By Alberto J. Montero, MD, MBA
Review of “Oncology Pocketcards” by “Börm Bruckmeier Publishing LLC” for “Apple iOS and Android”
The Oncology Pocketcard series was created with the goal of distilling the essential pieces of information that practicing medical oncologists and those in training need at their fingertips.
Obviously, oncology is a rapidly moving field. Consequently, the timeliness of the information being distilled into the Pocketcard format is extremely important, and you would certainly want to confine yourself to a time frame of less than 5 years. Unfortunately, it seems as if, for the sake of brevity, the authors have neglected incorporating extremely important timely information into the Oncology Pocketcards app, which limits its usefulness for health providers.
Evidence Behind the App
The Oncology Pocketcards app includes information on seven different cancers which are among the top leading causes of mortality: breast, non-small cell lung, small cell lung, colorectal, prostate, pancreatic, and bladder. This is entirely logical and appropriate, with the exception that the authors should have included ovarian cancer as the 5th leading cause of mortality in women, as shown in the app.
Each cancer in turn is organized into three sections: diagnostic workup, TNM classification, and staging, with the latter section also including some limited information on treatment and 5-year overall survival. Information contained in the diagnostic workup is rather scant, and not particularly useful. It does not contain any references that users could perhaps access to learn more as to what evidence these recommendations are based on. The TNM classification section appears to be adequate, however there are some nuances which are not covered here which are of importance. For instance, according to NCCN guidelines there are different TNM classifications for clinical vs. pathologic staging in breast cancer, yet in the breast cancer section only the clinical staging is detailed. This is not an inconsequential oversight since it is pathologic staging that is of greater importance for routine clinical decision-making.
Moving on to the staging sections, it is important to note that the 5-year overall survival (OS) data appears to be a bit outdated for colon, lung, and breast cancers, as it is not consistent with the most recent ACS data.1 Moreover, OS for stages 1-3 breast cancer is typically measured at 10 years not 5, yet in the breast cancer section this app quotes only 5-year OS. By contrast, Adjuvant Online, one of the most useful online programs free for all to use (www.adjuvantonline.com), provides accurate estimates of both 10-year disease-free and overall survival for breast cancer patients based on age and conventional clinical pathologic features, and not 5.
Perhaps one of the greatest disappointments with this app lies in the treatments that are not outlined in the staging section of each covered cancer. The oncogene KRAS is mutated in about 50% of all colon cancer cases. This is vitally important since only patients with wild type KRAS tumors benefit from treatment with anti-EGFR monoclonal antibody therapy.2 However, one would never know this fundamental fact by looking in the colon cancer Pocketcard section.
In the non-small cell lung cancer section, there is no mention of target treatments for stage IV tumors with somatic mutations of epithelial growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK), which have completely different clinical characteristics and are treated with targeted tyrosine kinase inhibitors.3
Also contained in the app is an ‘essentials’ section at the beginning, and a TNM staging system and ECOG performance status scale which outlines some basic definitions. The essentials section provides a one-page summary of each cancer section, plus includes some key oncology definitions with respect to how radiographic responses or progression are defined utilizing the gold standard in oncology trials, Response Evaluation Criteria in Solid Tumours (RECIST). The app cites the original RECIST criteria from 2000, however these definitions are outdated and differ in important ways from the more recent RECIST 1.1 criteria from 2009.4
- The Oncology pocketcard format under the essentials section.
- Inclusion of survival data with stage, since this is important when having discussions with patients on the risks and benefits of surgery, radiation, or systemic therapy.
- Having TNM and staging information at your fingertips for the most common cancers is useful to have, since this is rather difficult to commit to memory, and it is frequently changing.
- Nowhere in the app is it stated where the survival or treatment recommendations come from. The only references given are AJCC staging manual from 2002 and an ancient 1987 publication. Based on a very cursory review of NCCN guidelines (http://www.nccn.org/) or ACS cancer facts and figures.(1)
- Information in the app is rather outdated, at best it is from 2008 based on the copyright date, which is clearly too outdated for oncology. By contrast, NCCN guidelines are updated annually reflecting the fact that oncology is a fast moving field.
- No discussion of biologic subtypes in breast (hormone receptor positive, triple negative, HER2+), non-small cell lung cancer (EGFR and ALK mutations), or colon cancer (KRAS mutation), which is a critical flaw. Each have different natural histories and targeted therapies.
Leaving out even just a few lines regarding the biologic sub-classifications of different cancers, and their corresponding targeted therapies, is a huge, gaping blind spot in this app. While I do like the pocketcard concept, and the inclusion of survival information, the question is why should I have to pay $5.00 primarily for staging information which is free in other venues? Left with the choice between paying for outdated information distilled in a nice pocketcard format, or having more lengthy but timely information that is free, I would prefer the latter.
- Overall Score
- User Interface
- Multimedia Usage
- Real World Applicability
- Available for DownloadAndroidiPhoneiPad