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Albanell J, Svedman C, Gligorov J, Holt SD, Bertelli G, Blohmer J, Rouzier R, Lluch A, Eiermann W. Pooled analysis of prospective European studies assessing the impact of using the 21-gene Recurrence Score assay on clinical decision making in women with oestrogen receptor–positive, human epidermal growth factor receptor 2–negative early-stage breast cancer. Eur J Cancer 2016; 66:104-13. [DOI: 10.1016/j.ejca.2016.06.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/19/2016] [Accepted: 06/13/2016] [Indexed: 01/11/2023]
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Leung RC, Yau TC, Chan MC, Chan SW, Chan TW, Tsang YY, Wong TT, Chao C, Yoshizawa C, Soong IS, Kwan WH, Kwok CC, Suen JS, Ngan RK, Cheung PS. The Impact of the Oncotype DX Breast Cancer Assay on Treatment Decisions for Women With Estrogen Receptor-Positive, Node-Negative Breast Carcinoma in Hong Kong. Clin Breast Cancer 2016; 16:372-378. [DOI: 10.1016/j.clbc.2016.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
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Markopoulos C, van de Velde C, Zarca D, Ozmen V, Masetti R. Clinical evidence supporting genomic tests in early breast cancer: Do all genomic tests provide the same information? Eur J Surg Oncol 2016; 43:909-920. [PMID: 27639633 DOI: 10.1016/j.ejso.2016.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 08/17/2016] [Indexed: 01/17/2023] Open
Abstract
Breast cancer (BC) has historically been treated as a single disease entity; however, in the last decade, insights into its molecular heterogeneity have underpinned the development/commercialisation of several genomic tools whose goal is to guide patient management in early BC. These include the Oncotype DX® Breast Recurrence Score™ assay, MammaPrint®, Prosigna®, and EndoPredict®. Although these assays are similar in that they are all multigene assays reflecting risk of recurrence, they differ substantially in the technological platform used to measure gene expression; the number and identity of genes assessed; the patient populations used for development and validation; and the level of evidence supporting clinical utility. They also differ in the amount of evidence demonstrating their impact on treatment decisions and cost effectiveness in different countries. This review discusses these 4 assays, highlighting the clinical evidence that supports each of them, while focussing on the Recurrence Score assay. This assay has the greatest body of evidence supporting its clinical utility and decision impact/effectiveness, and currently is the only one validated as a predictor of response to adjuvant chemotherapy in hormone-receptor positive early BC patients treated with endocrine therapy and to be included as such in international/national BC treatment guidelines. The review also discusses ongoing prospective trials investigating the 4 assays, recent outcome studies, as well as analyses comparing different assays on the same tumour blocks.
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Affiliation(s)
- C Markopoulos
- Athens University Medical School, 8 Iassiou Street, 11521, Athens, Greece.
| | - C van de Velde
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - D Zarca
- Institut Français du Sein, 15 rue Jean Nicot, 75007, Paris, France
| | - V Ozmen
- Istanbul Faculty of Medicine, Istanbul University, Bahçelievler Mahallesi, E-5 Yanyol, Kültür Sokak, No: 14, Metroport Busidence, Bahçelievler, İstanbul, 34180, Istanbul, Turkey
| | - R Masetti
- Surgical Breast Unit, Catholic University of Rome, Largo Agostino Gemelli, 8, 00168, Rome, Italy
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Wen HY, Krystel-Whittemore M, Patil S, Pareja F, Bowser ZL, Dickler MN, Norton L, Morrow M, Hudis CA, Brogi E. Breast carcinoma with an Oncotype Dx recurrence score <18: Rate of distant metastases in a large series with clinical follow-up. Cancer 2016; 123:131-137. [PMID: 27526056 DOI: 10.1002/cncr.30271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/19/2016] [Accepted: 07/28/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A 21-gene expression assay (Oncotype DX recurrence score [RS]) that uses reverse transcriptase-polymerase chain reaction is used clinically in patients with early-stage, estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast carcinoma (ER+/HER2- BC) to determine both prognosis with tamoxifen therapy and the usefulness of adding adjuvant chemotherapy. Use of the assay is associated with reductions in overall chemotherapy use. The current study examined the treatments and outcomes in patients with low RS. METHODS The authors reviewed the institutional database to identify patients with lymph node-negative, ER+/HER2- BC who were treated at the study institution between September 2008 and August 2013 and their 21-gene RS results. RESULTS A total of 1406 consecutive patients with lymph node-negative ER+/HER2- BC and a low RS were identified (510 patients had an RS of 0-10 and 896 patients had an RS of 11-17). The median age at the time of diagnosis of BC was 56 years; 63 patients (4%) were aged <40 years. Overall, 1361 patients (97%) received endocrine therapy and 170 patients (12%) received chemotherapy. The median follow-up was 46 months. Six patients (0.4%) developed distant metastases (1 patient with an RS of 5 and 5 patients with an RS of 11-17). In the cohorts of patients with an RS of 11 to 17, the absolute rate of distant metastasis among patients aged <40 years was 7.1% (3 of 42 patients) versus 0.2% among patients aged ≥40 years (2 of 854 patients). CONCLUSIONS The data from the current study document a 0.4% rate of distant metastasis within 5 years of BC diagnosis among patients with lymph node-negative ER+/HER2- BC with an RS <18. Patients aged <40 years at the time of BC diagnosis were observed to have a higher rate of distant metastases. Analysis of data from other studies is necessary to validate this observation further. Cancer 2017;131-137. © 2016 American Cancer Society.
