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Hendrick RE, Monticciolo DL. USPSTF Recommendations and Overdiagnosis. JOURNAL OF BREAST IMAGING 2024:wbae028. [PMID: 38865364 DOI: 10.1093/jbi/wbae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Indexed: 06/14/2024]
Abstract
Overdiagnosis is the concept that some cancers detected at screening would never have become clinically apparent during a woman's lifetime in the absence of screening. This could occur if a woman dies of a cause other than breast cancer in the interval between mammographic detection and clinical detection (obligate overdiagnosis) or if a mammographically detected breast cancer fails to progress to clinical presentation. Overdiagnosis cannot be measured directly. Indirect methods of estimating overdiagnosis include use of data from randomized controlled trials (RCTs) designed to evaluate breast cancer mortality, population-based screening studies, or modeling. In each case, estimates of overdiagnosis must consider lead time, breast cancer incidence trends in the absence of screening, and accurate and predictable rates of tumor progression. Failure to do so has led to widely varying estimates of overdiagnosis. The U.S. Preventive Services Task Force (USPSTF) considers overdiagnosis a major harm of mammography screening. Their 2024 report estimated overdiagnosis using summary evaluations of 3 RCTs that did not provide screening to their control groups at the end of the screening period, along with Cancer Intervention and Surveillance Network modeling. However, there are major flaws in their evidence sources and modeling estimates, limiting the USPSTF assessment. The most plausible estimates remain those based on observational studies that suggest overdiagnosis in breast cancer screening is 10% or less and can be attributed primarily to obligate overdiagnosis and nonprogressive ductal carcinoma in situ.
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Affiliation(s)
- R Edward Hendrick
- Department of Radiology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
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2
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O’Keefe T, Yau C, Iaconetti E, Jeong E, Brabham C, Kim P, McGuire J, Griffin A, Wallace A, Esserman L, Harismendy O, Hirst G. Duration of Endocrine Treatment for DCIS impacts second events: Insights from a large cohort of cases at two academic medical centers. RESEARCH SQUARE 2024:rs.3.rs-3403438. [PMID: 38260526 PMCID: PMC10802747 DOI: 10.21203/rs.3.rs-3403438/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Ductal carcinoma in situ (DCIS) incidence has risen rapidly with the introduction of screening mammography, yet it is unclear who benefits from both the amount and type of adjuvant treatment (radiation therapy, (RT), endocrine therapy (ET)) versus what constitutes over-treatment. Our goal was to identify the effects of adjuvant RT, or ET+/- RT versus breast conservation surgery (BCS) alone in a large multi-center registry of retrospective DCIS cases (N = 1,916) with median follow up of 8.2 years. We show that patients with DCIS who took less than 2 years of adjuvant ET alone have a similar second event rate as BCS. However, patients who took more than 2 years of ET show a significantly reduced second event rate, similar to those who received either RT or combined ET+RT, which was independent of age, tumor size, grade, or period of diagnosis. This highlights the importance of ET duration for risk reduction.
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Affiliation(s)
- Thomas O’Keefe
- Department of Surgery, University of California, San Diego
| | - Christina Yau
- Department of Surgery, University of California, San Francisco, CA
| | - Emma Iaconetti
- Department of Surgery, University of California, San Francisco, CA
| | - Eliza Jeong
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Case Brabham
- Department of Surgery, University of California, San Francisco, CA
| | - Paul Kim
- Department of Surgery, University of California, San Francisco, CA
| | | | - Ann Griffin
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Anne Wallace
- Department of Surgery, University of California, San Diego
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA
| | - Olivier Harismendy
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Gillian Hirst
- Department of Surgery, University of California, San Francisco, CA
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Poelhekken K, Lin Y, Greuter MJW, van der Vegt B, Dorrius M, de Bock GH. The natural history of ductal carcinoma in situ (DCIS) in simulation models: A systematic review. Breast 2023; 71:74-81. [PMID: 37541171 PMCID: PMC10412870 DOI: 10.1016/j.breast.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVE Assumptions on the natural history of ductal carcinoma in situ (DCIS) are necessary to accurately model it and estimate overdiagnosis. To improve current estimates of overdiagnosis (0-91%), the purpose of this review was to identify and analyse assumptions made in modelling studies on the natural history of DCIS in women. METHODS A systematic review of English full-text articles using PubMed, Embase, and Web of Science was conducted up to February 6, 2023. Eligibility and all assessments were done independently by two reviewers. Risk of bias and quality assessments were performed. Discrepancies were resolved by consensus. Reader agreement was quantified with Cohen's kappa. Data extraction was performed with three forms on study characteristics, model assessment, and tumour progression. RESULTS Thirty models were distinguished. The most important assumptions regarding the natural history of DCIS were addition of non-progressive DCIS of 20-100%, classification of DCIS into three grades, where high grade DCIS had an increased chance of progression to invasive breast cancer (IBC), and regression possibilities of 1-4%, depending on age and grade. Other identified risk factors of progression of DCIS to IBC were younger age, birth cohort, larger tumour size, and individual risk. CONCLUSION To accurately model the natural history of DCIS, aspects to consider are DCIS grades, non-progressive DCIS (9-80%), regression from DCIS to no cancer (below 10%), and use of well-established risk factors for progression probabilities (age). Improved knowledge on key factors to consider when studying DCIS can improve estimates of overdiagnosis and optimization of screening.
