If one were to identify individuals who have had the greatest recent impact on daily breast cancer clinical practice, way up on the list would be the mop-haired boy genius and numbers king, Peter Ravdin, MD.

Our prior Patterns of Care studies have clearly documented the extensive integration of Peter’s Adjuvant! website and computer model into medical oncology practice (Figure 1).

More than half of practicing oncologists regularly incorporate numbers derived from Peter’s program into consultation sessions with patients considering adjuvant systemic treatment, particularly people with node-negative tumors contemplating chemotherapy.

The impressive uptake of Adjuvant! has had a profound impact on patient care. Prior to its advent, medical oncologists were often criticized for providing relative risk reduction numbers to patients, a practice that was confusing and potentially misleading (eg, telling a woman with a baseline risk of relapse of 10 percent that her chance of cancer relapse could be decreased by 40 to 50 percent with chemotherapy).

Now physicians can just fill in specifics such as a patient’s age, comorbidities and basic tumor characteristics, and Adjuvant! provides easy-to-read graphics showing the absolute benefit and actual likelihood that a therapy will prevent an event (Figure 2).

The program also enables docs to print the results for use during patient visits. Clearly, this has been a major boon to clinical decision-making.

In addition to providing specific numbers that can be reviewed with patients, Adjuvant! has become a profoundly useful tool in managing treatment specifically for older patients.

Because the program accurately predicts in aggregate competing causes of mortality, clinicians can use Adjuvant! to assess whether it really makes numeric sense to risk treating a 75- or 85-year-old patient with chemotherapy.

Peter adopted the raw numbers on nonbreast cancer mortality from the SEER Public Registries Files as a basis for Adjuvant! and it is apparent that age has a dramatic effect on the estimated absolute benefits of adjuvant systemic therapy (Figure 3).

He took the whole process to a new level in a collaboration with the British Columbia tumor registry when he verified the accuracy of the data (Olivotto 2005).

It is amazing to consider how Peter’s desire to deliver superior and accurate information to doctors has now been translated to an enormous impact on patient well-being.

Perhaps tens of thousands of individuals have elected to receive therapy that prevented relapse or death based on their exposure to Adjuvant! estimates, and countless others have avoided the toxicity of treatments because Peter’s numbers demonstrated that the benefit wasn’t quite worth it.

The program has become so important to clinicians that many are currently clamoring for Adjuvant! to incorporate HER2 and trastuzumab into the algorithm, but Peter notes that the adjuvant trastuzumab data really do not have adequate follow-up to be incorporated into his model, which focuses on 10-year risks of relapse and death.

However, on the way to his devoted audience is a new version (9.0) that will incorporate the HER2 story, and you can bet that the model will be used frequently, particularly for patients with lower-risk, node-negative, HER2-positive disease.

Even now, with a few twists and pulls you can derive numbers from Adjuvant! that should be reasonably accurate predictors of benefit of adding trastuzumab to chemotherapy (increase the baseline risk of recurrence by 50 percent, and decrease the risk of cancer relapse by 50 percent, or some similar machination), but it will be comforting to use the more familiar Ravdinian pathways.

One of the most interesting aspects of Adjuvant! is that for years Peter has feared that the site might be misleading to patients who wander in off the web, and he has tried hard to steer them away from it. For that reason, to enter Adjuvant! users must attest that they are in fact healthcare professionals.

Although Peter in no way wishes to deny patients access to Adjuvant! (he believes they should ask their oncologists to obtain the information), he is concerned about the potential adverse consequences of using the site in isolation without the appropriate background and understanding of its meaning.

Of interest is the enclosed US-based survey of 150 randomly selected practicing medical oncologists and 41 clinical investigators focusing on breast cancer. In contrast to Peter’s restrictive position, many of these physicians believe patients should be encouraged to consider using the site (Figures 4, 5).

Peter is actually featured in an in-depth audio interview on our new patient education audio/web program, and his opinions raise a critical question: Can patients understand sophisticated models like Adjuvant!, and particularly the concept of the effect of age on treatment impact?

Certainly only a highly motivated subset of patients will wish to become that involved with their oncologic care, but “the waiting room and infusion center theory of cancer information dissemination” would postulate that educating 10 to 20 percent of a patient population will result in a significant spillover to other patients who chat together.

Thus it may be that many of the key concepts in Adjuvant! are already affecting the collective patient consciousness.

Peter is one of the coolest guys in oncology, and as is often the case with such people, he is truly humble about his work. We need to encourage other creative thinkers and inventors to come up with new methods to make the best decisions possible for people with cancer.

— Neil Love, MD
NLove@ResearchToPractice.net

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