Transcript Click Here to Download: HFE742 Decision Presentation

Breast Cancer:
Treatment or Not?
HFE 742
Cathy Simmons
November 10, 2005
PLAN
Background
 Stages of breast cancer
 Influence diagram
 Treatments for stages – ”influence
diagrams”
 Decision tree
 The DECISION

Background
Personal reasons
Death of father
Incident in paternal grandfather
Death of mother-in-law
Statistics
Mortality rates
Incidence rates
US Mortality, 2002
Rank
Cause of Death
No. of
deaths
% of all
deaths
1.
Heart Diseases
696,947 28.5
2.
Cancer
557,271 22.8
3.
Cerebrovascular diseases
162,672 6.7
4.
Chronic lower respiratory diseases
124,816
5.
Accidents (Unintentional injuries)
106,742 4.4
6.
Diabetes mellitus
73,249
3.0
7.
Influenza and pneumonia
65,681
2.7
8.
Alzheimer disease
58,866
2.4
9.
Nephritis
40,974
1.7
33,865
1.4
10. Septicemia
5.1
Source: US Mortality Public Use Data Tape 2002, National Center for Health Statistics, Centers for Disease Control
and Prevention, 2004.
2005 Estimated US Cancer Deaths*
Lung and bronchus
31%
Prostate
10%
Colon and rectum
10%
Pancreas
5%
Leukemia
4%
Esophagus
4%
Liver and intrahepatic
bile duct
3%
Non-Hodgkin
Lymphoma
3%
Urinary bladder
3%
Kidney
3%
All other sites
24%
Men
295,280
Women
275,000
27%
Lung and bronchus
15%
Breast
10%
Colon and rectum
6%
Ovary
6%
Pancreas
4%
Leukemia
3%
Non-Hodgkin
lymphoma
3%
Uterine corpus
2%
Multiple myeloma
2%
Brain/ONS
22%
ONS=Other nervous system.
Source: American Cancer Society, 2005.
All other sites
2005 Estimated US Cancer Cases*
Prostate
33%
Lung and bronchus
Colon and rectum
Women
662,870
32%
Breast
13%
12%
Lung and bronchus
10%
11%
Colon and rectum
Urinary bladder
7%
Melanoma of skin
5%
Non-Hodgkin
lymphoma
4%
Kidney
3%
Leukemia
3%
Oral Cavity
3%
Pancreas
All Other Sites
Men
710,040
6%
Uterine corpus
4%
Non-Hodgkin
lymphoma
4%
Melanoma
of skin
3%
Ovary
2%
3%
Thyroid
17%
2%
Urinary bladder
2%
Pancreas
21%
All Other Sites
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2005.
Cancer Death Rates*, for
Women, US,1930-2001
100
Rate Per 100,000
Breast cancer has
consistently been a
leading cause of cancer
deaths since 1930.
80
60
Lung & bronchus
40
Uterus
Breast
Colon & rectum
Stomach
20
Ovary
*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.
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
Pancreas
1930
0
Age Specific Incidence & Death
Rates for Women with Breast
Cancer, by race, US,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
Cancer,
By Site, Women, US, 1999-2001
Site
Risk
All sites
Breast
1 in 3
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
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
Cancer Survival*(%) by Site and
Race,1995-2000
Site
White
African
American
Difference
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
*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.
Trends in Incidence Rates by Tumor &
Race, US,1988-1989 to 2001-2002
White
All races
