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This chapter will discuss the work of the cancer intervention and surveillance modeling network (CISNET) breast group. The discussion is structured around questions concerning the aims, results, process, and implications of the breast group experience. The general aim of CISNET is modeling the impact of cancer control interventions on population trends in incidence and mortality for breast, prostate, colorectal, and lung cancer. The seven breast cancer investigations collaborated on answering the main question, " What is the impact of adjuvant therapy and screening mammography on U.S. breast cancer mortality: 1975 – 2000? " (1). It took 4 years of effort in model building and validation, input preparation and calibration, and producing and interpreting the results to answer the main question. We start with discussing the formulation of the main question. Apart from adjuvant therapy and screening there have been other less conspicuous developments in treatment. These are the many small incremental improvements in preexisting treatments like surgery and anesthesiology, radiation therapy, and chemo-therapy. This additional contribution to survival improvement and mor tality reduction was not considered in the main question. As a consequence, each participating group more or less developed its own way of dealing with this issue. Groups who fi tted the incidence for 1975 – 2000 and predicted mortality by imposing screening and adjuvant therapy dissemination and effectiveness on the incidence ended up with a difference between observed mortality and predicted mortality. This difference can be attributed to other treatment improvements. Groups who also fi tted their model to survival or mortality had to fi nd other ways of dealing with this issue, one possibility being to attribute the mortality trend to adjuvant therapy and screening only. This issue of other treatment improvements could have been dealt with more consistently from the start and incorporated as one of the possible determinants of mortality improvement in the main question. But it would have been diffi cult to develop explicit inputs for these. One lesson learned in this exercise is to develop a comprehensive defi nition of what is and is not included in the modeling effort. The seven research groups estimated the contribution of breast cancer screening and adjuvant treatment to bringing down breast cancer mortality in the year 2000, compared to the hypothetical situation in which both types of interventions had not taken place. The result has been published in the New England Journal of Medicine (2) [see …

Chapter 16: Modeling Cancer Natural History, Epidemiology, and Control: Reflections on the CISNET Breast Group Experience