Outcomes associated with chemotherapy in elderly patients with early stage operable breast cancer

Background. Various clinical trials have proved the efficacy of adjuvant chemotherapy in women with breast cancer. Chemotherapy efficacy and guidelines for its use differ by stage of tumor and age of the patient with no clear recommendations for patients aged 70 and above. Objective. To examine the clinical and economic outcomes associated with chemotherapy use in and to examine the disparities in treatment and survival in elderly patients with early stage operable breast cancer by age and axillary node status. Methods. We studied a cohort of 23,110 node positive and 31,572 node negative women aged 65 and over diagnosed with incident American Joint Committee on Cancer (AJCC) stage I, II or IIIa breast cancer between January 1, 1991 and December 31, 2002 using SEER-Medicare data. Total patient costs were estimated using the phase of care approach and adjusted cost estimates were obtained from regression analysis using a 3% discount rate. Cox proportional hazard ratio of mortality was used to determine the effectiveness of chemotherapy. Propensity score approach was also used to minimize the bias associated with receipt of chemotherapy. To assess disparity in treatment, multivariate logistic regression analyses were performed to assess the relative odds of receiving surgery, chemotherapy and radiation after BCS for African Americans compared to Whites. Results. Regression adjusted cost estimates for all node positive patients receiving chemotherapy was approximately $2,300 and was significantly higher (p<0.05) than for patients not receiving chemotherapy. Mortality was significantly lower in node positive and node negative women aged 65-74 years receiving chemotherapy. There was a significant difference between African American and White women in receiving BCS and radiation after BCS; however this difference was explained by patient demographics, tumor characteristics and socioeconomic status (SES). African American node positive women were 21% less likely to receive chemotherapy than White women (OR, 0.79; CI, 0.68-0.92) in multivariate analysis. Conclusion. Chemotherapy is associated with increased survival in patients aged 65-74 and total costs attributable to chemotherapy differ by phase and age of the patient. Underutilization of systemic adjuvant chemotherapy in African American women requires attention and may serve as potential areas for appropriate intervention.^

Bayesian and survival model for tumor relapse status and disease-specific survival, with applications to breast cancer

Breast cancer is the most common non-skin cancer and the second leading cause of cancer-related death in women in the United States. Studies on ipsilateral breast tumor relapse (IBTR) status and disease-specific survival will help guide clinic treatment and predict patient prognosis.^ After breast conservation therapy, patients with breast cancer may experience breast tumor relapse. This relapse is classified into two distinct types: true local recurrence (TR) and new ipsilateral primary tumor (NP). However, the methods used to classify the relapse types are imperfect and are prone to misclassification. In addition, some observed survival data (e.g., time to relapse and time from relapse to death)are strongly correlated with relapse types. The first part of this dissertation presents a Bayesian approach to (1) modeling the potentially misclassified relapse status and the correlated survival information, (2) estimating the sensitivity and specificity of the diagnostic methods, and (3) quantify the covariate effects on event probabilities. A shared frailty was used to account for the within-subject correlation between survival times. The inference was conducted using a Bayesian framework via Markov Chain Monte Carlo simulation implemented in softwareWinBUGS. Simulation was used to validate the Bayesian method and assess its frequentist properties. The new model has two important innovations: (1) it utilizes the additional survival times correlated with the relapse status to improve the parameter estimation, and (2) it provides tools to address the correlation between the two diagnostic methods conditional to the true relapse types.