title: An investigation into the performance of the Adjuvant! Online prognostic programme in early breast cancer for a cohort of patients in the United Kingdom.
abstract: BACKGROUND
  Adjuvant! Online is an internet-based computer programme providing 10-year prognosis predictions for early breast cancer patients. It was developed in the United States, has been successfully validated in Canada, and is used in the United Kingdom and elsewhere. This study investigates the performance of Adjuvant! in a cohort of patients from the United Kingdom.
  
  
  METHODS
  Data on the prognostic factors and management of 1065 women with early breast cancer diagnosed consecutively at the Churchill Hospital in Oxford between 1986 and 1996 were entered into Adjuvant! to generate predictions of overall survival (OS), breast cancer-specific survival (BCSS), and event-free survival (EFS) at 10 years. Such predictions were compared with the observed 10-year outcomes of these patients.
  
  
  RESULTS
  For the whole cohort, Adjuvant! significantly overestimated OS (by 5.54%, P<0.001), BCSS (by 4.53%, P<0.001), and EFS (by 3.51%, P=0.001). For OS and BCSS, overestimation persisted across most demographic, pathologic, and treatment subgroups investigated. Differences between Adjuvant! predicted and observed EFS appeared smaller, and were significant for far fewer subgroups, only 5 out of the 28. The likely explanation for such discordance is that US breast cancer mortality rates (upon which Adjuvant! is based) appear to be systematically lower than breast cancer mortality rates in the United Kingdom. Differences in survival after recurrence would seem to be one contributory factor, with data suggesting that prognosis after relapse appears poorer in the United Kingdom. This may reflect the fact that new and more effective cancer drugs are often only approved for use in the United Kingdom many years after their adoption in the United States.
  
  
  CONCLUSIONS
  The use of Adjuvant! by clinicians within the UK National Health Service is increasing, under the assumption that the programme is transferrable to the United Kingdom. At least for women treated for breast cancer at the Churchill Hospital in Oxford, however, Adjuvant!'s predictions were on the whole overoptimistic. If the findings reported here could be shown to be generalisable to other areas of the United Kingdom, then thought should perhaps be given to the development of a UK-specific version of the programme.
authors.affiliation: Department of Public Health, Health Economics Research Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK. helen.campbell@dphpc.ox.ac.uk
authors.forename: H E
authors.initials: HE
authors.lastname: Campbell
authors.forename: M A
authors.initials: MA
authors.lastname: Taylor
authors.forename: A L
authors.initials: AL
authors.lastname: Harris
authors.forename: A M
authors.initials: AM
authors.lastname: Gray
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000401:mortality* / Q000628:therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D020407:Internet; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality; D011379:Prognosis; D018426:SEER Program; D012984:Software