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Affiliation(s)
- Keris Poelhekken
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands.
| | - Yixuan Lin
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands
| | - Marcel J W Greuter
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands
| | - Bert van der Vegt
- University of Groningen, University Medical Center Groningen, Groningen, Department of Pathology and Medical Biology, PO Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Monique Dorrius
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, PO Box 30.001, EB44, 9700, RB, Groningen, the Netherlands
| | - Geertruida H de Bock
- University of Groningen, University Medical Center Groningen, Groningen, Department of Epidemiology, P.O. Box 30 001, FA40, 9700, RB, Groningen, the Netherlands
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Sprague BL, Chen S, Miglioretti DL, Gard CC, Tice JA, Hubbard RA, Aiello Bowles EJ, Kaufman PA, Kerlikowske K. Cumulative 6-Year Risk of Screen-Detected Ductal Carcinoma In Situ by Screening Frequency. JAMA Netw Open 2023; 6:e230166. [PMID: 36808238 PMCID: PMC9941892 DOI: 10.1001/jamanetworkopen.2023.0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
IMPORTANCE Detection of ductal carcinoma in situ (DCIS) by mammography screening is a controversial outcome with potential benefits and harms. The association of mammography screening interval and woman's risk factors with the likelihood of DCIS detection after multiple screening rounds is poorly understood. OBJECTIVE To develop a 6-year risk prediction model for screen-detected DCIS according to mammography screening interval and women's risk factors. DESIGN, SETTING, AND PARTICIPANTS This Breast Cancer Surveillance Consortium cohort study assessed women aged 40 to 74 years undergoing mammography screening (digital mammography or digital breast tomosynthesis) from January 1, 2005, to December 31, 2020, at breast imaging facilities within 6 geographically diverse registries of the consortium. Data were analyzed between February and June 2022. EXPOSURES Screening interval (annual, biennial, or triennial), age, menopausal status, race and ethnicity, family history of breast cancer, benign breast biopsy history, breast density, body mass index, age at first birth, and false-positive mammography history. MAIN OUTCOMES AND MEASURES Screen-detected DCIS defined as a DCIS diagnosis within 12 months after a positive screening mammography result, with no concurrent invasive disease. RESULTS A total of 916 931 women (median [IQR] age at baseline, 54 [46-62] years; 12% Asian, 9% Black, 5% Hispanic/Latina, 69% White, 2% other or multiple races, and 4% missing) met the eligibility criteria, with 3757 screen-detected DCIS diagnoses. Screening round-specific risk estimates from multivariable logistic regression were well calibrated (expected-observed ratio, 1.00; 95% CI, 0.97-1.03) with a cross-validated area under the receiver operating characteristic curve of 0.639 (95% CI, 0.630-0.648). Cumulative 6-year risk of screen-detected DCIS estimated from screening round-specific risk estimates, accounting for competing risks of death and invasive cancer, varied widely by all included risk factors. Cumulative 6-year screen-detected DCIS risk increased with age and shorter screening interval. Among women aged 40 to 49 years, the mean 6-year screen-detected DCIS risk was 0.30% (IQR, 0.21%-0.37%) for annual screening, 0.21% (IQR, 0.14%-0.26%) for biennial screening, and 0.17% (IQR, 0.12%-0.22%) for triennial screening. Among women aged 70 to 74 years, the mean cumulative risks were 0.58% (IQR, 0.41%-0.69%) after 6 annual screens, 0.40% (IQR, 0.28%-0.48%) for 3 biennial screens, and 0.33% (IQR, 0.23%-0.39%) after 2 triennial screens. CONCLUSIONS AND RELEVANCE In this cohort study, 6-year screen-detected DCIS risk was higher with annual screening compared with biennial or triennial screening intervals. Estimates from the prediction model, along with risk estimates of other screening benefits and harms, could help inform policy makers' discussions of screening strategies.
