. The complex assortment of breast tumours might be responsive to toxins at different times during their initiation and progression. Environment itself is equally complex. Frustration remains for solving the blinding array of potential links that confronts us. The final chapter is well crafted and provocative (which we need), with 13 action items. The key recommendation is to reduce wellknown risks, but also to avoid less well recognised carcinogenic exposures
(radiation, occupational chemicals, potent carcinogens, and hormonally active personal exposures). This firm position represents substantial progress toward prevention. It states the obvious but it adds some new dimensions. Most importantly, it codifies our long-held suspicion that environmental factors contribute to breast cancer. Consensus documents such as this by their nature might not greatly improve knowledge, but their influence can be enormous in terms of guiding policy and research funding priorities. Thus, welcome news is that we must continue discovery of mechanisms while following the precautionary principle by promoting elimination of known or highly suspect risk factors for breast cancer. Richard Doll, who appreciated environmental links to cancer, said in 1975 that “We have clues to the causation of [breast cancer], and…we should learn how to prevent [it] before long.” How long? 40 years hasn’t been enough, but the door is still open.
Mary S Wolff
Voices from the front: September “Hey…you”, she said as she answered the phone. It was our greeting. I had taken over her care 3 years earlier when her first oncologist had left just as she was diagnosed with metastasis from her breast cancer. We forged a bond under difficult circumstances. She and her husband were a determined and loving couple who fought her cancer fully, yet never stopped raising their young children and living in their community. Now, she was home with hospice and I was calling to check in before going home to my own young family. She died before I could see her again. But, from time to time, she still greets me with that same inflection.
David M Mastrianni
868
www.thelancet.com/oncology Vol 13 September 2012