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Affiliation(s)
- Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fresia Pareja
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zenica L Bowser
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maura N Dickler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Larry Norton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Clifford A Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
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Marshall DA, Deal K, Bombard Y, Leighl N, MacDonald KV, Trudeau M. How do women trade-off benefits and risks in chemotherapy treatment decisions based on gene expression profiling for early-stage breast cancer? A discrete choice experiment. BMJ Open 2016; 6:e010981. [PMID: 27256091 PMCID: PMC4893875 DOI: 10.1136/bmjopen-2015-010981] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/01/2016] [Accepted: 03/30/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Gene expression profiling (GEP) of tumours informs baseline risk prediction, potentially affecting adjuvant chemotherapy decisions for women with early-stage breast cancer. Since only 15% will experience a recurrence, concerns have been raised about potential harms from overtreatment and high GEP costs in publicly funded healthcare systems. We aimed to estimate preferences and personal utility of GEP testing information and benefit-risk trade-offs in chemotherapy treatment decisions. DESIGN, SETTING AND INTERVENTION Based on literature review and findings from our qualitative research (focus groups, interviews with patients with breast cancer and medical oncologists), we developed a discrete choice experiment (DCE) survey and administered it via an internet panel. The DCE included 12 choice tasks with 5 attributes and 3 alternatives considering orthogonality, D-efficiency and level balance. PARTICIPANTS The DCE survey was administered to 1004 Canadian women from the general population. MAIN OUTCOME MEASURES Preferences were analysed using conditional logit and hierarchical Bayes and evaluated for goodness of fit. We conducted simulation analyses for alternative scenarios. RESULTS GEP test score indicating likely benefit from chemotherapy was the most important attribute. Doctor's clinical estimate of the risk of cancer returning, trust in your cancer doctor and side effects of chemotherapy (temporary and permanent) were relatively less important but showed significant differences among levels. In the scenario analyses, 78% were likely to choose chemotherapy in a high-risk scenario, 55% in a moderate-risk scenario and 33% in a low-risk scenario, with the other attributes held constant. A high GEP score was more important in influencing the choice of chemotherapy for those at intermediate clinical risk. CONCLUSIONS GEP testing information influences chemotherapy treatment decisions in early-stage breast cancer and varies depending on clinical risk. Clinicians should be aware of these differences and tailor the use of GEP testing accordingly.
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Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ken Deal
- DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
| | - Yvonne Bombard
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Leighl
- Department of Medicine, University of Toronto,Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Karen V MacDonald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Maureen Trudeau
- University of Toronto,Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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MacDonald KV, Bombard Y, Deal K, Trudeau M, Leighl N, Marshall DA. The influence of gene expression profiling on decisional conflict in decision making for early-stage breast cancer chemotherapy. Eur J Cancer 2016; 61:85-93. [PMID: 27155447 DOI: 10.1016/j.ejca.2016.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/04/2016] [Accepted: 03/21/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Women with early-stage breast cancer, of whom only 15% will experience a recurrence, are often conflicted or uncertain about taking chemotherapy. Gene expression profiling (GEP) of tumours informs risk prediction, potentially affecting treatment decisions. We examined whether receiving a GEP test score reduces decisional conflict in chemotherapy treatment decision making. METHODS A general population sample of 200 women completed the decisional conflict scale (DCS) at baseline (no GEP test score scenario) and after (scenario with GEP test score added) completing a discrete choice experiment survey for early-stage breast cancer chemotherapy. We scaled the 16-item DCS total scores and subscores from 0 to 100 and calculated means, standard deviations and change in scores, with significance (p < 0.05) based on matched pairs t-tests. RESULTS We identified five respondent subgroups based on preferred treatment option; almost 40% did not change their chemotherapy decision after receiving GEP testing information. Total score and all subscores (uncertainty, informed, values clarity, support, and effective decision) decreased significantly in the respondent subgroup who were unsure about taking chemotherapy initially but changed to no chemotherapy (n =33). In the subgroup of respondents (n = 25) who chose chemotherapy initially but changed to unsure, effective decision subscore increased significantly. In the overall sample, changes in total and all subscores were non-significant. CONCLUSIONS GEP testing adds value for women initially unsure about chemotherapy treatment with a decrease in decisional conflict. However, for women who are confident about their treatment decisions, GEP testing may not add value. Decisions to request GEP testing should be personalised based on patient preferences.
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Affiliation(s)
- Karen V MacDonald
- Department of Community Health Sciences, University of Calgary, Room 3C62, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Yvonne Bombard
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 209 Victoria Street, Room 312, Toronto, Ontario M5B 1T8, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, 209 Victoria Street, Room 312, Toronto, Ontario M5B 1T8, Canada
| | - Ken Deal
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4M4, Canada
| | - Maureen Trudeau
- University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Natasha Leighl
- Department of Medicine, University of Toronto, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada; Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, McMaster University, Room 3C56, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada.
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Jasem J, Amini A, Rabinovitch R, Borges VF, Elias A, Fisher CM, Kabos P. 21-Gene Recurrence Score Assay As a Predictor of Adjuvant Chemotherapy Administration for Early-Stage Breast Cancer: An Analysis of Use, Therapeutic Implications, and Disparity Profile. J Clin Oncol 2016; 34:1995-2002. [PMID: 27001563 DOI: 10.1200/jco.2015.65.0887] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The 21-gene Recurrence Score (RS) assay is used to predict disease recurrence and benefit of chemotherapy in estrogen receptor-positive, lymph node-negative early-stage breast cancer (EBC). Our study is the first analysis of trends and differences in the use of the RS assay and its impact on recommending chemotherapy in a population-based data set. METHODS Patients with EBC diagnosed from 2004 to 2012 and included in the National Cancer Data Base were analyzed. Multivariate logistic regression analysis was used to estimate the covariates associated with use of the test and its impact on chemotherapy decisions. RESULTS The RS assay was ordered for 54.0% of the 143,032 identified patients. Of all the variables, RS assay had the strongest association with recommendation for chemotherapy, with an adjusted odds ratio (AOR) of 83 for high assay scores. When indicated, test use was significantly associated with younger age, white race, academic centers, private insurance, and pT2/pN0(i+) grade 2 to 3 disease. Black patients (AOR, 1.31; 95% CI, 1.20 to 1.43) and those treated in community facilities (AOR, 1.49; 95% CI, 1.35 to 1.63) were more likely to be tested outside the National Comprehensive Cancer Network guidelines. Black patients (AOR, 1.51; 95% CI, 1.31 to 1.69) and those with high tumor grade (AOR, 30.76; 95% CI, 26.48 to 35.73) had significantly higher assay scores. Younger black patients (AOR, 1.33; 95% CI, 1.16 to 1.54) were more likely to receive chemotherapy despite low assay scores. CONCLUSION The RS assay significantly influences clinicians' recommendations for chemotherapy in patients with EBC. Black patients tended to have higher assay scores, which may reflect use patterns or less favorable tumor biology for estrogen receptor-positive disease. There are significant differences in use and clinical implications of the test on the basis of race, insurance, and type of facility.
