breast cancer: treatment or not? hfe 742 cathy simmons november 10, 2005
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Breast Cancer: Breast Cancer: Treatment or Not?Treatment or Not?
HFE 742HFE 742
Cathy SimmonsCathy Simmons
November 10, 2005November 10, 2005
PLANPLAN BackgroundBackground Stages of breast cancerStages of breast cancer Influence diagramInfluence diagram Treatments for stages – ”influence Treatments for stages – ”influence
diagrams”diagrams” Decision treeDecision tree The DECISIONThe DECISION
BackgroundBackgroundPersonal reasonsPersonal reasons
Death of fatherDeath of father
Incident in paternal grandfatherIncident in paternal grandfather
Death of mother-in-lawDeath of mother-in-law
StatisticsStatistics
Mortality ratesMortality rates
Incidence ratesIncidence rates
US Mortality, 2002US Mortality, 2002
Source: US Mortality Public Use Data Tape 2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2004.
1.1. Heart DiseasesHeart Diseases 696,947696,947 28.5 28.5
2.2. CancerCancer 557,271557,271 22.8 22.8
3.3. Cerebrovascular diseasesCerebrovascular diseases 162,672162,672 6.7 6.7
4.4. Chronic lower respiratory diseasesChronic lower respiratory diseases 124,816 5.1124,816 5.1
5.5. Accidents (Unintentional injuries)Accidents (Unintentional injuries) 106,742 106,742 4.4 4.4
6.6. Diabetes mellitusDiabetes mellitus 73,24973,249 3.0 3.0
7.7. Influenza and pneumoniaInfluenza and pneumonia 65,68165,681 2.7 2.7
8.8. Alzheimer diseaseAlzheimer disease 58,86658,866 2.4 2.4
9.9. NephritisNephritis 40,97440,974 1.7 1.7
10.10. SepticemiaSepticemia 33,86533,865 1.4 1.4
Rank Cause of DeathNo. of deaths
% of all deaths
2005 Estimated US Cancer 2005 Estimated US Cancer Deaths*Deaths*
ONS=Other nervous system.Source: American Cancer Society, 2005.
Men295,280
Women275,000
27%27% Lung and bronchusLung and bronchus
15%15% BreastBreast
10%10% Colon and rectumColon and rectum
6%6% OvaryOvary
6%6% PancreasPancreas
4%4% LeukemiaLeukemia
3%3% Non-HodgkinNon-Hodgkin lymphoma lymphoma
3%3% Uterine corpusUterine corpus
2%2% Multiple myelomaMultiple myeloma
2%2% Brain/ONSBrain/ONS
22% All other sites22% All other sites
Lung and bronchus 31%
Prostate 10%
Colon and rectum 10%
Pancreas 5%
Leukemia 4%
Esophagus 4%
Liver and intrahepatic 3%bile duct
Non-Hodgkin 3% Lymphoma
Urinary bladder 3%
Kidney 3%
All other sites 24%
2005 Estimated US Cancer Cases*2005 Estimated US Cancer Cases*
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2005.
Men710,040
Women662,870 32%32% BreastBreast
12%12% Lung and bronchusLung and bronchus
11%11% Colon and rectumColon and rectum
6%6% Uterine corpus Uterine corpus
4%4% Non-HodgkinNon-Hodgkin lymphoma lymphoma
4%4% MelanomaMelanomaof skinof skin
3% Ovary3% Ovary
3%3% ThyroidThyroid
2%2% Urinary bladderUrinary bladder
2%2% PancreasPancreas
21%21% All Other SitesAll Other Sites
Prostate 33%
Lung and bronchus 13%
Colon and rectum 10%
Urinary bladder 7%
Melanoma of skin 5%
Non-Hodgkin4% lymphoma
Kidney 3%
Leukemia 3%
Oral Cavity 3%
Pancreas 2%
All Other Sites 17%
Cancer Death Rates*, for Cancer Death Rates*, for Women, US,1930-2001Women, US,1930-2001
*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2001, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2004.
