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 Source: US Mortality Public Use Data Tape 2002, National Center for Health Statistics, Centers for Disease Control and Prevention, Heart Diseases696, Cancer557, Cerebrovascular diseases162, Chronic lower respiratory diseases124, Accidents (Unintentional injuries)106, Diabetes mellitus73, Influenza and pneumonia65, Alzheimer disease58, Nephritis40, Septicemia33, RankCause of Death No. of deaths % of all deaths

2005 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, Men 295,280 Women 275,000 27%Lung and bronchus 15%Breast 10%Colon and rectum 6%Ovary 6%Ovary 6%Pancreas 6%Pancreas 4%Leukemia 4%Leukemia 3%Non-Hodgkin lymphoma 3%Non-Hodgkin lymphoma 3%Uterine corpus 3%Uterine corpus 2%Multiple myeloma 2%Multiple myeloma 2%Brain/ONS 2%Brain/ONS 22% All other sites Lung and bronchus31% Prostate10% Colon and rectum10% Pancreas5% Leukemia4% Esophagus4% Liver and intrahepatic3% bile duct Non-Hodgkin 3% Lymphoma Urinary bladder3% Kidney3% All other sites 24%

2005 Estimated US Cancer Cases* *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Men 710,040 Women 662,870 32%Breast 12%Lung and bronchus 11%Colon and rectum 6%Uterine corpus 4%Non-Hodgkin lymphoma 4%Non-Hodgkin lymphoma 4%Melanoma of skin 3% Ovary 3% Ovary 3%Thyroid 3%Thyroid 2%Urinary bladder 2%Pancreas 21%All Other Sites Prostate33% Lung and bronchus13% Colon and rectum10% Urinary bladder7% Melanoma of skin5% Non-Hodgkin4% lymphoma Kidney3% Leukemia3% Oral Cavity3% Pancreas2% All Other Sites17%

Cancer Death Rates*, for Women, US, *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes , US Mortality Volumes , National Center for Health Statistics, Centers for Disease Control and Prevention, Lung & bronchus Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000 Breast cancer has consistently been a leading cause of cancer deaths since 1930.

Age Specific Incidence & Death Rates for Women with Breast Cancer, by race, US, Source: Incidence – Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Science, National Cancer Institute, Deaths – National Center for Health Statistics, Centers for disease Control and Prevention, 2005.

Lifetime Probability of Developing Cancer, By Site, Women, US, Source:DevCan: Probability of Developing or Dying of Cancer Software, Version 5.2 Statistical Research and Applications Branch, NCI, SiteRisk 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 Race, *5-year relative survival rates based on cancer patients diagnosed from 1995 to 2000 and followed through Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Sciences, National Cancer Institute, All Sites Breast (female) Colon Esophagus Leukemia Non-Hodgkin lymphoma Oral cavity Prostate Rectum Urinary bladder Uterine cervix74668 Uterine corpus Site White Difference African American

Trends in Incidence Rates by Tumor & Race, US, to Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Science, National Cancer Institute, White All races African American

Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Science, National Cancer Institute, White All races African American Trends in Incidence Rates by Stage & Race, US, to

Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Science, National Cancer Institute, Female Breast Cancer, US,

STAGETUMOR SPREAD? 0carcinoma in situ (abnormal cells) NO Itumor < 2 cm NO IIA1) no tumor in breast but cancer in underarm lymph YES nodes only 2) tumor < 2 cm & spread to underarm lymph nodes YES only 3) tumor > 2 cm but < 5 cm NO IIB1) tumor > 2 cm but < 5 cm & spread to underarm YES lymph nodes only 2) tumor > 5 cm NO Stages of Female Breast Cancer Source: National Cancer Institute, 2005.

STAGETUMOR SPREAD? IIIA1) 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 IIIBAny size tumor and spread to other tissues near the YES breast and may have spread to the underarm lymph nodes IIICCancer has spread to the lymph nodes near the neck YES and under the collarbone. (May be operable or inoperable) IVCancer has spread to other organs YES Stages of Female Breast Cancer Source: National Cancer Institute, 2005.

