Application of Decision Support Systems

for Selection of Radiotherapy Methods Breast Cancer Patients

Rafli Filano and Boy Subirosa Sabarguna

Biomedical Engineering Study Program, Faculty of Engineering, Universitas Indonesia, Jl Kampus UI, Kukusan, Beji, Kota

Depok, Jawa Barat 16424

Keyword: Decision Support System, Breast Cancer, Radiotherapy, 3D-CRT, IMRT, VMAT.

Abstract: Radiotherapy is a treatment against malignant tumor or cancer by using ionizing radiation, such as X-rays,

gamma rays or high-energy electrons. Radiotherapy methods include 3D-CRT, IMRT, VMAT. Decision-

making in the selection of radiotherapy methods in case of breast cancer is unique to each patient so doctors

need consideration. Selection of radiotherapy method for breast cancer patients so that it becomes optimal

with support of decision support system. Analytical Hierarchy Process's decision support system helps solve

complex problems by structuring a hierarchy of criteria, stakeholders, outcomes and displaying considerations

to develop possible options. The purpose of this research is the application of AHP-based aids decision system

that can be used by doctors as an alternative selection tool from existing radiotherapy methods and educational

facilities of prospective doctors in learning about radiotherapy methods in breast cancer patients. The resulting

of decision support system is used in the selection of radiotherapy methods in breast cancer patients that

greatly assist the physician in selecting decisions. Suggested software applications need to develop step

instructions and questions to be more complex and tailored to the condition of patients and hospitals.

1 INTRODUCTION

Breast cancer is a degenerative disease resulting from

cells in the breast tissue dividing and growing

uncontrollably (Miranda, et al 2013). According to

data Globacan, International Agency for Research on

Cancer (IARC) in 2012 found that breast cancer ranks

first as the most common type of cancer suffered by

women in the world. Breast cancer accounts for 25%

of all newly diagnosed overall cancer cases (Infodatin

Kemenkes, 2015). Breast cancer has a contribution of

30% and is the most dominant type of cancer in

Indonesia, beating cervical cancer that contributes

24% (DepKes RI, 2013).

One treatment of cancer is to use radiotherapy

where Radiotherapy is a recognized therapy, and 45-

50% of cancer patients are cured, radiotherapy plays

a role in the healing. New and growing radiotherapy

methods are used for breast cancer therapy, which is

radiation using 3DCRT (Three-dimensional

Conformal Radiation Therapy) techniques, IMRT

(Intensity Modulated Radiotherapy) techniques, and

VMAT (Volumetric Modulated Arc Therapy)

techniques (Liu, et al 2013).

Decision-making in the selection of breast cancer

therapy using various methods of radiotherapy is

often a problem that is often faced for a doctor

(clinician) and a patient / patient with breast cancer,

including cancer stage, surgery that has been done,

radiation target, and total dose of radiation.

Therefore, one of the methods that can be

implemented in the health world is a decision-based

system based on Analytical Hierarchy Process.

Decision support system based on Analytical

Hierarchy Process that can be used in determining the

selection of the best alternative radiotherapy methods

and becomes very important in providing knowledge

and learning about radiotherapy methods.

The purpose of this research is the selection of

radiotherapy method for breast cancer patients so that

it becomes optimal with the support of decision

support system based on Analytical Hierarchy

Process and can know the limitations of radiotherapy

method selection manually.

944

Filano, R. and Sabarguna, B.

Application of Decision Support Systems for Selection of Radiotherapy Methods Breast Cancer Patients.

DOI: 10.5220/0007554509440950

In Proceedings of the 2nd International Conference Postgraduate School (ICPS 2018), pages 944-950

ISBN: 978-989-758-348-3

2 LITERATURE REVIEW

2.1 Breast Cancer

Breast cancer is principally a malignant tumor of one

of the skins on the outside of the chest cavity. The

armpit lymph gland forms the lymphatic drainage

system for both upper quadrants of the body, as well

as the breasts including both arms (Jong, 2005).

Breast cancer is a malignancy of breast tissue that

may originate in the ductal and lobular epithelium.

Breast cancer is one of the most cancer types in

Indonesia.