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Affiliation(s)
- Jagar Jasem
- All authors: University of Colorado, Aurora, CO
| | - Arya Amini
- All authors: University of Colorado, Aurora, CO
| | | | | | | | | | - Peter Kabos
- All authors: University of Colorado, Aurora, CO
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Kuchel A, Robinson T, Comins C, Shere M, Varughese M, Sparrow G, Sahu A, Saunders L, Bahl A, Cawthorn SJ, Braybrooke JP. The impact of the 21-gene assay on adjuvant treatment decisions in oestrogen receptor-positive early breast cancer: a prospective study. Br J Cancer 2016; 114:731-6. [PMID: 26954715 PMCID: PMC4984867 DOI: 10.1038/bjc.2016.48] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/26/2016] [Accepted: 02/08/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND International guidelines, including NICE, recommend using the 21-gene Recurrence Score assay for guiding adjuvant treatment decisions in ER+, HER2-negative early breast cancer (BC). We investigated the impact of adding this assay to standard pathological tests on clinicians'/patients' treatment decisions and on patients' decisional conflict in the United Kingdom. METHODS In this prospective multicentre study, eligibility criteria included: ER+ HER2-negative BC (N0/Nmic for patients ⩽50 years; ⩽3 positive lymph nodes for patients >50 years) and being fit for chemotherapy. Physicians'/patients' treatment choices and patients' decisional conflict were recorded pre- and post testing. RESULTS The analysis included 137 patients. Overall, adjuvant treatment recommendations changed in 40.7% of patients, with the direction of the change consistent with the Recurrence Score results (net decrease in chemotherapy recommendation rate in low Recurrence Score patients and net increase in high Recurrence Score patients). Patients' choices were generally consistent with physicians' recommendations. Post-testing, patients' decisional conflict decreased significantly (P<0.0001). In the 67 patients meeting the NICE criteria for testing, the recommendation change rate was 49.3%. CONCLUSIONS Recurrence Score testing significantly influenced treatment recommendations overall and in the subgroup of patients meeting the NICE criteria, suggesting that this test could substantially alter treatment patterns in the United Kingdom.
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Affiliation(s)
- Anna Kuchel
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
| | - Tim Robinson
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
| | - Charles Comins
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
| | - Mike Shere
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Mohini Varughese
- The Beacon Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton TA1 5DA, UK
| | - Geoff Sparrow
- Yeovil District Hospital NHS Foundation Trust, Yeovil BA21 4AT, UK
| | - Ajay Sahu
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Louise Saunders
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Amit Bahl
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
| | - Simon J Cawthorn
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Jeremy P Braybrooke
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
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Martin M, Brase JC, Ruiz A, Prat A, Kronenwett R, Calvo L, Petry C, Bernard PS, Ruiz-Borrego M, Weber KE, Rodriguez CA, Alvarez IM, Segui MA, Perou CM, Casas M, Carrasco E, Caballero R, Rodriguez-Lescure A. Prognostic ability of EndoPredict compared to research-based versions of the PAM50 risk of recurrence (ROR) scores in node-positive, estrogen receptor-positive, and HER2-negative breast cancer. A GEICAM/9906 sub-study. Breast Cancer Res Treat 2016; 156:81-9. [PMID: 26909792 DOI: 10.1007/s10549-016-3725-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/16/2016] [Indexed: 01/15/2023]
Abstract
There are several prognostic multigene-based tests for managing breast cancer (BC), but limited data comparing them in the same cohort. We compared the prognostic performance of the EndoPredict (EP) test (standardized for pathology laboratory) with the research-based PAM50 non-standardized qRT-PCR assay in node-positive estrogen receptor-positive (ER+) and HER2-negative (HER2−) BC patients receiving adjuvant chemotherapy followed by endocrine therapy (ET) in the GEICAM/9906 trial. EP and PAM50 risk of recurrence (ROR) scores [based on subtype (ROR-S) and on subtype and proliferation (ROR-P)] were compared in 536 ER+/HER2− patients. Scores combined with clinical information were evaluated: ROR-T (ROR-S, tumor size), ROR-PT (ROR-P, tumor size), and EPclin (EP, tumor size, nodal status). Patients were assigned to risk-categories according to prespecified cutoffs. Distant metastasis-free survival (MFS) was analyzed by Kaplan–Meier. ROR-S, ROR-P, and EP scores identified a low-risk group with a relative better outcome (10-year MFS: ROR-S 87 %; ROR-P 89 %; EP 93 %). There was no significant difference between tests. Predictors including clinical information showed superior prognostic performance compared to molecular scores alone (10-year MFS, low-risk group: ROR-T 88 %; ROR-PT 92 %; EPclin 100 %). The EPclin-based risk stratification achieved a significantly improved prediction of MFS compared to ROR-T, but not ROR-PT. All signatures added prognostic information to common clinical parameters. EPclin provided independent prognostic information beyond ROR-T and ROR-PT. ROR and EP can reliably predict risk of distant metastasis in node-positive ER+/HER2− BC patients treated with chemotherapy and ET. Addition of clinical parameters into risk scores improves their prognostic ability.
