Correspondence to : Francisco Acevedo. Email: fnacevedo gmail. Background: Breast cancer BC is the leading cause of cancer death in Chilean women. Adjuvant chemotherapy decreases recurrence and death from BC. The recommendation to indicate chemotherapy is complex.
Online performance could be considered too weak in term of cost-effectiveness, given the scarcity of health care resources. How much survival benefit is necessary for breast cancer patients to opt for adjuvant chemotherapy? Breat Oncol. Online was identified in almost all subgroups and could be explained by the over-representation Preggo stripping young patients in the overall population. Adjuvant on line breast cancer prediction was highly overoptimistic. Online tool but the manual agreement obtained between observation and prediction relies on operator judgement. There is a high agreement between patients and their partners in the benefit considered being worthwhile, which seems to be enhanced in a worse prognosis scenario [ 8 ].
Sex statistics in ukraine. Introduction
The reliability of predictions for other groups depends in part on the knowledge and judgement of the operator in making adjustments using the PFIC. Resources for Trainees. Some of the recommendations have been retained in Adjuvant on line breast cancer new guideline. PFICthe 10 year predictions were no longer significantly different. The search textbox has an autosuggest feature. Integrative Therapies Editorial Board. Ovarian Abl. Women who met the following criteria were included in the calculations of baseline risk: Had invasive, unilateral canccer non-inflammatory breast cancer. There is often a residual feeling of body pain or achiness Adult small a mild loss of physical functioning. In the context of breast cancer, neoadjuvant chemotherapy administered before surgery can braest survival in patients. Even if your periods have stopped while you are on chemo, you may still be able to get pregnant. As a result of complications that can stem from liberal use of adjuvant breazt, the philosophy surrounding the use of adjuvant therapy in the Adjuant setting has shifted towards the goal of Greigo gay as little harm as possible to patients. Currently efforts are focussed on developing the next major release of Adjuvant!
Predict is an online tool that helps patients and clinicians see how different treatments for early invasive breast cancer might improve survival rates after surgery.
- Adjuvant therapy , also known as adjunct therapy , add-on therapy , and adjuvant care , is therapy that is given in addition to the primary or initial therapy to maximize its effectiveness.
- Breast Cancer Treatment Outcome Calculator.
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- Understand your options before you decide whether adjuvant therapy is for you.
- Chemotherapy chemo uses anti-cancer drugs that may be given intravenously injected into your vein or by mouth.
Correspondence to : Francisco Acevedo. Email: fnacevedo gmail. Background: Breast cancer BC is the leading cause of cancer death in Chilean women. Adjuvant chemotherapy decreases recurrence and death from BC. The recommendation to indicate chemotherapy is complex. Online is a valuable computational tool to predict survival benefit obtained with adjuvant systemic therapy.
Previous studies in Caucasian patients with BC showed that they are willing to receive chemotherapy for a small benefit. No studies, to our knowledge, have been done in the Hispanic or Latino populations. Methods: We interviewed females with BC who had previously received adjuvant chemotherapy.
Age, stage at presentation, time since last chemotherapy, type of chemotherapy, marital status, number of children, and level of education were recorded. We used the graphic representation from Adjuvant! Online to question each patient on how much survival benefit she required to accept chemotherapy. Results: There were women surveyed. The average age was Conclusion: In our study, the acceptance of chemotherapy by the Hispanic population requires minimal survival benefit and is in agreement with the Caucasian population reported elsewhere.
To our knowledge, our report is the first study that evaluates the perception of Latino patients regarding the benefit of chemotherapy in early BC. Keywords: breast cancer , adjuvant , chemotherapy. Breast cancer BC is the leading cause of cancer death in Chilean women www. Adjuvant chemotherapy has demonstrated an increase in survival, and also produces adverse effects that can impair quality of life QoL or induce morbidity and mortality [ 1 ]. Most of the prognostic factors that allow us to predict BC relapse are based on the assessment of pathologic tumour features.
Tumour size, axillary lymph node involvement, histological grade, presence or absences of hormone receptor status, and epidermal growth factor receptor type 2 Her-2 are classical determinants to define prognosis.
Recently, subgroups of BC based on molecular intrinsic subtypes have been described, with therapeutic and prognostic implications [ 2 ]. However, the implementation of these genetic profiles in clinical practice has technical and economical limitations, especially in our country. Therefore, classic pathological elements are still used in the decision making. Nevertheless, the subjective evaluation of these factors does not allow a quantitative assessment of the benefit.