^ Prediction of patients at highest risk for IBTR after local excision of ductal carcinoma in situ (DCIS) remains a clinical concern. The goals of the second part of this dissertation were to evaluate a published nomogram from Memorial Sloan-Kettering Cancer Center, to determine the risk of IBTR in patients with DCIS treated with local excision, and to determine whether there is a subset of patients at low risk of IBTR. Patients who had undergone local excision from 1990 through 2007 at MD Anderson Cancer Center with a final diagnosis of DCIS (n=794) were included in this part. Clinicopathologic factors and the performance of the Memorial Sloan-Kettering Cancer Center nomogram for prediction of IBTR were assessed for 734 patients with complete data. Nomogram for prediction of 5- and 10-year IBTR probabilities were found to demonstrate imperfect calibration and discrimination, with an area under the receiver operating characteristic curve of .63 and a concordance index of .63. In conclusion, predictive models for IBTR in DCIS patients treated with local excision are imperfect. Our current ability to accurately predict recurrence based on clinical parameters is limited.^ The American Joint Committee on Cancer (AJCC) staging of breast cancer is widely used to determine prognosis, yet survival within each AJCC stage shows wide variation and remains unpredictable. For the third part of this dissertation, biologic markers were hypothesized to be responsible for some of this variation, and the addition of biologic markers to current AJCC staging were examined for possibly provide improved prognostication. The initial cohort included patients treated with surgery as first intervention at MDACC from 1997 to 2006. Cox proportional hazards models were used to create prognostic scoring systems. AJCC pathologic staging parameters and biologic tumor markers were investigated to devise the scoring systems. Surveillance Epidemiology and End Results (SEER) data was used as the external cohort to validate the scoring systems. Binary indicators for pathologic stage (PS), estrogen receptor status (E), and tumor grade (G) were summed to create PS+EG scoring systems devised to predict 5-year patient outcomes. These scoring systems facilitated separation of the study population into more refined subgroups than the current AJCC staging system. The ability of the PS+EG score to stratify outcomes was confirmed in both internal and external validation cohorts. The current study proposes and validates a new staging system by incorporating tumor grade and ER status into current AJCC staging. We recommend that biologic markers be incorporating into revised versions of the AJCC staging system for patients receiving surgery as the first intervention.^ Chapter 1 focuses on developing a Bayesian method to solve misclassified relapse status and application to breast cancer data. Chapter 2 focuses on evaluation of a breast cancer nomogram for predicting risk of IBTR in patients with DCIS after local excision gives the statement of the problem in the clinical research. Chapter 3 focuses on validation of a novel staging system for disease-specific survival in patients with breast cancer treated with surgery as the first intervention. ^

