ed E D Pisano
Amsterdam: IOS Press (2001)
128pp, price: $90.00, ISBN: 1-58603-168-6

Breast Imaging is a single issue of volume 13 of the journal Breast Disease (http://www.iospress.nl/site/navfr/navframe2.html) published additionally as a separate paperback book. Etta Pisano, the issue editor, is also on the journal's Editorial Board. The whole issue is available online to subscribers. Nonsubscribers have online access to the abstracts and reference lists of each paper, the latter including links to some of the references. E-mail addresses of the authors have been appended below.

As the editor freely admits, this issue `covers ... a large number of quite disparate topics, affecting both public health and clinical practice' (Pisano, 2001a). For the physicist in medicine, it provides a snapshot of current clinical thinking about the breast cancer epidemic. It does not delve much into alternatives to standard (film/screen or digital) mammography.

A difficult decision that women over 40 have to face in regard to breast cancer is whether or not to participate in screening mammography. (No technology exists for women under 40.) Sadler and Fullerton (2001) give three categories of `women ... at risk for under-utilization for mammography', but ignore those who avoid it because of the controversy over mammography's effectiveness. Their approach, and that of Moyer et al (2001) and Sadler et al (2001), is to assume that mammography is effective and only requires better marketing.

Huang, Chang and Shen (2001) note a recent abrupt increase in breast cancer incidence amongst Chinese women. Many Chinese women with breast cancer are younger and present radiographically denser breasts than Western women with breast cancer. These authors are more critical of mammography and thus are groping for `a more sensitive screening modality'.

Kinsinger and Harris (2001) acknowledge that `breast cancer screening for women in their forties has been one of the most controversial medical issues of the past 20 years, and that the controversy is not resolved'. They propose that informed consent, fought for by women for decades, be replaced by `shared-decision making' (SDM): `In cases involving a close call, such as with breast cancer screening for women in their forties, providers must be careful not to bias a patient's decision. For this to occur, providers must truly believe that the best decision is the one that the patient chooses. In the end, provider and patient need to reach an agreement on the decision.' While SDM eschews the marketing approach, it is `inappropriate for ... situations in which the balance between potential benefits and harms is clearly negative. Allowing patients to choose potentially harmful options could lead to overall patient harm .... We believe SDM, refined by research, will eventually become the standard of care.' SDM, except in the hands of saints, would appear to be a return towards `the traditional authoritarian physician-patient relationship' (Lerner 2001). Rather than eliminating informed consent, I hope that research would go into a replacement for mammography that is not so close to a flip of a coin (cf Gordon and Sivaramakrishna 1999).

Curiously, the `harms' of mammography listed by Kinsinger and Harris (2001) do not include radiation danger, dismissed as `hysteria' by Birdwell and Wilcox (2001) in their history of how we came to the point that breast imagers `are unique among our radiologic colleagues, and, in fact, all of medicine, as to the stringent requirements outlining every aspect of our daily practice'. Perhaps it was a cavalier attitude towards radiation danger (Bailar 1976) that brought about heavy-handed government regulation.

Three articles, Liberman and Kaplan (2001), Gregory and Rebner (2001) and Harms (2001), review the spectrum between biopsy and ablation of breast lesions. One is struck in these articles, and in Stamper and Stamper (2001), by the acknowledged difficulties in knowing whether a sufficient resection margin has been achieved. Here is a challenge for the medical physics researcher (Gregory and Rebner 2001): `The search should continue for less invasive/noninvasive methods of accurately separating benign from malignant disease, and for an effective method to percutaneously excise and treat minimal breast cancer.'

Ollila and Rager (2001) carefully review lymphatic mapping, but it seems out of context, in that no imaging techniques are described (cf Spanu et al 2001).

The need for three dimensional imaging is alluded to by Stomper (2001): `The two-dimensional specimen mammographic image does not assess transection or proximity to margins in the third dimension;' `CT-like images ... offer the opportunity to remove the clutter of overlaying tissue that often obscures lesions' (Conant and Maidment 2001). Digital mammography, like film/screen mammography, is a flatland approach to breast imaging. Instead of `a very large, prospective trial ... to determine if a significant difference in the sensitivity of cancer detection exists between screen-film and digital mammography' (Conant and Maidment 2001), to be funded by a new hierarchical level of grantsmanship with `a large number of committees that set the research agenda' (Pisano 2001b), perhaps we should move on by broad funding of individual initiatives in 3D breast imaging (Poulin and Gordon 2001).

In summary, this is a useful set of 13 articles, but as a whole they do not present a balanced view of the increasing controversies or opportunities in breast imaging.