Evidence map›Paper›PMID 29376135›Full record

ArticleMDM policy & practice2017

Using Collaborative Simulation Modeling to Develop a Web-Based Tool to Support Policy-Level Decision Making About Breast Cancer Screening Initiation Age.

Elizabeth S Burnside, Sandra J Lee, Carrie Bennette, Aimee M Near, Oguzhan Alagoz, Hui Huang, Jeroen J van den Broek, Joo Yeon Kim, Mehmet A Ergun, Nicolien T van Ravesteyn and 3 more

Abstract read
In one paragraph

Article in MDM policy & practice, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 8 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
8citing papers in PubMed, 1 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

8 citing papers in PubMed, 1 synthesis or guideline pooled it.

  1. Pooled it
  2. Article
  3. Review
  4. Article
  5. Article
  6. Article
  7. Article
  8. Comparing CISNET Breast Cancer Models Using the Maximum Clinical Incidence Reduction Methodology.Medical decision making : an international journal of the Society for Medical Decision Making · 2018
    Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

13 authors.

Elizabeth S BurnsideBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Sandra J LeeBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Carrie BennetteBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Aimee M NearBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Oguzhan AlagozBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Hui HuangBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Jeroen J van den BroekBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Joo Yeon KimBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Mehmet A ErgunBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Nicolien T van RavesteynBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Natasha K StoutBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Harry J de KoningBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).
Jeanne S MandelblattBreast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET). Three independent modeling teams did this work from Dana-Farber Cancer Institute, Harvard Medical School (PI: Lee); Erasmus Medical Center (PI: de Koning); Harvard Medical School, University of Wisconsin (PI: Trentham-Dietz/Stout/Alagoz). Elizabeth Burnside, Jeanne Mandelblatt, Sandra Lee, and Aimee Near were the writing and coordinating committee for the project. From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (ESB); Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts (SJL, HH); Group Health Research Institute, Seattle, Washington (CB); Department of Oncology, Georgetown University Medical Center, and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC (JSM, AMN); Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin (OA, MAE); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (HJK, NTR, JJB); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh (JYK); Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (NKS).

Funding

UW COMPREHENSIVE CANCER CENTER SUPPORTP30CA014520 · NCI · UNIVERSITY OF WISCONSIN-MADISON · PI Christian Capitini · 1985 to 2026
$142.6M
Risk-based Imaging Strategies to Improve Breast Cancer Surveillance OutcomesP01CA154292 · NCI · UNIVERSITY OF CALIFORNIA AT DAVIS · PI Diana L Miglioretti · 2011 to 2026
$52.9M
Institutional Clinical and Translational Science AwardUL1TR000427 · NCATS · UNIVERSITY OF WISCONSIN-MADISON · PI DREZNER, MARC KENNETH · 2012 to 2016
$32.2M
TrainingU54AI117924 · NIAID · UNIVERSITY OF WISCONSIN-MADISON · PI CRAVEN, MARK W. · 2014 to 2018
$11.3M
Comparative Modeling: Informing Breast Cancer Control Practice & PolicyU01CA152958 · NCI · GEORGETOWN UNIVERSITY · PI BERRY, DONALD A, DE KONING, HARRY J · 2010 to 2015
$7.6M
Vermont Screening Process Documentation UnitU54CA163303 · NCI · UNIVERSITY OF VERMONT & ST AGRIC COLLEGE · PI SPRAGUE, BRIAN L · 2011 to 2017
$6.4M
Informatics Techniques to Optimize Mammography for Aging PopulationsR01CA165229 · NCI · UNIVERSITY OF WISCONSIN-MADISON · PI BURNSIDE, ELIZABETH S · 2012 to 2016
$1.7M
Mentoring And Research In Patient-Oriented Breast Cancer DiagnosisK24CA194251 · NCI · UNIVERSITY OF WISCONSIN-MADISON · PI BURNSIDE, ELIZABETH S · 2015 to 2019
$963k
NCATS NIH HHS UL1 TR000427NCI NIH HHS HHSN261201100031CNCI NIH HHS K24 CA194251NCI NIH HHS P01 CA154292NCI NIH HHS P30 CA014520NCI NIH HHS R01 CA165229NCI NIH HHS U01 CA152958NCI NIH HHS U54 CA163303NIAID NIH HHS U54 AI117924
6 · The paper itself

Abstract

backgroundThere are no publicly available tools designed specifically to assist policy makers to make informed decisions about the optimal ages of breast cancer screening initiation for different populations of US women.

objectiveTo use three established simulation models to develop a web-based tool called Mammo OUTPuT.

methodsThe simulation models use the 1970 US birth cohort and common parameters for incidence, digital screening performance, and treatment effects. Outcomes include breast cancers diagnosed, breast cancer deaths averted, breast cancer mortality reduction, false-positive mammograms, benign biopsies, and overdiagnosis. The Mammo OUTPuT tool displays these outcomes for combinations of age at screening initiation (every year from 40 to 49), annual versus biennial interval, lifetime versus 10-year horizon, and breast density, compared to waiting to start biennial screening at age 50 and continuing to 74. The tool was piloted by decision makers (n = 16) who completed surveys.

resultsThe tool demonstrates that benefits in the 40s increase linearly with earlier initiation age, without a specific threshold age. Likewise, the harms of screening increase monotonically with earlier ages of initiation in the 40s. The tool also shows users how the balance of benefits and harms varies with breast density. Surveys revealed that 100% of users (16/16) liked the appearance of the site; 94% (15/16) found the tool helpful; and 94% (15/16) would recommend the tool to a colleague.

conclusionsThis tool synthesizes a representative subset of the most current CISNET (Cancer Intervention and Surveillance Modeling Network) simulation model outcomes to provide policy makers with quantitative data on the benefits and harms of screening women in the 40s. Ultimate decisions will depend on program goals, the population served, and informed judgments about the weight of benefits and harms.

Indexed as

breast cancer screeningdecision makinghealth care policymammographysimulation modeling

Identifiers

PMID29376135
PMCPMC5785917

What OpenQuestion holds

Textmetadata
LicenceCC BY-NC
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.