Ravdin et al [ 3 ] built an online application Adjuvant! Online [ www. The estimation is calculated considering the age of the patient at diagnosis, comorbidities, presence of oestrogen receptor, tumour size, histological grade, and nodal involvement. In addition to anticipate prognosis, the program permits the estimation of the benefit of different therapeutic options in an easy-to-understand format, adapted to shared-decision making with the patient. To our knowledge, no data exist in our country or for a Latin population, describing how patients evaluate or analyse the decision to receive chemotherapy, or the magnitude of the benefit required to accept it, when asked in their native language and in their own country.
The aim of this study is to determine the absolute survival benefits that our patients judge adequate to receive chemotherapy and the relation with potential demographic and clinical variables associated with this decision.
We decided to use graphics models from Adjuvant! Online for better comprehension and to use an objective and quantitative method.
This is a prospective clinical study of one cohort. We surveyed female patients from the Pontificia Universidad Catolica de Chile, Cancer Centre, who had received chemotherapy for early BC and had completed chemotherapy at least three months before the interview. Patients were excluded if they had metastatic BC at the time of interview or did not receive chemotherapy.
The patients were interviewed between January and April The protocol was approved by the local ethics committee, and all patients signed informed consent. Details from the medical history, BC features, and treatment received were obtained from medical records.
At the interview, relevant demographic data were updated age, date of diagnosis, marital status, number of children, and level of education. Then, a single treatment decision question was asked, offering several alternatives:. To make sure that the patient understood the concept of survival benefit, we showed her graphics obtained from Adjuvant!
Online, displaying several hypothetical scenarios. These cases have different risks and therefore different magnitudes of benefit in overall survival. The poll was conducted by any of the two main investigators Cesar Sanchez and Francisco Acevedo using a standardised form and in the context of a spontaneous outpatient visit.
The duration of the interview varied from 15 to 20 min. We analysed the data to assess the relationship between demographic factors, age at diagnosis, type of therapy received, number of children, and level of education, and quantitative estimates of treatment benefit elected. Preferences are presented descriptively with figures and frequency tables. Associations between characteristics and preferences of patients were assessed with the X 2 test. Because of the low number of patients recruited and to simplify analyses, we decided to dichotomise some variables e.
Logistic regression was used to explore associations between dichotomised dependent and independent variables. A comparison between mean of ages regarding preferences was done with t -score for independent variables.
We interviewed patients, all of whom agreed to participate in the study and signed the consent form. The main characteristics of the participants are shown in Table 1. The median of time from last chemotherapy to interview was 19 months range 3— We also found a non-significant trend in age and level of education Table 2.
This is the first report, to our knowledge, evaluating the perception of Latino patients regarding the benefit of chemotherapy in early BC, especially when they are asked in their own language. Interestingly, most of the patients, as described previously in the Caucasian population, needed a small survival benefit to accept treatment with chemotherapy despite the significant side effects and the inconveniences derived from the treatment.
Table 1. Demographics characteristics of the patients. Figure 1: Response to adjuvant survey. Table 2. Response based on subgroups. Regarding the former, the same results have been reported elsewhere [ 2 ]. Our interpretation is that patients who perceive themselves as at higher risk of systemic disease are more likely to accept chemotherapy [ 6 ].
Regarding the time interval from chemotherapy, the group that recently finished chemotherapy accepted a smaller survival benefit than the group who was surveyed one year after the completion of treatment. Nevertheless, neither of these findings was able to predict response in the multivariate analysis. The few statistically significant predictive factors found in our study may be due to a small sample of patients and the low prevalence of the tested characteristics.
Other studies have shown that treatment preferences may also be affected by other demographic variables, such as living with others, being a parent or having dependent children [ 7 ]. There is a high agreement between patients and their partners in the benefit considered being worthwhile, which seems to be enhanced in a worse prognosis scenario [ 8 ]. Interestingly, in the same paper, having dependent children was associated with partners requiring higher benefits [ 8 ].
