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      Prediction Model for Postoperative Quality of Life Among Breast Cancer Survivors Along the Survivorship Trajectory From Pretreatment to 5 Years: Machine Learning–Based Analysis

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          Abstract

          Background

          Breast cancer is the most common cancer and the most common cause of cancer death in women. Although survival rates have improved, unmet psychosocial needs remain challenging because the quality of life (QoL) and QoL-related factors change over time. In addition, traditional statistical models have limitations in identifying factors associated with QoL over time, particularly concerning the physical, psychological, economic, spiritual, and social dimensions.

          Objective

          This study aimed to identify patient-centered factors associated with QoL among patients with breast cancer using a machine learning (ML) algorithm to analyze data collected along different survivorship trajectories.

          Methods

          The study used 2 data sets. The first data set was the cross-sectional survey data from the Breast Cancer Information Grand Round for Survivorship (BIG-S) study, which recruited consecutive breast cancer survivors who visited the outpatient breast cancer clinic at the Samsung Medical Center in Seoul, Korea, between 2018 and 2019. The second data set was the longitudinal cohort data from the Beauty Education for Distressed Breast Cancer (BEST) cohort study, which was conducted at 2 university-based cancer hospitals in Seoul, Korea, between 2011 and 2016. QoL was measured using European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 questionnaire. Feature importance was interpreted using Shapley Additive Explanations (SHAP). The final model was selected based on the highest mean area under the receiver operating characteristic curve (AUC). The analyses were performed using the Python 3.7 programming environment (Python Software Foundation).

          Results

          The study included 6265 breast cancer survivors in the training data set and 432 patients in the validation set. The mean age was 50.6 (SD 8.66) years and 46.8% (n=2004) had stage 1 cancer. In the training data set, 48.3% (n=3026) of survivors had poor QoL. The study developed ML models for QoL prediction based on 6 algorithms. Performance was good for all survival trajectories: overall (AUC 0.823), baseline (AUC 0.835), within 1 year (AUC 0.860), between 2 and 3 years (AUC 0.808), between 3 and 4 years (AUC 0.820), and between 4 and 5 years (AUC 0.826). Emotional and physical functions were the most important features before surgery and within 1 year after surgery, respectively. Fatigue was the most important feature between 1 and 4 years. Despite the survival period, hopefulness was the most influential feature on QoL. External validation of the models showed good performance with AUCs between 0.770 and 0.862.

          Conclusions

          The study identified important factors associated with QoL among breast cancer survivors across different survival trajectories. Understanding the changing trends of these factors could help to intervene more precisely and timely, and potentially prevent or alleviate QoL-related issues for patients. The good performance of our ML models in both training and external validation sets suggests the potential use of this approach in identifying patient-centered factors and improving survivorship care.

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          Most cited references34

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          The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology.

          In 1986, the European Organization for Research and Treatment of Cancer (EORTC) initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. We report here the results of an international field study of the practicality, reliability, and validity of the EORTC QLQ-C30, the current core questionnaire. The QLQ-C30 incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social); three symptom scales (fatigue, pain, and nausea and vomiting); and a global health and quality-of-life scale. Several single-item symptom measures are also included. The questionnaire was administered before treatment and once during treatment to 305 patients with nonresectable lung cancer from centers in 13 countries. Clinical variables assessed included disease stage, weight loss, performance status, and treatment toxicity. The average time required to complete the questionnaire was approximately 11 minutes, and most patients required no assistance. The data supported the hypothesized scale structure of the questionnaire with the exception of role functioning (work and household activities), which was also the only multi-item scale that failed to meet the minimal standards for reliability (Cronbach's alpha coefficient > or = .70) either before or during treatment. Validity was shown by three findings. First, while all interscale correlations were statistically significant, the correlation was moderate, indicating that the scales were assessing distinct components of the quality-of-life construct. Second, most of the functional and symptom measures discriminated clearly between patients differing in clinical status as defined by the Eastern Cooperative Oncology Group performance status scale, weight loss, and treatment toxicity. Third, there were statistically significant changes, in the expected direction, in physical and role functioning, global quality of life, fatigue, and nausea and vomiting, for patients whose performance status had improved or worsened during treatment. The reliability and validity of the questionnaire were highly consistent across the three language-cultural groups studied: patients from English-speaking countries, Northern Europe, and Southern Europe. These results support the EORTC QLQ-C30 as a reliable and valid measure of the quality of life of cancer patients in multicultural clinical research settings. Work is ongoing to examine the performance of the questionnaire among more heterogenous patient samples and in phase II and phase III clinical trials.
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            A Unified Approach to Interpreting Model Predictions