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Roberts MC, Weinberger M, Dusetzina SB, Dinan MA, Reeder-Hayes KE, Carey LA, Troester MA, Wheeler SB. Racial Variation in the Uptake of Oncotype DX Testing for Early-Stage Breast Cancer. J Clin Oncol 2015; 34:130-8. [PMID: 26598755 DOI: 10.1200/jco.2015.63.2489] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Oncotype DX (ODX) is a tumor gene-profiling test that aids in adjuvant chemotherapy decision-making. ODX has the potential to improve quality of care; however, if not equally accessible across racial groups, disparities in cancer care quality may persist or worsen. We examined racial disparities in ODX testing uptake. METHODS We used data from the Carolina Breast Cancer Study, phase III, a longitudinal, population-based study of 2,998 North Carolina women who received a diagnosis of breast cancer between 2008 and 2014. Our primary analysis used modified Poisson regression to determine the association between race and whether ODX testing was ordered among two strata: node-negative and node-positive breast cancer. RESULTS A total of 1,468 women with estrogen receptor-positive, human epidermal growth factor receptor-2-negative, stage I or II breast cancer met inclusion criteria. Black patients had higher-grade and larger tumors, more comorbidities, younger age at diagnosis, and lower socioeconomic status than non-black women. Overall, 42% of women had ODX test results in their pathology reports. Compared with those who did not receive ODX testing, women who received ODX testing tended to be younger and have medium tumor size and grade. Our regression analyses indicated no racial disparities in ODX uptake among node-negative patients. However, racial differences were detected among node-positive patients, with black patients being 46% less likely to receive ODX testing than non-black women (adjusted relative risk, 0.54; 95% CI, 0.35 to 0.84; P = .006). CONCLUSION We did not find racial disparities in ODX testing for node-negative patients for whom ODX testing is guideline recommended and widely covered by insurers. However, our findings suggest that a newer, non-guideline-concordant application of ODX testing for node-positive breast cancer was accessed less by black women than by non-black women, reflecting more guideline concordant care among black women.
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Affiliation(s)
- Megan C Roberts
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC.
| | - Morris Weinberger
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stacie B Dusetzina
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Michaela A Dinan
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Katherine E Reeder-Hayes
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Lisa A Carey
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Melissa A Troester
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stephanie B Wheeler
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
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Dreyfus C, Ballester M, Gligorov J, Agranat P, Antoine M, Tengher I, Bricou A. [Impact of the 21-gene assay in decision-making during multidisciplinary breast meeting: A French experience]. Gynecol Obstet Fertil 2015; 43:780-5. [PMID: 26584893 DOI: 10.1016/j.gyobfe.2015.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/29/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The 21-gene assay (Oncotype DX(®)) test is used to estimate the risk of recurrence and to predict the benefit of adjuvant chemotherapy at an early stage of endocrine responsive breast cancers, without HER2 overexpression or amplification. This test corresponds to a recurrence score (RS), classifying patients into three groups (low, intermediate or high risk). The objective of this two-center prospective study is to define the impact of Oncotype DX(®) in clinical practice. METHODS Between August 2013 and May 2015, an Oncotype DX(®) test was decided in multidisciplinary meeting, to certain patients with an indication of adjuvant chemotherapy for HR+ and HER2 negative cancers. The therapeutic changes after knowledge of RS were collected. An estimate of the economic impact was performed and a correlation between the RS and usual breast cancer prognostic markers was investigated. RESULTS Thirty-nine patients had a test, twenty-six (66.7%) of them have finally been no indication retaining chemotherapy. The economy obtained through the use of the test was estimated around 173,000euros. It has not been demonstrated correlation between the RS, the usual decisional and prognostic factors for breast cancer or with adjuvant! Online. CONCLUSIONS The RS has an additional decision value compared to other common decision criteria. Use of Oncotype DX(®) reduced in our experience the indications of adjuvant chemotherapy. The medical and economic impact could be significant.
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Affiliation(s)
- C Dreyfus
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France
| | - M Ballester
- Service de gynécologie-obstétrique, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - J Gligorov
- Service d'oncologie médicale, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - P Agranat
- Service d'oncologie médicale, université Paris XIII-Bobigny, AP-HP, Avicenne, 125, rue de Stalingrad, 93000 Bobigny, France
| | - M Antoine
- Laboratoire d'anatomopathologie, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - I Tengher
- Laboratoire d'anatomopathologie, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France
| | - A Bricou
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France.