Although most of the patients with BC prefer to make decisions together with their doctor [ 9 ], many physicians remain reluctant to provide patients with detailed information of their treatment and prognosis [ 5 , 10 ]. Although patients with cancer have to be assessed in a multidisciplinary manner, the uncoordinated evaluation of several physicians may influence information delivery and can complicate the communication process [ 11 , 12 ].
Moreover, patients with cancer tend to overestimate their benefit with treatment and judged smaller benefits to be worthwhile than medical and nursing professionals [ 5 , 13 ]. Worldwide, there is a growing interest to involve the patient in decision making. Even though there are patients who do not want to make the final decision, most of them want doctors to understand their preferences [ 14 ].
To make a shared-decision model possible, clinicians should explain treatment options in a language accessible to the patient, highlighting options and discussing the pros and cons of those alternatives. Risk estimation based on numerical measures is complex and difficult to interpret even for doctors [ 15 ]. It is not easy to be certain that patients understand this concept. To facilitate understanding, visual aids or graphics have been reported to enhance and improve communication with cancer patients [ 11 , 19 , 20 ].
The purpose of these tools is to translate the results from the decision analyses or prognosis from evidence-based studies into friendlier formats. Peele et al [ 20 ] showed in a randomised trial that in patients whose benefits were small, the use of a decision aid helped women to decide whether to receive chemotherapy or not [ 20 ].
However, even with the use of visual aids, do they really understand the concept of benefit? Would they accept chemotherapy for no benefit at all? Chemotherapy may provide vulnerable BC patients with a feeling that they are doing something active to deal with their disease [ 22 ] so the final decision could actually represent a mechanism of protection. Time is crucial for this system to work. Poor reimbursement for time spent in a long discussion about pros and cons may be unattractive to some oncologists.
Guy and Richardson [ 23 ] found that the length of time physicians spend with their patients may vary across different characteristics. It is unclear whether this could affect information delivery or not. The main strength of our report is that we were able to estimate the magnitude of benefit required for Latino patients to consider chemotherapy worthwhile, when asked in their native language and in their own country. In the United States, there is evidence suggesting that black patients with BC have a poorer prognosis and survival rates comparing with white patients [ 25 ].
This disparity has been noticed, to a lesser extent, in Hispanic patients too [ 26 ]. Part of this difference might be explained as due to biologic factors [ 27 , 28 ], but there are data that show that Latino patients are less likely to report receiving a mammography or to participate in healthcare decisions, with half of the final treatment resolution being determined by their families [ 29 , 30 ].
Adherence to medical suggestions in this population depends on various factors including a preference to being interviewed in Spanish and physician involvement [ 31 , 32 ]. Despite communication issues, Hispanics did not show evidence of under treatment in a large, diverse, population-based sample of women diagnosed with BC, regardless of the level of acculturation [ 33 ].
On the contrary, low acculturated Hispanics were the most likely to report having received adjuvant chemotherapy than better educated Hispanics or black patients. Could this be attributed to a lack of patient— physician interaction about the pros and cons of treatment because of a language barrier? Low acculturated patients may be more likely to agree to a treatment that they do not fully understand.
Although this point was not an objective of our paper, we think that this limitation may be overcome with the use of visual aids.
NCI Grant Policies. There are also versions of Adjuvant! NCBI Bookshelf. Alternative cancer treatments: 10 options to consider Atypical cells: Are they cancer? If the abdomen or spine is irradiated, nausea, vomiting, diarrhea, and dysphagia can occur. My pathology report states infiltrating ductal carcinoma, nottingham grade III, angio-lymphatic invasion-absent, associated DCIS-absent.
Adjuvant on line breast cancer. Early and Locally Advanced Breast Cancer: Diagnosis and Treatment [Internet].
Such cancers include renal cell carcinoma , and certain forms of brain cancer. Hyperthermia therapy or heat therapy is also a kind of adjuvant therapy that is given along with radiation or chemotherapy to boost the effects of these conventional treatments.
Heating the tumor by Radio Frequency RF or Microwave energy increases oxygen content in the tumor site, which results in increased response during radiation or chemotherapy.
For example, Hyperthermia is added twice a week to radiation therapy for the full course of the treatment in many cancer centers, and the challenge is to increase its use around the world. A motif found throughout the history of cancer therapy is the tendency for overtreatment. From the time of its inception, the use of adjuvant therapy has received scrutiny for its adverse effects on the quality of life of cancer patients.