African American
Source: Surveillance, Epidemiology, and End Results Program,
1973-2002, Division of Cancer Control and Population Science,
National Cancer Institute, 2005.
Trends in Incidence Rates by Stage &
Race, US,1975-1976 to 2001-2002
White
All races
African American
Source: Surveillance, Epidemiology, and End Results Program,
1973-2002, Division of Cancer Control and Population Science,
National Cancer Institute, 2005.
Female Breast Cancer, US,1995-2001
Source: Surveillance, Epidemiology, and End Results Program, 1973-2002, Division of
Cancer Control and Population Science, National Cancer Institute, 2005.
Stages of Female Breast Cancer
STAGE TUMOR
0
carcinoma in situ (abnormal cells)
SPREAD?
NO
I
tumor < 2 cm
NO
IIA
1) no tumor in breast but cancer in underarm lymph
nodes only
2) tumor < 2 cm & spread to underarm lymph nodes
only
3) tumor > 2 cm but < 5 cm
YES
1) tumor > 2 cm but < 5 cm & spread to underarm
lymph nodes only
2) tumor > 5 cm
YES
IIB
Source: National Cancer Institute, 2005.
YES
NO
NO
Stages of Female Breast Cancer
STAGE TUMOR
IIIA
SPREAD?
1) no tumor but has spread to underarm lymph nodes
& are attached to each other or other structures
2) tumor < 5 cm and spread to underarm lymph nodes
& are attached to each other or other structures
3) tumor > 5 cm and spread to underarm lymph nodes
& may be attached to each other or other structures
YES
IIIB
Any size tumor and spread to other tissues near the
breast and may have spread to the underarm lymph
nodes
YES
IIIC
Cancer has spread to the lymph nodes near the neck
and under the collarbone. (May be operable or
inoperable)
YES
IV
Cancer has spread to other organs
YES
Source: National Cancer Institute, 2005.
YES
YES
Objectives
Choose to receive treatments
for breast cancer
Maintain quality
of life
Able to care
For oneself
Five year survival
Able to
work
Able to
go places
with family
Decision
Fundamental
Objectives
Means
Objectives
Influence Diagram
Diagnosed with
breast cancer
Diagnose stage
of breast cancer
Receive treatments?
Remission
Death
Stage 0 Treatment Influence Diagram
Surgery
Pre-cancerous
cells only
Radiation
Chemotherapy
May have to have
this treatment
=
Stage I Treatment Influence Diagram
Tumor < 2 cm
92%
Stage I
Surgery
Radiation
Chemotherapy
May have to have
this treatment
=
Stage II Treatment Influence Diagram
Stage IIA
Tumor < 2 cm
92%
Stage IIA
Lymph nodes
underarm
Stage IIA
2 cm <Tumor < 5 cm
77%
Stage IIB
Tumor > 5 cm
55%
Stage IIB
Surgery,
Radiation &
Chemotherapy
Stage III Treatment Influence Diagram
Tumor < 5 cm
Surgery,
Radiation &
Chemotherapy
Stage IIIA
Lymph nodes
underarm attached
to each other
Stage IIIA
Stage IIIA
Stage IIIB
Other tissues
Stage IIIB
Stage IIIC
Tumor > 5 cm
55%
May also have
this condition
=
Lymph nodes
other than underarm
Stage IV Treatment Influence Diagram
Spread to other
organs in the
body
Surgery,
Radiation &
Chemotherapy
Planning the Decision Tree

