134

Reviews of Books

Communication in Cancer Care

Ivan Lichter. Edinburgh: Churchill Livingstone. 1987. Pp 209.19.95. ISBN 0-443036985.

THERE is a mystique about cancer, common among bothdoctors and the general public, which seems to stem fromthe general perception that cancer implies a slow, painful,and inevitable death. These characteristics are not peculiarto neoplasia and not all patients with malignant diseaseexperience them, but cancer remains something to be talkedabout in hushed tones with a sad shake of the head. Thisbook arises from the author’s personal experience in

appreciating that the traditional approach of not tellingpatients with cancer about their disease is harmful and

perpetuates the problem. I do wonder, however, if theexistence of books about communication specifically withcancer patients does not help add to the mystique.The fundamental science of communicating with cancer

patients is basically the same as that for patients with otherdiagnoses. One of the strengths of this book is that publishedwork on the psychology of the consultation is well reviewed.The main weakness is in that it discusses communicationwith patients who have completed the phase of theirmanagement where attempts have been made to reducetumour burden, to the exclusion of communication

problems associated with so-called active treatment. Even inthose sections that deal with children and adolescents with

cancer, in whom there is the highest proportion of tumourscurable with systemic therapy, this subject is glossed over. Itis a crucial omission because of the need for rapport at this

stage: the cancer specialist must encourage the patient toreceive therapy to the optimum level; and, when treatment isnot successful, this rapport can form the basis of a

continuing relationship into the terminal phase. All this isoutside Lichter’s experience. His book is mainly a statementof lessons learned from his work as a surgeon and hospicedirector, with a substantial supporting component fromreferences to the published work.The other strong point of this book is the way in which the

need to divulge information is discussed and the case is putconvincingly. Those doctors who still believe that patientswith cancer should rarely, if ever, be told the diagnosisshould be bought a copy, read it, and think again.Clinical Oncology Unit,University of Bradford S. MICHAEL CRAWFORD

Diseases of the Tongue1. van der Waal and J. J. Pindborg. New Malden and Chicago:Quintessence. 1986. Pp 199. 46.40. ISBN 0-86715165X.

TONGUE lesions may occur as primary diseases of thetongue or as stigmata of gastrointestinal and other disorders.Inspection of the tongue is a routine part of the generalexamination yet there are few texts to aid interpretation ofthe findings. This book admirably fills the gap. In 199highly illustrated pages, the authors cover every lingualblemish likely to confront the student, doctor, or dentist.Each chapter includes definition and frequency of the lesion,aetiology, clinical aspects, and treatment.The introductory chapter on anatomy, histology,

embryology, and physiology makes interesting reading andis accompanied by a series of photomicrographs and

scanning electron micrographs of papillae, taste buds, andgustatory hairs. The chapter on congenital and

developmental disorders covers some rare disorders withlong Latin names but also more widely known lesions suchas haemangiomas, lingual thyroid, polyps, and midlinefistulas. The section on local disease of the tongue provides abrief but detailed account of common disorders such as

hairy tongue (treated by brushing twice daily for 2 minutes),geographic tongue (classified into four types), plicatedtongue, and a few less familiar conditions such as medianrhomboid glossitis.The tongue is often affected by generalised diseases of the

oral cavity and a chapter is devoted to lingual involvement infungal stomatitis (who knows that Candida albicans can becultured from 50% of normal individuals?) and variousother oral disorders. Special attention is focused ontraumatic tongue lesions caused by ill fitting dentures,dental caries, and metallic dental restorations. The chapteron lingual lesions in systemic disease includes acute andchronic infection (syphilis, tuberculosis, scarlatina, andherpetic gingivostomatitis) and a comprehensive review oflingual involvement in blood diseases, vitamin deficiency,metabolic disorders (uraemia, diabetes), skin disease (thereare four varieties of psoriatic lesions of the tongue), andcollagenoses. There is a chapter on neurological disturbanceand the tongue, and a concise review of cystic lesions. Thechapter on benign tumours includes a thoughtful section onpseudotumours and tumours of the lingual glands. The finalpart reviews premalignant and malignant lesions. Thesection on leucoplakia summarises the epidemiology oflingual (as opposed to oral) leucoplakia, its predisposingfactors, and its differential diagnosis and there is a

description of the hairy leucoplakia that occurs in AIDS.Lichen planus is included under the section on

premalignant disorders but should have been classed withskin diseases. There is a detailed description of squamous

L cell carcinoma, and a balanced review of less common, lingual carcinomas, malignant lymphoma including mycosis: fungoides, metastatic tumours, and salivary gland tumours.