For example, because side effects of adjuvant chemotherapy can range from nausea to loss of fertility, physicians regularly practice caution when prescribing chemotherapy. One of the most notable side effects of adjuvant therapy is the loss of fertility.
For pre-pubescent males, testicular tissue cryopreservation is an option for preserving future fertility. For post-pubescent males, this side effect can be assuaged through semen cryopreservation. For pre-menopausal females, options to preserve fertility are oftentimes much more complex. In the some low-risk, low-benefit situations, forgoing adjuvant treatment altogether can be a reasonable decision, but in cases where the risk of metastasis is high, patients may be forced to make a difficult decision.
Though options for fertility preservation exist e. As a result of complications that can stem from liberal use of adjuvant therapy, the philosophy surrounding the use of adjuvant therapy in the clinical setting has shifted towards the goal of doing as little harm as possible to patients.
The standards for dose intensity of adjuvant treatments and treatment duration are regularly updated to optimize regimen efficiency while minimizing toxic side effects that patients must shoulder.
Concomitant or concurrent systemic cancer therapy refers to administering medical treatments at the same time as other therapies, such as radiation. Adjuvant hormonal therapy is given after prostate removal in prostate cancer, but there are concerns that the side effects , in particular the cardiovascular ones, may outweigh the risk of recurrence.
In breast cancer, adjuvant therapy may consist of chemotherapy doxorubicin , herceptin , paclitaxel , docetaxel , cyclophosphamide , fluorouracil , and methotrexate and radiotherapy, especially after lumpectomy , and hormonal therapy tamoxifen, femara. Adjuvant therapy in breast cancer is used in stage one and two breast cancer following lumpectomy, and in stage three breast cancer due to lymph node involvement.
In glioblastoma multiforme , adjuvant chemoradiotherapy is critical in the case of a completely removed tumor, as with no other therapy, recurrence occurs in 1—3 months [ citation needed ]. In early stage one small cell lung carcinoma , adjuvant chemotherapy with gemzar, cisplatin , paclitaxel , docetaxel , and other chemotherapeutic agents, and adjuvant radiotherapy is administered to either the lung , to prevent a local recurrence, or the brain to prevent metastases. In testicular cancer , adjuvant either radiotherapy or chemotherapy may be used following orchidectomy.
Previously, mainly radiotherapy was used, as a full course of cytotoxic chemotherapy produced far more side effects then a course of external beam radiotherapy EBRT. Adjuvant therapy is particularly effective in certain types of cancer, including colorectal carcinoma , lung cancer , and medulloblastoma. Prophylactic cranial irradiation for acute lymphoblastic leukemia ALL is technically adjuvant, and most experts agree that cranial irradiation decreases risk of central nervous system CNS relapse in ALL and possibly acute myeloid leukemia AML , but it can cause severe side effects, and adjuvant intrathecal methotrexate and hydrocortisone may be just as effective as cranial irradiation, without severe late effects , such as developmental disability , dementia , and increased risk for second malignancy.
Dose-dense chemotherapy DDC has recently emerged as an effective method of adjuvant chemotherapy administration.
DDC uses the Gompertz curve to explain tumor cell growth after initial surgery removes most of the tumor mass. Cancer cells that are left over after a surgery are typically rapidly dividing cells, leaving them the most vulnerable to chemotherapy. Standard chemotherapy regimens are usually administered every 3 weeks to allow normal cells time to recover. This practice has led scientists to the hypothesis that the recurrence of cancer after surgery and chemo may be due to the rapidly diving cells outpacing the rate of chemotherapy administration.
DDC tries to circumvent this issue by giving chemotherapy every 2 weeks. To lessen the side effects of chemotherapy that can be exacerbated with more closely administered chemotherapy treatments, growth factors are typically given in conjunction with DDC to restore white blood cell counts.
The role of adjuvant therapy in malignant melanoma is and has been hotly debated by oncologists. In a multicenter study reported improved long-term and disease-free survival in melanoma patients using interferon alpha 2b as an adjuvant therapy.
Thus, later that year the U. Food and Drug Administration FDA approved interferon alpha 2b for melanoma patients who are currently free of disease, to reduce the risk of recurrence. Since then, however, some doctors [ who? Those claims have not been validated by scientific research.
