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Health services research, Radiation oncology, Breast oncology
My research focuses on the comparative effectiveness of breast cancer treatments and is conducted at the Center for Outcomes and Policy Research at DFCI. Comparative effectiveness research (CER) includes the generation and synthesis of evidence to compare alternative methods of treatment. CER is especially useful in bridging the gap between what we know from randomized trials and what we need to know to optimize treatment. My work in CER includes decision analyses to define outcomes after omission of radiation therapy in post-menopausal women with early-stage breast cancer, to compare endocrine therapy sequencing strategies for hormone receptor- positive breast cancer, and to separate outcomes on tamoxifen by CYP2D6 genotype. We have also used Medicare claims data to reveal that delay initiating radiation after breast-conserving surgery leads to increased local recurrence.My current focus of study has been the management of ductal carcinoma in situ (DCIS), one of the highest-priority topics for CER per the Institute of Medicine. Despite a dramatic increase in the number of DCIS diagnoses, population-based analyses reveal vast discrepancies in its treatment. We created a decision-analytic model to study the comparative effectiveness of lumpectomy alone versus lumpectomy and radiation for DCIS. We found that radiation is associated with small improvements in survival outcomes, especially for younger women. However, radiation paradoxically decreased the likelihood of lifetime breast preservation, since mastectomy is the standard surgical option for a recurrence or new diagnosis in a previously irradiated breast. We recently completed multi-institutional contract from AHRQ to study the effectiveness of alternate treatment strategies for DCIS in a “real-world” setting, define treatment of recurrence, and translate information through construction of a web-based decision aid to improve and individualize decision-making. I have also recently received funding from PCORI to further characterize the impact of radiation therapy on DCIS outcomes.
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