Steven Narod has written a wide-ranging book of 18 chapters in 5 parts on breast cancer. Steven is a highly cited Cancer Epidemiologist and statistician who is a Senior Scientist at Women’s College Hospital Research and Innovation Institute; Director, Familial Breast Cancer Research Unit, Women’s College Research Institute; Professor, Dalla Lana School of Public Health, University of Toronto; Professor, at the Department of Medicine, University of Toronto and the Tier 1 Canada Research Chair in Breast Cancer (2003-2024). He is also a qualified physician. He was involved in papers leading to the cloning of the BRCA1 and BRCA2 genes.

The two main pillars of the book surround the arguments around breast cancer survival. He posits that survival from breast cancer is pretty much set in stone at first diagnostic treatment and that preventing local recurrence has no effect on survival. As such ipsilateral mastectomy has no effect on survival and that radiotherapy to reduce local recurrence is mainly to avoid local recurrence rather than improve survival. He uses data from the SEER (Surveillance, Epidemiology, and End Results) program on cancer incidence and mortality in the United States as well as his own local (Bunting) dataset from Toronto, Canada. He argues as per Bernard Fisher that the ‘conventional view’ on this subject is wrong and that the ‘parallel view’ on the cause of breast cancer mortality is the accurate one. He even discusses the fact that 2% of women with pre-invasive ductal carcinoma in situ (DCIS) die from breast cancer although some of these may be from pre-existing invasive tumours that were already present in the ipsilateral or contralateral breast. Although many readers may disagree with his arguments, they are eloquently presented along with the data to support them.

The second main area for discussion is that of mammography screening. When the main randomised control trials on breast cancer screening with mammography were published in the 1980s the one outlier appeared to be the Canadian National Breast Screening Study (NBSS) which showed no apparent benefit. Many detractors of this study purported that this was due to poor randomisations with breast examinations occurring prior to randomisation. The issue was whether women with lumps were wrongly assigned to the mammography arm rather than being excluded from the trial. He argues that this will not have had an effect by excluding these cases and still showing no benefit. He does, nonetheless not fully discuss the other randomised trials that did show benefit. He discusses the toxicity that exists in the debate around mammography screening with personalities on both sides of the debate being overzealous, although in his arguments he mainly talks about the ‘detractors’ who he means as those that oppose his view who are in fact in favour of mammography.

I would recommend readers interested in breast cancer survival to read this book. Although I started reading as someone who was not fully persuaded by his arguments around local recurrence not being important and was fully in favour of mammography screening, he does present compelling data which is important to weigh up in making one’s own decisions. It will certainly challenge many of you and you may be persuaded by his sometimes compelling data presentations.