Adjuvant chemotherapy has been used in malignant melanoma, but there is little hard evidence to use chemotherapy in the adjuvant setting. However, melanoma is not a chemotherapy-resistant malignancy. Multiple studies have shown that adjuvant radiotherapy improves local recurrence rates in high-risk melanoma patients.
The studies include at least two M. Anderson cancer center studies. However, none of the studies showed that adjuvant radiotherapy had a statistically significant survival benefit. A number of studies are currently underway to determine whether immunomodulatory agents which have proven effective in the metastatic setting are of benefit as adjuvant therapy for patients with resected stage 3 or 4 disease. Adjuvant chemotherapy is effective in preventing the outgrowth of micrometastatic disease from colorectal cancer that has been removed surgically.
Studies have shown that fluorouracil is an effective adjuvant chemotherapy among patients with microsatellite stability or low-frequency microsatellite instability , but not in patients with high-frequency microsatellite instability. Exocrine pancreatic cancer has one of the lowest 5-year survival rates out of all cancers. A series of studies has established that 6 months of chemotherapy with either gemcitabine or fluorouracil, as compared with observation, improves overall survival.
Newer trials incorporating immune checkpoint inhibitors such as the inhibitors to programmed death 1 PD-1 and the PD-1 ligand PD-L1 are under way.
The toxicity resulting from adjuvant chemotherapy was believed to be manageable. Neoadjuvant platinum-based chemotherapy has been demonstrated to improve overall survival in advanced bladder cancer , but there exists some controversy in the administration. While it may shrink tumors in some patients, others may not respond to the treatment at all.
It has been demonstrated that a delay in surgery of greater than 12 weeks from the time of diagnosis can decrease overall survival. Thus, the timing for neoadjuvants becomes critical, as a course of neoadjuvant therapy could delay a cystectomy and allow the tumor to grow and further metastasize. However, ethical concerns have been raised about the magnitude of benefit of this therapy since it involves further treatment of patients without knowing the possibility of relapse. Bernard Fisher, among the first to conduct a clinical trial evaluating the efficacy of adjuvant therapy on patients with breast cancer, described it as an "value judgement" in which the potential benefits must be evaluated against the toxicity and cost of treatment and other potential side effects.
Giving two or more chemotheraputic agents at once may decrease the chances of recurrence of the cancer, and increase overall survival in patients with breast cancer. Commonly used combination chemotherapy regimines used include:.
An additional surgical focus for young women with early-stage cancers is on the conservation of the contralateral ovary for the preservation of fertility. Most cases of ovarian cancers are detected at the advanced stages, when the survival is greatly reduced. In early stage cervical cancers, research suggests that adjuvant platinum-based chemotherapy after chemo-radiation may improve survival. For advanced cervical cancers, further research is needed to determine the efficacy, toxicity and effect on the quality of life of adjuvant chemotherapy.
Since most early-stage endometrial cancer cases are diagnosed early and are typically very curable with surgery, adjuvant therapy is only given after surveillance and histological factors determine that a patient is at high risk for recurrence.
Adjuvant pelvic radiation therapy has received scrutiny for its use in women under 60, as studies have indicated decreased survival and increased risk of second malignancies following treatment. In advanced-stage endometrial cancer, adjuvant therapy is typically radiation, chemotherapy, or a combination of the two. For seminoma, the three standard options are: active surveillance, adjuvant radiotherapy, or adjuvant chemotherapy. Online provides reliable predictions of the benefits of adjuvant therapy.
The reliability of predictions for other groups depends in part on the knowledge and judgement of the operator in making adjustments using the PFIC. It should be noted that more recent versions of Adjuvant! Loprinzi et al. As part of this, they asked 11 US oncologists for their estimates of year disease-free survival.
The mean of these estimates were compared to predictions generated by Adjuvant! The degree of correlation was not measured formally; the graphical representation of the correlation suggests a reasonable degree of agreement. These published data provides weak evidence for the validity of Adjuvant!
However, the fact that the predictions of oncologists vary supports the rationale that there is a need for a tool, which provides evidence-based predictions in an understandable format.
Online is to provide predictions of risk that support dialogue between clinician and patient about the most appropriate adjuvant therapies for that patient. There is little published literature evaluating the impact of Adjuvant!
A USA study Siminoff et al. Online compared to well presented information pamphlets did not find statistically significant differences between the groups. After adjusting for disease-related and socio-demographic confounders, they found that those who used Adjuvant!