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Kuijer A, van Bommel AC, Drukker CA, van der Heiden-van der Loo M, Smorenburg CH, Westenend PJ, Linn SC, Rutgers EJ, Elias SG, van Dalen T. Using a gene expression signature when controversy exists regarding the indication for adjuvant systemic treatment reduces the proportion of patients receiving adjuvant chemotherapy: a nationwide study. Genet Med 2016; 18:720-6. [PMID: 26583684 DOI: 10.1038/gim.2015.152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/14/2015] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The Dutch national guideline advises use of gene-expression signatures, such as the 70-gene signature (70-GS), in case of ambivalence regarding the benefit of adjuvant chemotherapy (CT). In this nationwide study, the impact of 70-GS use on the administration of CT in early breast cancer patients with a dubious indication for CT is assessed. METHODS Patients within a national guideline directed indication area for 70-GS use who were surgically treated between November 2011 and April 2013 were selected from the Netherlands Cancer Registry database. The effect of 70-GS use on the administration of CT was evaluated in guideline- and age-delineated subgroups addressing potential effect of bias by linear mixed-effect modeling and instrumental variable (IV) analyses. RESULTS A total of 2,043 patients within the indicated area for 70-GS use were included, of whom 298 received a 70-GS. Without use of the 70-GS, 45% of patients received CT. The 70-GS use was associated with a 9.5% decrease in CT administration (95% confidence interval (CI): -15.7 to -3.3%) in linear mixed-effect model analyses and IV analyses showed similar results (-9.9%; 95% CI: -19.3 to -0.4). CONCLUSION In patients in whom the Dutch national guidelines suggest the use of a gene-expression profile, 70-GS use is associated with a 10% decrease in the administration of adjuvant CT.Genet Med 18 7, 720-726.Genetics in Medicine (2016); 18 7, 720-726. doi:10.1038/gim.2015.152.
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Affiliation(s)
- Alvin I Mushlin
- Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street, Suite 301, NY 10065, USA
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Smyth L, Watson G, Walsh EM, Kelly CM, Keane M, Kennedy MJ, Grogan L, Hennessy BT, O'Reilly S, Coate LE, O'Connor M, Quinn C, Verleger K, Schoeman O, O'Reilly S, Walshe JM. Economic impact of 21-gene recurrence score testing on early-stage breast cancer in Ireland. Breast Cancer Res Treat 2015; 153:573-82. [PMID: 26364296 DOI: 10.1007/s10549-015-3555-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/21/2015] [Indexed: 12/21/2022]
Abstract
The 21-gene test is a validated multi-gene diagnostic test that predicts chemotherapy (CT) benefit in oestrogen receptor positive (ER+), lymph node-negative (N0) breast cancer (BC) patients (pts). Ireland was the first public health care system to reimburse this test in Europe. Study objectives were to assess the impact of this test on decision-making and to analyse the economic impact of testing. Between October 2011 and February 2013, a national, retrospective, cross-sectional observational study of ER+, N0 BC pts tested with the 21-gene test was conducted. Surveyed breast medical oncologists, provided the assumption for the decision impact analysis that grade (G) 1 pts would not have received CT before testing and G2/3 pts would have received CT before testing. Descriptive statistical analyses were performed. 592 pts were identified; Low, intermediate and high recurrence score were identified in 53, 36 and 10 % pts, respectively. 384 (70 %) pts had G2, 129 (22 %) G3 and 76 (13 %) G1 tumours. Post testing, 345 pts (59 %) experienced a change in CT decision; 339 changed to hormone therapy alone and 6 advised to receive CT. 172 (30 %) pts received CT, 12 (3.9 %) of pts with low scores, 108 (50.9 %) of intermediate risk and 50 (90.9 %) of pts with high risk scores. Net reduction in CT use was 58 % and net savings achieved were €793,565. Since public reimbursement, the introduction of the 21-gene test has resulted in a significant reduction in chemotherapy administration and cost savings for the Irish public healthcare system.
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Abstract
An important and often complicated management decision in early stage hormone receptor (HR)-positive breast cancer relates to the use of adjuvant systemic chemotherapy. Although traditional clinicopathologic markers exist, tremendous progress has been achieved in the field of predictive biomarkers and genomics with both prognostic and predictive capabilities to identify patients who will potentially benefit from additional therapy. The use of these genomic tests in the neoadjuvant setting is also being studied and may lead to these tests providing clinical benefit even earlier in the disease course. Landmark articles published in the last few years have expanded our knowledge of breast cancer genomics to an unprecedented level, and mutational analysis via next-generation sequencing methods allows the identification of molecular targets for novel targeted therapeutic agents and clinical trials testing efficacy of targeted therapies, such as PI3K inhibitors, in addition to endocrine therapy for HR-positive breast cancer, are ongoing. We provide an in-depth review on the role of gene expression-based predictors in early stage breast cancer and an overview of future directions, including next-generation sequencing. Over the coming years, we anticipate a significant increase in utilization of genomic-based predictors for individualized selection and duration of endocrine therapy with and without genotype-driven targeted therapy, and a major decrease in the use of chemotherapy, possibly even leading to a chemotherapy-free road for early stage HR-positive breast cancer.
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Affiliation(s)
- Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
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Augustovski F, Soto N, Caporale J, Gonzalez L, Gibbons L, Ciapponi A. Decision-making impact on adjuvant chemotherapy allocation in early node-negative breast cancer with a 21-gene assay: systematic review and meta-analysis. Breast Cancer Res Treat 2015; 152:611-25. [PMID: 26126971 DOI: 10.1007/s10549-015-3483-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/18/2015] [Indexed: 01/10/2023]
Abstract
Risk stratification based on results provided by a 21-gene assay (Oncotype DX(®)) in early stage breast cancer can help optimize hormone therapy (HT) and/or chemotherapy (CT) decisions. We performed a systematic review and meta-analysis of decision impact (DI) and net change in CT use before and after assay results, both in the whole studies' population and by recurrence risk score (RS) strata. A systematic search of studies with prospective data collection reported physician's decision on treatment allocation in early stage node-negative breast cancer was performed. DI reflects the proportion of patients whose management was changed, and net change focuses on CT change. A random-effects model is reported. Fifteen studies (N = 2229) met our inclusion criteria: 50.09, 37.35, and 13.38 % of patients with low, intermediate, and high RS. Treatment decision changed in 29.5 % (95 % CI 26.29-32.86). Net reduction of CT use was 12 % (8-17 %). It was 16 % (12.00-19.00) in the low RS group, 0 % (-3.00 to 3.00) in the intermediate RS group, and increased by 2 % (-1.00 to 3.00) in the high RS group. Use of a 21-gene assay showed a significant impact on treatment decisions. From 100 women tested, 30 could have their treatment optimized, and 12 could avoid CT. Its main effects consist of sparing chemotherapy in low risk patients and slightly increasing it in the high risk category. DI could be higher in selected patient populations with greater uncertainty regarding initial treatment decisions.
