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Jayasekera J, Stein S, Wilson OWA, Wojcik KM, Kamil D, Røssell EL, Abraham LA, O'Meara ES, Schoenborn NL, Schechter CB, Mandelblatt JS, Schonberg MA, Stout NK. Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study. J Gen Intern Med 2024; 39:428-439. [PMID: 38010458 PMCID: PMC10897118 DOI: 10.1007/s11606-023-08518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/27/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old. OBJECTIVE To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice. DESIGN, SETTING, AND PARTICIPANTS We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population). MAIN OUTCOMES AND MEASURES Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women. RESULTS Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses. CONCLUSIONS Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.
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Affiliation(s)
- Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities (NIMHD) Intramural Research Program (IRP), National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Sarah Stein
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Oliver W A Wilson
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities (NIMHD) Intramural Research Program (IRP), National Institutes of Health, Bethesda, MD, 20892, USA
| | - Kaitlyn M Wojcik
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities (NIMHD) Intramural Research Program (IRP), National Institutes of Health, Bethesda, MD, 20892, USA
| | - Dalya Kamil
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities (NIMHD) Intramural Research Program (IRP), National Institutes of Health, Bethesda, MD, 20892, USA
| | | | - Linn A Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Nancy Li Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clyde B Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeanne S Mandelblatt
- Georgetown Lombardi Institute for Cancer and Aging Research and the Cancer Prevention and Control Program at the Georgetown Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Jayasekera J, Zhao A, Schechter C, Lowry K, Yeh JM, Schwartz MD, O'Neill S, Wernli KJ, Stout N, Mandelblatt J, Kurian AW, Isaacs C. Reassessing the Benefits and Harms of Risk-Reducing Medication Considering the Persistent Risk of Breast Cancer Mortality in Estrogen Receptor-Positive Breast Cancer. J Clin Oncol 2023; 41:859-870. [PMID: 36455167 PMCID: PMC9901948 DOI: 10.1200/jco.22.01342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Recent studies, including a meta-analysis of 88 trials, have shown higher than expected rates of recurrence and death in hormone receptor-positive breast cancer. These new findings suggest a need to re-evaluate the use of risk-reducing medication to avoid invasive breast cancer and breast cancer death in high-risk women. METHODS We adapted an established Cancer Intervention and Surveillance Modeling Network model to evaluate the lifetime benefits and harms of risk-reducing medication in women with a ≥ 3% 5-year risk of developing breast cancer according to the Breast Cancer Surveillance Consortium risk calculator. Model input parameters were derived from meta-analyses, clinical trials, and large observational data. We evaluated the effects of 5 years of risk-reducing medication (tamoxifen/aromatase inhibitors) with annual screening mammography ± magnetic resonance imaging (MRI) compared with no screening, MRI, or risk-reducing medication. The modeled outcomes included invasive breast cancer, breast cancer death, side effects, false positives, and overdiagnosis. We conducted subgroup analyses for individual risk factors such as age, family history, and prior biopsy. RESULTS Risk-reducing tamoxifen with annual screening (± MRI) decreased the risk of invasive breast cancer by 40% and breast cancer death by 57%, compared with no tamoxifen or screening. This is equivalent to an absolute reduction of 95 invasive breast cancers, and 42 breast cancer deaths per 1,000 high-risk women. However, these drugs are associated with side effects. For example, tamoxifen could increase the number of endometrial cancers up to 11 per 1,000 high-risk women. Benefits and harms varied by individual characteristics. CONCLUSION The addition of risk-reducing medication to screening could further decrease the risk of breast cancer death. Clinical guidelines for high-risk women should consider integrating shared decision making for risk-reducing medication and screening on the basis of individual risk factors.
