Breast Cancer Decision-Making
My research focus lies at the intersection of medical decision-making and optimization, and aims to help high-risk patients make better decisions regarding breast cancer prevention and treatment. One in eight women develops breast cancer in her lifetime, and for those with a BRCA genetic mutation, the risk jumps to 60-80%. These women face many difficult decisions related to cancer prevention, early diagnosis, preferred treatment options, and post-cancer survivorship. In particular, female BRCA mutation carriers must decide whether to undergo preventive surgeries to reduce the risks of developing breast and ovarian cancer—and at what age. In collaboration with Eike Nohdurft and Stefan Spinler, we develop a finite-horizon stochastic dynamic program, where the state space includes a woman's age and various health states before and after a cancer diagnosis, and the actions correspond to surgery choices (prophylactic bilateral mastectomy or ovary removal). We exploit the structural properties of a simplified version, analytically derive monotone policies, and then solve the full problem by converting it to an infinite-horizon model and solving via linear programming. We compute the optimal policy to maximize quality-adjusted life expectancy (e.g., BRCA1 mutation carriers to undergo bilateral mastectomy between ages 30 and 60; and ovary removal anytime after age 40), and we conduct a wide range of sensitivity analyses. In 2015, I received a UCLA Faculty Career Development Award for this stream of research.
In collaboration with Dr. Patricia Ganz at UCLA, we develop a simple decision-tree model to evaluate the health benefits and costs of offering universal BRCA genetic testing to all women. At a current test price of $4,000 and very low prevalence—only 1 in 400 women carry a BRCA mutation—we find that it is not cost-effective to screen all women, alhough it would be cost-saving to screen women of Ashkenazi Jewish descent, among whom 1 in 50 carry a mutation. If a widely available genetic test drops to below $250, however, then universal BRCA screening appears cost-effective. I gave an invited keynote talk at the Future of Genomic Medicine conference at the Scripps Translational Science Institute and spoke about BRCA testing at two synagogues in Los Angeles.