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Affiliation(s)
- Brian L. Sprague
- Office of Health Promotion Research, University of Vermont, Burlington
- Department of Surgery, University of Vermont, Burlington
- University of Vermont Cancer Center, Burlington
| | - Shuai Chen
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis
| | - Diana L. Miglioretti
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Charlotte C. Gard
- Department of Economics, Applied Statistics, and International Business, New Mexico State University, Las Cruces
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Erin J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Peter A. Kaufman
- Division of Hematology/Oncology, University of Vermont Cancer Center, Burlington
| | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
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Trentham-Dietz A, Alagoz O, Chapman C, Huang X, Jayasekera J, van Ravesteyn NT, Lee SJ, Schechter CB, Yeh JM, Plevritis SK, Mandelblatt JS. Reflecting on 20 years of breast cancer modeling in CISNET: Recommendations for future cancer systems modeling efforts. PLoS Comput Biol 2021; 17:e1009020. [PMID: 34138842 PMCID: PMC8211268 DOI: 10.1371/journal.pcbi.1009020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Since 2000, the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network (CISNET) modeling teams have developed and applied microsimulation and statistical models of breast cancer. Here, we illustrate the use of collaborative breast cancer multilevel systems modeling in CISNET to demonstrate the flexibility of systems modeling to address important clinical and policy-relevant questions. Challenges and opportunities of future systems modeling are also summarized. The 6 CISNET breast cancer models embody the key features of systems modeling by incorporating numerous data sources and reflecting tumor, person, and health system factors that change over time and interact to affect the burden of breast cancer. Multidisciplinary modeling teams have explored alternative representations of breast cancer to reveal insights into breast cancer natural history, including the role of overdiagnosis and race differences in tumor characteristics. The models have been used to compare strategies for improving the balance of benefits and harms of breast cancer screening based on personal risk factors, including age, breast density, polygenic risk, and history of Down syndrome or a history of childhood cancer. The models have also provided evidence to support the delivery of care by simulating outcomes following clinical decisions about breast cancer treatment and estimating the relative impact of screening and treatment on the United States population. The insights provided by the CISNET breast cancer multilevel modeling efforts have informed policy and clinical guidelines. The 20 years of CISNET modeling experience has highlighted opportunities and challenges to expanding the impact of systems modeling. Moving forward, CISNET research will continue to use systems modeling to address cancer control issues, including modeling structural inequities affecting racial disparities in the burden of breast cancer. Future work will also leverage the lessons from team science, expand resource sharing, and foster the careers of early stage modeling scientists to ensure the sustainability of these efforts. Since 2000, our research teams have used computer models of breast cancer to address important clinical and policy-relevant questions as part of the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network (CISNET). Our 6 CISNET breast cancer models embody the key features of systems modeling by incorporating numerous data sources and reflecting tumor, person, and health system factors that change over time and interact to represent the burden of breast cancer. We have used our models to investigate questions related to breast cancer biology, compare strategies to improve the balance of benefits and harms of screening mammography, and support insights into the delivery of care by modeling outcomes following clinical decisions about breast cancer treatment. Moving forward, our research will continue to use systems modeling to address issues related to reducing the burden of breast cancer including modeling structural inequities affecting racial disparities. Our future work will also leverage lessons from engaging multidisciplinary scientific teams, expand efforts to share modeling resources with other researchers, and foster the careers of early stage modeling scientists to ensure the sustainability of these efforts.
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Affiliation(s)
- Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
| | - Oguzhan Alagoz
- Department of Population Health Sciences and Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Christina Chapman
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Xuelin Huang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Jinani Jayasekera
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, United States of America
| | | | - Sandra J. Lee
- Department of Data Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Clyde B. Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Jennifer M. Yeh
- Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sylvia K. Plevritis
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, United States of America
| | - Jeanne S. Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, United States of America
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van den Broek JJ, Schechter CB, van Ravesteyn NT, Janssens ACJW, Wolfson MC, Trentham-Dietz A, Simard J, Easton DF, Mandelblatt JS, Kraft P, de Koning HJ. Personalizing Breast Cancer Screening Based on Polygenic Risk and Family History. J Natl Cancer Inst 2021; 113:434-442. [PMID: 32853342 PMCID: PMC8599807 DOI: 10.1093/jnci/djaa127] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 08/10/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We assessed the clinical utility of a first-degree breast cancer family history and polygenic risk score (PRS) to inform screening decisions among women aged 30-50 years. METHODS Two established breast cancer models evaluated digital mammography screening strategies in the 1985 US birth cohort by risk groups defined by family history and PRS based on 313 single nucleotide polymorphisms. Strategies varied in initiation age (30, 35, 40, 45, and 50 years) and interval (annual, hybrid, biennial, triennial). The benefits (breast cancer deaths averted, life-years gained) and harms (false-positive mammograms, overdiagnoses) were compared with those seen with 3 established screening guidelines. RESULTS Women with a breast cancer family history who initiated biennial screening at age 40 years (vs 50 years) had a 36% (model range = 29%-40%) increase in life-years gained and 20% (model range = 16%-24%) more breast cancer deaths averted, but 21% (model range = 17%-23%) more overdiagnoses and 63% (model range = 62%-64%) more false positives. Screening tailored to PRS vs biennial screening from 50 to 74 years had smaller positive effects on life-years gained (20%) and breast cancer deaths averted (11%) but also smaller increases in overdiagnoses (10%) and false positives (26%). Combined use of family history and PRS vs biennial screening from 50 to 74 years had the greatest increase in life-years gained (29%) and breast cancer deaths averted (18%). CONCLUSIONS Our results suggest that breast cancer family history and PRS could guide screening decisions before age 50 years among women at increased risk for breast cancer but expected increases in overdiagnoses and false positives should be expected.