Decisions


Receive treatments or not
Uncertain events
Stage of breast cancer
 Survival vs. death


Objectives
Maintain quality of life
 Five year survival

“Values” assigned to each outcome:
Decision Tree
20%
6 = survival with no treatment
Stage 0
5 = surgery
EMV = 5
CONTINUED…
4 = chemotherapy
37%
3 = surgery & radiation
EMV = 1.84
Stage I
CONTINUED…
Stage II
CONTINUED…
2 = surgery & chemotherapy
1 = surgery, radiation & chemotherapy
0 = death
EMV = 2.43
27%
Receive treatments
11%
Diagnosed with
breast cancer.
Choose to receive
treatment or not?
5%
1%
EMV = 1.84
EMV= 2.16
Stage III CONTINUED…
EMV= 0.20
Stage
IV CONTINUED…
Survival
6
EMV= 1.08
EMV= 1.08
Don’t receive treatments
99%
Death
0
Stage 0 Branch of Decision Tree
1 Lumpectomy
EMV1 = 5
100%
1
0%
EMV = 5
EMV2 = 4
Receive treatments
Survival 5
Death
100%
2
2 Lumpectomy with radiation
Survival 4
0%
Death
100%
EMV = 5
EMV3 = 5
Stage 0
3
0
Survival 5
0%
3 Total mastectomy
Death
1%
Survival
6
EMV = 0.06
Don’t receive treatments
99%
0
Death
0
0
Stage I Branch of Decision Tree
1 Lumpectomy with removal of
some lymph nodes with radiation
92%
& adjuvant therapy
1
EMV1 = 1.84
Survival 2
8%
Death
0
EMV = 1.84
Receive treatments
92%
EMV2 = 1.84
EMV = 1.84
2
2 Mastectomy with removal of
some lymph nodes with radiation
& adjuvant therapy
Stage I
1%
Survival 2
8%
Death
6
Survival
EMV = 0.06
Don’t receive treatments
99%
Death
0
0
Stage II Branch of Decision Tree
1 Lumpectomy with removal of
some lymph nodes with
radiation & adjuvant therapy
EMV= 1.84
1
EMV1 = 1.84
92%
8%
Stage IIA
92%
2
EMV2 = 1.84
2 Mastectomy with removal
of some lymph nodes with
radiation & adjuvant therapy
Receive treatments
1 Lumpectomy with removal of
some lymph nodes with
radiation & adjuvant therapy
EMV= 1.84
Stage II
EMV= 1.62
1
EMV1 = 1.62
Stage IIB
8%
81%
19%
81%
2
EMV2 = 1.62
2 Mastectomy with removal of
some lymph nodes with
radiation & adjuvant therapy
1%
Survival
6
EMV = 0.06
Don’t receive treatments
99%
Death
0
Survival 2
Death
0
Survival 2
Death
0
Survival 2
Death
0
Survival 2
19%
Death
0
Stage III Branch of Decision Tree
1 Modified radical mastectomy with
radiation & adjuvant therapy
EMV= 1.34
1
67%
EMV1 = 1.34
33%
Stage IIIA
EMV2 = 1.34
67%
2 Chemotherapy then lumpectomy
with radiation & adjuvant therapy
33%
2
1 Systemic chemotherapy
EMV= 2.16
Receive treatments
1
EMV= ? >0
Stage III
Stage IIIC
1%
EMV2 = 2.16
EMV1 = ? >0
54%
46%
?%
?%
Don’t receive treatments
Death
0
Death
0
Survival 1
Death
0
Survival 2
Death
0
Survival 1
EMV2 = ? >0
2 Inoperable – systemic
chemotherapy, surgery and radiation
Survival
6
EMV= 0.06
99%
0
Survival 4
?%
2
Survival 2
54%
46%
1 Operable - modified radical
mastectomy with radiation & adjuvant
therapy
1
0
EMV1 = 2.16
2 Systemic chemotherapy, surgery
and radiation
EMV= 2.16
Death
Death
Stage IIIB
2
Survival 2
?%
Death
0
Stage IV Branch of Decision Tree
Treatment can be done to lengthen and maintain quality of life.
20%
Receive treatments
1
Survival
EMV = 0.20
EMV= 0.20
80%
Death
0%
Survival
0
Stage IV
6
EMV= 0.06
Don’t receive treatments
100%
Death
0
Conclusion: DECISION
ASSUMPTIONS:
•White
•Woman
•Age 35-40 years
If diagnosed in the next 5 years, the decision
would be to receive treatments with an
EMV = 2.43.
No matter what stage of cancer the testing
reveals, still choose to receive treatments.
Bibliography
1. National Center for Health Statistics, Centers for Disease Control and
Prevention, 2004. US Mortality Public Use Data Tape 2002
2. American Cancer Society (2004). Cancer Facts & Figures 2004.
Retrieved November 1, 2005, from American Cancer Society website:
http://www.cancer.org/downloads/STT/CAFF_finalPWSecured.pdf
3. American Cancer Society (2005). Breast Cancer Facts & Figures 20052006. Retrieved November 1, 2005, from American Cancer Society
website: http://www.cancer.org/downloads/STT/CAFF2005BrF.pdf
4. American Cancer Society (2005). Cancer Reference Information.
Retrieved November 1, 2005, from American Cancer Society website:
http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_After_the_tests_S
taging_5.asp?sitearea
5. National Cancer Institute (2005). Breast Cancer: Treatment. Retrieved
November 1, 2005, from the National Cancer Institute website:
http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient/page2
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November 1, 2005 from the Susan G. Komen Breast Cancer Foundation
website:
http://www.komen.org/bsl_kbc/en/kbc_01_01a.htm
Bibliography
7. National Cancer Institute (2005). SEER Stat Fact Sheets. Retrieved
November 1, 2005 from the National Cancer Institute website:
http://seer.cancer.gov/statfacts/html/breast.html?statfacts_page=breast.ht
ml&x=15&y=13
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website:
http://www.cdc.gov/cancer/nbccedp/Reports/NationalReport/tables/6.htm
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Retrieved from Washington Hospital website:
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