© 1999 by Oxford University Press
Journal of the National Cancer Institute, Vol. 91, No. 24, 2124-2125,
December 15, 1999
© 1999 Oxford University Press
BOOK REVIEW |
Understanding Cancer: A Patient's Guide to Diagnosis, Prognosis, and Treatment
C. Norman Coleman. Baltimore (MD): The Johns Hopkins University Press, 1998. 186 pp., $32.50. ISBN 0-8018-6019-9
Correspondence to: Merle O'Rourke Thompson, Ph.D., 6012 Morgan Ct., Alexandria VA 22312 (e-mail: merlethompson{at}compuserve.com).
Dr. C. Norman Coleman, a Harvard professor trained at Yale in medical oncology and radiology, seems to be an interesting, compassionate man. In her introduction, Ellen Stoval, Executive Director of the National Coalition for Cancer Survivorship, says that he was the one expert on a federal panel of cancer care specialists who made her feel as though he had learned something from her, a lay person and 26-year cancer survivor. In his book, Dr. Coleman shows that he is able to listen to patients and to moderate his medical practice to take their needs into consideration. Understanding that it is very hard for newly diagnosed cancer patients to concentrate on much of anything at first, Dr. Coleman has set forth a lot of information in a small book about medical terms used in cancer care, the scientific concepts behind cancer, and cancer treatment. He wants his book to free patients from two unpleasant situations: information overload and feelings of lost control.
The steps involved in the diagnosis and treatment of cancer are reviewed in chapter 1. The first figure of the book, a sweeping pathway beginning with diagnosis and ending with follow-up with many stops along the way, diagrams the bulk of this chapter. He describes and defines specialists' titles, medical terms, and processes along this path as the patient consults specialists other than her family doctor; completes staging studies; investigates treatment options; seeks second opinions; discusses treatment options with various doctors; attends to medical, personal, work, and home matters; and selects and receives treatment(s). I was particularly interested by his discussion of the different types of second opinions. When I was diagnosed with breast cancer 12 years ago, I wanted a second opinion and was knowledgeable enough that, living as I did in a medically sophisticated community, I should go to a surgeon from a different medical circle of doctors to get a different perspective. I was so proud of myself until I had to tell the second doctor that I hadn't asked my first doctor for my pathology report and test results. So much for being smart. As Dr. Coleman knows, newly diagnosed cancer patients are not operating on all cylinders. In this chapter, we find the first of many patient checklists that he knows will help patients sort out information and gain control.
Understanding how a normal cell behaves or becomes a cancer cell is covered in chapter 2. This chapter is highly scientific and probably should not be read while a patient is in treatment. My experience on a hot line for several years is that, about 2 years after treatment, some people like me become very interested in the mechanics of their disease. Currently, one of my doctors is just 6 months out from renal cancer surgery and he told me that he isn't up to researching various treatments; he is just trusting his doctors. However, at any step, I agree with Dr. Coleman that knowledge is control. I also appreciated the discussion of genetic inheritance, which is worrisome to many. Most of my breast cancer survivor friends become very concerned about their daughters.
Chapter 3 explains all of the laboratory tests and imaging studies that will be done before treatment. Generally, the information is clear, although I wondered if an initiate following the discussion on differentiation would know that the sentence, "A grade 1 tumor has a better natural history," means it is well differentiated and has a better prognosis for cure. After reading all of the cases cited, the reader slowly realizes that a high-grade tumor is poorly differentiated and, therefore, bad, and vice versa. It is a complex issue.
Chapters 4 and 5 explain how the outcomes of treatment are measured and how to weigh the benefits of treatment against the risks of treatment or the risk of having no treatment. Dr. Coleman doesn't shy away from the statistical analyses that are difficult to follow. With careful examples, he leads the reader through risk-benefit ratio, actuarial risk, statistical graphs, and vertical and horizontal difference curves that compare treatments. I did statistics for my doctoral examinations, so I could stick with this chapter, but it is a bit hard going. Nevertheless, a patient who wants to know "How long do I have?" will see why this question is hard to answer definitively. He tackles the problem of outcomes, as in a treatment might prolong a person's life but make a negative impact on the quality of life.
Chapter 6 covers conventional treatments. Surgery is covered briefly; breast cancer patients whom I know would do well to read about this major part of the treatment in a book by a nurse. Throughout the detailed discussion of chemotherapy with the lists of drugs, their efficacy, and their side effects, and the same lists for radiation therapy, Dr. Coleman pulls no punches, for example, on toxicity or organ damage, but he keeps his tone calm and reassuring. This chapter ends with a discussion of bone marrow transplant, peripheral stem cell rescue, growth factor treatment, and hormonal therapy, again with lists of types and side effects.
Chapter 7 is all about clinical trials, for example, what it means to be phase II or III, and more important, why a patient might choose to enter a trial. It is here that a person might have done well to absorb the risk-benefit statistics of chapter 5.
All of the previous chapters are summarized succinctly in chapter 8, when Dr. Coleman presents four case studies: on Hodgkin's disease, breast cancer, prostate cancer, and brain cancer (for which only palliative treatment is indicated). In each case, he shows how one might have filled out his patient checklist and come to a treatment decision.
Appendices explain genetic studies, how to analyze cost-effectiveness, and include a patient's checklist that can be photocopied.
Since Dr. Coleman makes it clear throughout the book that he realizes patients have to factor in family, work, and personal issues, perhaps he should make room on his patient's checklist for such considerations. I'm reminded of Nancy Reagan's decision to have a mastectomy because she couldn't fit radiation therapy into her busy schedule as First Lady. Dr. Coleman would surely understand such a decision.
This book is rather dense, with little white space, few diagrams, and no pictures. Its scientific bent, however, is mitigated by the author's voice, which is always concerned for the patient's emotional as well as medical welfare. Interestingly enough, I think that doctors would do well with this book. Stymied as many of them are about explaining complex medical processes and outcomes, they might benefit from Dr. Coleman's calm but thorough explanations. Many contemporary patients who feel that they have to know everything to participate in their treatments will find answers in this book, which is on the high end of complexity.
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