This book is an atlas, a reference work, and an up-to-dateL review of the published work. The colour pictures are

stunning and most chapters have between 50 and 100references. Only the index falls short: there is nothing, for

t instance, for "ulcer", "aphthous ulcer", or "Crohn’ss disease" although the information is in the text. I stronglys recommend this book to anyone who peers into patients’

mouths.

Royal Free Hospital,London NW3 2QG OWEN EPSTEIN

Genitourinary Cancer ManagementEdited by J. B. deKernion and D. F. Paulson. Philadelphia: Leaand Febiger. 1987. Pp 297.$52.25. ISBN 0-812110439.

TWELVE American urologists and one nurse have herebeen given about a chapter apiece to review the managementof tumours at each main genitourinary site. The diagnosishas been made, so there is little on presentations-nothing,for example, on the systemic effects of renal carcinoma.There is great emphasis on the importance of staging andgrading of tumours; European readers will welcome the useof the TNM classification and will forgive the occasionalinaccuracy.The bulk of the text is devoted to the details of surgical

treatment. It is an excellent operative surgical book with

135

descriptions and good diagrams of the main operations andmany alternatives. A surgeon planning aggressive treatmentfor fit and well-motivated cancer patients will learn all thatcan be taught. The book must be read if only for the chapterson prostate and upper tract urothelial cancer.

All treatment methods are discussed though the

American bias is evident-surgery whenever possible, andthe bigger the operation the more likely the cure. Thealternatives to surgery are set out but tend to get short shrift,in particular radiotherapy for invasive bladder cancer andthe surveillance policy for non-seminomatous germ celltumours. The testis tumour chapter, Controversies inTestis Cancer Management, hardly justifies the title: like theother chapters it is mainly descriptive of the authors’

opinions. Writing on testis cancer for a postgraduateaudience is difficult since the words will be out of date beforethe ink is dry.The editors promise specific recommendations on

common and difficult problems and this is certainlyachieved. They also say that the text is not "simply aliterature review". Some contributors have taken this so farthat even essential references are omitted; the item onnon-invasive bladder carcinoma is especially at fault. Ingeneral references are cited up to 1984.

In short, this is essential reading for all who have the careof urological cancer patients, but it should not be their firstor only text: the views of the authors are not the only tenableviews, and are not applicable to every patient in the ordinaryclinic.

Institute of Urology,London WC2H 8JE C. R. J. WOODHOUSE

Coping with Life on Insulin

Judith M. Steel and Margaret Dunn. Edinburgh: W & RChambers. 1987. Pp 134. £2.95 (paperback) ISBN 0-550205144.

Diabetes: a Beyond the Basics Guide

Rowan Hillson. London: Optima. 1987. Pp 143. 4.95(paperback). ISBN 0-35614545X.

A GLANCE in your bookshop at the shelf marked Healthwill show that household medical encyclopaedias have givenway to a profusion of paperbacks promising simple, direct,and clear answers to questions about your health problem.Healthy eating and sex are best served but patient educationmanuals cover the alphabet from anorexia to ulcerativecolitis. Most of these books, especially those concerned withillness rather than health in general, do not encourageself-treatment; treatment continues to be the province of thedoctor. In this respect diabetes is in a class on its own andover 50 years ago Dr R. D. Lawrence used to tell his diabetic

patients to be their own doctors, dieticians, and labtechnicians and backed it up with his patient instructionmanual The Diabetic Life. His philosophy is firmly espousedby Judith Steel and Rowan Hillson, whose books encourageinsulin-dependent diabetics to lead as normal a life as

possible by freeing themselves from the tyranny of over-rigid regimens, paternalistic doctors, and prohibitions onwhat they can eat or do in their leisure time. They stress thatthis can be achieved by the right mental outlook ("Icommand my diabetes, it does not command me"), athorough understanding of the condition, a willingness tomeasure blood sugar frequently, an adventurous spirit, anda dauntless will. Neither book promises that this is easy andboth devote much space to the ever-present threat of

hypoglycaemia nicely described by Judith Steel’s lay

co-author as "At best a mild disorientation of little

consequence, at worst a terrifying tumble through a blackhole in the world".