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Affiliation(s)
- Jinani Jayasekera
- Population and Community Health Sciences Branch, Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Amy Zhao
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Clyde Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Kathryn Lowry
- Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| | - Jennifer M. Yeh
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Marc D. Schwartz
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Suzanne O'Neill
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Natasha Stout
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Healthcare Institute, Boston, MA
| | - Jeanne Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Allison W. Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Claudine Isaacs
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
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Schmitz RSJM, Wilthagen EA, van Duijnhoven F, van Oirsouw M, Verschuur E, Lynch T, Punglia RS, Hwang ES, Wesseling J, Schmidt MK, Bleiker EMA, Engelhardt EG, PRECISION Consortium GC. Prediction Models and Decision Aids for Women with Ductal Carcinoma In Situ: A Systematic Literature Review. Cancers (Basel) 2022; 14:cancers14133259. [PMID: 35805030 PMCID: PMC9265509 DOI: 10.3390/cancers14133259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Ductal carcinoma in situ (DCIS) is a potential precursor to invasive breast cancer (IBC). Although in many women DCIS will never become breast cancer, almost all women diagnosed with DCIS undergo surgery with/without radiotherapy. Several studies are ongoing to de-escalate treatment for DCIS. Multiple decision support tools have been developed to aid women with DCIS in selecting the best treatment option for their specific goals. The aim of this study was to identify these decision support tools and evaluate their quality and clinical utility. Thirty-three studies were reviewed, in which four decision aids and six prediction models were described. While some of these models might be promising, most lacked important qualities such as tools to help women discuss their options or good quality validation studies. Therefore, the need for good quality, well validated decision support tools remains unmet. Abstract Even though Ductal Carcinoma in Situ (DCIS) can potentially be an invasive breast cancer (IBC) precursor, most DCIS lesions never will progress to IBC if left untreated. Because we cannot predict yet which DCIS lesions will and which will not progress, almost all women with DCIS are treated by breast-conserving surgery +/− radiotherapy, or even mastectomy. As a consequence, many women with non-progressive DCIS carry the burden of intensive treatment without any benefit. Multiple decision support tools have been developed to optimize DCIS management, aiming to find the balance between over- and undertreatment. In this systematic review, we evaluated the quality and added value of such tools. A systematic literature search was performed in Medline(ovid), Embase(ovid), Scopus and TRIP. Following the PRISMA guidelines, publications were selected. The CHARMS (prediction models) or IPDAS (decision aids) checklist were used to evaluate the tools’ methodological quality. Thirty-three publications describing four decision aids and six prediction models were included. The decision aids met at least 50% of the IPDAS criteria. However, most lacked tools to facilitate discussion of the information with healthcare providers. Five prediction models quantify the risk of an ipsilateral breast event after a primary DCIS, one estimates the risk of contralateral breast cancer, and none included active surveillance. Good quality and external validations were lacking for all prediction models. There remains an unmet clinical need for well-validated, good-quality DCIS risk prediction models and decision aids in which active surveillance is included as a management option for low-risk DCIS.
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Affiliation(s)
- Renée S. J. M. Schmitz
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
| | - Erica A. Wilthagen
- Department of Scientific Information Service, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | | | - Marja van Oirsouw
- Borstkanker Vereniging Nederland, 3511 DT Utrecht, The Netherlands; (M.v.O.); (E.V.)
| | - Ellen Verschuur
- Borstkanker Vereniging Nederland, 3511 DT Utrecht, The Netherlands; (M.v.O.); (E.V.)
| | - Thomas Lynch
- Division of Surgical Oncology, Duke University, Durham, NC 27708, USA; (T.L.); (E.S.H.)
| | - Rinaa S. Punglia
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - E. Shelley Hwang
- Division of Surgical Oncology, Duke University, Durham, NC 27708, USA; (T.L.); (E.S.H.)
| | - Jelle Wesseling
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Pathology, Nethelands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Marjanka K. Schmidt
- Department of Molecular Pathology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (R.S.J.M.S.); (J.W.); (M.K.S.)