Online were less likely to choose adjuvant treatment OR 0. This is broadly consistent with the findings of an apparently related study Peele et al. A study of treatment management decisions in a Hong Kong oncology centre Epstein et al. Based on analysis of this decision-making, Adjuvant! The study found that treatment decisions continued to be strongly influenced by factors omitted from the version of Adjuvant!
Online used in the study for example lymphovascular invasion and HER2 expression. Clinicians in this study tended to ignore the adjustments to risk recommended by the programme on the basis of low tumour grade when these adjustments were perceived to conflict with other indicators such as lymph node-positivity.
Online were varied but the study authors formed the impression that, in the context of case discussions, the tool enabled groups to achieve consensus more quickly. There is a body of literature concerning the impact of other decision tools on a range of patient-clinician interactions. More recently, there has been at least one trial to evaluate the effect of a decision support tool on the knowledge and satisfaction of breast cancer patients in particular Whelan et al.
A full review of this literature is beyond the scope of this assessment. The predictions made by Adjuvant! Online are based on a published methodology, which has been updated periodically as evidence of treatment effectiveness and data on risk factors becomes available.
Help files and published descriptions of the tool make clear some of the assumptions and limitations that underpin the methodology.
The impact of these individual assumptions is difficult to assess, and beyond the scope of this paper. Online deals with key uncertainties by alerting the user to them at relevant points. Survival estimates are derived from a US population. Quantifying the impact on survival of socio-economic background and of ethnic differences between the US and UK populations is difficult. The strongest evidence of Adjuvant! This study found its predictions to be reliable for most groups.
Further validation is under way using European populations. Dr Ravdin would welcome similar validation against a UK population. Weaker evidence for its validity includes comparisons of its predictions with the predictions of clinicians. The development path for Adjuvant! Online appears to be consistent with a product which intends to remain evidence-based. Online will remain free of charge. This together with its web-based design means that the cost to users of using Adjuvant!
Online should remain very low. There are only two trials assessing the impact of Adjuvant! Online in patient and clinician interactions.
These indicate that in a USA setting patients considering adjuvant treatment were less likely to select adjuvant treatment if their consultation involved use of Adjuvant! Online instead of an information pamphlet. A third study of clinician decisions about patient management found that using Adjuvant! No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licenses issued by the Copyright Licensing Agency in the UK.
Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks etc. Turn recording back on. National Center for Biotechnology Information , U.
Some of the recommendations have been retained in the new guideline. This full guideline includes the evidence supporting the recommendations. Information that has been replaced by the new guideline has been shaded in grey in the PDF.
Appendix 1 Adjuvant! Online: review of evidence concerning its validity, and other considerations relating to its use in the NHS. Research question The primary purpose of the appraisal was to summarise and critique what is known about Adjuvant! It addresses: A description of Adjuvant! Online: its intended purpose and use. Current usage in the NHS. Methodology underpinning Adjuvant! Online, including how it was developed and how it is updated.
Commercial considerations — implications for Adjuvant! Any other practical considerations relating to Adjuvant! Specific questions raised by GDG members that were included within the appraisal To what extent does the SEER database on which the tool is based consider adverse reactions? Excluded from the appraisal The decision about which chemotherapy or endocrine therapy regimen to recommend are separate questions, which fall outside the scope of this appraisal.
Search parameters A pilot search experimented with a number of synonyms for Adjuvant! Table A1. Further screening and supplementary information The results of the automated search were manually screened, by reading the abstracts, in order to identify relevant articles and to exclude all other papers that were not reporting research into Adjuvant!
Search results Executing the automated search strategy resulted in the identification of papers satisfying the search parameters. Findings Adjuvant! Online tool The purpose of Adjuvant! Conceptual design The concept behind Adjuvant! Epply this effect to the baseline risk so that direct comparisons can be made of the estimated risks of mortality or relapse between treatments and with no treatment.
User functionality The current version of Adjuvant! User functionality comprises facilities to: Enter patient information including age, comorbidities plus tumour information including size, oestrogen receptor status and number of involved lymph nodes. This is used to estimate risk at 10 years of breast cancer related death or relapse without additional therapy. Display information about the efficacy of different therapy options, with the option of overriding the estimated efficacies.
