That screening mammography substantially reduces mortality from breast cancer is a major medical accomplishment of our time and one with potential remaining to be fulfilled. During its development, mammography has taught us much about the biology of breast cancer, the validation and quantification of both the benefit and the potential harm of screening, the relation of technical and interpretive quality to outcomes, the need for scientific assessment of new imaging methods that might supplement or replace mammography, and the uncertainties of mammographic interpretation. In each of these areas, the history of mammography provides invaluable lessons that are applicable to the rest of medicine.
Breast Imaging includes case examples and overviews of all these important issues. Rather than just describe how to perform and interpret mammography, this book also discusses breast disease from a substantially wider viewpoint. It should therefore be of great interest to all physicians who care for women. Contributing to the practical value of this book are its discussions of the aspects of anatomy, histology, physiology, pathology, and biology that relate to the accuracy of screening, diagnosis, and staging. Moreover, the material on breast-cancer initiation, invasion and metastasis, oncogenes, suppressor genes, and tumor angiogenesis provides a broad perspective on the role of screening. The author's knowledge of and insight into areas outside his own specialty are impressive.
In his discussions of screening, and throughout the book, Kopans uses diagrams to make complex subjects understandable and fascinating. For example, cancers are depicted as new balloons rising at a constant rate from the ocean floor and increasing in size as they rise. In this analogy, how deep one dives to recover the balloons represents the threshold of detection. How often one dives represents the frequency of screening. The prevalence screening test is portrayed as the first dive, and incidence screening tests as subsequent dives. The balloon analogy makes the concepts of cancer yield, detection stage, lead time, and sojourn time understandable. In his subsequent discussions of the controversy regarding the screening of women 40 to 49 years of age, the author explains how various experts reached opposite conclusions after reviewing the same data. Kopans presents a convincing case for beginning annual screening at the age of 40 but gives the reader enough unbiased data to reach an independent conclusion.
Half of this book is devoted to topics found in traditional mammography textbooks, but Kopans presents this material so well that physicians other than radiologists will gain insight into the intriguing process of how screening and diagnostic mammography work. The process begins with the challenge of finding the subtlest deviation from "normal," determining whether the deviation is real, locating it in three dimensions from various mammographic views, forming an opinion of what it is by means of additional mammographic views and other imaging tests, and finally advising on a strategy for follow-up or invasive procedures. To gain an appreciation of this chain of events is reason enough to read Kopan's book. An extremely useful feature of the book is that one or two key sentences in each figure legend have been printed in boldface type, enabling readers to virtually skip the text, skim the figures, and absorb the major points efficiently. Yet the more than 800 illustrations and tables are so well selected, sequenced, and reproduced that they invite the reader to explore the text further for more details.
Kopans discusses how, after the completion of breast-imaging studies, the radiologist, using commonly defined terminology, should compose a report that briefly describes the mammographic findings and provides clear recommendations for management. Regardless of how thoroughly the book is read, the reader will reach the inescapable conclusion that the evaluation of mammograms is an inexact science. This conclusion is not surprising, since pathologists working at a much higher level of resolution cannot always easily distinguish between benign growths and malignant disease. Interpreting breast-imaging studies requires making a trade-off between sensitivity and specificity: maximizing early cancer detection while maintaining acceptable rates of repeated testing and biopsy.
The radiologist continues to have a role after the biopsy of a nonpalpable lesion is advised, either by providing preoperative guidance of needle localization for an excisional biopsy or by performing a core biopsy guided by radiography or ultrasonography. The discussion of these techniques considers the reasons core biopsy has been accepted as an alternative to needle-guided excisional biopsy without its having been subjected to adequate scientific scrutiny. Whether or not one agrees with the author, his opinions are always thought-provoking. In this instance and throughout the book, he questions the justification for every diagnostic protocol and never accepts old or new dogma at face value. One of the book's final chapters, on the medicolegal aspects of breast imaging, which in other hands could have been a dry legalistic discourse, is instead filled with perceptive observations that get right to the central problems of our highly flawed medicolegal system. Breast Imaging is an extraordinary book.
Reviewed by Stephen A. Feig, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an out of print or unavailable edition of this title.
