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Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial Meeting Kathleen Cronin Statistical Research and Applications Branch National Cancer Institute May 12, 2006

Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

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Page 1: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Modeled Estimates of the Effects of Screening: Results from the CISNET

Breast Cancer Consortium

International Breast Cancer Screening Network Biennial Meeting

Kathleen Cronin

Statistical Research and Applications Branch

National Cancer Institute

May 12, 2006

Page 2: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

What Is CISNET?

• NCI Sponsored Consortium of Modelers Focused on– Modeling of the Impact of Cancer Control

Interventions on Current and Future Population Trends in Incidence and Mortality

– Optimal Cancer Control Planning

• 15 funded grantees in Breast, Prostate, Colorectal, and Lung Cancer

• Comparative modeling approach – Base Cases are joint modeling exercises

Page 3: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Breast Cancer Investigators in CISNET Dana Farber - Marvin Zelen

Sandra J. Lee, Hui Huang, Rebecca Gelman

Erasmus University – Dik HabbemaSita Y.G.L. Tan, Gerrit J. van Oortmarssen, Harry J. de Koning, Rob Boer

Georgetown University – Jeanne MandelblattClyde B. Schechter, K. Robin Yabroff, William Lawrence, Bin Yi, Jennifer Cullen

MD Anderson – Donald BerryLurdes Inoue, Mark Munsell, John Venier, Yu Shen, Greg Ball, Emma Hoy, Richard L. Theriault, Melissa Bondy

Stanford University – Sylvia PlevritisBronislava Signal, Peter Salzman, Peter Glynn, Jarrett Rosenberg, Sanatan Rai

University of Rochester – Andrei YakovlevAlexander V. Zorin, Leonid G. Hanin

University of Wisconsin – Dennis FrybackMarjorie A. Rosenberg, Amy Trentham-Dietz, Patrick L. Remington, Natasha K. Stout,Vipat Kuruchittham

National Cancer InstituteEric J. Feuer, Kathleen A. Cronin, Angela Mariotto

Cornerstone Systems NorthwestLauren Clarke

Page 4: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Joint Analysis of the Seven CISNET Groups: Breast Cancer Base Case

What is the Impact of Adjuvant Therapy and Screening Mammography on US Breast

Cancer Mortality: 1975-2000 ?

Page 5: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Publications

Berry et al. N ENGL J MED 2005;353:1784-1792

JNCI Monograph due out summer 2006• Common inputs• Model descriptions• Comparisons of

– Modeling assumptions

– Intermediate outcomes

– Mortality outcomes

Page 6: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Population Models

7 Different Breast CancerModels

Backgroundtrends

Screeningbehavior

Diffusion ofnew treatments

BCIncidence

&mortality

Common InputsUnique Simulation or Analytical Model

Other Common Inputs

Page 7: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Common Inputs

Page 8: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Background Trends In Incidence

What would incidence have looked like without mammography screening?

Modeled incidence as a function of age, calendar period and birth cohort using historical Connecticut and SEER registry data.

• Assume that the “calendar period” effect reflects screening– Age-Period-Cohort represent that observed data points– Age-Cohort represents incidence without screening

• JNCI Monograph

Page 9: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Connecticut Breast Cancer Incidence By Age Group

Age 60-69

Age 30-39

Age 50-59

Age 40-49

Age 70-84

1940 1950 1960 1970 1980 1990 2000

Page 10: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Age 60-69

Age 30-39

Age 50-59

Age 40-49

Diagnosis year

Rat

e pe

r 10

0,00

0 w

omen

SEER Breast Cancer Incidence By Age Group Weighting for SEER

Age 70-84

1940 1950 1960 1970 1980 1990 2000

Page 11: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Screening Behaviors

How much screening is there between 1975 and 2000?

• Developed a simulation program that would generate screening histories over the course of a woman’s lifetime

• Modeled the age of first screen using survey data• Modeled repeat screening behaviors using longitudinal

data from the breast cancer surveillance consortium

Cronin et al. The Dissemination Of Mammography In The United States. Cancer Causes Control 2005;16:701-712.

Program posted on CISNET site under Input Parameter Generator Interfaces (http://cisnet.cancer.gov/)

Page 12: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Modeled Mammography Screening Over Time, Women age 40-79

0

25

50

75

100

1985 1990 1995 2000

Year

Biannual

Annual

Irregular

Never

Page 13: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Diffusion Of Adjuvant Chemotherapy and Tamoxifen

What is the usage of adjuvant chemotherapy and Tamoxifen by calendar year, age, stage and ER status?