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Affiliation(s)
- Jeroen J van den Broek
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Clyde B Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - Michael C Wolfson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Amy Trentham-Dietz
- Carbone Cancer Center and Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jacques Simard
- Department of Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Douglas F Easton
- Centre for Cancer Genetic Epidemiology, Department Public Health, and Primary Care, University of Cambridge, Cambridge, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Jeanne S Mandelblatt
- Department of Oncology, Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Peter Kraft
- Department of Biostatistics and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
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Heller SL, Plaunova A, Gao Y. Ductal Carcinoma In Situ and Progression to Invasive Cancer: A Review of the Evidence. JOURNAL OF BREAST IMAGING 2021; 3:135-143. [PMID: 38424826 DOI: 10.1093/jbi/wbaa119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Indexed: 03/02/2024]
Abstract
Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.
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Affiliation(s)
- Samantha L Heller
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
| | | | - Yiming Gao
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
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8
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Data Needs in Opioid Systems Modeling: Challenges and Future Directions. Am J Prev Med 2021; 60:e95-e105. [PMID: 33272714 PMCID: PMC8061725 DOI: 10.1016/j.amepre.2020.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/05/2020] [Accepted: 08/17/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The opioid crisis is a pervasive public health threat in the U.S. Simulation modeling approaches that integrate a systems perspective are used to understand the complexity of this crisis and analyze what policy interventions can best address it. However, limitations in currently available data sources can hamper the quantification of these models. METHODS To understand and discuss data needs and challenges for opioid systems modeling, a meeting of federal partners, modeling teams, and data experts was held at the U.S. Food and Drug Administration in April 2019. This paper synthesizes the meeting discussions and interprets them in the context of ongoing simulation modeling work. RESULTS The current landscape of national-level quantitative data sources of potential use in opioid systems modeling is identified, and significant issues within data sources are discussed. Major recommendations on how to improve data sources are to: maintain close collaboration among modeling teams, enhance data collection to better fit modeling needs, focus on bridging the most crucial information gaps, engage in direct and regular interaction between modelers and data experts, and gain a clearer definition of policymakers' research questions and policy goals. CONCLUSIONS This article provides an important step in identifying and discussing data challenges in opioid research generally and opioid systems modeling specifically. It also identifies opportunities for systems modelers and government agencies to improve opioid systems models.
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van Ravesteyn NT, Schechter CB, Hampton JM, Alagoz O, van den Broek JJ, Kerlikowske K, Mandelblatt JS, Miglioretti DL, Sprague BL, Stout NK, de Koning HJ, Trentham-Dietz A, Tosteson ANA. Trade-Offs Between Harms and Benefits of Different Breast Cancer Screening Intervals Among Low-Risk Women. J Natl Cancer Inst 2021; 113:1017-1026. [PMID: 33515225 PMCID: PMC8502479 DOI: 10.1093/jnci/djaa218] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 10/30/2020] [Accepted: 12/21/2020] [Indexed: 01/25/2023] Open
Abstract
Background A paucity of research addresses breast cancer screening strategies for women at lower-than-average breast cancer risk. The aim of this study was to examine screening harms and benefits among women aged 50-74 years at lower-than-average breast cancer risk by breast density. Methods Three well-established, validated Cancer Intervention and Surveillance Network models were used to estimate the lifetime benefits and harms of different screening scenarios, varying by screening interval (biennial, triennial). Breast cancer deaths averted, life-years and quality-adjusted life-years gained, false-positives, benign biopsies, and overdiagnosis were assessed by relative risk (RR) level (0.6, 0.7, 0.85, 1 [average risk]) and breast density category, for US women born in 1970. Results Screening benefits decreased proportionally with decreasing risk and with lower breast density. False-positives, unnecessary biopsies, and the percentage overdiagnosis also varied substantially by breast density category; false-positives and unnecessary biopsies were highest in the heterogeneously dense category. For women with fatty or scattered fibroglandular breast density and a relative risk of no more than 0.85, the additional deaths averted and life-years gained were small with biennial vs triennial screening. For these groups, undergoing 4 additional screens (screening biennially [13 screens] vs triennially [9 screens]) averted no more than 1 additional breast cancer death and gained no more than 16 life-years and no more than 10 quality-adjusted life-years per 1000 women but resulted in up to 232 more false-positives per 1000 women. Conclusion Triennial screening from age 50 to 74 years may be a reasonable screening strategy for women with lower-than-average breast cancer risk and fatty or scattered fibroglandular breast density.