            Understanding why a model makes a certain prediction can be as crucial as the prediction's accuracy in many applications. However, the highest accuracy for large modern datasets is often achieved by complex models that even experts struggle to interpret, such as ensemble or deep learning models, creating a tension between accuracy and interpretability. In response, various methods have recently been proposed to help users interpret the predictions of complex models, but it is often unclear how these methods are related and when one method is preferable over another. To address this problem, we present a unified framework for interpreting predictions, SHAP (SHapley Additive exPlanations). SHAP assigns each feature an importance value for a particular prediction. Its novel components include: (1) the identification of a new class of additive feature importance measures, and (2) theoretical results showing there is a unique solution in this class with a set of desirable properties. The new class unifies six existing methods, notable because several recent methods in the class lack the proposed desirable properties. Based on insights from this unification, we present new methods that show improved computational performance and/or better consistency with human intuition than previous approaches. To appear in NIPS 2017
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              Explainable AI: A Review of Machine Learning Interpretability Methods

              Recent advances in artificial intelligence (AI) have led to its widespread industrial adoption, with machine learning systems demonstrating superhuman performance in a significant number of tasks. However, this surge in performance, has often been achieved through increased model complexity, turning such systems into “black box” approaches and causing uncertainty regarding the way they operate and, ultimately, the way that they come to decisions. This ambiguity has made it problematic for machine learning systems to be adopted in sensitive yet critical domains, where their value could be immense, such as healthcare. As a result, scientific interest in the field of Explainable Artificial Intelligence (XAI), a field that is concerned with the development of new methods that explain and interpret machine learning models, has been tremendously reignited over recent years. This study focuses on machine learning interpretability methods; more specifically, a literature review and taxonomy of these methods are presented, as well as links to their programming implementations, in the hope that this survey would serve as a reference point for both theorists and practitioners.
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                Author and article information

                Contributors
                Journal
                JMIR Public Health Surveill
                JMIR Public Health Surveill
                JPH
                JMIR Public Health and Surveillance
                JMIR Publications (Toronto, Canada )
                2369-2960
                2023
                24 August 2023
                : 9
                : e45212
                Affiliations
                [1 ] Department of Clinical Research Design and Evaluation SAIHST Sungkyunkwan University Seoul Republic of Korea
                [2 ] Center for Clinical Epidemiology Samsung Medical Center Seoul Republic of Korea
                [3 ] Medical AI Research Center Samsung Medical Center Seoul Republic of Korea
                [4 ] Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
                Author notes
                Corresponding Author: Se Kyung Lee zzangdoc@ 123456gmail.com
                Author information
                https://orcid.org/0000-0003-0244-7714
                https://orcid.org/0000-0001-5241-289X
                https://orcid.org/0000-0001-9081-0266
                https://orcid.org/0000-0002-7104-3943
                https://orcid.org/0000-0002-6271-3343
                https://orcid.org/0000-0003-0037-2456
                https://orcid.org/0000-0003-1072-8954
                https://orcid.org/0000-0002-6130-7570
                https://orcid.org/0000-0001-9546-100X
                https://orcid.org/0000-0003-1564-0978
                https://orcid.org/0000-0001-5405-7385
                https://orcid.org/0000-0003-1630-1783
                Article
                v9i1e45212
                10.2196/45212
                10485708
                37309655
                0d0e0569-e58d-461b-ab41-545f07b4cad4
                ©Danbee Kang, Hyunsoo Kim, Juhee Cho, Zero Kim, Myungjin Chung, Jeong Eon Lee, Seok Jin Nam, Seok Won Kim, Jonghan Yu, Byung Joo Chae, Jai Min Ryu, Se Kyung Lee. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 24.08.2023.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org, as well as this copyright and license information must be included.

                History
                : 20 December 2022
                : 20 April 2023
                : 2 May 2023
                : 13 June 2023
                Categories
                Original Paper
                Original Paper

                breast cancer survivor,quality of life,machine learning,trajectory,predict,develop,breast cancer,survivor,cancer,oncology,algorithm,model,qol

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