1. CBACT: Cost Benefit Analysis for Cancer Treatments Adeeti Aggarwal Saratoga High School February 20, 2009

2. Background During my summer internship at Santa Clara Valley Medical Center (SCVMC), I worked with Dr. Lin and Dr. Kouzminova on a research project in which we retrospectively analyzed 437 patients with stage I-IIIA breast cancer who underwent initial breast conserving surgery at SCVMC during 1994-2004 with confirmed margin information. We found that the presence of residual cancer after the first surgery did indeed increase the rate of distant metastases (22.8% vs. 6.6%, HR 3.5, 95% CI 1.8-7.4, p=0.001) and death.

3. Case Study: A Breast Cancer Patient MastectomyLumpectomy Pros Conservative surgery One surgery Cons Cosmetic reasons Extensive surgery Pros Cosmetic Smaller surgery Cons Risk of second surgery Possible delays in systemic therapy What is the Opportunity cost for these patients?

4. Since Cancer Protocols are well defined, we provide a system for performing a cost benefit analysis, which Is easy to integrate with Electronic Medical Records Is Web based so that it can be used widely Uses known data systems such as SEER data and Medicare-costs’ data At the moment, this system and algorithm is theoretical in nature (and it is not yet coded) I am hoping to work with a group or college to make this “paper” system into a usable prototype.

5. Graphical User Interface Analytics Engine Cost Estimation Engine Database (cases protocols) Database (market information) Database (treatment costs) Database (hospital costs) Internet Input parameters 102104106 108110112 114 116

6. Analytics Engine Analytical Rule Based Engine Artificial Neural Network Engine Cost Estimation Engine 104 106 204 202

7. Patient’s Cancer Type Drop-Down Menu Melanoma Skin cancer Lung cancer Colon cancer Breast cancer Head and Neck cancer Patient Information: Drop- Down Menu Age: Ethnicity: Gender: Residency: Family History: Stage: Grade: Lymph nodes: Tests: Adjuvant Therapy OtherWhat if? Cost: $-- FOLFOX: 6 months Tests: 5 FL/LV: 6 months Tests: XELODA: 6 months Tests: XELOX: 6 months Tests: OtherWhat if? 302 306 304 308 310 312 314 Other What if?

8. Start Receive a plurality of input parameters for a patient for treatment of cancer Obtain information related to available cancer treatment protocols Select one or more cancer treatment protocols Generate a set of output parameters based on a close cohort and input parameters Estimate the cost associated with the selected cancer treatment protocols Display the output parameters and associated cost for the cancer treatment protocol s to the user Stop 402 404 406 408 410 412

9. Patient’s Cancer Type Drop-Down Menu Patient Information and Initial Work-up: Age: Ethnicity: Gender: Residency: Family History: Menopausal: Age at Menarche: Age at Menopause: Last Menstrual Period: Obstetric History: Breast Feeding: Age at first pregnancy: Past Medical History: Past surgical history: Physical findings: Tumor Characteristics Stage: Tumor size: Lymph Nodes: Grade: Histology: Estrogen Receptor: Progestron Receptor: Her2neu: Lymphovasucalr invasion: Margin: Tests: Blood: Pathology: Imaging: Tumor Characteristics Stage: Tumor size: Lymph Nodes: Grade: Histology: Estrogen Receptor: Progestron Receptor: Her2neu: Lymphovasucalr invasion: Margin: Surgery Preoperative Chemotherap y Preoperative Chemotherapy AC-Taxol: AC-Taxotere: AC+Taxotere+Herceptin: AC-Taxotere+Herceptin: Ongoing Clinical Clinical Trial Or Other Surgery Lumpectomy + Axillary node removal Mastectomy + axillary node removal Surgery Lumpectomy + Axilliary node removal Mastectomy + Axilliary node removal Breast cancer FIG. A A

10. +ve Margins and/or +ve Sentinal Lymphnodes Adjuvant Chemo- therapy? Reexcision + Axillary node removal Mastectomy + axillary node removal Tumor Characteristics Stage: Tumor size: Lymph Nodes: Grade: Histology: Estrogen Receptor: Progestron Receptor: Her2neu: Lymphovasucalr invasion: Margin: Blood Test: CBC Electrolytes LFT CA27-29 CA 15-3 Imaging: CT scan Bone scan Ultrasound PET/CT scan Chest Xray No Chemotherapy Radiation Therapy No Hormonal therapy No Axillary node removal No Metastasis Metastasis AC –Taxol AC –Taxotere AC+ Taxotere+ Herceptin AC –Taxol+ Herceptin Taxotere/Carbo/Herceptin CMF Clinical trial and other Blood tests to be done with each cycle: Radiation to the breast with tumor bed boost Chest wall radiation Axillary radiation Supraclavicular radiation Internal memory lymph node radaition If needed, provide supportive care Tamoxifen Anastrozole Letrizole Examestane Clinical Trial and other A FIG. B

11. Future Work Make a unified patient history database Create a unified data base for costs, Medicare, Medicaid, etc. Create a continuation in part for chronic diseases; HIV seems to be the best candidate because it has one of the more well defined protocols Any other thoughts, comments, ideas?