Evaluación y análisis de la trazabilidad metrológica en redes para la verificación y calibración de instrumental GNSS (Global Navigation Satellite System)

Los estudios realizados hasta el momento para la determinación de la calidad de medida del instrumental geodésico han estado dirigidos, fundamentalmente, a las medidas angulares y de distancias. Sin embargo, en los últimos años se ha impuesto la tendencia generalizada de utilizar equipos GNSS (Global Navigation Satellite System) en el campo de las aplicaciones geomáticas sin que se haya establecido una metodología que permita obtener la corrección de calibración y su incertidumbre para estos equipos. La finalidad de esta Tesis es establecer los requisitos que debe satisfacer una red para ser considerada Red Patrón con trazabilidad metrológica, así como la metodología para la verificación y calibración de instrumental GNSS en redes patrón. Para ello, se ha diseñado y elaborado un procedimiento técnico de calibración de equipos GNSS en el que se han definido las contribuciones a la incertidumbre de medida. El procedimiento, que se ha aplicado en diferentes redes para distintos equipos, ha permitido obtener la incertidumbre expandida de dichos equipos siguiendo las recomendaciones de la Guide to the Expression of Uncertainty in Measurement del Joint Committee for Guides in Metrology. Asimismo, se han determinado mediante técnicas de observación por satélite las coordenadas tridimensionales de las bases que conforman las redes consideradas en la investigación, y se han desarrollado simulaciones en función de diversos valores de las desviaciones típicas experimentales de los puntos fijos que se han utilizado en el ajuste mínimo cuadrático de los vectores o líneas base. Los resultados obtenidos han puesto de manifiesto la importancia que tiene el conocimiento de las desviaciones típicas experimentales en el cálculo de incertidumbres de las coordenadas tridimensionales de las bases. Basándose en estudios y observaciones de gran calidad técnica, llevados a cabo en estas redes con anterioridad, se ha realizado un exhaustivo análisis que ha permitido determinar las condiciones que debe satisfacer una red patrón. Además, se han diseñado procedimientos técnicos de calibración que permiten calcular la incertidumbre expandida de medida de los instrumentos geodésicos que proporcionan ángulos y distancias obtenidas por métodos electromagnéticos, ya que dichos instrumentos son los que van a permitir la diseminación de la trazabilidad metrológica a las redes patrón para la verificación y calibración de los equipos GNSS. De este modo, ha sido posible la determinación de las correcciones de calibración local de equipos GNSS de alta exactitud en las redes patrón. En esta Tesis se ha obtenido la incertidumbre de la corrección de calibración mediante dos metodologías diferentes; en la primera se ha aplicado la propagación de incertidumbres, mientras que en la segunda se ha aplicado el método de Monte Carlo de simulación de variables aleatorias. El análisis de los resultados obtenidos confirma la validez de ambas metodologías para la determinación de la incertidumbre de calibración de instrumental GNSS. ABSTRACT The studies carried out so far for the determination of the quality of measurement of geodetic instruments have been aimed, primarily, to measure angles and distances. However, in recent years it has been accepted to use GNSS (Global Navigation Satellite System) equipment in the field of Geomatic applications, for data capture, without establishing a methodology that allows obtaining the calibration correction and its uncertainty. The purpose of this Thesis is to establish the requirements that a network must meet to be considered a StandardNetwork with metrological traceability, as well as the methodology for the verification and calibration of GNSS instrumental in those standard networks. To do this, a technical calibration procedure has been designed, developed and defined for GNSS equipment determining the contributions to the uncertainty of measurement. The procedure, which has been applied in different networks for different equipment, has alloweddetermining the expanded uncertainty of such equipment following the recommendations of the Guide to the Expression of Uncertainty in Measurement of the Joint Committee for Guides in Metrology. In addition, the three-dimensional coordinates of the bases which constitute the networks considered in the investigationhave been determined by satellite-based techniques. There have been several developed simulations based on different values of experimental standard deviations of the fixed points that have been used in the least squares vectors or base lines calculations. The results have shown the importance that the knowledge of experimental standard deviations has in the calculation of uncertainties of the three-dimensional coordinates of the bases. Based on high technical quality studies and observations carried out in these networks previously, it has been possible to make an exhaustive analysis that has allowed determining the requirements that a standard network must meet. In addition, technical calibration procedures have been developed to allow the uncertainty estimation of measurement carried outby geodetic instruments that provide angles and distances obtained by electromagnetic methods. These instruments provide the metrological traceability to standard networks used for verification and calibration of GNSS equipment. As a result, it has been possible the estimation of local calibration corrections for high accuracy GNSS equipment in standardnetworks. In this Thesis, the uncertainty of calibration correction has been calculated using two different methodologies: the first one by applying the law of propagation of uncertainty, while the second has applied the propagation of distributions using the Monte Carlo method. The analysis of the obtained results confirms the validity of both methodologies for estimating the calibration uncertainty of GNSS equipment.

Desarrollo de un Laboratorio Virtual para la realización de e-comparisons en los ensayos de aislamiento acústico de fachadas según UNE-EN ISO 140-5