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Affiliation(s)
| | - Clyde B Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - John M Hampton
- Carbone Cancer Center, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Oguzhan Alagoz
- Carbone Cancer Center, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.,Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeroen J van den Broek
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Karla Kerlikowske
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jeanne S Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, WA, USA
| | - Diana L Miglioretti
- Department of Public Health Sciences, UC Davis School of Medicine, Davis, CA, USA.,Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Brian L Sprague
- Department of Surgery and University of Vermont Cancer Center, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Harry J de Koning
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Amy Trentham-Dietz
- Carbone Cancer Center, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.,Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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10
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Weedon-Fekjær H, Li X, Lee S. Estimating the natural progression of non-invasive ductal carcinoma in situ breast cancer lesions using screening data. J Med Screen 2020; 28:302-310. [PMID: 32854582 DOI: 10.1177/0969141320945736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In addition to invasive breast cancer, mammography screening often detects preinvasive ductal carcinoma in situ (DCIS) lesions. The natural progression of DCIS is largely unknown, leading to uncertainty regarding treatment. The natural history of invasive breast cancer has been studied using screening data. DCIS modeling is more complicated because lesions might progress to clinical DCIS, preclinical invasive cancer, or may also regress to a state undetectable by screening. We have here developed a Markov model for DCIS progression, building on the established invasive breast cancer model. METHODS We present formulas for the probability of DCIS detection by time since last screening under a Markov model of DCIS progression. Progression rates were estimated by maximum likelihood estimation using BreastScreen Norway data from 1995-2002 for 336,533 women (including 399 DCIS cases) aged 50-69. As DCIS incidence varies by age, county, and mammography modality (digital vs. analog film), a Poisson regression approach was used to align the input data. RESULTS Estimated mean sojourn time in preclinical, screening-detectable DCIS phase was 3.1 years (95% confidence interval: 1.3, 7.6) with a screening sensitivity of 60% (95% confidence interval: 32%, 93%). No DCIS was estimated to be non-progressive. CONCLUSION Most preclinical DCIS lesions progress or regress with a moderate sojourn time in the screening-detectable phase. While DCIS mean sojourn time could be deduced from DCIS data, any estimate of preclinical DCIS progressing to invasive breast cancer must include data on invasive cancers to avoid strong, probably unrealistic, assumptions.
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Affiliation(s)
- Harald Weedon-Fekjær
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Xiaoxue Li
- Department of Data Sciences, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts, USA
| | - Sandra Lee
- Department of Data Sciences, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
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Chootipongchaivat S, van Ravesteyn NT, Li X, Huang H, Weedon-Fekjær H, Ryser MD, Weaver DL, Burnside ES, Heckman-Stoddard BM, de Koning HJ, Lee SJ. Modeling the natural history of ductal carcinoma in situ based on population data. Breast Cancer Res 2020; 22:53. [PMID: 32460821 PMCID: PMC7251719 DOI: 10.1186/s13058-020-01287-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background The incidence of ductal carcinoma in situ (DCIS) has increased substantially since the introduction of mammography screening. Nevertheless, little is known about the natural history of preclinical DCIS in the absence of biopsy or complete excision. Methods Two well-established population models evaluated six possible DCIS natural history submodels. The submodels assumed 30%, 50%, or 80% of breast lesions progress from undetectable DCIS to preclinical screen-detectable DCIS; each model additionally allowed or prohibited DCIS regression. Preclinical screen-detectable DCIS could also progress to clinical DCIS or invasive breast cancer (IBC). Applying US population screening dissemination patterns, the models projected age-specific DCIS and IBC incidence that were compared to Surveillance, Epidemiology, and End Results data. Models estimated mean sojourn time (MST) in the preclinical screen-detectable DCIS state, overdiagnosis, and the risk of progression from preclinical screen-detectable DCIS. Results Without biopsy and surgical excision, the majority of DCIS (64–100%) in the preclinical screen-detectable state progressed to IBC in submodels assuming no DCIS regression (36–100% in submodels allowing for DCIS regression). DCIS overdiagnosis differed substantially between models and submodels, 3.1–65.8%. IBC overdiagnosis ranged 1.3–2.4%. Submodels assuming DCIS regression resulted in a higher DCIS overdiagnosis than submodels without DCIS regression. MST for progressive DCIS varied between 0.2 and 2.5 years. Conclusions Our findings suggest that the majority of screen-detectable but unbiopsied preclinical DCIS lesions progress to IBC and that the MST is relatively short. Nevertheless, due to the heterogeneity of DCIS, more research is needed to understand the progression of DCIS by grades and molecular subtypes.