0
20
40
60
80
100
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Lung & bronchus
Colon & rectum
Uterus
Stomach
Breast
Ovary
Pancreas
Rate Per 100,000
Breast cancer hasconsistently been a
leading cause of cancerdeaths since 1930.
Age Specific Incidence & Age Specific Incidence & Death Rates for Women with Death Rates for Women with
Breast Cancer, by race, Breast Cancer, by race, US,1998-2002US,1998-2002
Source: Incidence – Surveillance, Epidemiology, and End Results Program, 1973-2002, Division of Cancer Control and Population Science, National Cancer Institute, 2005. Deaths – National Center for Health Statistics, Centers for disease Control and Prevention, 2005.
Lifetime Probability of Developing Lifetime Probability of Developing Cancer, Cancer,
By Site, Women, US, 1999-2001By Site, Women, US, 1999-2001
Source:DevCan: Probability of Developing or Dying of Cancer Software, Version 5.2 Statistical Research and Applications Branch, NCI, 2004. http://srab.cancer.gov/devcan
Site Risk
All sites 1 in 3
Breast 1 in 7
Lung & bronchus 1 in 18
Colon & rectum 1 in 18
Uterine corpus 1 in 38
Non-Hodgkin lymphoma 1 in 56
Ovary 1 in 68
Melanoma 1 in 78
Pancreas 1 in 81
Urinary bladder 1 in 88
Uterine cervix 1 in 130
Cancer Survival*(%) by Site and Cancer Survival*(%) by Site and Race,1995-2000Race,1995-2000
*5-year relative survival rates based on cancer patients diagnosed from 1995 to 2000 and followed through 2001. Source: Surveillance, Epidemiology, and End Results Program, 1975-2001, Division of Cancer Control and Population Sciences, National Cancer Institute, 2004.
All Sites 66 55 11
Breast (female) 89 75 14
Colon 64 54 10
Esophagus 16 9 7
Leukemia 48 39 9
Non-Hodgkin lymphoma 60 51 9
Oral cavity 61 39 22
Prostate 100 96 4
Rectum 65 55 10
Urinary bladder 83 62 21
Uterine cervix 74 66 8
Uterine corpus 86 63 23
Site White DifferenceAfricanAmerican
Trends in Incidence Rates by Trends in Incidence Rates by Tumor & Race, US,1988-1989 to Tumor & Race, US,1988-1989 to
2001-20022001-2002
Source: Surveillance, Epidemiology, and End Results Program, 1973-2002, Division of Cancer Control and Population Science, National Cancer Institute, 2005.
WhiteWhite
All racesAll races
African African AmericanAmerican
Source: Surveillance, Epidemiology, and End Results Program, 1973-2002, Division of Cancer Control and Population Science, National Cancer Institute, 2005.
WhiteWhite
All racesAll races
African African AmericanAmerican
Trends in Incidence Rates by Trends in Incidence Rates by Stage & Race, US,1975-1976 to Stage & Race, US,1975-1976 to
2001-20022001-2002
Source: Surveillance, Epidemiology, and End Results Program, 1973-2002, Division of Cancer Control and Population Science, National Cancer Institute, 2005.
Female Breast Cancer, US,1995-Female Breast Cancer, US,1995-20012001
STAGE TUMOR SPREAD?0 carcinoma in situ (abnormal cells) NO
I tumor < 2 cm NO
IIA 1) no tumor in breast but cancer in underarm lymph YES nodes only
2) tumor < 2 cm & spread to underarm lymph nodes YES
only3) tumor > 2 cm but < 5 cm NO
IIB 1) tumor > 2 cm but < 5 cm & spread to underarm YES lymph nodes only
2) tumor > 5 cm NO
Stages of Female Breast CancerStages of Female Breast Cancer
Source: National Cancer Institute, 2005.
STAGE TUMOR SPREAD?
