Abstract P5-09-04: Consensus and disagreement between experts and community practitioners asked to make therapeutic recommendations for early breast cancer (EBC)
Authors: Obholz KL , Rosenthal KM , O'Regan RM , Swain SM , Yardley DA , Brady ED 
Published: May 2016

Abstract
Intro. Most patients with stage II BC will receive surgery along with systemic therapy, but no consensus exists among experts on optimal use of neoadjuvant vs adjuvant therapy in many cases. Furthermore, treatment guidelines list multiple reasonable regimens for EBC, but lack patient-specific recommendations. We have shown previously that online decision support tools can affect treatment decisions of community practitioners. In this study, we sought to determine areas of consensus and disagreement among expert faculty providing treatment recommendations for a 2015 decision support tool on EBC as well as those using the online tool.
Methods. An online decision support tool was developed with input from 5 experts on systemic therapy recommendations for 235 patient scenarios in EBC. Tool users were asked to enter specific patient criteria and their intended management for each case before displaying the 5 expert recommendations for the user-entered case. Users were asked to indicate if the expert recommendations changed their intended approach.
Results. At interim analysis, 406 individuals used this tool, with 674 patient scenarios entered. Among users reporting on the tool's clinical impact, 88% indicated expert recommendations either confirmed or changed their intended therapy. Expert recommendations in the tool showed areas of consensus and disagreement in treating patients with EBC. For example, expert recommendations varied in the choice of systemic therapy prior to surgery and when to continue directly to surgery before systemic treatment.
Expert recommendations for initiating systemic neoadjuvant therapy in HER2-, HR+ EBCcNcTExpert 1Expert 2Expert 3Expert 4Expert 5NCCN GuidelinesNegativecT1a cT1b cT1c Recommend cT2 RecommendConsider cT3ConsiderRecommendConsiderPositivecT1a RecommendConsider cT1b RecommendConsider cT1c RecommendConsider cT2ConsiderRecommendConsider cT3ConsiderRecommendConsider
Experts did agree on starting with surgery in patients with node-negative, T1a disease; however, only 30% of tool users agreed. Both experts and users agreed in recommending systemic neoadjuvant therapy for patients with HER2+, node-positive T2 disease. In patients with HER2+ EBC, experts always chose to include dual HER2-targeted therapy in neoadjuvant systemic therapy but only included trastuzumab in adjuvant regimens. However, only 51% of tool users selected dual HER2-targeted therapy as part of neoadjuvant therapy and 13% use dual HER2-targeted therapy in the adjuvant setting. Expert opinion varied on when to use adjuvant chemotherapy in patients with HR+, HER2- EBC, particularly for those with intermediate or unknown recurrence scores and no lymph node involvement. Detailed comparison of expert consensus and disagreement, analysis of practice pattern information from user responses, and perceived impact of the expert recommendations will be presented.
Conclusions. This EBC tool highlights specific clinical scenarios having either consensus or disagreement among experts and community practitioners. Education that includes online decision support tools may increase the number of clinicians making optimal treatment decisions for patients with EBC.
Citation Format: Obholz KL, Rosenthal KM, O'Regan RM, Swain SM, Yardley DA, Brady ED. Consensus and disagreement between experts and community practitioners asked to make therapeutic recommendations for early breast cancer (EBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-09-04.