Objectives Choose to receive treatments for breast cancer Decision Maintain quality of life Five year survival Able to care For oneself Fundamental Objectives Means Objectives Able to work go places with family

Influence Diagram Diagnosed with breast cancer Receive treatments? Diagnose stage of breast cancer Remission Death

Pre-cancerous cells only Surgery Radiation Chemotherapy May have to have this treatment = Stage 0 Treatment Influence Diagram

Stage I Treatment Influence Diagram Tumor < 2 cm 92% Stage I May have to have this treatment = Surgery Radiation Chemotherapy

Stage II Treatment Influence Diagram Tumor < 2 cm 92% Surgery, Radiation & Chemotherapy 2 cm <Tumor < 5 cm 77% Tumor > 5 cm 55% Lymphnodes Lymph nodesunderarm Stage IIA Stage IIB Stage IIA Stage IIB

Stage III Treatment Influence Diagram Tumor > 5 cm 55% Lymph nodes underarm attached to each other Surgery, Radiation & Chemotherapy Stage IIIA Tumor < 5 cm Stage IIIA Other tissues Stage IIIB Lymph nodes other than underarm Stage IIIC May also have this condition = Stage IIIB

Stage IV Treatment Influence Diagram Surgery, Radiation & Chemotherapy Spread to other organs in the body

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

Decision Tree Diagnosed with breast cancer. Choose to receive treatment or not? Survival Death CONTINUED… 0 6 EMV = 5 EMV = 1.84 EMV= 2.16 EMV= 0.20 EMV= 1.08 EMV = 2.43 EMV= % 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 Tree 1 Lumpectomy 2 Lumpectomy with radiation 3 Total mastectomy Survival Death Survival Death Survival Death Survival 100% 0% 1% 99% EMV = 0.06 EMV = 5 EMV 1 = 5 EMV 3 = 5 EMV 2 = 4 EMV = 5 Receive treatments Don’t receive treatments Stage 0

Stage I Branch of Decision Tree 1 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 Survival Death Survival % 8% 1% 99% EMV 1 = 1.84 EMV 2 = 1.84 EMV = 0.06 EMV = 1.84 Stage I Receive treatments Don’t receive treatments EMV = 1.84

Stage II Branch of Decision Tree 1 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 Death Survival Death Survival Death Survival Death Survival 92% 81% 8% 19% 1% 99% EMV 1 = 1.62 EMV 2 = 1.62 EMV = 0.06 EMV 1 = 1.84 EMV 2 = 1.84 EMV= 1.62 EMV= 1.84 Stage II Receive treatments Don’t receive treatments

Stage III Branch of Decision Tree 1 Modified radical mastectomy with radiation & adjuvant therapy 2 Chemotherapy then lumpectomy with radiation & adjuvant therapy Survival Death Stage IIIA Stage IIIB Death 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% 54% 46% 33% 1% 99% ?% EMV 1 = 1.34 EMV 2 = 1.34 EMV= 1.34 EMV 1 = 2.16 EMV 2 = 2.16 EMV= 2.16 EMV 1 = ? >0 EMV 2 = ? >0 EMV= ? >0 EMV= 0.06 EMV= 2.16 Receive treatments Don’t receive treatments Stage III

Stage IV Branch of Decision Tree Survival Death Treatment can be done to lengthen and maintain quality of life. 100% 0% 0 6 Survival Death 80% 20% 0 1 EMV= 0.06 EMV = 0.20 Receive treatments Don’t receive treatments Stage IV

Conclusion: DECISION ASSUMPTIONS: WhiteWhite WomanWoman Age yearsAge years If diagnosed in the next 5 years, the decision would be to receive treatments with an EMV = 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, US Mortality Public Use Data Tape American Cancer Society (2004). Cancer Facts & Figures Retrieved November 1, 2005, from American Cancer Society website: American Cancer Society (2005). Breast Cancer Facts & Figures Retrieved November 1, 2005, from American Cancer Society website: American Cancer Society (2005). Cancer Reference Information. Retrieved November 1, 2005, from American Cancer Society website: taging_5.asp?sitearea taging_5.asp?sitearea 5. National Cancer Institute (2005). Breast Cancer: Treatment. Retrieved November 1, 2005, from the National Cancer Institute website: 6. The Susan G. Komen Breast Cancer Foundation ( ). Retrieved November 1, 2005 from the Susan G. Komen Breast Cancer Foundation website:

7. National Cancer Institute (2005). SEER Stat Fact Sheets. Retrieved November 1, 2005 from the National Cancer Institute website: ml&x=15&y=13 ml&x=15&y=13 8. Kamenova, B.S, Sanmugarajah J. and Solomon, W. (2005). Tumor size and stage distribution among the newly diagnosed breast cancer patients in an inner-city hospital in Brooklyn. Journal of Clinical Oncology, V 23, No. 16S (June 1 Supplement). Retrieved from Journal of Clinical Oncology website: Center for Disease Control and Prevention (2005). Retrieved from CDC website: “2004 Cancer Committee Annual Report” released Oct Retrieved from Washington Hospital website: 20Committee%20Annual%20Report.pdf 20Committee%20Annual%20Report.pdfBibliography