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Affiliation(s)
- Sarocha Chootipongchaivat
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
| | - Nicolien T van Ravesteyn
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Xiaoxue Li
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hui Huang
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Harald Weedon-Fekjær
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Marc D Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.,Department of Mathematics, Duke University, Durham, NC, USA
| | - Donald L Weaver
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont and UVM Cancer Center, Burlington, VT, USA
| | - Elizabeth S Burnside
- Radiology Department, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Sandra J Lee
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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12
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Grimm LJ, Destounis SV, Rahbar H, Soo MS, Poplack SP. Ductal Carcinoma In Situ Biology, Language, and Active Surveillance: A Survey of Breast Radiologists' Knowledge and Opinions. J Am Coll Radiol 2020; 17:1252-1258. [PMID: 32278849 DOI: 10.1016/j.jacr.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To understand how breast radiologists perceive ductal carcinoma in situ (DCIS). MATERIALS AND METHODS A 19-item survey was developed by the Society of Breast Imaging Patient Care and Delivery Committee and distributed to all Society of Breast Imaging members. The survey queried respondents' demographics, knowledge of DCIS biology, language used to discuss a new diagnosis of DCIS, and perspectives on active surveillance for DCIS. Five-point Likert scales (1 = strongly disagree, 3 = neutral, 5 = strongly agree) were used. RESULTS There were 536 responses for a response rate of 41%. There was agreement that DCIS is the primary driver of overdiagnosis in breast cancer screening (median 4), and respondents provided mean and median overdiagnosis estimates of 29.7% and 25% for low-grade DCIS as well as 4.2% and 0% for high-grade DCIS, respectively. Responses varied in how to describe DCIS but most often used the word "cancer" with a qualifier such as "early" (32%) or "pre-invasive" (25%). Respondents disagreed (median 2) with removing the word "carcinoma" from DCIS. Finally, there was agreement that current standard of care therapy for some forms of DCIS is overtreatment (median 4) and that active surveillance as an alternative management strategy should be studied (mean 4), but felt that ultrasound (median 4) and MRI (median 4) should be used to exclude women with occult invasive disease before active surveillance. CONCLUSIONS Breast radiologists' opinions about DCIS biology, language, and active surveillance are not homogenous, but general trends exist that can be used to guide research, education, and advocacy efforts.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | | | - Habib Rahbar
- Clinical Director of Breast Imaging, Seattle Cancer Care Alliance; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Mary Scott Soo
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Steven P Poplack
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St Louis, Saint Louis, Missouri
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13
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van den Broek JJ, van Ravesteyn NT, Heijnsdijk EA, de Koning HJ. Simulating the Impact of Risk-Based Screening and Treatment on Breast Cancer Outcomes with MISCAN-Fadia. Med Decis Making 2019; 38:54S-65S. [PMID: 29554469 DOI: 10.1177/0272989x17711928] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The MISCAN-Fadia microsimulation model uses continuous tumor growth to simulate the natural history of breast cancer and has been used extensively to estimate the impact of screening and adjuvant treatment on breast cancer incidence and mortality trends. The model simulates individual life histories from birth to death, with and without breast cancer, in the presence and in the absence of screening and treatment. Life histories are simulated according to discrete events such as birth, tumor inception, the tumor's clinical diagnosis diameter in the absence of screening, and death from breast cancer or death from other causes. MISCAN-Fadia consists of 4 main components: demography, natural history of breast cancer, screening, and treatment. Screening impact on the natural history of breast cancer is assessed by simulating continuous tumor growth and the "fatal diameter" concept. This concept implies that tumors diagnosed at a size that is between the screen detection threshold and the fatal diameter are cured, while tumors diagnosed at a diameter larger than the fatal tumor diameter metastasize and lead to breast cancer death. MISCAN-Fadia has been extended by including a different natural history for molecular subtypes based on a tumor's estrogen receptor (ER) status and human epidermal growth factor receptor 2 (HER2) status. In addition, personalized screening strategies that target women based on their risk such as breast density have been incorporated into the model. This personalized approach to screening will continue to develop in light of potential polygenic risk stratification possibilities and new screening modalities.
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Affiliation(s)
| | | | | | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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14
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Tina Shih YC, Dong W, Xu Y, Shen Y. Assessing the Cost-Effectiveness of Updated Breast Cancer Screening Guidelines for Average-Risk Women. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:185-193. [PMID: 30711063 DOI: 10.1016/j.jval.2018.07.880] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 07/11/2018] [Accepted: 07/16/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Several specialty societies have recently updated their breast cancer screening guidelines in late 2015/early 2016. OBJECTIVES To evaluate the cost-effectiveness of US-based mammography screening guidelines. METHODS We developed a microsimulation model to generate the natural history of invasive breast cancer and capture how screening and treatment modified the natural course of the disease. We used the model to assess the cost-effectiveness of screening strategies, including annual screening starting at the age of 40 years, biennial screening starting at the age of 50 years, and a hybrid strategy that begins screening at the age of 45 years and transitions to biennial screening at the age of 55 years, combined with three cessation ages: 75 years, 80 years, and no upper age limit. Findings were summarized as incremental cost-effectiveness ratio (cost per quality-adjusted life-year [QALY]) and cost-effectiveness acceptability frontier. RESULTS The screening strategy that starts annual mammography at the age of 45 years and switches to biennial screening between the ages of 55 and 75 years was the most cost-effective, yielding an incremental cost-effectiveness ratio of $40,135/QALY. Probabilistic analysis showed that the hybrid strategy had the highest probability of being optimal when the societal willingness to pay was between $44,000/QALY and $103,500/QALY. Within the range of commonly accepted societal willingness to pay, no optimal strategy involved screening with a cessation age of 80 years or older. CONCLUSIONS The screening strategy built on a hybrid design is the most cost-effective for average-risk women. By considering the balance between benefits and harms in forming its recommendations, this hybrid screening strategy has the potential to optimize the health care system's investment in the early detection and treatment of breast cancer.