Based on Pathological Based Registration in

Indonesia, Breast Cancer ranks first with relative

frequency of 18.6% (Cancer Data in Indonesia Year

2010, according to Histopathological data, Cancer

Registry Agency of Indonesian Pathology Specialist

Association and Indonesian Cancer Foundation

(YKI)). It is estimated that the incidence rate in

Indonesia is 12 / 100,000 women, whereas in the

United States are about 92 / 100,000 women with a

fairly high mortality of 27 / 100,000 or 18% of deaths

found in women. This disease can also be suffered in

men with frequency about 1%. In Indonesia, more

than 80% of cases are found to be in an advanced

stage, where treatment efforts are difficult. Therefore,

it is necessary to understand about prevention efforts,

early diagnosis, curative and palliative remedies as

well as good rehabilitation efforts, so that the service

in patients can be done optimally (Komite

Penanggulangan Kanker Nasional DepKes RI, 2015).

2.2 Radiotherapy

Radiotherapy is an utilization of ionizing rays in a

therapeutic attempt by providing a precise dose of

radiation to a determined tumor volume by reducing

normal surrounding tissue damage to a minimum.

The principle of radiotherapy is to kill cancer cells by

giving the appropriate dose to the targeted tumor or

target and to keep the radiation effect on healthy

tissue to a minimum (Murat, et al, 2010).

Radiotherapy is a treatment against malignant

cancer or cancer by using ionizing radiation, such as

X-rays, gamma rays or high-energy electrons (Sarkar,

et al 2012). Radiotherapy is a recognized therapy, and

45-50% of cancer patients are cured, radiotherapy

plays role in the healing (Susworo, 2007).

2.3 Radiotherapy Methods

2.3.1 3D-CRT Method (3 Dimension

Conformal Radiation Theraphy)

3D-CRT (Conformal Radiation Theraphy) is a

radiotherapy irradiation method based on 3D

anatomical information and uses the appropriate dose

distribution for volume targets in the case of adequate

doses of target volume and minimal doses of healthy

tissue. With the computer system work 3D-CRT

method can know the shape, size, and location of

tumors and can calculate the virtual three-

dimensional tumor.3D-CRT inidimana planning and

delivery treatment based on 3 dimensions of

volumetric image data with each radiation field in

accordance with the form of target volume

conformity (Khan, 2014).

2.3.2 IMRT Method (Intensity Modulated

Radiotheraphy)

The principle of IMRT is to provide irradiation to the

patient with some amount of irradiation direction with

a non-uniform pitch which has been optimized to give

the maximal dose to the target organ and provide

minimal dosage to the surrounding organ. Radiation

The IMRT method may be provided by the operation

of MLC (Multi Leaf Collimator) from one of the three

bases; The segmented MLC, or so-called step and

shoot, dynamic MLC or often called sliding, and

intensity modulated arc therapy (IMAT). In the MLC

step and shoot, there is a field inside the radiation

field, the MLC will move to cover the already enough

dose, and the radiation will come out if the MLC

finishes moving. In dynamic MLC, MLC will

continue to cover the part of organ that has enough

dose, as long as it is also radiation out. In the IMAT

(VMAT), MLC will move following the organ shape

and the gantry will rotate around the patient (Levitt,

et al, 2012).

2.3.3 VMAT Method (Rapid Arc)

VMAT was first introduced in 2007 and is described

as a new radiation method that allows simultaneous

variation of three parameters during treatment, ie

gantry rotation speed, aperture form of treatment

through MLC leaf movement and dose rate (Teoh, et

al, 2011). RapidArc uses the Volumetric Modulated

Arc Therapy (VMAT) Method, in which treatment is

given at a dose for the overall volume of the cancer

(Cimasi. RJ, 2014). RapidArc is a dynamic treatment

by way of radiation with 360-degree gantry rotation

around a given patient with complex planning

Application of Decision Support Systems for Selection of Radiotherapy Methods Breast Cancer Patients

945

whereby the velocity of the gantry, dose rate, and

shape of the irradiation field will change following

the shape of the tumor itself using a device called

MLC or Multi Leaf Collimator. The rotating gantry

and irradiation of the radiation field following the

overall shape of the tumor reduces the irradiation

times compared to the conventional Modulated

Radiotherapy (IMRT) Method. Besides reducing the

exposure time, the use of RapidArc is also very useful

in reducing the doses received by the risky organs

around without reducing the radiation that reaches the

target organ.

