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  • br When designing this research

    2019-10-10


    When designing this research, we focus on what is medically good for patients. Therefore, the criteria and weights of the criteria are determined by the physicians rather than patients; and medical oncologists are the main decision makers in this algorithm. How-ever, we also included financial/social/logistics factors in order to incorporate patients’ specific considerations and limitations. Prior to making a treatment decision, the doctor consults with the pa-tient to see whether the patient agrees to have the suggested ther-apy or not. If the patient is unable to have that treatment for any reason, there might be a slight change of the plan and that is why we designed the algorithm to suggest several treatment options.
    Table 1
    Breast cancer treatment options for primary therapy in first decision step.
    7. Neoadjuvant Chemotherapy (NECTx)→ MA → RT
    11. Neoadjuvant Endocrine Therapy (NEET) → MA → RT
    → sequential therapies + concurrent therapies
    However, even if the decision may need an alteration, the oncolo-gists usually recommend that the patient take the suggested ther-apy.
    3.1. First decision step (primary treatment)
    Primary treatment is comprised of different kinds of surgeries, neoadjuvant therapy, radiation therapy, and their combinations, as presented in Table 1. The decision for surgery depends on the size of the tumor, type of breast cancer, grade of the tumor, and, most importantly, whether the patient’s cancer is in the metastasis stage or not. Breast surgery may consist of excisional biopsy, axillary node dissection, and sentinel RVX-208 node biopsy along with differ-ent types of surgeries. Depending on the condition of the patient, the following types of surgeries could be performed: simple mas-tectomy (removal of one entire breast), bilateral mastectomy (BMA) (removal of both breasts), or lumpectomy (LU) (removal of the tu-mor and surrounding tissues only). In the current study, we focus only on MA without specifying its type because this consideration could lead to a tremendous number of alternatives, thus imped-ing data collection and analysis. Once an MA decision is made, the surgeon can determine its type and specifics based on the patient’s situation.
    Primary treatment is also referred to as local treatment because it is mainly applied as a surgical procedure to a local area. While primary treatment therapy is a local control effort, we include neoadjuvant therapy within primary treatment because neoadju-vant therapy may help to shrink the tumor or bulky lymph node before removal of the primary tumor. Neoadjuvant therapy can also aid in testing the effect of the chemotherapy regimen in deal-ing with the cancer.
    Therapies can be sequential or concurrent. Sequential therapies are represented by the symbol →, and concurrent therapies are in-dicated by the sign + , as shown in Tables 1 and 2. In both the first decision step and the second decision step following the first treat-ment, the “observe” strategy, which does not include any type of treatment, is a viable alternative strategy. For example, a patient 
    Table 2
    Treatment options for secondary therapy in second decision step.
    Adjuvant Therapy
    1. Adjuvant chemotherapy (ACTx)
    2. Adjuvant endocrine therapy (AET)
    6. AET + TT Palliative Therapy
    7. Palliative chemotherapy (PACTx)
    8. Palliative radiation therapy (PART)
    9. Palliative endocrine therapy (PAET)
    → sequential therapies + concurrent therapies
    with Tis (carcinoma in situ) stage cancer might be kept under ob-servation to observe the progression of the tumor growth if none of the treatment options is viable [24].