Management of Gastrointestinal Cancer
Eds P McCulloch, A Kingsnorth, 404pp, ISBN 0-7279-1071-X, London: BMJ Publishing, 1996
I enjoyed reading and referring to this book, but it does have shortcomings. Perhaps the great length of the preface indicates a recognition by the editors that they have not entirely succeeded in their intentions. McCulloch and Kingsnorth have assigned their chosen topics to an international team consisting predominantly of surgeons and oncologists. I suspect that it is here that misjudgment has occurred, as many of my criticisms relate to difficulties at the interface between these disciplines.
Although a refreshing balance is introduced by a distinct emphasis on Japanese practice, the multidisciplinary approach now characteristic of many spheres of gastroenterology (and espoused in the preface) is not observed in its entirety. A substantial proportion of patients with gastrointestinal malignancy present to gastroenterologists, are investigated by gastroenterologists, and are treated by them (especially when endoscopic palliation is indicated). Medical gastroenterologists, however, are not prominent amongst the authors.
The book begins with several chapters on the biology of malignancy. They are excellent, but I think the publishers may have misordered them, as it seems perverse to discuss the mechanism of metastasis before the nature of malignancy and carcinogenesis. A greater use of summary boxes or key-points (normally a strength of the House of BMJ) might also have been helpful. The chapter on molecular biology gives a sense that one is working through a list of different tumours rather than concentrating on points of general application.
In view of the dearth of medical gastroenterologists amongst the authors it is perhaps no surprise that the sections on endoscopic therapy are the weakest in the book, and that expressed opinions often verge on the anecdotal even when reasonable or good data exist. The deliberate splitting of main topics between two chapters (aetiology, clinical presentation and surgery, versus oncological therapy and palliation) has unfortunately exacerbated this tendency, with both surgical and oncological author pairs giving brief attention to these ‘crossover’ areas, but neither providing material of high quality. As an example, the 59 pages devoted to oesophageal carcinoma include less than 4 on non-surgical palliative intervention, despite the fact that this option will be pertinent to most European and North American patients for the foreseeable future. Kingsnorth’s own section on the pancreas is a happier example, as he has taken clear responsibility for endoscopic intervention within the surgical chapter. I am sure that incorporation of gastroenterologists would have diminished this difficulty, if only because physician endoscopists would have wished to defend their own turf.
This might also have avoided controversial but unsupported statements such as the ‘metal stent [for biliarv obstruction] is best placed by the percutaneous route’ (p 211); and I suspect that many transplant surgeons would be less dismissive of the role of liver transplantation in neoplasia than the book suggests (p 292). The generally impressive surgical chapter on colorectal carcinoma is weakened by its inclusion of a superficial account of the tumour’s molecular biology. The editors could have briefed this author better (or exercised a kind blue pencil), in view of the more detailed account earlier in the book. This is not the only example of needless repetition.
I recognize that my comments are biased by my affiliations. The book does represent a valuable addition to the published work.