• Modeled the use of adjuvant therapy using SEER patterns of care studies and SEER treatment information

– Mariotto et al. Trends in use of adjuvant multi-agent chemotherapy and Tamoxifen for breast cancer in the United States: 1975-1999. J Natl Cancer Inst 2002;94:1626-34.

– Updates in to include ER status in JNCI monograph

Page 14: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Dissemination of Adjuvant therapyWomen age 50-69 with node positive stage II or IIIA

0

10

20

30

40

50

60

1970 1980 1990 2000

Year

Multi-agent chemotherapy

only

Tamoxifen only

Both

Page 15: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Modeling Results

Page 16: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Model Runs From One GroupMortality Rates For Women 40-79 Under

Various Modeling Scenarios

0

10

20

30

40

50

60

70

1975 1980 1985 1990 1995 2000

year

mor

tali

ty r

ate

US actual

No Sc or Tr

Sc only

Tr only

Both Sc and Tr

Page 17: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Modeled Mortality For Women Age 40-70 Without Screening Or Adjuvant Treatment

0

10

20

30

40

50

60

70

80

1975 1980 1985 1990 1995 2000

year

mor

talit

y ra

te

DEGMSRW

Page 18: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Modeled Mortality For Women Age 40-70 With Screening and Adjuvant Treatment

0

10

20

30

40

50

60

1975 1980 1985 1990 1995 2000

Year

G M

WR

SE

USD

Mortality rate

Page 19: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Estimated percent decline in mortality due to screening and adjuvant therapy for the 7 models

Due to Screening

Due

to T

reat

men

t

0 5 10 15 20 25 30

0

5

10

15

20

25

30

W

G

D

S

EMR

Page 20: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Conclusions and Press Coverage

• Mammograms Validated as Key In Cancer Fight (New York Times)

Page 21: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Conclusions and Press Coverage

• Mammograms Validated as Key In Cancer Fight (New York Times)

• Mammography in question: Benefits of breast cancer screening may be small, researchers say (Chicago Tribune)

Page 22: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Conclusions and Press Coverage

• Mammograms Validated as Key In Cancer Fight (New York Times)

• Mammography in question: Benefits of breast cancer screening may be small, researchers say (Chicago Tribune)

• Statistical Blitz Helps Pin Down Mammography Benefits - “An unprecedented statistical assault” (CNN – medpage today)

Page 23: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Conclusions and Press Coverage

“What seems most important is that each team found at least some benefit from mammograms. The likelihood that they are beneficial seems a lot more solid today than it did four years ago, although the size of the benefit remains in dispute”

New York Times Editorial

Page 24: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Future Work

• Individual groups are working modeling risk factors and impact on cancer incidence.

• Optimal screening schedules for the population and for high risk groups.

• Factors influencing disparities.

• Several groups are participating in modeling progress toward HP2010 goals.

• A base case II – Modeling the impact of new treatments on population breast cancer mortality rates.

Page 25: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial
Page 26: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Age of First Mammography Screening By Birth Cohort

00.10.20.30.40.50.60.70.80.9

1

25 35 45 55 65 75 85 95

Age

% e

ver

scre

ened

Based on a series of NHIS surveys

1898-1912

1918-22

1928-321938-421948-52

1958-62

Page 27: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Time Between Subsequent Screening Exams For Women age 50-59

Based on data from the Breast Cancer Surveillance Consortium

0

20

40

60

80

100

0 5 10 15

years

% h

ad n

ext

ex

am

.

Annual

Biennial

Irregular

Page 28: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Classification Of Screening Type By Age

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

18-39 40-49 50-59 60-69 70-79 80+

Age Group

% o

f P

ou

lati

on

irregular

biennial

annual

Based on data from the Breast Cancer Surveillance Consortium

Page 29: Modeled Estimates of the Effects of Screening: Results from the CISNET Breast Cancer Consortium International Breast Cancer Screening Network Biennial

Next Steps

CISNET Reissuance

Discovery

Basic Mathematical and Statistical Relationships

Necessary for the Development of Multi-

Cohort Population Models

Development

Data Sources and Realistic Scenarios

to Evaluate Past Intervention Impact

in Population Settings and

Project Future Impact

Delivery

Synthesis of Relevant Scenarios

for Informing Policy Decisions

and Cancer Control Planning &

Implementation

CISNET Original Issuance