Adjuvant! and Other Computerized Risk Estimate Models

“I am really pleased about how many practitioners are using computer-based models in their practice, and I expect that the number will continue to increase rapidly. I have found that it is difficult to convince practitioners to try these models; however, once they do, they see the power of the numbers and how the presentation of absolute benefits to the patient can make decision-making an easier and much more objective process. I use these models for every patient who comes in the door for a discussion of adjuvant therapy. For the past two years I have printed out the results and usually give them to the patient. I love the Adjuvant! model because it helps me to avoid biases. There are all types of factors that influence how physicians think about a specific patient — personality type, type of relationship that is established, referral source — these models totally remove those from the equation.”

Robert W Carlson, MD
Patterns of Care, Issue 2, 2004

Dose-Dense Adjuvant Chemotherapy

“I’ve heard physicians state that they don’t want to use a more aggressive dose-dense regimen unless the patients are at very high risk. Frankly, the dose-dense regimen is less toxic, more effective and faster. If CALGB-9741 had demonstrated that the regimens had equal efficacy, there would be real arguments for using a dose-dense regimen just from the toxicity point of view.”

Larry Norton, MD
Breast Cancer Update for Medical Oncologists,
Issue 4, 2004

Aromatase Inhibitors in the Adjuvant Setting

“Current data support anastrozole as first-line adjuvant hormonal therapy, or a change to AIs after 2-3 years of tamoxifen, or the use of letrozole at the end of a 5-year course of tamoxifen as first-choice treatment options for the management of hormone receptor positive breast carcinoma in postmenopausal women.”

The Role of Aromatase Inhibitors in the Adjuvant Treatment
of Breast Carcinoma: The University of Texas MD
Anderson Cancer Center Evidence-Based Approach
Paolo Morandi, MD, et al. Cancer 2004;101:1482-9.

“Many more years will be required to fine-tune the risk benefit assessment of adjuvant aromatase inhibitors, but the use of these agents should be discussed with patients who are suitable candidates, and they should be informed about the limitations of the current data. In my opinion, women whose risk of recurrence is high are reasonable candidates for the inclusion of an aromatase inhibitor in plans for adjuvant treatment, whereas women with a low risk of recurrence might give more weight to long-term safety and be better served by tamoxifen therapy.”

Martine J Piccart-Gebhart, MD, PhD
New Stars in the Sky of Treatment for Early Breast Cancer.
New Engl J Med 2004; 350:1140-42.

“For postmenopausal patients who are on tamoxifen for any length of time, our practice today is to switch to an aromatase inhibitor. There was a time when we would leave patients on tamoxifen if they were already on tamoxifen, because there was really no evidence that crossing over was beneficial. But, after all three of the crossover trials came out this past year, there was really no justification in our minds to continue tamoxifen.”

Gabriel N Hortobagyi, MD
Breast Cancer Update for Medical Oncologists,
Issue 9, 2004

“I am impressed by the IES data, that switching to an aromatase inhibitor is beneficial in terms of lowering risk of recurrence. And, similarly, for women who have been finishing five years of tamoxifen, I frequently offer letrozole.

The data from MA17 are particularly compelling for the women at higher risk — node-positive patients — that there is ongoing residual risk for breast cancer recurrence years and years after the initial diagnosis.”

Harold J Burstein, MD, PhD
Breast Cancer Update for Surgeons,
Issue 5, 2004

Trastuzumab in the Adjuvant and Neoadjuvant Settings

“If pathologic complete response rate (PCR) really turns out, in NSABP-B-27, to be a robust surrogate in the analysis of early-stage breast cancer cohorts, then PCR has value in Buzdar’s ASCO neoadjuvant trastuzumab study in forecasting what we might expect in these larger adjuvant studies with regard to the survival endpoint. Buzdar’s data are provocative but preliminary and don’t establish a standard of care. Community physicians can only look at this data and say it’s reassuring that there is a bright future, perhaps, for the adjuvant trastuzumab programs. But for it to be used more in the neoadjuvant setting, it will still require confirmation. In particular, we have to be careful about the incorporation of anthracyclines with trastuzumab containing regimens.”

Mark Pegram, MD
Breast Cancer Update for Medical Oncologists,
Issue 9, 2004