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.

BibliographyBibliography

1. National Center for Health Statistics, Centers for Disease 1. National Center for Health Statistics, Centers for Disease Control and Control and Prevention, 2004. Prevention, 2004. US Mortality Public Use Data Tape 2002US Mortality Public Use Data Tape 20022. American Cancer Society (2004). 2. American Cancer Society (2004). Cancer Facts & Figures 2004.Cancer Facts & Figures 2004.Retrieved November 1, 2005, from American Cancer Society Retrieved November 1, 2005, from American Cancer Society website: website: http://www.cancer.org/downloads/STT/CAFF_finalPWSecured.pdf3. American Cancer Society (2005). 3. American Cancer Society (2005). Breast Cancer Facts & Breast Cancer Facts & Figures 2005-2006. Figures 2005-2006. Retrieved November 1, 2005, from American Retrieved November 1, 2005, from American Cancer Society website: Cancer Society website: http://www.cancer.org/downloads/STT/CAFF2005BrF.pdf4. American Cancer Society (2005). 4. American Cancer Society (2005). Cancer Reference Cancer Reference Information. Information. Retrieved November 1, 2005, from American Cancer Retrieved November 1, 2005, from American Cancer Society website:Society website:http://www.cancer.org/docroot/CRI/content/http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_After_the_tests_Staging_5.asp?siteareaCRI_2_2_3X_After_the_tests_Staging_5.asp?sitearea5. National Cancer Institute (2005). 5. National Cancer Institute (2005). Breast Cancer: Treatment.Breast Cancer: Treatment. RetrievedRetrievedNovember 1, 2005, from the National Cancer Institute website:November 1, 2005, from the National Cancer Institute website:http://www.cancer.gov/cancertopics/pdq/treatment/breast/http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient/page2Patient/page26. The Susan G. Komen Breast Cancer Foundation (2003-2005). 6. The Susan G. Komen Breast Cancer Foundation (2003-2005). RetrievedRetrievedNovember 1, 2005 from the Susan G. Komen Breast Cancer November 1, 2005 from the Susan G. Komen Breast Cancer Foundation website:Foundation website:http://www.komen.org/bsl_kbc/en/kbc_01_01a.htmhttp://www.komen.org/bsl_kbc/en/kbc_01_01a.htm

7. National Cancer Institute (2005). SEER Stat Fact Sheets. 7. National Cancer Institute (2005). SEER Stat Fact Sheets. Retrieved November 1, 2005 from the National Cancer Institute Retrieved November 1, 2005 from the National Cancer Institute website:website:http://seer.cancer.gov/statfacts/html/breast.html?http://seer.cancer.gov/statfacts/html/breast.html?statfacts_page=breast.html&x=15&y=13statfacts_page=breast.html&x=15&y=138. Kamenova, B.S, Sanmugarajah J. and Solomon, W. (2005). 8. Kamenova, B.S, Sanmugarajah J. and Solomon, W. (2005). Tumor size and stage distribution among the newly diagnosed Tumor size and stage distribution among the newly diagnosed breast cancer patients in an inner-city hospital in Brooklyn. breast cancer patients in an inner-city hospital in Brooklyn. Journal of Clinical OncologyJournal of Clinical Oncology, , V 23, No. 16S (June 1 Supplement). V 23, No. 16S (June 1 Supplement). Retrieved from Journal of Clinical Oncology website: Retrieved from Journal of Clinical Oncology website: http://meeting.jco.org/cgi/content/abstract/23/16_suppl/902http://meeting.jco.org/cgi/content/abstract/23/16_suppl/9029. Center for Disease Control and Prevention (2005). Retrieved 9. Center for Disease Control and Prevention (2005). Retrieved from CDC website: from CDC website: http://www.cdc.gov/cancer/nbccedp/Reports/NationalReport/tableshttp://www.cdc.gov/cancer/nbccedp/Reports/NationalReport/tables/6.htm/6.htm10. “2004 Cancer Committee Annual Report” released Oct. 2005. 10. “2004 Cancer Committee Annual Report” released Oct. 2005. Retrieved from Washington Hospital website:Retrieved from Washington Hospital website:http://www.washingtonhospital.org/Cancer%20Reports/http://www.washingtonhospital.org/Cancer%20Reports/2004%20Cancer%20Committee%20Annual%20Report.pdf2004%20Cancer%20Committee%20Annual%20Report.pdf

BibliographyBibliography