Our main office in Miami is currently the scene of complete and total mayhem, as dozens of dusty construction workers tear apart our previously nondescript academic environs high in the sky to make way for the world’s first international CME audio production and Podcasting studio. The work is slated to be complete in time for a series of scheduled events in July, including several Think Tanks and Meet The Professors recording sessions. Until then, we continue to push ahead attempting to ignore a cacophony of sounds that often makes it hard just to think.

Some might question our business acumen in taking this bold step forward in the midst of a crashing economy, a dearth of new cancer drugs in the so-called pipeline and mounting concerns about congress-people and bean-counting, nine-to-five university-based “educators” trying to shut down the totally legitimate and pretty decently functioning private-sector business of CME. With all of this and more to worry about, we decided to further spice up the mix with an interesting education experiment for our first Patterns of Care study of 2008.

By way of background, we’ve spent the last year rebuilding our website, and a key aspect of this unexpectedly complex undertaking was how to optimally categorize the seemingly infinite pieces of content in our programs to facilitate high-quality search functionality. Out of these discussions we began to consider whether CME might be most effectively organized based on specific clinical decisions encountered by physicians — in this case, medical oncologists.

With that in mind, and using invasive breast cancer as a pilot in a mad effort to go inside the brain of the monster called evidence-based oncology, we developed a list of the most challenging management decisions in both the adjuvant and metastatic settings. In January, during our most recent breast cancer Think Tank, we asked the learned faculty to weigh in on our selections and based on their input arrived at a “Top 20” list.

In March, as part of the enclosed national Patterns of Care survey, we asked 100 practicing oncologists and 43 breast cancer investigators (all US based) to think very carefully about these identified issues and then provide three numbers for each, as follows:

1. About how often they encounter the situation in their practice.
2. Their level of interest (0 to 10 rating) in CME related to the particular clinical decision. It is important to note that when we say CME, we are not referring to your average local dinner meeting but to Socratic CME — our name for what we have been doing for 20 years — specifically, asking investigators and docs in practice what they know, think and believe.
3. Their level of support (0 to 10 rating) for clinical research to further define the optimal management strategies for patients in the described situation.

Our co-conspirators in this educational adventure were Drs Kathy Miller and Hy Muss, both of whom helped a great deal in shaping the methods. On the following pages, we summarize the results graphically, utilizing for the first time what we call the “Table-Graph,” in which…well, look at it and tell us if it works. Here are a few of the team’s thoughts about our initial attempt to bring quantitation to education and research needs assessment:

HY MUSS…was pleased that most of the high-priority research issues are being addressed in ongoing clinical trials. He was particularly intrigued by the answers to a scenario he came up with — the patient with prior anthracycline/taxane adjuvant therapy who now has a second primary tumor that is triple-negative. This question broke our record for recommended responses, as there were 33 different regimens listed by the 100 practicing docs. Understanding that a level 3 evidence-based answer is unlikely to ever be determined, Hy would choose between TC (docetaxel/cyclophosphamide) and XT (or is it TC2?) (docetaxel/capecitabine).

KATHY MILLER…thinks these docs likely overestimated the number of patients they see under age 40 with ER-positive, node-positive disease, noting that “these young women stand out in our minds because of the compelling human issues with this situation.” Good point, Kathy. She also expressed “curiosity” that so much interest was expressed in this issue, when trials like TEXT and SOFT that are geared toward exactly this patient population are withering away like neglected plants because of poor accrual. However, as we go to press, Mike Gnant and the Austrian Breast Cancer Trialists Group completely turned this issue on its ear with a stunning ASCO plenary presentation that demonstrated little difference in choice of endocrine therapy in patients on an LHRH agonist but an eye-opening 35 percent reduction in relapse rate in women receiving zoledronic acid every six months, and you can hear Dr Gnant and others talk all about it in the current issue of the Breast Cancer Update audio series.

Dr Miller was particularly fascinated by the relatively high level of support for clinical research addressing the issue of continuation of a biologic — in this case, bevacizumab — in spite of tumor progression. In colon cancer, Axel Grothey’s BRiTE tumor registry analysis has led to the launch of the iBET trial, evaluating a question that was never settled for trastuzumab.

Kathy noted that as part of this type of clinical trial, translational studies could be employed to look at the potential for rebound VEGF expression upon withdrawal of bevacizumab that might explain why her pivotal trial of bev/paclitaxel demonstrated an impressive progression-free survival but no overall survival advantage.

YOUR HUMBLE EDITOR…is desperate to figure out whether others will think this is as interesting and relevant as we do. From the perspective of CME, we have long believed that a more scientific and research-like platform is essential to move the field forward, and the impressive number of oncologists who rate their interest in “Socratic” CME as a “9” or “10” supports the fact that docs in practice value the perspectives of their colleagues on critical decisions. It is particularly striking that this thirst for input regarding common tumors like breast cancer seems unquenchable.

So as our editorial staff huddles together in temporarily cramped working conditions with hard hats ripping our walls down to build the studio, we amuse ourselves by coming up with slightly bizarre, pseudo-scientific graphs that perhaps in their own unique way tell a simple but powerful story, which is that docs in practice want input on many important decisions in breast oncology, and the more frequently they encounter a situation, the more pressing is the need for answers.

Our ever-evolving ideas laboratory continues to put together interesting new education adventures and creations, and in the very near future we will ask investigators, practicing docs, nurses and patients to join us in our new special recording digs overlooking beautiful Biscayne Bay and Miami Beach beyond, and perhaps as we gaze out to the ocean, ideas and solutions will emerge that might finally have a meaningful impact on this horrendous disease.

— Neil Love, MD
DrNeilLove@ResearchToPractice.com

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Click on the image to enlarge