Both books are well written and informative and thereader will get the message that Dr Steel and Dr Hillson areconcerned diabetologists who give their patients a high levelof personal service. I make this point because both stress thatthe good diabetologist should be interested in the patient’sfeelings and that medical help should be sought early ratherthan late if things seem to be going wrong. I am sure thatthere is a well organised system for doing this in Edinburghand Oxford but elsewhere readers may be disappointed.Rowan Hillson is renowned as the driving force behind

the outward-bound courses in which she has shown that

insulin-dependent diabetics can undertake any strenuousactivity as safely and competently as their non-diabeticpeers. The cover picture of a girl abseiling and the subtitle, ABeyond Basics Guide, had led me to expect a patienteducation guide with a difference. In a way it is, since thechapters on exercise, outward-bound, and travelling are thebest of their kind. What I found unsatisfactory is that thebook appears to be written partly for patients with

non-insulin-dependent diabetes and includes sections onoral hypoglycaemic agents and exercising after a heart

’ attack. The insulin-dependent diabetic will find this: confusing, and the non-insulin-dependent patient will feel’ cheated since fewer than 10 pages have any direct relevance

to him or her. Both books are good but the Steel/Dunn onewins my vote because of its chatty style supplemented bypatients’ comments and jokes. At 2.95 for 134 pages it isone of the best buys for insulin-dependent diabetics andtheir relatives.

University HospitalNottingham NG7 2UH ROBERT TATTERSALL

What Price Community Medicine?

The Philosophy, Practice and Politics of Public Health since 1919.Jane Lewis. Brighton: Wheatsheaf. Pp 172. 15.95. ISBN0-745003494.

COMMUNITY physicians have "sold their hierarchicalheritage for a mess of consultancy"; so says one of DrLewis’s interviewees. In this well researched and closelyargued study, Jane Lewis covers developments in publichealth since the First World War and illustrates thefundamental tensions in the role of community physicians inthe UK. She underlines two turning-points. The first wasthe 1974 reorganisation, when community physicians losttheir independent voice and security of tenure in

safeguarding public health; now they are employed as part ofthe NHS management with its cash limits. (This calls tomind the district medical officer who was recentlysuspended after giving professional advice on supplyingcondoms in schools as just one part of his public healthstrategy to fight AIDS. Such a suspension would not havebeen possible at any time between the appointment of thefirst medical officer of health in 1847 and the 1974

reorganisation.) The second was the 1984 Griffiths Report,which eroded the decision-making power of the districtmedical officer in favour of general management.The book briefly mentions the current inquiry by the

Chief Medical Officer into the development of the specialty;let us hope that the independence of community physicianswill be restored. Jane Lewis makes clear that the relationbetween unemployment and deteriorating health has been

136

and is still consistently ignored for political and economicreasons. The book touches briefly on the extent to which thename community medicine itself contributes to misunder-standing of the role. Even health professionals confuse itwith community health. "Public health" in North Americahas a clear identity and higher status.

It is worth ploughing through the thickets of acronyms forthe wealth of valuable information and insight that the bookcontains. Dr Lewis enlivens her own rather dry style withgnomic nuggets from pioneers of the specialty. She takes thenew specialty to task for being preoccupied with its

responsibility to the health authorities rather than to health.This is essential reading for anyone wishing to understandthe emergence and current position of community medicine.

Eastbourne Health Authority E. STEPHEN SEARLE

The Basic Science of Oncology

Edited by Ian F. Tannock and Richard P. Hill. New York:Pergamon. 1987. Pp 398.$37.50. ISBN 0-08032388X.

