There is currently a wide variety of detailed cancer information available on the World Wide Web. We look forward to the integration of these resources into point-of-service support that integrates with patient data and will further reduce cancer-related pain and suffering (see Figure 10.1).

Acts are chosen based on data describing the context of the decision and evidence/knowledge bearing on the relative merit of acts based on the given context. Figure 10.1 is very general in that many acts that are not cancer related are based on evidence and context data (it is similar to a model of an agent,52 a basic entity in the study of artificial intelligence). For example, e-business transactions include product information, evidence about purchasing patterns, context data that include a consumer's transaction history as well as highly sensitive (e.g., credit card) information, alerts, and sophisticated decision support tools that suggest transactions. Below, we provide examples of three classes of decisions that require informatics support: clinicians' decisions, laypersons' decisions, and researchers' decisions.

Clinicians' Decisions. Clinicians act based on patient information and medical knowledge. Rectangles in Box 1 represent classes of information, not individual information sources. For example, "Context Data" for a clinician decision include patient medical information in electronic medical records, handwritten notes, a patient's observations communicated verbally to the clinician, and unrecorded observations based on a physical exam. Scientific evidence comes from training, experience and medical literature. "Scientific evidence" is used here to include a broad range of evidence-based information that includes, for example, the seven warning signs of cancer and DNA mutation databases.

• How will estrogen therapy affect a particular patient's cancer risk?

• Does a patient's family history of cancer warrant genetic testing?

• A patient being seen for an aneuryism is otherwise healthy but a has spot on a chest X-ray. Should I refer for a bioposy, refer to take out a lobe of the lung, or follow noninvasively?

Laypersons' Decisions. Like clinicians, laypersons act based on their medical history and medical knowledge, but in practice these decisions are very different. Clinicians' and laypersons' acts may be of different types; for example, a clinician's act may be an order for a laboratory test, an act that is unavailable to laypersons. In practice, important acts of laypersons include finding an oncologist, finding a clinical trial, making an appointment with a clinician, identifying a question or observation to present to a clinician, gathering information before a visit to a clinician, a change in lifestyle, and worrying.

Even when clincians and laypersons are evaluating the same actions, however, clinicans' and laypersons' decisions are, in practice, made with very different informatics support. Clinicians make decisions based on formal medical records, years of professional training and experience, and peer-reviewed medical literature. Laypersons make decisions without such detailed and reliable support, because they may act based on an incomplete understanding of their medical history, limited medical knowledge, hearsay, and information they find on the World Wide Web that is not peer reviewed.

• Should I reduce my cell phone use to reduce my cancer risk?

• I have an unusual mole; do I have skin cancer?

• I have been diagnosed with cancer. How do I find an oncologist, clinical trial, or support group?

Researchers' Decisions. Researchers' acts include the design of experiments, including identification of hypotheses, and inference based on experimental results. For researchers the context data include their experimental data. Scientific evidence includes primary databases (for example, DNA sequence and clinical trials databases), primary literature, and technical synopses.

• Why did prostate cancer incidence increase dramatically in the late 1980s?

• What is the molecular cause of Li Fraumeni syndrome?

• Given gene expression data from a tumor, what is the course of a particular carcinoma?

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