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Affiliation(s)
- Ya-Chen Tina Shih
- Section of Cancer Economics and Policy, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Wenli Dong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Xu
- Section of Cancer Economics and Policy, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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Alagoz O, Ergun MA, Cevik M, Sprague BL, Fryback DG, Gangnon RE, Hampton JM, Stout NK, Trentham-Dietz A. The University of Wisconsin Breast Cancer Epidemiology Simulation Model: An Update. Med Decis Making 2018; 38:99S-111S. [PMID: 29554470 PMCID: PMC5862066 DOI: 10.1177/0272989x17711927] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The University of Wisconsin Breast Cancer Epidemiology Simulation Model (UWBCS), also referred to as Model W, is a discrete-event microsimulation model that uses a systems engineering approach to replicate breast cancer epidemiology in the US over time. This population-based model simulates the lifetimes of individual women through 4 main model components: breast cancer natural history, detection, treatment, and mortality. A key feature of the UWBCS is that, in addition to specifying a population distribution in tumor growth rates, the model allows for heterogeneity in tumor behavior, with some tumors having limited malignant potential (i.e., would never become fatal in a woman's lifetime if left untreated) and some tumors being very aggressive based on metastatic spread early in their onset. The model is calibrated to Surveillance, Epidemiology, and End Results (SEER) breast cancer incidence and mortality data from 1975 to 2010, and cross-validated against data from the Wisconsin cancer reporting system. The UWBCS model generates detailed outputs including underlying disease states and observed clinical outcomes by age and calendar year, as well as costs, resource usage, and quality of life associated with screening and treatment. The UWBCS has been recently updated to account for differences in breast cancer detection, treatment, and survival by molecular subtypes (defined by ER/HER2 status), to reflect the recent advances in screening and treatment, and to consider a range of breast cancer risk factors, including breast density, race, body-mass-index, and the use of postmenopausal hormone therapy. Therefore, the model can evaluate novel screening strategies, such as risk-based screening, and can assess breast cancer outcomes by breast cancer molecular subtype. In this article, we describe the most up-to-date version of the UWBCS.
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Affiliation(s)
- Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI
| | - Mehmet Ali Ergun
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI
| | | | - Brian L Sprague
- Department of Surgery and University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Dennis G Fryback
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI
| | - Ronald E Gangnon
- Department of Population Health Sciences and Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - John M Hampton
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
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16
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Alagoz O, Berry DA, de Koning HJ, Feuer EJ, Lee SJ, Plevritis SK, Schechter CB, Stout NK, Trentham-Dietz A, Mandelblatt JS. Introduction to the Cancer Intervention and Surveillance Modeling Network (CISNET) Breast Cancer Models. Med Decis Making 2018; 38:3S-8S. [PMID: 29554472 PMCID: PMC5862043 DOI: 10.1177/0272989x17737507] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Cancer Intervention and Surveillance Modeling Network (CISNET) Breast Cancer Working Group is a consortium of National Cancer Institute-sponsored investigators who use statistical and simulation modeling to evaluate the impact of cancer control interventions on long-term population-level breast cancer outcomes such as incidence and mortality and to determine the impact of different breast cancer control strategies. The CISNET breast cancer models have been continuously funded since 2000. The models have gone through several updates since their inception to reflect advances in the understanding of the molecular basis of breast cancer, changes in the prevalence of common risk factors, and improvements in therapy and early detection technology. This article provides an overview and history of the CISNET breast cancer models, provides an overview of the major changes in the model inputs over time, and presents examples for how CISNET breast cancer models have been used for policy evaluation.
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Affiliation(s)
- Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Donald A Berry
- Department of Biostatistics, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eric J Feuer
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Sandra J Lee
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Sylvia K Plevritis
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Clyde B Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeanne S Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
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Lee SJ, Li X, Huang H, Zelen M. The Dana-Farber CISNET Model for Breast Cancer Screening Strategies: An Update. Med Decis Making 2018; 38:44S-53S. [PMID: 29554465 PMCID: PMC5929104 DOI: 10.1177/0272989x17741634] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We present updated features to a model developed by Dana-Farber investigators within the Cancer Intervention and Surveillance Modeling Network (CISNET). The initial model was developed to evaluate the impact of mammography screening strategies. METHODS This major update includes the incorporation of ductal carcinoma in situ (DCIS) as part of the natural history of breast cancer. The updated model allows DCIS in the pre-clinical state to regress to undetectable early-stage DCIS, or to transition to invasive breast cancer, or to clinical DCIS. We summarize model assumptions for DCIS natural history and model parameters. Another new development is the derivation of analytical expressions for overdiagnosis. Overdiagnosis refers to mammographic identification of breast cancer that would never have resulted in disease symptoms in the patient's remaining lifetime (i.e., lead time longer than residual survival time). This is an inevitable consequence of early detection. Our model uniquely assesses overdiagnosis using an analytical formulation. We derive the lead time distribution resulting from the early detection of invasive breast cancer and DCIS, and formulate the analytical expression for overdiagnosis. RESULTS This formulation was applied to assess overdiagnosis from mammography screening. Other model updates involve implementing common model input parameters with updated treatment dissemination and effectiveness, and improved mammography performance. Lastly, the model was expanded to incorporate subgroups by breast density and molecular subtypes. CONCLUSIONS The incorporation of DCIS and subgroups and the derivation of an overdiagnosis estimation procedure improve the model for evaluating mammography screening programs.