| | - Eveline M. A. Bleiker
- Department of Psycho-Oncology and Epidemiology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
- Correspondence:
| | - Ellen G. Engelhardt
- Department of Psycho-Oncology and Epidemiology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
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A Comparison of Predicted Ipsilateral Tumor Recurrence Risks in Patients With Ductal Carcinoma in Situ of the Breast After Breast-Conserving Surgery by Breast Radiation Oncologists, the Van Nuys Prognostic Index, the Memorial Sloan Kettering Cancer Center DCIS Nomogram, and the 12-Gene DCIS Score Assay. Adv Radiat Oncol 2020; 6:100607. [PMID: 33912731 PMCID: PMC8071725 DOI: 10.1016/j.adro.2020.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose To compare ipsilateral breast event (IBE) risks in patients with ductal carcinoma in situ of the breast (DCIS) post-lumpectomy, as estimated by breast radiation oncologists, the Van Nuys Prognostic Index, the Memorial Sloan Kettering Cancer Center (MSKCC) DCIS nomogram, and the 12-gene Oncotype DX DCIS score assay. Methods and Materials Consecutive DCIS cases treated with lumpectomy from November 2011 to August 2014 with available DCIS score results were identified. Three radiation oncologists independently estimated the 10-year IBE risk. The Van Nuys Prognostic Index and MSKCC nomogram 10-year IBE risk estimates were generated. Differences and correlations between the IBE estimates and clinicopathologic factors were evaluated. Results Ninety-one patients were identified for inclusion. Forty-eight percent would have been ineligible for the E5194 study. The mean risk of IBE from the DCIS score assay was 12.4%, compared with a range of 18.9% to 26.8% from other sources. The mean IBE risk from the DCIS score assay was lower regardless of E5194 eligibility. The MSKCC nomogram and DCIS score assay risk estimates were weakly correlated with each other (P = .23) and were each moderately correlated with the other risk estimates (P = .41-.56). When applying the radiation oncologists’ treatment recommendations based on their proposed risk cutoffs, evaluating risk according to the DCIS score assay led to the highest proportion of patients recommended excision alone. Conclusions IBE risk estimates for this general community cohort of DCIS cases vary significantly among commonly available clinical predictive tools and individual radiation oncologist estimates. Surgical margins and tumor size continue to factor prominently in radiation oncologist decision algorithms. The differences found between the IBE risk estimate methods suggests that they are not interchangeable and the methods that rely on clinicopathologic features may tend to overestimate risk.
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Ozanne EM, Soeteman DI, Frank ES, Clarke J, Hassett MJ, Stout NK, Punglia RS. Commentary: Creating a patient-centered decision aid for ductal carcinoma in situ. Breast J 2020; 26:1498-1499. [PMID: 32034829 DOI: 10.1111/tbj.13779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Djøra I Soeteman
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts
| | - Elizabeth S Frank
- Dana-Farber/Harvard Center Breast Cancer Advocacy Group, DFCI, Boston, Massachusetts
| | - John Clarke
- Cornerstone Systems Northwest Inc, Boston, Massachusetts
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Westvik ÅS, Weedon-Fekjær H, Mæhlen J, Liestøl K. Evaluating different breast tumor progression models using screening data. BMC Cancer 2018; 18:209. [PMID: 29463227 PMCID: PMC5819671 DOI: 10.1186/s12885-018-4130-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background Mammography screening is used to detect breast cancer at an early treatable stage, reducing breast cancer mortality. Traditionally, breast cancer has been seen as a disease with only progressive lesions, and here we examine the validity of this assumption by testing if incidence levels after introducing mammography screening can be reproduced assuming only progressive tumors. Methods Breast cancer incidence data 1990–2009 obtained from the initially screened Norwegian counties (Akershus, Oslo, Rogaland and Hordaland) was included, covering the time-period before, during and after the introduction of mammography screening. From 1996 women aged 50–69 were invited for biennial public screening. Using estimates of tumor growth and screening sensitivity based on pre-screening and prevalence screening data (1990–1998), we simulated incidence levels during the following period (1999–2009). Results The simulated incidence levels during the period with repeated screenings were markedly below the observed levels. The results were robust to changes in model parameters. Adjusting for hormone replacement therapy use, we obtained levels closer to the observed levels. However, there was still a marked gap, and only by assuming some tumors that undergo regressive changes or enter a markedly less detectable state, was our model able to reproduce the observed incidence levels. Conclusions Models with strictly progressive tumors are only able to partly explain the changes in incidence levels observed after screening introduction in the initially screened Norwegian counties. More complex explanations than a time shift in detection of future clinical cancers seem to be needed to reproduce the incidence trends, questioning the basis for many over-diagnosis calculations. As data are not randomized, similar studies in other populations are wanted to exclude effect of unknown confounders. Electronic supplementary material The online version of this article (10.1186/s12885-018-4130-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Harald Weedon-Fekjær
- Oslo Center for biostatistics and epidemiology, Research Support Services, Oslo University Hospital, Norway, P.O. Box 4956 Nydalen, 0424, Oslo, Norway.