CLINIC and laboratory based oncologists sometimesdespair when they are faced with the breadth of the basicscience with which they need to become and remainfamiliar. Very few textbooks are short enough yetsufficiently broadly based and up-to-date to help much, andthis new offering is a well-produced attempt to cover therelevant areas. The chapters are written by Canadianauthorities on epidemiology, carcinogenesis, cell andmolecular biology, immunology, and the basic sciences thatunderlie the practice of radiotherapy, chemotherapy, andbiological therapy. It therefore deals with all of the basiconcological science excluding pathology; this exclusion

initially seems strange but in fact the book can be seen ascomplementary to the many existing pathology textbooks.The resultant survey is clear, concise, and readable. The

editors have achieved a uniform and very high standard ofcontent for each chapter, with clear schematic explanationsof scientific principles and methods. The balance betweenexperimental method and conclusions is appropriate. Themain readership will be trainee and established specialists inall of the clinical oncology disciplines but it will also be ofvalue to professional scientists in cancer research and

teaching who need a rapid but current and accurate updateon areas outside their special interest. It is well illustratedand inexpensive for a textbook of this standard and I believeit will rapidly find a place as a standard text in oncology.

Royal Marsden Hospital,Sutton SM2 5PT PETER SELBY

A Handbook of Clinical Adult PsychologyEdited by Stan Lindsay and Graham Powell. Aldershot:Gower. 1987. Pp 800. 65. ISBN 0-566051028.

MANY handbooks are simply collections of essays that onemight read once and then put away. This one is different.While it certainly does not make light reading, I believe thatmost clinical psychologists would want to have it constantlyat hand. If you are confronted with a client and the

presenting problem is not one you know much about thenthis book will almost certainly tell you how to assess theproblem and also what psychological treatments have beensuccessful.

All the contributors have been firmly disciplined topresent their material in the same format. Thus for each

problem there is one section on assessment and one ontreatment. In addition only those assessments and

treatments for which there is published evidence of somevalidity are considered. As a result the emphasis is stronglyon behavioural treatments. There is almost nothing in thisbook to interest the dedicated psychotherapist. Fortunatelythe days in which only observable behaviour could bestudied are long over. As a consequence, thoughts andattitudes can also be modified by means of what areessentially behavioural techniques. Such techniquesinclude, for example, cognitive therapy and thoughtstopping-which are discussed in relation to depression andobsessions.As I have implied, the book is almost entirely problem-

oriented. Problems include those traditionally treated bybehavioural methods, such as fears and sexual dysfunction,as well as those more recently brought into this domain, suchas cardiovascular disorders and disorders of sleep. The onlytraditional psychiatric category that receives a chapter isschizophrenia, but in this case also the emphasis is onbehavioural treatments for modifying specific symptomssuch as delusions and hallucinations.The last section discusses experimental design and, in

particular, single case methodology. It is one of the strengthsof the approach espoused in this book that it is possible tocombine the treatment of a client with an experimentalinvestigation of the success of that treatment. I hope that thisbook will encourage more clinical psychologists to takeadvantage of this strength.Division of Psychiatry,Clinical Research Centre,Harrow HA1 3UJ CHRIS FRITH

Guide to Planning and Managing Multiple ClinicalStudies

B. Spilker. New York: Raven. 1987. Pp 410.$42.00. ISBN0-881672645.

THIS is the last of a trilogy. The two previous volumeswere Guide to Clinical Studies and Developing Protocols(1984) and Guide to Clinical Interpretation of Data (1986).Spilker continues the "nuts and bolts" style and there aredozens of lists, tables, and figures. There are three sections- own planning and conducting a range of clinical studies onthe same compound, including the ethical issues; on specialstudies (eg, surgery, the elderly, orphan drugs, pharma-cokinetics) ; and on the management of studies includingresource allocation, monitoring, and costs.When a new drug becomes available for clinical testing,

there is a bewildering array of options relating to dose,dosage form, indications, and patient populations. Thoughit is not possible to make a bad drug into a good one, it is easyto do a good one less than justice. Drug control authoritieshave become progressively harder to satisfy and this book isreally about how to secure approval (notably by the USFood and Drug Administration) in the most expeditiousway. The process has become an enormously complexlogistic exercise which is always expensive but especially soif avoidable shortcomings cause delay or failure.Those directly concerned in the process will find this

book invaluable. It reflects the author’s wide experience andkeenly analytical mind and it is very well produced.However, the hope expressed in the preface that it will

appeal to a wider audience with industrial, academic, orgovernment affiliations is rather optimistic.15 The Causeway,Horsham RH12 1HE T. B. BiNNs