Derive estimates of risk at 10 years of breast cancer related death or relapse for the treatments selected by the user. Technological implementation Users access Adjuvant! Further evaluation of the physical implementation is beyond the scope of this study. Control and licensing Adjuvant! Maintenance and development Maintenance of functionality in the current version of the tool is undertaken by Adjuvant! Users are not required to undertake any maintenance.
The US population has a larger percentage of the population in the under 55 age groups and fewer in the over 55 age groups, when compared to the population of England and Wales Office of National Statistics.
This is related to the States that are included in the database e. The ethnic mix of the US population differs from that of England and Wales. Only broad categories can be considered due to differences in categorising ethnicity, but broadly speaking in the US there are lower percentages of white and mixed races, with higher percentages of black and other races US National Cancer Institute.
Date and cause of death are recorded. Date of death is considered robust, however cause of death is of poor quality Warren et al. Selection Ravdin et al. Women who met the following criteria were included in the calculations of baseline risk: Had invasive, unilateral and non-inflammatory breast cancer. Those aged under 35 years.
This group of young women were observed to have a worse prognosis than the other age groups. A correction applied to allow for this group of women is described below. Those aged over 59 years. This group of women was believed to be healthier and have better access to health care. Analysis of this group revealed that women with breast cancer appeared to have better survival than the general US population of the same age.
Impact of ER status. There were data issues around ER status that led to estimates inconsistent with what would be expected from the literature. For this reason a relative risk of 1. The effect of stage of tumour and adjuvant therapy received. An assumption was made that a percentage of the population would have received adjuvant therapy. Constant hazard. Estimating negative outcomes averted Adjuvant!
Applying calculation to previous baseline The Oxford Overviews report the results of clinical trials. Validation Since Ravdin et al. Prospective population-based validation Olivotto et al. The strength of evidence it provides in this assessment is limited by the following factors: The study was undertaken on version 5 of Adjuvant! It is implicit that the operators were very familiar with the tool, and may have included its author.
Clinician-based validation Loprinzi et al. Impact and usefulness The purpose of Adjuvant! References Adjuvant! Ravdin PM. A computer program to assist in making breast cancer adjuvant therapy decisions. Seminars in Oncology. Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. Journal of Clinical Oncology. Understanding the utility of adjuvant systemic therapy for primary breast cancer.
A method for making estimates of the benefit of the late use of letrozole in patients completing 5 years of tamoxifen. Clinical Breast Cancer. Whelan TJ, Loprinzi C. A decision aid to assist in adjuvant therapy choices for breast cancer. Decreased use of adjuvant breast cancer therapy in a randomized controlled trial of a decision aid with individualized risk information.
Medical Decision Making. Utility of a web-based breast cancer predictive algorithm for adjuvant chemotherapeutic decision making in a multidisciplinary oncology center. Cancer Investigation. Ravdin P. Personal communication to: J. Gribbin regarding Adjuvant! Feb, Agarwal V. Personal communication to J. Gribbin regarding plans for surveying usage of Adjuvant Online. Mar, US National Cancer Institute. Surveillance, Epidemiology and End Results program.
Medical Care. Decision aids for patients facing treatment or screening decisions: systematic review. British Medical Journal.
In a population-based cohort study in Ontario, Canada, reported in the Journal of Clinical Oncology , Levine et al found that use of the gene recurrence score RS assay altered decisions regarding receipt of chemotherapy compared with use of Adjuvant! Online in patients with axillary node—negative or nodal micrometastatic, estrogen receptor—positive, HER2-negative breast cancer. The major change was from unsure about chemotherapy to no chemotherapy. A total of 1, patients were recruited from all cancer treatment centers in Ontario between January and July Oncologists made a preliminary recommendation for endocrine therapy with or without chemotherapy based on Adjuvant!
Online risk estimation, and patients were asked for preference regarding chemotherapy. Patients returned for final decision-making after recurrence scores were available.
Correlations between the gene recurrence score and Adjuvant! Of patients with low risk on Adjuvant! Of patients with intermediate risk on Adjuvant! Of patients with high risk on Adjuvant! None of patients with grade I tumors had a high-risk recurrence score. The major effect was avoidance of chemotherapy when Adjuvant! Online indicated high or intermediate risk. Mark N. Toggle navigation. Use of Gene Recurrence Score vs Adjuvant!