After a cancer diagnosis, patients and doctors try to make a decision about which treatment options will be most likely to extend or improve quality of life. This discussion should consider both the benefits and the harms that treatment could cause. Until recently, very few tools were available to support this critical process.
The one of breast is the most common cancer among women and affects more than two million of them each year. Those who experience early breast cancer are often faced with the agonizing decision to receive add-on (adjuvant) chemotherapy, a treatment that is suggested in addition to surgery, with the goal of stopping cancer from coming back.
Some women continue to over-treat by undergoing invasive and unpleasant therapy that will not increase their chances of survival. Others become victims of insufficient treatment, without therapies that could have improved their outcome.
Prostate cancer, meanwhile, is the second most common cancer in men, with about 1.3 million cases worldwide each year. The radical therapy immediately for many of these patients carries a high risk of serious adverse effects, such as incontinence, impotence, and bowel dysfunction, while providing few therapeutic benefits.
Determined to improve outcomes for these men and women, Cambridge researchers developed Predict, a pair of online risk communication tools that facilitate informed treatment decision making.
Breast Predict and Prostate Predict, both free tools, have been recognized by physicians, patients, policymakers, and professional organizations around the world. By improving treatment orientation. They have contributed to better clinical outcomes in many parts of the world, as well as reducing patient distress and unnecessary medical procedures.
The way to integrate
In 2010, Paul Pharoah, Professor of Cancer Epidemiology at Cambridge, developed the first version of an online tool to help healthcare professionals and their patients to understand how different invasive treatments for early breast cancer could improve survival rates after surgery.
“In 2007, we were talking to the Cambridge Breast Unit about how they made chemotherapy decisions,” recalls Pharoah. They used a tool that they did not like very much because it was based on data from the United States. I suggested that we could do something similar with the UK data. They were a little surprised that I was ready to give it a try, but that’s how it started.”
Working with a doctoral student, Pharoah began by analyzing the survival data of 5,700 women with early breast cancer treated between 1999 and 2003. This research allowed the identification of key predictors of survival and the production of a prognostic model that was then validated with independent data sets from England and Canada.
“There are many prediction models,” explains Pharoah, ” many of which are never used. We’ve probably had some luck, but I also have an unusual set of skills. I was a clinician before training in public health and then in epidemiology, so I understood that a prediction model is only useful for doctors if it really helps them make a decision”.
Initially, the Cambridge Breast Unit used Breast Predict in parallel with their previous tool, but after a year they stopped. Other breast units found out about the project and it expanded organically from there.
In the breast units of most UK hospitals, Breast Predict has been adopted as the tool of choice for clinical management. ANDa has been used with over 100,000 women in the UK, of whom at least 18,500 have been able to make better decisions about whether adjuvant chemotherapy is right for them.
A clinical review of 200 patients managed by the Cambridge Breast Unit found that 7.5% of patients who would have been classified as low risk and have offered no chemotherapy, were classified as high risk by the platform and offered chemotherapy. In contrast, 11% of patients who would have been classified as high risk and offered chemotherapy were reclassified as low risk and without chemotherapy.
A conservative estimate suggests that since 2013 in the UK, Breast Predict has resulted in about 7,500 women being offered chemotherapy that otherwise would not have been offered and that around 11,000 were spared unnecessary chemotherapy.
Pharoah suggests that: “Doctors tend to overestimate risk, they are more likely to prescribe chemotherapy if they don’t have an estimating tool. There are good reasons for that: If you have 100 patients and, for the sake of argument, 80 of them are cured and 20 come back with recurrence, you will remember those 20 and forget the 80 that do not return. Therefore, their perception of risk is much higher than it really is.”
Also in prostate
Building on the success of Breast, between 2016 and 2019 Cambridge researchers developed Prostate Predict, the first online resource for individualized treatment decision-making in the treatment of non-metastatic prostate cancer.
As Breast examines the value of adding additional chemotherapy or hormone therapy after surgery, Prostate asks a more basic question: Should we treat or just monitor? ”
More specifically, the tool provides patients with estimated survival rates after treatment in the context of the absolute mortality rate, allowing patients to make an informed decision about the value of treatment and its potential side effects.
Vincent Gnanapragasam, Professor of Urology at Cambridge and Honorary Consultant Urologist at Addenbrooke Hospital, recalls: “ When I started more than a decade ago, the mantra was that prostate cancer needs treatment. The tools we were using, which are still in use, are quite rudimentary, so many men classified as low and intermediate risk were receiving treatment that was not beneficial”.
Using data from more than 12,000 prostate cancer patients in two international cohorts, the team, including Gnanapragasam’s exceptional Ph.D. student David Thurtle, developed a model that estimated 10 and 15-year survival outcomes for men with cancer of the newly diagnosed prostate.
“I used to do prostate removal surgery,” says Gnanapragasam, “but I became less convinced that we were doing a lot of good for many patients. That is not to say that surgery is not beneficial, but we were operating a variety of cases in which cancer would never become problematic, but we did not have reliable ways to determine when and when not.”
When using the platform, the specialist can show patients the numbers and figures, setting a firm boundary around the benefits of treatment. “For the patient, knowing exactly what we are talking about and having that consistency gives them a lot of peace of mind”, completes Gnanapragasam.
Predict is expected to evolve by taking advantage of advances in AI so that predictive tools can be tailored to an individual patient’s condition as it develops. There may also be scope to help with other cancers.