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Affiliation(s)
- Federico Augustovski
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024 (1414), Ciudad Autónoma de Buenos Aires, Argentina,
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Gligorov J, Pivot XB, Jacot W, Naman HL, Spaeth D, Misset JL, Largillier R, Sautiere JL, de Roquancourt A, Pomel C, Rouanet P, Rouzier R, Penault-Llorca FM. Prospective Clinical Utility Study of the Use of the 21-Gene Assay in Adjuvant Clinical Decision Making in Women With Estrogen Receptor-Positive Early Invasive Breast Cancer: Results From the SWITCH Study. Oncologist 2015; 20:873-9. [PMID: 26112003 DOI: 10.1634/theoncologist.2014-0467] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The 21-gene Oncotype DX Recurrence Score assay is a validated assay to help decide the appropriate treatment for estrogen receptor-positive (ER+), early-stage breast cancer (EBC) in the adjuvant setting. The choice of adjuvant treatments might vary considerably in different countries according to various treatment guidelines. This prospective multicenter study is the first to assess the impact of the Oncotype DX assay in the French clinical setting. METHODS A total of 100 patients with ER+, human epidermal growth factor receptor 2-negative EBC, and node-negative (pN0) disease or micrometastases in up to 3 lymph nodes (pN1mi) were enrolled. Treatment recommendations, physicians' confidence before and after knowing the Recurrence Score value, and physicians' perception of the assay were recorded. RESULTS Of the 100 patients, 95 were evaluable (83 pN0, 12 pN1mi). Treatment recommendations changed in 37% of patients, predominantly from chemoendocrine to endocrine treatment alone. The proportion of patients recommended chemotherapy decreased from 52% pretest to 25% post-test. Of patients originally recommended chemotherapy, 61% were recommended endocrine treatment alone after receiving the Recurrence Score result. For both pN0 and pN1mi patients, post-test recommendations appeared to follow the Recurrence Score result for low and high values. Physicians' confidence improved significantly. CONCLUSION These are the first prospective data on the impact of the Oncotype DX assay on adjuvant treatment decisions in France. Using the assay was associated with a significant change in treatment decisions and an overall reduction in chemotherapy use. These data are consistent with those presented from European and non-European studies.
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Affiliation(s)
- Joseph Gligorov
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Xavier B Pivot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - William Jacot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Hervé L Naman
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Dominique Spaeth
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Louis Misset
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Rémy Largillier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Loup Sautiere
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Anne de Roquancourt
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Christophe Pomel
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Philippe Rouanet
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Roman Rouzier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Frederique M Penault-Llorca
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
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Le Du F, Gonzalez-Angulo AM, Park M, Liu DD, Hortobagyi GN, Ueno NT. Effect of 21-Gene RT-PCR Assay on Adjuvant Therapy and Outcomes in Patients With Stage I Breast Cancer. Clin Breast Cancer 2015; 15:458-66. [PMID: 26233757 DOI: 10.1016/j.clbc.2015.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/11/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recurrence score (RS) derived from a 21-gene reverse transcriptase-polymerase chain reaction assay is used to stratify patients with early-stage estrogen receptor-positive, HER2-normal breast cancer into 3 groups on the basis of 10-year distant metastasis risk: low, intermediate, and high. Published data are limited regarding the effect of RS on choice of adjuvant therapy for T1 breast cancer. We investigated the relationship between RS and choice of adjuvant therapy, prognosis, and benefit of chemotherapy (CT) in stage I breast cancer. MATERIALS AND METHODS We reviewed the records of 1030 patients with estrogen receptor-positive, HER2-normal stage I breast cancer and RS available. RSs were correlated with clinicopathologic characteristics, treatment, and outcome. RESULTS Patients with pathologic (p)T1a, pT1b, and pT1c disease did not differ in distribution of low, intermediate, and high RS (P = .673). Overall, fewer than 10% of patients had a high RS. Histologic grade 1, nuclear grade 1, and low Ki-67 expression had only 1%, 0%, and 6% of high RSs, respectively. Among patients with intermediate RSs, 41% with pT1b and 46% with pT1c disease received CT. Among patients with intermediate RSs, for pT1b disease, distant disease-free survival (DDFS) did not differ between hormonal therapy (HT) alone and CT with HT (P = .752); for pT1c, DDFS was superior for CT with HT (P = .020). Histologic grade was the only independent prognostic factor of DDFS (P = .0007, 1 vs. 3; P = .035, 2 vs. 3); RS did not predict DDFS (P = .083, high vs. low; P = .066, intermediate vs. low). CONCLUSION The added value of RS to known prognostic factors appears limited to patients with pT1b breast cancer. However, this study lacked long-term follow-up.
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Affiliation(s)
- Fanny Le Du
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Medical Oncology, Eugène Marquis Cancer Center, Rennes, France
| | - Ana M Gonzalez-Angulo
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Kip M, Monteban H, Steuten L. Long-term cost-effectiveness of Oncotype DX® versus current clinical practice from a Dutch cost perspective. J Comp Eff Res 2015; 4:433-45. [PMID: 25872415 DOI: 10.2217/cer.15.18] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION This study analyzes the incremental cost-effectiveness of Oncotype DX(®) testing to support adjuvant chemotherapy recommendations, versus current clinical practice, for patients with estrogen receptor-positive (ER(+)), node-negative or micrometastatic (pN1mic) early-stage breast cancer in The Netherlands. METHODS Markov model projecting distant recurrence, survival, quality-adjusted life years (QALYs) and healthcare costs over a 30-year time horizon. RESULTS Oncotype DX was projected to increase QALYs by 0.11 (0.07-0.58) and costs with €1236 (range: -€142-€1236) resulting in an incremental cost-effectiveness ratio of €11,236/QALY under the most conservative scenario. CONCLUSION Reallocation of adjuvant chemotherapy based on Oncotype DX testing is most likely a cost-effective use of scarce resources, improving long-term survival and QALYs at marginal or lower costs.
