Abstract
BackgroundA 2% threshold, traditionally used as a level above which breast biopsy recommended, has been generalized to all patients from several specific situations analyzed in the literature. We use a sequential decision analytic model considering clinical and mammography features to determine the optimal general threshold for image guided breast biopsy and the sensitivity of this threshold to variation of these features.Methodology/Principal FindingsWe built a decision analytical model called a Markov Decision Process (MDP) model, which determines the optimal threshold of breast cancer risk to perform breast biopsy in order to maximize a patient’s total quality-adjusted life years (QALYs). The optimal biopsy threshold is determined based on a patient’s probability of breast cancer estimated by a logistic regression model (LRM) which uses demographic risk factors (age, family history, and hormone use) and mammographic findings (described using the established lexicon–BI-RADS). We estimate the MDP model's parameters using SEER data (prevalence of invasive vs. in situ disease, stage at diagnosis, and survival), US life tables (all cause mortality), and the medical literature (biopsy disutility and treatment efficacy) to determine the optimal “base case” risk threshold for breast biopsy and perform sensitivity analysis. The base case MDP model reveals that 2% is the optimal threshold for breast biopsy for patients between 42 and 75 however the thresholds below age 42 is lower (1%) and above age 75 is higher (range of 3–5%). Our sensitivity analysis reveals that the optimal biopsy threshold varies most notably with changes in age and disutility of biopsy.Conclusions/SignificanceOur MDP model validates the 2% threshold currently used for biopsy but shows this optimal threshold varies substantially with patient age and biopsy disutility.
Highlights
The overall annual utilization rate of breast biopsies of 62.6 per 10,000 patients per year, translates to just over 700,000 breast biopsies per year in the United States [1,2] While image-guided core needle biopsy of the breast has certainly become an integral part of breast cancer diagnosis, little is known about the optimal breast cancer risk threshold that radiologists should use to recommend this procedure
In order to analyze the optimal threshold at which to recommend breast biopsy, we developed a finite-horizon, discrete-time Markov Decision Process (MDP) [22,26], which provides a mathematical framework for modeling decision-making in situations where outcomes are partly uncertain and partly under the control of the decision maker
We found the optimal threshold for biopsy to be 2% for patients between 42 and 75 years of age
Summary
The overall annual utilization rate of breast biopsies of 62.6 per 10,000 patients per year, translates to just over 700,000 breast biopsies per year in the United States [1,2] While image-guided core needle biopsy of the breast has certainly become an integral part of breast cancer diagnosis, little is known about the optimal breast cancer risk threshold that radiologists should use to recommend this procedure. Shared decision-making through physician-patient communication in order to tailor health care decisions to individual patient preferences [4] is becoming more prevalent in the context of novel [5,6] and established screening tests [7]. This increased interest in personalized medicine in general [8,9] and in the domain breast cancer in particular [10]. We use a sequential decision analytic model considering clinical and mammography features to determine the optimal general threshold for image guided breast biopsy and the sensitivity of this threshold to variation of these features
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