IIIA 1) no tumor but has spread to underarm lymph nodes YES & are attached to each other or other structures
2) tumor < 5 cm and spread to underarm lymph nodes YES & are attached to each other or other structures
3) tumor > 5 cm and spread to underarm lymph nodes YES & may be attached to each other or other structures
IIIB Any size tumor and spread to other tissues near the YES
breast and may have spread to the underarm lymph nodes
IIIC Cancer has spread to the lymph nodes near the neck YES
and under the collarbone. (May be operable or inoperable)
IV Cancer has spread to other organs YES
Stages of Female Breast CancerStages of Female Breast Cancer
Source: National Cancer Institute, 2005.
ObjectivesObjectives
Choose to receive treatmentsChoose to receive treatmentsfor breast cancerfor breast cancer
Decision
Maintain qualityMaintain qualityof lifeof life
Five year survivalFive year survival
Able to careAble to careFor oneselfFor oneself
FundamentalObjectives
MeansObjectives
Able toAble toworkwork
Able toAble togo placesgo places
with familywith family
Influence DiagramInfluence Diagram
Diagnosed withbreast cancer
Receive treatments?
Diagnose stage of breast cancer
Remission Death
Pre-cancerousPre-cancerouscells onlycells only
Surgery
Radiation
Chemotherapy
May have to have this treatment =
Stage 0 Treatment Influence Stage 0 Treatment Influence DiagramDiagram
Stage I Treatment Influence Stage I Treatment Influence DiagramDiagram
Tumor < 2 cmTumor < 2 cm92%92% Stage I
May have to have this treatment =
Surgery
Radiation
Chemotherapy
Stage II Treatment Influence Stage II Treatment Influence DiagramDiagram
Tumor < 2 cmTumor < 2 cm92%92% Surgery,
Radiation &Chemotherapy
2 cm <Tumor < 5 cm2 cm <Tumor < 5 cm77%77%
Tumor > 5 cmTumor > 5 cm55%55%
LymphLymph nodesnodesunderarmunderarm
Stage IIA
Stage IIA
Stage IIB
Stage IIA
Stage IIB
Stage III Treatment Influence Stage III Treatment Influence DiagramDiagram
Tumor > 5 cmTumor > 5 cm55%55%
Lymph nodesLymph nodesunderarm attachedunderarm attached
to each otherto each other
Surgery,Radiation &
Chemotherapy
Stage IIIATumor < 5 cmTumor < 5 cm
Stage IIIA
Stage IIIA
Other tissuesOther tissuesStage IIIB
Lymph nodesLymph nodesother than underarmother than underarm
Stage IIIC
May also have
this condition=
Stage IIIB
Stage IV Treatment Influence Stage IV Treatment Influence DiagramDiagram
Surgery,Radiation &
Chemotherapy
Spread to otherSpread to otherorgans in theorgans in the
bodybody
Planning the Decision TreePlanning the Decision Tree
DecisionsDecisions Receive treatments or notReceive treatments or not
Uncertain eventsUncertain events Stage of breast cancerStage of breast cancer Survival vs. deathSurvival vs. death
ObjectivesObjectives Maintain quality of lifeMaintain quality of life Five year survivalFive year survival
Decision TreeDecision Tree
Diagnosed with breast cancer.
Choose to receive treatment or not?
