title: External validation of Adjuvant! Online breast cancer prognosis tool. Prioritising recommendations for improvement.
abstract: BACKGROUND
  Adjuvant! Online is a web-based application designed to provide 10 years survival probability of patients with breast cancer. Several predictors have not been assessed in the original Adjuvant! Online study. We provide the validation of Adjuvant! Online algorithm on two breast cancer datasets, and we determined whether the accuracy of Adjuvant! Online is improved with other well-known prognostic factors.
  
  
  METHODS
  The French data set is composed of 456 women with early breast cancer. The Dutch data set is composed of 295 women less than 52 years of age. Agreement between observation and Adjuvant! Online prediction was checked, and logistic models were performed to estimate the prognostic information added by risk factors to Adjuvant! Online prediction.
  
  
  RESULTS
  Adjuvant! Online prediction was overall well-calibrated in the French data set but failed in some subgroups of such high grade and HER2 positive patients. HER2 status, Mitotic Index and Ki67 added significant information to Adjuvant! Online prediction. In the Dutch data set, the overall 10-year survival was overestimated by Adjuvant! Online, particularly in patients less than 40 years old.
  
  
  CONCLUSIONS
  Adjuvant! Online needs to be updated to adjust overoptimistic results in young and high grade patients, and should consider new predictors such as Ki67, HER2 and Mitotic Index.
authors.affiliation: Department of Biostatistics, Institut Curie, Paris, France.
authors.forename: David
authors.initials: D
authors.lastname: Hajage
authors.forename: Yann
authors.initials: Y
authors.lastname: de Rycke
authors.forename: Marc
authors.initials: M
authors.lastname: Bollet
authors.forename: Alexia
authors.initials: A
authors.lastname: Savignoni
authors.forename: Martial
authors.initials: M
authors.lastname: Caly
authors.forename: Jean-Yves
authors.initials: JY
authors.lastname: Pierga
authors.forename: Hugo M
authors.initials: HM
authors.lastname: Horlings
authors.forename: Marc J
authors.initials: MJ
authors.lastname: Van de Vijver
authors.forename: Anne
authors.initials: A
authors.lastname: Vincent-Salomon
authors.forename: Brigitte
authors.initials: B
authors.lastname: Sigal-Zafrani
authors.forename: Claire
authors.initials: C
authors.lastname: Senechal
authors.forename: Bernard
authors.initials: B
authors.lastname: Asselain
authors.forename: Xavier
authors.initials: X
authors.lastname: Sastre
authors.forename: Fabien
authors.initials: F
authors.lastname: Reyal
mesh_terms: D000465:Algorithms; D001943:Breast Neoplasms / Q000175:diagnosis / Q000401:mortality*; D017076:Computer-Aided Design; D016208:Databases, Factual; D005260:Female; D005602:France; D006801:Humans; D020407:Internet; D019394:Ki-67 Antigen; D008938:Mitosis; D009426:Netherlands; D011379:Prognosis; D018719:Erb-b2 Receptor Tyrosine Kinases; D016019:Survival Analysis
chemical_list: D019394:Ki-67 Antigen; D018719:Erb-b2 Receptor Tyrosine Kinases
references.citation: Oncologist. 2008 Dec;13(12):1235-45
references.pmid: 19091781
references.citation: Bull Cancer. 1995 Dec;82 Suppl 5:561s-564s
references.pmid: 8680066
references.citation: Clin Oncol. 1979 Sep;5(3):227-36
references.pmid: 498615
references.citation: J Clin Oncol. 2001 Feb 15;19(4):980-91
references.pmid: 11181660
references.citation: J Clin Oncol. 2011 Mar 1;29(7):852-8
references.pmid: 21189388
references.citation: Nat Rev Clin Oncol. 2011 Aug 30;9(1):58-64
references.pmid: 21878891
references.citation: Breast Cancer Res. 2008;10(6):R93
references.pmid: 19014521
references.citation: Clin Oncol (R Coll Radiol). 2011 Mar;23(2):159-60
references.pmid: 21112194
references.citation: Br J Cancer. 1987 Oct;56(4):489-92
references.pmid: 3689666
references.citation: Nat Rev Clin Oncol. 2010 Dec;7(12):725-32
references.pmid: 20975745
references.citation: J Clin Oncol. 2008 Dec 1;26(34):5569-75
references.pmid: 18981464
references.citation: Ann Oncol. 2011 Nov;22(11):2381-2386
references.pmid: 21363879
references.citation: Semin Oncol. 1996 Feb;23(1 Suppl 2):43-50
references.pmid: 8614844
references.citation: Stat Med. 2003 Jul 30;22(14):2299-308
references.pmid: 12854094
references.citation: J Clin Oncol. 2005 Apr 20;23(12):2716-25
references.pmid: 15837986
references.citation: Lancet. 2000 May 20;355(9217):1757-70
references.pmid: 10832826
references.citation: Eur J Cancer. 2010 May;46(8):1382-91
references.pmid: 20359886
references.citation: Hum Pathol. 1992 Jun;23(6):603-7
references.pmid: 1592381
references.citation: Br J Cancer. 1982 Mar;45(3):361-6
references.pmid: 7073932
references.citation: Lancet Oncol. 2009 Nov;10(11):1070-6
references.pmid: 19801202
references.citation: Breast Cancer Res Treat. 2008 Feb;107(3):309-30
references.pmid: 17377838
references.citation: Nat Rev Clin Oncol. 2011 May;8(5):272-9
references.pmid: 21364525
references.citation: Ann Oncol. 2009 Feb;20(2):258-64
references.pmid: 18824499
references.citation: Ann Oncol. 2011 Jun;22(6):1461-1462
references.pmid: 21508175
references.citation: Arch Pathol Lab Med. 2007;131(1):18-43
references.pmid: 19548375
references.citation: Lancet. 1998 May 16;351(9114):1451-67
references.pmid: 9605801
references.citation: Lancet Oncol. 2010 Feb;11(2):174-83
references.pmid: 20152769
references.citation: J Clin Epidemiol. 2003 Sep;56(9):826-32
references.pmid: 14505766
references.citation: N Engl J Med. 2002 Dec 19;347(25):1999-2009
references.pmid: 12490681
references.citation: Br J Cancer. 2009 Oct 6;101(7):1074-84
references.pmid: 19724274
references.citation: Lancet. 1998 Sep 19;352(9132):930-42
references.pmid: 9752815
references.citation: Clin Cancer Res. 2011 Sep 15;17(18):6012-20
references.pmid: 21807638
references.citation: Breast Cancer Res. 2006;8(6):216
references.pmid: 17164010