| | - Jan Mæhlen
- Department of Pathology, Oslo University Hospital, Norway, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Knut Liestøl
- Center of Cancer Biomedicine, Department of Informatics, University of Oslo, Norway, P.O. Box 1080 Blindern, 0316, Oslo, Norway
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Rutherford C, Mercieca-Bebber R, Butow P, Wu JL, King MT. Treatment decision-making in ductal carcinoma in situ: A mixed methods systematic review of women's experiences and information needs. PATIENT EDUCATION AND COUNSELING 2017; 100:1654-1666. [PMID: 28442156 DOI: 10.1016/j.pec.2017.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Decision-making in ductal carcinoma in situ (DCIS) is complex due to the heterogeneity of the disease. This study aimed to understand women's experience of making treatment decisions for DCIS, their information and support needs, and factors that influenced decisions. METHODS We searched six electronic databases, conference proceedings, and key authors. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Thematic analysis was used to combine and summarise findings. RESULTS We identified six themes and 28 subthemes from 18 studies. Women with DCIS have knowledge deficits about DCIS, experience anxiety related to information given at diagnosis and the complexity of decision-making, and have misconceptions regarding risks and outcomes of treatment. Women's decisions are influenced by their understanding of risk, the clinical features of their DCIS, and the benefits and harms of treatment options. Women are dissatisfied with the decisional support available. CONCLUSIONS Informed and shared decision-making in this complex decision setting requires clear communication of information specific to DCIS and individual's, as well as decision support for patients and clinicians. PRACTICE IMPLICATIONS This approach would educate patients and clinicians, and assist clinicians in supporting patients to an evidence-based treatment plan that aligns with individual values and pReferences.
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Affiliation(s)
- Claudia Rutherford
- School of Psychology, University of Sydney, NSW, 2006, Australia; Psycho-Oncology Co-operative Group (PoCoG), University of Sydney, NSW, 2006, Australia.
| | - Rebecca Mercieca-Bebber
- School of Psychology, University of Sydney, NSW, 2006, Australia; Psycho-Oncology Co-operative Group (PoCoG), University of Sydney, NSW, 2006, Australia; Central Clinical School, Sydney Medical School, University of Sydney, NSW, 2006, Australia
| | - Phyllis Butow
- School of Psychology, University of Sydney, NSW, 2006, Australia; Psycho-Oncology Co-operative Group (PoCoG), University of Sydney, NSW, 2006, Australia
| | - Jenny Liang Wu
- School of Psychology, University of Sydney, NSW, 2006, Australia
| | - Madeleine T King
- School of Psychology, University of Sydney, NSW, 2006, Australia; Psycho-Oncology Co-operative Group (PoCoG), University of Sydney, NSW, 2006, Australia; Central Clinical School, Sydney Medical School, University of Sydney, NSW, 2006, Australia
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Degeling K, Koffijberg H, IJzerman MJ. A systematic review and checklist presenting the main challenges for health economic modeling in personalized medicine: towards implementing patient-level models. Expert Rev Pharmacoecon Outcomes Res 2016; 17:17-25. [PMID: 27978765 DOI: 10.1080/14737167.2017.1273110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The ongoing development of genomic medicine and the use of molecular and imaging markers in personalized medicine (PM) has arguably challenged the field of health economic modeling (HEM). This study aims to provide detailed insights into the current status of HEM in PM, in order to identify if and how modeling methods are used to address the challenges described in literature. Areas covered: A review was performed on studies that simulate health economic outcomes for personalized clinical pathways. Decision tree modeling and Markov modeling were the most observed methods. Not all identified challenges were frequently found, challenges regarding companion diagnostics, diagnostic performance, and evidence gaps were most often found. However, the extent to which challenges were addressed varied considerably between studies. Expert commentary: Challenges for HEM in PM are not yet routinely addressed which may indicate that either (1) their impact is less severe than expected, (2) they are hard to address and therefore not managed appropriately, or (3) HEM in PM is still in an early stage. As evidence on the impact of these challenges is still lacking, we believe that more concrete examples are needed to illustrate the identified challenges and to demonstrate methods to handle them.