Actualmente son una práctica común los procesos de normalización de métodos de ensayo y acreditación de laboratorios, ya que permiten una evaluación de los procedimientos llevados a cabo por profesionales de un sector tecnológico y además permiten asegurar unos mínimos de calidad en los resultados finales. En el caso de los laboratorios de acústica, para conseguir y mantener la acreditación de un laboratorio es necesario participar activamente en ejercicios de intercomparación, utilizados para asegurar la calidad de los métodos empleados. El inconveniente de estos ensayos es el gran coste que suponen para los laboratorios, siendo en ocasiones inasumible por estos teniendo que renunciar a la acreditación. Este Proyecto Fin de Grado se centrará en el desarrollo de un Laboratorio Virtual implementado mediante una herramienta software que servirá para realizar ejercicios de intercomparación no presenciales, ampliando de ese modo el concepto e-comparison y abriendo las bases a que en un futuro este tipo de ejercicios no presenciales puedan llegar a sustituir a los llevados a cabo actualmente. En el informe primero se hará una pequeña introducción, donde se expondrá la evolución y la importancia de los procedimientos de calidad acústica en la sociedad actual. A continuación se comentará las normativas internacionales en las que se soportará el proyecto, la norma ISO 145-5, así como los métodos matemáticos utilizados en su implementación, los métodos estadísticos de propagación de incertidumbres especificados por la JCGM (Joint Committee for Guides in Metrology). Después, se hablará sobre la estructura del proyecto, tanto del tipo de programación utilizada en su desarrollo como la metodología de cálculo utilizada para conseguir que todas las funcionalidades requeridas en este tipo de ensayo estén correctamente implementadas. Posteriormente se llevará a cabo una validación estadística basada en la comparación de unos datos generados por el programa, procesados utilizando la simulación de Montecarlo, y unos cálculos analíticos, que permita comprobar que el programa funciona tal y como se ha previsto en la fase de estudio teórico. También se realizará una prueba del programa, similar a la que efectuaría un técnico de laboratorio, en la que se evaluará la incertidumbre de la medida calculándola mediante el método tradicional, pudiendo comparar los datos obtenidos con los que deberían obtenerse. Por último, se comentarán las conclusiones obtenidas con el desarrollo y pruebas del Laboratorio Virtual, y se propondrán nuevas líneas de investigación futuras relacionadas con el concepto e-comparison y la implementación de mejoras al Laboratorio Virtual. ABSTRACT. Nowadays it is common practise to make procedures to normalise trials methods standards and laboratory accreditations, as they allow for the evaluation of the procedures made by professionals from a particular technological sector in addition to ensuring a minimum quality in the results. In order for an acoustics laboratory to achieve and maintain the accreditation it is necessary to actively participate in the intercomparison exercises, since these are used to assure the quality of the methods used by the technicians. Unfortunately, the high cost of these trials is unaffordable for many laboratories, which then have to renounce to having the accreditation. This Final Project is focused on the development of a Virtual Laboratory implemented by a software tool that it will be used for making non-attendance intercomparison trials, widening the concept of e-comparison and opening the possibility for using this type of non-attendance trials instead of the current ones. First, as a short introduction, I show the evolution and the importance today of acoustic quality procedures. Second, I will discuss the international standards, such as ISO 145-5, as well the mathematic and statistical methods of uncertainty propagation specified by the Joint Committee for Guides in Metrology, that are used in the Project. Third, I speak about the structure of the Project, as well as the programming language structure and the methodology used to get the different features needed in this acoustic trial. Later, a statistical validation will be carried out, based on comparison of data generated by the program, processed using a Montecarlo simulation, and analytical calculations to verify that the program works as planned in the theoretical study. There will also be a test of the program, similar to one that a laboratory technician would carry out, by which the uncertainty in the measurement will be compared to a traditional calculation method so as to compare the results. Finally, the conclusions obtained with the development and testing of the Virtual Laboratory will be discussed, new research paths related to e-comparison definition and the improvements for the Laboratory will be proposed.

A new day for the colored woman worker: a study of colored women in industry in New York City

Joint Committee to Study the Employment of Colored Women in New York City and Brooklyn.

U.S. immigration policy and the national interest /

Originally published March 1981 as U.S. immigration policy ... final report and recommendations of the Select Commission on Immigration and Refugee Policy.

Mexico's oil and gas policy : an analysis /

Prepared by G. J. Pagliano and others.

Private investment in Latin America. A report of the Subcommittee on Inter-American Economic Relationships.

At head of title: 88th Congress, 2d session. Joint committee print.

U.S. arms control and disarmament agency 1984 annual report : message from the president of the United States transmitting the 24th annual...

At head of title: 99th Congress, 1st session. Joint committee print.

Summary on H.R. 9827 : An act to provide revenue by imposing a corporate excess profits tax.

Mode of access: Internet.

Suggestions of modern science concerning education,

Lectures considered before the "Joint committee on education", a self-organized body of Chicago citizens. Foreword signed: E. S. D. [i. e. Mrs. E. S. Dummer] for the committee.

Radioactive fallout; a two-year summary report.

Cover title.

Summary of new data on atmospheric fallout /

"Prepared for presentation at the Hearings on Fallout before the Joint Committee on Atomic Energy, May 5-8, 1959."

Stratospheric radioactivity data obtained by balloon sampling /

Cover title.

Stratospheric fallout particularly from the Russian October series /

"Prepared for Presentation at the Hearings on Fallout Before the Joint Committee on Atomic Energy, May 5-8, 1959."