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Affiliation(s)
- Michelle Kip
- Panaxea BV, Health Economics & Reimbursement, Enschede, The Netherlands.,Department of Health Technology & Services Research, University of Twente, Enschede, The Netherlands
| | | | - Lotte Steuten
- Panaxea BV, Health Economics & Reimbursement, Enschede, The Netherlands.,Hutchinson Institute for Cancer Outcomes Research (HICOR), Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Abstract
OBJECTIVE Multigene predictors are being used increasingly in early-stage breast cancer patients for prediction and prognosis. However, one consequence of the increased use of multigene predictors, and the heightened efforts toward their incorporation into routine clinical practice, is the potential for future malpractice litigation. It is, therefore, important to ascertain the strength of the evidence for using the different commercially available multigene predictor assays clinically. We evaluated the literature for evidence of clinical validity of four currently available gene signatures and to assess the influence of the 21-gene-expression assay on changes in treatment recommendations. METHODS A systematic search of the peer-reviewed literature from January 2002 to March 2014 for multigene predictor assays was carried out, and a meta-analysis was conducted. RESULTS The adjusted Cox hazard ratio average for studies that met the eligibility criteria was 3.538 (95% CI: 1.513-8.469). The 21-gene signature showed the highest stability in the estimation of likelihood of distant risk of recurrence. Using the recurrence scores resulted in changes in treatment recommendations in 31.8% of all patients in the studies. CONCLUSION This study may provide insight about the use of multigene predictors in clinical practice for prediction and prognosis of breast cancer.
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Affiliation(s)
- Amalia M Issa
- Program in Personalized Medicine and Targeted Therapeutics, University of the Sciences, 600 South 43rd Street, Philadelphia, PA 19104, USA
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Jekunen A. Clinicians' expectations for gene-driven cancer therapy. Clin Med Insights Oncol 2014; 8:159-64. [PMID: 25574148 PMCID: PMC4271717 DOI: 10.4137/cmo.s20737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/19/2014] [Accepted: 11/21/2014] [Indexed: 12/15/2022]
Abstract
A new era of medicine is rapidly approaching, which will change not only pathological diagnosis but also medical decision-making. This paper raises the question of how well prepared doctors are to address the new issues that will soon confront them. The human genome has been completely sequenced and general understanding about cancer biology has increased enormously with understanding that unregulated gene function and complicated changes in signal pathways are related to uncontrolled cell growth. Thus, gene-driven therapy involving alterations to genes are recognized to present new therapy options. This advance will necessitate major changes to the decision-making aspect of physicians. This article focuses on defining the pertinent changes and addressing what they mean for practicing physicians.
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Affiliation(s)
- Antti Jekunen
- Vaasa Oncology Clinic, Turku University, Vaasa, Finland
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Sheppard VB, O'Neill SC, Dilawari A, Horton S, Hirpa FA, Isaacs C. Patterns of 21-gene assay testing and chemotherapy use in black and white breast cancer patients. Clin Breast Cancer 2014; 15:e83-92. [PMID: 25555816 DOI: 10.1016/j.clbc.2014.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/20/2014] [Accepted: 11/25/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND In women with early stage, hormone receptor (HR)-positive (HR(+)) breast cancer, the 21-gene recurrence score (RS) assay quantifies recurrence risk and predicts chemotherapy responsiveness. Recent data suggest that not all women with early-stage, HR(+) disease receive this testing. We examined sociodemographic, clinical, and attitudinal factors associated with RS testing receipt and the RS testing effect on chemotherapy use in black and white patients. PATIENTS AND METHODS Women with newly diagnosed invasive, nonmetastatic breast cancer were recruited and interviewed to collect sociocultural and health care process data; clinical data were collected from charts. Of the sample (n = 359), 270 had HR(+) disease. Primary analysis focused on those with HR(+) node-negative disease (n = 143); secondary analyses included node-positive women. Logistic regression models evaluated factors associated with receipt of RS testing and chemotherapy. RESULTS Among women eligible for the 21-gene assay, 62 patients [43%] received RS testing. In multivariable analysis, older age (odds ratio, 1.04 per 1 year increase; 95% confidence interval, 1.01-1.08) was associated with RS testing after adjustment for covariates. Chemotherapy use was 23%. In multivariable analysis, positive attitudes about chemotherapy and greater risk of recurrence were associated with chemotherapy use (P < .05). CONCLUSION Patterns of genomic testing might vary according to age. Efforts to understand factors associated with low testing rates will be important.