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Affiliation(s)
- Koen Degeling
- a Health Technology and Services Research Department, MIRA institute for Biomedical Technology and Technical Medicine , University of Twente , Enschede , The Netherlands
| | - Hendrik Koffijberg
- a Health Technology and Services Research Department, MIRA institute for Biomedical Technology and Technical Medicine , University of Twente , Enschede , The Netherlands
| | - Maarten J IJzerman
- a Health Technology and Services Research Department, MIRA institute for Biomedical Technology and Technical Medicine , University of Twente , Enschede , The Netherlands
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onlineDeCISion.org: a web-based decision aid for DCIS treatment. Breast Cancer Res Treat 2016; 154:181-90. [PMID: 26475704 DOI: 10.1007/s10549-015-3605-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
Women diagnosed with DCIS face complex treatment decisions and often do so with inaccurate and incomplete understanding of the risks and benefits involved. Our objective was to create a tool to guide these decisions for both providers and patients. We developed a web-based decision aid designed to provide clinicians with tailored information about a patient’s recurrence risks and survival outcomes following different treatment strategies for DCIS. A theoretical framework, microsimulation model (Soeteman et al., J Natl Cancer 105:774–781, 2013) and best practices for web-based decision tools guided the development of the decision aid. The development process used semi-structured interviews and usability testing with key stakeholders, including a diverse group of multidisciplinary clinicians and a patient advocate. We developed onlineDeCISion.org to include the following features that were rated as important by the stakeholders: (1) descriptions of each of the standard treatment options available; (2) visual projections of the likelihood of time-specific (10-year and lifetime) breast-preservation, recurrence, and survival outcomes; and (3) side-by-side comparisons of down-stream effects of each treatment choice. All clinicians reviewing the decision aid in usability testing were interested in using it in their clinical practice. The decision aid is available in a web-based format and is planned to be publicly available. To improve treatment decision making in patients with DCIS, we have developed a web-based decision aid onlineDeCISion.org that conforms to best practices and that clinicians are interested in using in their clinics with patients to better inform treatment decisions.
