This book, by an Australian public health physician and his daughter, a young English and drama graduate working in film and television, aims to interest and educate a wide readership, both professional and lay. They certainly succeeded in holding the interest of this (lay) reader, and it was helpful to have recent evidence about the possible strategies for breast cancer prevention set out clearly, in a jargon‐free style.
As the authors say, prevention is not early detection. We need to look at epidemiological evidence to understand the role of various life‐style factors, mainly diet, in the aetiology of breast cancer. These are matters that we can take into our own hands. We can cut down our meat and animal fat consumption, eat fresh fruit and vegetables, avoid weight gain, take exercise, consume alcohol in moderation, and (if possible) have babies early. As the authors note, the role of ‘chemoprevention’ with tamoxifen is still controversial, and they do not discuss prophylactic mastectomy.
Some well‐known risk factors for breast cancer such as early menarche and late menopause are of course difficult to modify, but diet restriction in pregnancy could raise the age of menarche in the next generation. High socio‐economic status, on the other hand, is a risk factor that few will wish to change.
A relatively new suggestion made in this book is that diet during pregnancy is of particular importance for daughters (and sons): over‐nutrition results in big babies, who are at greater risk of breast cancer (and prostate cancer). Once the baby is born, breastfeeding for as long as possible is recommended. The risks of oral contraceptives and hormone replacement therapy (HRT) need to be individually assessed in the light of family history, but these should be used with caution.
The scientific evidence for all these recommendations is carefully reviewed, and the detective work involved in assessing and evaluating the sometimes contradictory studies makes fascinating reading. Throughout the book we are reminded of the human face behind the statistics through the biography of ‘Elizabeth Sutherland’, whose story forms the first chapter of the book. In some ways Elizabeth’s story illustrates well‐known risk factors for breast cancer, but in other ways it doesn’t (for example, she had all four babies early). All the technical terms used are explained as they occur, and the authors even manage to teach the reader the elementary principles of how to read a research paper and evaluate the evidence, explaining such mysteries as confidence intervals in a lucid manner.
It is disappointing therefore to note a few inaccuracies. The figure of 8000 given for annual UK breast cancer mortality is incorrect: although it is declining, the latest published figure from the Cancer Research Campaign is 14 443. To talk about ‘undifferentiated’ cancer cells without mentioning ‘well differentiated’ cells does not seem helpful. The authors state categorically that ‘breast cancer is not caused by chemicals’ (p.154), but recent work on DDE, lindane and dieldrin suggests that there may be some link, and the work of Samuel Epstein on the environmental causes of cancer has been ignored. The advice on breast self‐examination is inadequate: only two signs to look for are mentioned out of a possible seven or eight. Recommendations on mammography (every 2 years after age 40 and yearly after age 50) would be seen as controversial in the UK. And although the book is well referenced, there are no suggestions for further reading: notable omissions are Cathy Read’s Preventing Breast Cancer: the Politics of an Epidemic (HarperCollins 1995) and Dr Susan Love’s Breast Book (2nd Edition, Addison‐Wesley 1995).
Also, one important aspect is missing from this otherwise comprehensive overview: psychological history and personality as possible risk factors for breast cancer (and other cancers). These are well documented in the literature, and the science of psychoneuroimmunology is now enabling us to understand some of the underlying mechanisms. Since it is actually possible to change behaviour by altering (say) ways of responding to stress, it is a pity that this topic was omitted from an otherwise readable, helpful, and timely book.