[New therapies in oncogeriatrics]. / Nouvelles thérapeutiques en oncogériatrie.

Cancer management is changing rapidly. Changes in practices are not all transferable to the elderly population, which is heterogeneous. The description of the intrinsic toxicity of anti-cancer treatments is insufficient in the elderly. Recent studies dedicated to the elderly incorporate composite evaluation criteria combining efficacy and toxicity with a broad definition including, among other things, loss of functional autonomy. These new data acquired, as well as new organisations integrating the new profession of advanced practice nurse in oncogeriatrics will enable us to better respond to the challenge of caring for elderly patients in the future.

Implementation of an ontological reasoning to support the guideline-based management of primary breast cancer patients in the DESIREE project.

The DESIREE project has developed a platform offering several complementary therapeutic decision support modules to improve the quality of care for breast cancer patients. All modules are operating consistently with a common breast cancer knowledge model (BCKM) following the generic entity-attribute-value model. The BCKM is formalized as an ontology including both the data model to represent clinical patient information and the termino-ontological model to represent the application domain concepts. This ontological model is used to describe data semantics and to allow for reasoning at different levels of abstraction. We present the guideline-based decision support module (GL-DSS). Three breast cancer clinical practice guidelines have been formalized as decision rules including evidence levels, conformance levels, and two types of dependency, "refinement" and "complement", used to build complete care plans from the reconciliation of atomic recommendations. The system has been assessed on 138 decisions previously made without the system and re-played with the system after a washout period on simulated tumor boards (TBs) in three pilot sites. When TB clinicians changed their decision after using the GL-DSS, it was for a better decision than the decision made without the system in 75 % of the cases.

Making a Subjective Notion Computer-Interpretable: The Case of the Tumour-Volume to Breast-Volume Ratio for the Surgical Decision of Breast Cancer.

Clinical practice guidelines (CPGs) often include ambiguous criteria making their translation as computer-interpretable guidelines a difficult task. In breast cancer management, whether to perform a breast conservative surgery (BCS) or not is one example. Most international CPGs recommend to perform a BCS when the tumour volume / breast volume ratio allows for good cosmetic results, which cannot be directly translated into a computable format. We propose to compute an estimate of the ratio using the maximum size of the tumour to compute the tumour volume and the bra size to compute the breast volume. In addition, we take into account the location of the tumour according to quadrants and unions of quadrants. The model has been tested on a retrospective sample of 34 clinical decisions of a breast cancer unit in a Parisian university hospital (France). Concordance was found in 91.2% of the cases, with good sensibility and specificity. This finding could set a new pathway to advance on the development of actionable decision criteria to be used in a future clinical decision support system for breast cancer management.

Using the Recommendations Inferred by a Decision Support System to Compare Breast Cancer Clinical Practice Guidelines.

Numerous studies have reported that inconsistencies exist between clinical practice guidelines (CPGs) elaborated on the same topic and at the same date. These results are usually established from the analyses handled on narrative CPGs or on their semi-structured version. In the context of the European-funded DESIREE project, we have developed a guideline-based decision support system embedding various contemporary CPGs on breast cancer management. We have run the GL-DSS on a sample of 571 retrospective clinical cases and specifically assessed the level of inconsistencies between the recommendations issued by the US National Comprehensive Cancer Network (NCCN) Guidelines for Breast Cancer and those issued by Assistance Publique - Hôpitaux de Paris (AP-HP, France) CPGs. We proposed a typology with six different situations from total incompatibility to complete identity as a result of the comparison of NCCN and AP-HP CPGs for each clinical case. It was interesting to observe that we got 38% of inconsistencies with 3% of total incompatibility, and 62% of similarity with 0% of complete identity. The silence of one CPG was resolved by the other CPG providing recommendations in 21% of the cases.

Taking into Account the Complementarity of Contemporary Breast Cancer Guidelines to Leverage Decision Support in the DESIREE Project.

Breast cancer is one of the most common cancers in Western countries and the first cause of death among women in France. Studies have reported that the compliance of the treatment with breast cancer clinical practice guidelines (CPGs) is accompanied with a significant improvement of recurrence-free survival and overall survival rates. However, compliance of multidisciplinary tumour board decisions with CPGs remains non-satisfactory. The European project DESIREE aims at building a software package to support the guideline-based management of breast cancer patients. The aim is to select multiple relevant contemporary CPGs published on the management of breast cancer and to concurrently apply them to benefit of the complementarity of the recommendations issued, and leverage the guideline-based decision support. We used a clinical case to compare NCCN and ESMO CPGs in terms of concordance, complementarity, and conflicts. Out of the 757 decision rules extracted from both CPGs, 64 rules were triggered (32 from NCCN, and 32 from ESMO) by the clinical case. Ten rules were concordant, 52 complementary, and two conflicting. Complementarity relies on the different levels of granularity of the IF-parts of the rules that lead to different specific THEN-parts. Another type of complementarity comes from the provision of specific care apart from the breast cancer therapeutic management. The few inter- and intra-CPGs conflicts show the limits of CPGs in particular situations still debated by medical research.

Reconciliation of multiple guidelines for decision support: a case study on the multidisciplinary management of breast cancer within the DESIREE project.

Breast cancer is the most common cancer among women. DESIREE is a European project which aims at developing web-based services for the management of primary breast cancer by multidisciplinary breast units (BUs). We describe the guideline-based decision support system (GL-DSS) of the project. Various breast cancer clinical practice guidelines (CPGs) have been selected to be concurrently applied to provide state-of-the-art patient-specific recommendations. The aim is to reconcile CPG recommendations with the objective of complementarity to enlarge the number of clinical situations covered by the GL-DSS. Input and output data exchange with the GL-DSS is performed using FHIR. We used a knowledge model of the domain as an ontology on which relies the reasoning process performed by rules that encode the selected CPGs. Semantic web tools were used, notably the Euler/EYE inference engine, to implement the GL-DSS. "Rainbow boxes" are a synthetic tabular display used to visualize the inferred recommendations.