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Nichols HB, Bowles EJA, Islam J, Madziwa L, Stürmer T, Tran DT, Buist DSM. Tamoxifen Initiation After Ductal Carcinoma In Situ. Oncologist 2016; 21:134-40. [PMID: 26768485 PMCID: PMC4746086 DOI: 10.1634/theoncologist.2015-0310] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/28/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endocrine therapy initiation after ductal carcinoma in situ (DCIS) is highly variable and largely unexplained. National guidelines recommend considering tamoxifen for women with estrogen receptor-positive (ER+) DCIS or who undergo excision alone. We evaluated endocrine therapy use after DCIS over a 15-year period in an integrated health care setting to identify factors related to initiation. METHODS Female Group Health Cooperative enrollees ages 18-89 years with a DCIS diagnosis during 1996-2011 were eligible for inclusion. Endocrine therapy was identified through pharmacy records. Tumor and treatment information were from tumor registry reports; demographics and other risk factors were from questionnaires and electronic medical records. Relative risks (RRs) and 95% confidence intervals (CIs) for endocrine therapy initiation were calculated using multivariable generalized linear models. RESULTS We identified 727 women with a DCIS diagnosis, including 163 (22%) who initiated endocrine therapy (149 tamoxifen, 14 aromatase inhibitor). Younger women were more likely to initiate endocrine therapy (RR 1.69; 95% CI 1.16-2.46 for ages 45-54 vs. 65-74 years). Compared with breast-conserving surgery (BCS) with radiation, women who had BCS alone (RR 0.46; 95% CI 0.25-0.84) or mastectomy (RR 0.54; 95% CI 0.39-0.75) were less likely to use endocrine therapy. ER testing increased from 4% of DCIS cases in 2001 to 71% in 2011; however, endocrine therapy initiation decreased from 58% of ER+ DCIS in 2001-2005 to 37% in 2009-2011. CONCLUSION Increasing ER testing since 2001 has not corresponded to parallel increases in endocrine therapy initiation. Age, surgery, and radiation were the primary factors associated with initiation. IMPLICATIONS FOR PRACTICE National guidelines recommend considering tamoxifen for women with ductal carcinoma in situ (DCIS) who are estrogen receptor-positive (ER+) or who undergo excision alone. In this study, the rapid increase in ER testing caused by tamoxifen's approval in 2000 did not lead to increases in endocrine therapy initiation, despite recognition of an increasing number of DCIS tumors as ER+ each year. Contrary to the suggested guidelines, women who had breast-conserving surgery without radiation were less likely to use tamoxifen than those who had radiation. Future Food and Drug Administration approval of new endocrine agents for DCIS (such as aromatase inhibitors) may provide an opportunity to reemphasize benefits by ER and surgery status.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents, Hormonal/administration & dosage
- Aromatase Inhibitors/administration & dosage
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/genetics
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Estrogen Receptor alpha/genetics
- Female
- Guidelines as Topic
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Tamoxifen/administration & dosage
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Affiliation(s)
- Hazel B Nichols
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Jessica Islam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diem-Thy Tran
- Group Health Research Institute, Seattle, Washington, USA
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Qian GW, Ni XJ, Wang Z, Jiang YZ, Yu KD, Shao ZM. Effect of radiotherapy on survival of women with locally excised ductal carcinoma in situ of the breast: a Surveillance, Epidemiology, and End Results population-based analysis. Onco Targets Ther 2015; 8:1407-18. [PMID: 26089689 PMCID: PMC4467663 DOI: 10.2147/ott.s82087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Although it has been previously reported that radiotherapy (RT) effectively reduced the incidence of local recurrence of ductal carcinoma in situ (DCIS) following breast-conserving surgery (BCS), little is known about the effect of RT on survival of patients with locally excised DCIS. Patients and methods Using Surveillance, Epidemiology, and End Results registry data, we selected 56,968 female DCIS patients treated with BCS between 1998 and 2007. Overall survival (OS) and breast cancer-specific survival (BCSS) were compared among patients who received RT or no RT using the Kaplan–Meier methods and Cox proportional hazards regression models. Results Median follow-up was 91 months. In the multivariable model, patients receiving postoperative RT had better OS than those undergoing BCS alone (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.53–0.67, P<0.001). This pattern remained after stratification by estrogen receptor (ER) status and age. In contrast, RT delivery was not significantly associated with improved BCSS (HR 0.71, 95% CI 0.48–1.03, P=0.073). However, after stratifying by the above two variables, RT contributed to better BCSS in ER-negative/borderline patients (HR 0.41, 95% CI 0.19–0.88, P=0.023) and younger patients (≤50 years old; HR 0.37, 95% CI 0.15–0.91, P=0.030). Conclusion Our analysis confirms the beneficial effect of RT on OS in women with locally excised DCIS and reveals the specific protective effect of RT on BCSS in ER-negative/borderline and younger patients.