2.4 Decision Support System

Decision Support System as a set of model-based

procedures for processing and assessment data to help

managers make decisions. Decision support systems

have the primary goal of helping decision makers

through several stages of each decision-making

process through the exploitation of computerized

information systems (Hartono. AA, 2014).

Decision support system has three main sub

system, namely database management subsystem,

model subsystem, and dialog subsystem. These three

subsystems are important elements in modeling and

decision-making simulations to provide more

appropriate decision alternatives using the AHP

(Analytical Hierarchy Process) method (Shaot. A, et

al, 2014).

The basis for thinking of the AHP method is the

numerical forming process to rank each decision

alternative based on how the alternative should be

matched against the decision-making criteria

(Supriyono, 2007). This AHP method helps solve

complex problems by structuring a hierarchy of

criteria, stakeholders, outcomes and by drawing

considerations for developing weights or priorities.

Thus AHP is used when decisions are taken

involving many factors, when decision makers have

difficulty in determining the weight of each factor.

AHP will solve a complex, unstructured situation into

several components in a hierarchical arrangement. By

giving subjective values about the relative importance

of each variable, and specifying which variable has

the highest priority aims to influence the outcome of

the situation when the decision will be taken.

The steps or procedures on the AHP method are:

(Saaty. TL, 2004)

Figure 1: Flowchart procedure on AHP.

3 METHODS

This research uses qualitative method with

experimental quasi, with approach of longitudinal

research because in research implementation not at

certain period of time. The research was carried out

from August to November 2017 at the Radiotherapy

Installation of MRCCC Siloam Jakarta and the

Biomedical Technology Campus of FTUI Salemba,

Jakarta. Samples taken purposively based on

assessment by programmers and doctors PPDS

Radiation Oncology at RSCM Hospital Jakarta.

Tools and materials used in this research are:

a. Computers / Laptops, with AMD A8 processor

specifications or Intel core-i7 processors and

RAM memory of 2-3 GB.

b. Programming language

1) Front base: Html 5, CSS, Bootstrap, JS

2) Back base: Php

3) Database: Mysql

Data collection methods used are:

a. Literature Review

b. Interview

c. Preparation of Analytical Hierarchy Process

d. Systems Analysis and Design

e. Creation of Application software

f. Trials

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4 RESULTS

4.1 Analysis and Design System

A system architecture design is done by doing the

analysis so that the proposed system will be made.

Figure 2: System interconnection.

Figure 3: Interface design system.

4.2 Application of AHP

4.2.1 Define the Problem and Determine the

Desired Solution, then Determine the

Hierarchy.

First we have to define the situation carefully,

include as many relevant details as possible, then

arrange the model in a hierarchy consisting of

several levels of detail, ie the focus of the problem,

criteria, and alternatives.

Figure 4: Structure of AHP.

4.2.2 Creating a Pairwise Matrix Matrix

Matrix of pairwise comperition is made by

comparing the setlap of alternative pairs against the

criteria tested.

4.2.3 Synthesizing Comparisons

Synthesis aims to obtain the priority of all decision

alternatives after all data in the benchmark matrix is

performed. Synthetic is done by comparing the

matrix normalization, which is obtained by dividing

each entry by the number of columns in the

corresponding entry. The number of each column

will be equal to one. From a normalized matrix,

multiply the relative priority value with each entry in

the corresponding column in the benchmark matrix.

Add the multiplication in a row.

Next on the row number column, for each entry

with the entry corresponding to the priority vector, the

result is a consistency vector. The lambda value is the

average of the consistency vector. And then

calculated consistency index (CI) which n used in this

research that is 3 (number of alternative compare).

1−

−

………...…

(1)

For n = 3, the random index (RI) is 0.58, so the

consistency ratio (CR) is:

CR =

…………….

(2)

The CR result in the example shows that CR =

0.011 means that the response is quite consistent and

true, and does not need to re-evaluate the comparative

matrix that has been made because CR <10% (0.1)

Analytical Hierarchy process process that has been

done got the final result that is:

Table 1: Final summary.