Survival
Death
CONTINUED…
CONTINUED…
CONTINUED…
CONTINUED…
CONTINUED…
0
6
EMV = 5
EMV = 1.84
EMV = 1.84
EMV= 2.16
EMV= 0.20
EMV= 1.08
EMV = 2.43
EMV= 1.08
20%
37%
27%
11%
5%
Receive treatments
Don’t receive treatments
Stage 0
Stage I
Stage II
Stage III
Stage IV
1%
99%
“Values” assigned to each outcome:
6 = survival with no treatment
5 = surgery
4 = chemotherapy
3 = surgery & radiation
2 = surgery & chemotherapy
1 = surgery, radiation & chemotherapy
0 = death
Stage 0 Branch of Decision TreeStage 0 Branch of Decision Tree
1 Lumpectomy
2 Lumpectomy with radiation
3 Total mastectomy
Survival
Death
Death
Survival
Death
Survival
1
2
3
Death
Survival
100%
100%
100%
0%
0%
0%
1%
99%
0
0
0
0
5
4
5
6
EMV = 0.06
EMV = 5
EMV1 = 5
EMV3 = 5
EMV2 = 4
EMV = 5
Receive treatments
Don’t receive treatments
Stage 0
Stage I Branch of Decision TreeStage I Branch of Decision Tree1 Lumpectomy with removal of some lymph nodes with radiation & adjuvant therapy
2 Mastectomy with removal of some lymph nodes with radiation & adjuvant therapy
Survival
Death
Death
Survival
Death
Survival
1
2
92%
92%
8%
8%
1%
99%0
0
0
2
2
6
EMV1 = 1.84
EMV2 = 1.84
EMV = 0.06
EMV = 1.84
Stage I
Receive treatments
Don’t receive treatments
EMV = 1.84
Stage II Branch of Decision TreeStage II Branch of Decision Tree1 Lumpectomy with removal of some lymph nodes with radiation & adjuvant therapy
2 Mastectomy with removal of some lymph nodes with radiation & adjuvant therapy
Survival
Death
Stage IIA
Stage IIB
1 Lumpectomy with removal of some lymph nodes with radiation & adjuvant therapy
2 Mastectomy with removal of some lymph nodes with radiation & adjuvant therapy
Death1
2
1
2
Survival
Death
Survival
Death
Survival
Death
Survival
92%
92%
81%
81%
8%
8%
19%
19%
1%
99%
0
0
0
0
0
6
2
2
2
2
EMV1 = 1.62
EMV2 = 1.62
EMV = 0.06
EMV1 = 1.84
EMV2 = 1.84
EMV= 1.62
EMV= 1.84
EMV= 1.84
Stage II
Receive treatments
Don’t receive treatments
Stage III Branch of Decision TreeStage III Branch of Decision Tree1 Modified radical mastectomy with radiation & adjuvant therapy
2 Chemotherapy then lumpectomy with radiation & adjuvant therapy
Survival
Death
Stage IIIA
Stage IIIB
Death1
2
1
2
Survival
Death
Survival
Death
Survival
Death
Survival
Stage IIIC
1
2
Death
Survival
Death
Survival
1 Operable - modified radical mastectomy with radiation & adjuvant therapy
2 Inoperable – systemic chemotherapy, surgery and radiation
2 Systemic chemotherapy, surgery and radiation
1 Systemic chemotherapy
67%
67%
54%
54%
46%
46%
33%
33%
1%
99%0
0
0
0
0
0
0
6
1
2
4
1
2
2
?%
?%
?%
?%
EMV1 = 1.34
EMV2 = 1.34
EMV= 1.34
EMV1 = 2.16
EMV2 = 2.16
EMV= 2.16
EMV1 = ? >0
EMV2 = ? >0
EMV= ? >0
EMV= 0.06
EMV= 2.16
Receive treatments
Don’t receive treatments
Stage III
Stage IV Branch of Decision TreeStage IV Branch of Decision Tree
Survival
Death
Treatment can be done to lengthen and maintain quality of life.
100%
0%
0
6
Survival
Death80%
20%
0
1
EMV= 0.06
EMV = 0.20
EMV= 0.20
Receive treatments
Don’t receive treatments
Stage IV
Conclusion: DECISIONConclusion: DECISION
ASSUMPTIONS:ASSUMPTIONS:
•WhiteWhite
•WomanWoman
•Age 35-40 yearsAge 35-40 years
If diagnosed in the next 5 years, the If diagnosed in the next 5 years, the decision would be to receive treatments decision would be to receive treatments with an EMV = 2.43.with an EMV = 2.43.
No matter what stage of cancer the No matter what stage of cancer the testing reveals, still choose to receive testing reveals, still choose to receive treatments.treatments.
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