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Affiliation(s)
- Guo-Wei Qian
- Department of Breast Surgery, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
| | - Xiao-Jian Ni
- Department of Breast Surgery, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
| | - Zheng Wang
- Department of Radiation Oncology, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
| | - Yi-Zhou Jiang
- Department of Breast Surgery, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
| | - Ke-Da Yu
- Department of Breast Surgery, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Shanghai Cancer Center and Cancer Institute, Fudan University, Shanghai, People's Republic of China
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Leveraging comparative effectiveness research to improve the quality of multidisciplinary care for breast cancer patients. Cancer Treat Res 2015; 164:15-30. [PMID: 25677016 DOI: 10.1007/978-3-319-12553-4_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Breast cancer is the most commonly diagnosed cancer among women. To date, the use of efficacy randomized controlled trials (RCTs) in breast cancer have resulted in dramatic improvements in oncologic outcomes for this disease. However, not every question pertinent to breast cancer is amenable to such efficacy trials. This chapter will discuss some of the unique aspects of breast cancer that make efficacy RCTs challenging and/or impractical, how comparative effectiveness research can be used to address these issues, and identify several key questions which would benefit from ongoing comparative effectiveness research.
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Radiotherapy in DCIS, an underestimated benefit? Radiother Oncol 2014; 112:1-8. [DOI: 10.1016/j.radonc.2014.06.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/18/2014] [Accepted: 06/15/2014] [Indexed: 12/28/2022]
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14
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Greenberg CC, Habel LA, Hughes ME, Nekhlyudov L, Achacoso N, Acton L, Schrag D, Jiang W, Edge S, Weeks JC, Punglia RS. Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ. Ann Surg Oncol 2014; 21:3766-73. [PMID: 24859938 DOI: 10.1245/s10434-014-3802-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The optimal treatment strategy for ductal carcinoma in situ (DCIS) continues to evolve and should consider the consequences of initial treatment on the likelihood, type, and treatment of recurrences. METHODS We conducted a retrospective cohort study using two data sources of patients who experienced a recurrence (DCIS or invasive cancer) following breast-conserving surgery (BCS) for index DCIS: patients with an index DCIS diagnosed from 1997 to 2008 at the academic institutions of the National Comprehensive Cancer Network (NCCN; N = 88) and patients with an index DCIS diagnosed from 1990 to 2001 at community-based integrated healthcare delivery sites of the Health Maintenance Organization Cancer Research Network (CRN) (N = 182). RESULTS Just under half of local recurrences in both cohorts were invasive cancer. While 40 % of patients in both cohorts underwent mastectomy alone at recurrence, treatment of the remaining patients varied. In the earlier CRN cohort, most other patients underwent repeat BCS (39 %) with only 18 % receiving mastectomy with reconstruction, whereas only 16 % had repeat BCS and 44 % had mastectomy with reconstruction in the NCCN cohort. Compared with patients not treated with radiation, those who received radiation for index DCIS were less likely to undergo repeat BCS (NCCN: 6.6 vs. 37 %, p = 0.001; CRN: 20 vs. 48 %, p = 0.0004) and more likely to experience surgical complications after treatment of recurrence (NCCN: 15 vs. 4 %, p = 0.17; CRN: 40 vs. 25 %, p = 0.09). CONCLUSION We found that treatment of recurrences after BCS and subsequent complications may be affected by the use of radiotherapy for the index DCIS. Initial treatment of DCIS may have long-term implications that should be considered.
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Affiliation(s)
- Caprice C Greenberg
- Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA,
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Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat 2013; 143:343-50. [DOI: 10.1007/s10549-013-2813-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 12/06/2013] [Indexed: 11/12/2022]
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Jagsi R, Hayman J. Informing patient decisions regarding management of ductal carcinoma in situ. J Natl Cancer Inst 2013; 105:758-9. [PMID: 23644481 DOI: 10.1093/jnci/djt113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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