Alte

rnati

Prioritas

Stage

Cance

The

Operatio

n has

been

done

Radiation

Target

Total

Dose of

radiation

3D-

0.16

(*3)

0.16 (*3) 0.13 (*3) 0.55 (*1)

IMR

0.59

(*1)

0.30 (*2) 0.38 (*2) 0.18 (*3)

Application of Decision Support Systems for Selection of Radiotherapy Methods Breast Cancer Patients

947

0.25

(*2)

0.54 (*1) 0.54 (*1) 0.27 (*2)

4.3 Implementation of Interface

For implementation of interface design assisted by

programmer. There are three views in Interface:

patient data menu (data already done decision system

decision process), patient input menu (included

patient data and existing medical resume, and start of

Decision Support System for selection method of

radiotherapy in breast cancer patients).

4.3.1 Display Login Menu

Figure 5: Menu login.

4.3.2 Recent Patient List Menu Display

Contains the latest patient data set intended to make

it easier for doctors to find information from their

current patients.

Figure 6: Recent patient data.

4.3.3 Display of Patient Form

The Patient Form is the first part of a series of

therapeutic end-points determination for patients.

Here is an example of a patient form:

Figure 7: Patient form.

After that just go into the questionnaire is

arranged hierarchically from one to ten questions,

with some examples of the display are:

a. Does Patient Have Breast Cancer?

b. Does the patient include an early stage?

c. Does the patient include an advanced stage?

d. Is the patient already in surgery?

e. Has the patient been fully operational

(Mastectomy)?

f. Has the patient been partially surgically removed

(Lumpectomy)?

g. Does the patient need radiation on the chest

wall?

g. Does the patient need radiation on all breasts?

h. Does the patient need radiation on the regional

lymph nodes?

i. Does the patient need Booster on a tumor bed?

After the process on each question is completed

then ultimately boils down to the result.

4.4 Trial and Verification Test

4.4.1 The Test Results on the Programmer

Trials are Conducted on Three

Programmers to Assess Whether the

Program is Working or not, and

Compliance with Programming.

Figure 8: Programmer trial.

4.4.2 The Test Results on User

Trials were conducted on three physicians PPDS

Radiation Oncology FKUI for general and

ICPS 2018 - 2nd International Conference Postgraduate School

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comprehensive assessments by assessing whether the

program can run or not, the suitability of the content,

provide an overview of information and software

usability.

Figure 9: User trial.

4.4.3 Verification Test Results

Software verification verification conducted by 3

doctor PPDS specialist Radiation oncology FKUI at

Cipto Mangunkusumo Hospital. PPDS doctors are

tested on how they can make quick and precise

decisions on the choice of radiotherapy methods to

breast cancer patients directly and manually without

the use of software that has been created and fill out

the form provided. However, PPDS doctors

specializing in radiation oncology are still getting

difficulties such as knowledge and field experience is

still lacking and limitations in making consideration

questions, such as: Questions are good, Questions are

added to be more specific, choice of radiotherapy

method is added according to the type of therapy that

has been undertaken by the patient, Questions and

references added for treatment recommendations.

At this time the doctors ppds specialist radiation

oncology in decision-making radiotherapy method

selection is still done manually with the mindset and

condition of the patient, the choice of radiotherapy

methods are also still experiencing many difficulties,

especially in cases of breast cancer. So with the

software system decision aids for the selection of

radiotherapy methods in breast cancer patients and

this software can be used by PPDS radiation

oncologists to facilitate in taking a decision quickly

and precisely.

5 CONCLUSIONS

The results of this research in the form of web based

application software that is a decision-based system

Analytical Hierarchy Process in the selection of

radiotherapy methods in breast cancer patients. This

research produces an overview and helps / facilitates

the specialist radiation oncologist ppds physicians in

making decisions for the selection of rapid,

appropriate and appropriate radiotherapy methods

from several available alternatives and provides

appropriate information as reference materials for the

choice of radiotherapy methods, and the resulting

decision support system and recommended in the

system directly by the program as well as any

permanent decisions of a specialist doctor or radiation

oncologist specifies even though in making decisions

the choice of radiotherapy methods is still done

manually and also still experiencing many

difficulties, especially in cases of breast cancer.

Suggested Further research software application

needs to develop step instructions and questions to be

more complex and tailored to the condition of patients

and hospitals.

ACKNOWLEDGEMENTS

Hereby, we would like to express our gratitude to the

DRPM Universitas Indonesia who has funded the

participation on International Conference

Postgraduate School Universitas Airlangga 2018

through the PITTA's Grant 2018

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