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Affiliation(s)
- Sandra J Lee
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xiaoxue Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hui Huang
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marvin Zelen
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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18
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Huang X, Li Y, Song J, Berry DA. A Bayesian Simulation Model for Breast Cancer Screening, Incidence, Treatment, and Mortality. Med Decis Making 2018; 38:78S-88S. [PMID: 28627297 PMCID: PMC5711634 DOI: 10.1177/0272989x17714473] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The important but complicated research questions regarding the optimization of mammography screening for the detection of breast cancer are unable to be answered through any single trial or a simple meta-analysis of related trials. The Cancer Intervention and Surveillance Network (CISNET) breast groups provide answers using complex statistical models to simulate population dynamics. Among them, the MD Anderson Cancer Center (Model M) takes a unique approach by not making any assumptions on the natural history of breast cancer, such as the distribution of the indolent time before detection, but simulating only the observable part of a woman's disease and life. METHODS The simulations start with 4 million women in the age distribution found in the year 1975, and follow them over several years. Input parameters are used to describe their breast cancer incidence rates, treatment efficacy, and survival. With these parameters, each woman's history of breast cancer diagnosis, treatment, and survival are generated and recorded each year. Research questions can then be answered by comparing the outcomes of interest, such as mortality rates, quality-adjusted life years, number of false positives, differences between hypothetical scenarios, such as different combinations of screening and treatment strategies. We use our model to estimate the relative contributions of screening and treatments on the mortality reduction in the United States, for both overall and different molecular (ER, HER2) subtypes of breast cancer. RESULTS We estimate and compare the benefits (life-years gained) and harm (false-positives, over-diagnoses) of mammography screening strategies with different frequencies (annual, biennial, triennial, mixed) and different starting (40 and 50 years) and end ages (70 and 80 years). CONCLUSIONS We will extend our model in future studies to account for local, regional, and distant disease recurrences.
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Affiliation(s)
- Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yisheng Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald A Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Mittmann N, Stout NK, Tosteson ANA, Trentham-Dietz A, Alagoz O, Yaffe MJ. Cost-effectiveness of mammography from a publicly funded health care system perspective. CMAJ Open 2018; 6:E77-E86. [PMID: 29440151 PMCID: PMC5878949 DOI: 10.9778/cmajo.20170106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The implementation of population-wide breast cancer screening programs has important budget implications. We evaluated the cost-effectiveness of various breast cancer screening scenarios in Canada from a publicly funded health care system perspective using an established breast cancer simulation model. METHODS Breast cancer incidence, outcomes and total health care system costs (screening, investigation, diagnosis and treatment) for the Canadian health care environment were modelled. The model predicted costs (in 2012 dollars), life-years gained and quality-adjusted life-years (QALYs) gained for 11 active screening scenarios that varied by age range for starting and stopping screening (40-74 yr) and frequency of screening (annual, biennial or triennial) relative to no screening. All outcomes were discounted. Marginal and incremental cost-effectiveness analyses were conducted. One-way sensitivity analyses of key parameters assessed robustness. RESULTS The lifetime overall costs (undiscounted) to the health care system for annual screening per 1000 women ranged from $7.4 million (for women aged 50-69 yr) to $10.7 million (40-74 yr). For biennial and triennial screening per 1000 women (aged 50-74 yr), costs were less, at about $6.1 million and $5.3 million, respectively. The incremental cost-utility ratio varied from $36 981/QALY for triennial screening in women aged 50-69 versus no screening to $38 142/QALY for biennial screening in those aged 50-69 and $83 845/QALY for annual screening in those aged 40-74. INTERPRETATION Our economic analysis showed that both benefits of mortality reduction and costs rose together linearly with the number of lifetime screens per women. The decision on how to screen is related mainly to willingness to pay and additional considerations such as the number of women recalled after a positive screening result.
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Affiliation(s)
- Nicole Mittmann
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
| | - Natasha K Stout
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
| | - Anna N A Tosteson
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
| | - Amy Trentham-Dietz
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
| | - Oguzhan Alagoz
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
| | - Martin J Yaffe
- Affiliations: Sunnybrook Research Institute (Mittmann), Sunnybrook Health Sciences Centre; Department of Pharmacology and Toxicology (Mittmann), University of Toronto, Toronto, Ont.; Department of Population Medicine (Stout), Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass.; Dartmouth Institute for Health Policy and Clinical Practice (Tosteson), Geisel School of Medicine, Dartmouth College, Hanover, NH; Department of Population Health Sciences and Carbone Cancer Center (Trentham-Dietz, Alagoz); Department of Industrial and Systems Engineering (Alagoz), University of Wisconsin-Madison, Madison, Wisc.; Physical Sciences Program (Yaffe), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre; Departments of Medical Biophysics and Medical Imaging (Yaffe), University of Toronto, Toronto, Ont
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