Use Of Prognostic And Predictive Factors In Clinical Practice

The standard prognostic factors such as tumor size and node status provide important information about likely patient outcome, but within the good prognosis groups such as axillary node-negative cases there can be differences in behavior. There is increasing emphasis on separating defined prognostic groups into low and high risk,14 and using this, along with predictive markers, for the selection of adjuvant systemic therapy. Expert consensus meetings such as those held at St Gallen consider the primary therapy of early breast cancer and make recommendations which are published every 2 years or so.15-17 The Early Breast Cancer Trialists' Collaborative Group undertake quinquennial overviews of the randomized trials in breast cancer, with the last overview being published in 2005,18 and these provide data on recurrence and mortality rates in relation to therapy. Using this, and in conjunction with the Nottingham Prognostic Index (NPI),8 a prognostic table has been devised19,20 and updated21 to provide information about the benefit or not of poly-chemotherapy and endocrine therapy to individual patients. A National Health Service (NHS) R&D Health Technology Assessment22 considered the NPI to be a useful clinical tool, and that additional factors may enhance its use.

Web-based tools are being used more extensively - www.adjuvantonline.com is one used by many clinicians for estimating the benefit of adjuvant therapy for women with stage I and II breast cancers. A population-based validation of the model (ADJUVANT!) showed it to perform reliably, although for women younger than 35 years of age, or with known adverse prognostic factors such as lympho-vascular invasion, adjustments of risks were required.23

For these tools to be effective there is a need for the factors that form them to be derived accurately. Determination of tumor size, type, grade, node status, presence or not of lymphovascular invasion is the remit of the pathologists who are part of the breast multidis-ciplinary team, and this is discussed in Chapter 2. In order to ensure reproducibility, guidelines have been produced,24 and quality assurance of the different parameters is undertaken in the UK. Pathologists are very much involved with the analysis of estrogen and progesterone receptors (Chapter 9) and HER2 (Chapter 13), which are the determinants for the selection of endocrine therapy and trastuzumab, respectively, now both used as adjuvant therapies as well as for metastatic disease. There are many factors which can affect performance of assays, and interpreta-tion,25,26 and whilst there are quality assurance schemes for the tests, quality assurance for interpretation has yet to be introduced.

Much of the above has related to the use of systemic therapy. However, local recurrence following conservative surgery for breast cancer is also important and the various therapeutic factors are discussed in Chapter 4, along with the surgical and pathological determinants of local recurrence.

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