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Affiliation(s)
- Vanessa B Sheppard
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC.
| | - Suzanne C O'Neill
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC
| | - Asma Dilawari
- Medstar Georgetown University Hospital, Washington, DC
| | - Sara Horton
- Department of Oncology, Howard University Hospital, Washington, DC
| | - Fikru A Hirpa
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC
| | - Claudine Isaacs
- Breast Cancer Program, Lombardi Comprehensive Cancer Center and Departments of Oncology and Medicine, Georgetown University School of Medicine, Medstar Georgetown University Hospital, Washington, DC
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Bargallo JE, Lara F, Shaw‐Dulin R, Perez‐Sánchez V, Villarreal‐Garza C, Maldonado‐Martinez H, Mohar‐Betancourt A, Yoshizawa C, Burke E, Decker T, Chao C. A study of the impact of the 21‐gene breast cancer assay on the use of adjuvant chemotherapy in women with breast cancer in a Mexican public hospital. J Surg Oncol 2014; 111:203-7. [DOI: 10.1002/jso.23794] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 08/28/2014] [Indexed: 11/07/2022]
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Nerich V, Curtit E, Bazan F, Montcuquet P, Villanueva C, Chaigneau L, Cals L, Méneveau N, Dobi E, Altmotlak H, Algros MP, Choulot MJ, Nallet G, Limat S, Mansion S, Pivot X. [Economic assessment of the routine use of Oncotype DX® assay for early breast cancer in Franche-Comte region]. Bull Cancer 2014; 101:681-9. [PMID: 25091650 DOI: 10.1684/bdc.2014.1923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Oncotype DX® has been validated as quantifying the likelihood of distant recurrence at 10 years and overall chemotherapy benefit in patients with estrogen-receptor-positive and HER-2-negative early breast cancer. In 2012, this genomic signature was routinely available for patients in Franche-Comté, France. Patients eligible for Oncotype DX(®) testing had a ER-positive, HER-2-négative early breast cancer with a nodal involvement limited to 0 or 1 positive-node without extracapsular spread; an adjuvant chemotherapy was indicated based on usual prognostic factors. The aim was to assess the economic impact of Oncotype DX(®) testing in a French region. A cost-minimisation analysis from the French Public Healthcare System perspective was performed. The availability of Oncotype DX(®) in Franche-Comté, France, and its use in clinical routine allowed a decrease of 73 % of adjuvant chemotherapy without increase of the cost of the patients' management and with a potential reduction of the cost for the French Public Healthcare System. This strategy was successful and may allow the reimbursement of this test in France for patients with early breast cancer.
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Jaafar H, Bashir MA, Taher A, Qawasmeh K, Jaloudi M. Impact of Oncotype DX testing on adjuvant treatment decisions in patients with early breast cancer: a single-center study in the United Arab Emirates. Asia Pac J Clin Oncol 2014; 10:354-60. [PMID: 25243360 DOI: 10.1111/ajco.12259] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2014] [Indexed: 01/01/2023]
Abstract
AIM To evaluate the distribution of the Oncotype DX Recurrence Score (a validated prognostic/predictive tool in early-stage estrogen-receptor positive [ER+] breast cancer) and its impact on adjuvant treatment decisions in the United Arab Emirates. METHODS A retrospective analysis of a single-center cohort. RESULTS The analysis included 47 node-negative ER+ breast cancer patients with low-to-intermediate risk according to the St. Gallen criteria. The mean (SD) Recurrence Score result was 17.7 (8.0); 25 (53.2%), 19 (40.4%) and 3 (6.4%) patients had low, intermediate and high Recurrence Score results, respectively. Recurrence Score risk categories were concordant with risk groups according to the St. Gallen criteria in 23 patients (48.9%). Before testing, 24 patients (51.1%) were recommended endocrine therapy alone and 23 patients (48.9%) were recommended chemoendocrine therapy. After testing, 13 patients (27.7%; 95% confidence interval 16.3-42.4%) had a treatment change (from pretesting recommendation to posttesting actual treatment), and chemotherapy use decreased overall (from 48.9 to 25.5%; P = 0.0023, McNemar's test), and particularly in the low Recurrence Score category (from 56.0 to 8.0%; P = 0.0005, McNemar's test). After testing, the proportions of patients with chemoendocrine therapy recommendations differed significantly across the Recurrence Score categories (8.0, 36.8 and 100% in the low, intermediate and high Recurrence Score categories, respectively; P = 0.0012, Fisher's exact test). With an average follow-up of 31.2 months (range: 17-51), no locoregional/systemic relapses were observed. CONCLUSION This first decision impact study in a Middle Eastern country showed the significant effect of Oncotype DX testing on clinical practice, further demonstrating the consistent impact of such testing worldwide.
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Affiliation(s)
- Hassan Jaafar
- Department of Oncology, Tawam Hospital, Al-Ain, United Arab Emirates
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Lee MH, Han W, Lee JE, Kim KS, Park H, Kim J, Bae SY, Shin HJ, Lee JW, Lee ES. The clinical impact of 21-gene recurrence score on treatment decisions for patients with hormone receptor-positive early breast cancer in Korea. Cancer Res Treat 2014; 47:208-14. [PMID: 25381828 PMCID: PMC4398124 DOI: 10.4143/crt.2013.223] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 01/27/2014] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The 21-gene (Oncotype DX) recurrence score (RS) assay is useful in predicting the benefits of adjuvant chemotherapy for early breast cancer patients and is widely used in Western countries. However, to date, it has not gained much popularity in East Asia. We analyzed the results from five institutions' experience from using the 21-gene assay and examined the impact of assay results on decision making of chemotherapy in Korean breast cancer patients and the associations between RS and clinicopathologic characteristics. MATERIALS AND METHODS The 21-gene assay was performed on 212 patients with estrogen receptor-positive early breast cancer in five institutions. Each center made systemic treatment decisions both before and after the knowledge of assay results. RESULTS Among the 212 patients, 132 (62.3%) had a low RS of < 18, 60 (28.3%) had an intermediate RS of 18-30, and 20 (9.4%) had a high RS of ≥ 31. Histologic grade, presence of micrometastases, Ki-67, and presence of lymphatic invasion were statistically associated with the RS results. Treatment decisions were changed in 115 of 212 patients (54.2%) in 109 of 212 (51.4%) from chemotherapy plus hormone therapy to hormone therapy, and in six of 212 (2.8%) from hormone therapy to chemotherapy plus hormone therapy. CONCLUSION The 21-gene breast cancer assay proved to have a significant impact on treatment decision- making. The test reduces chemotherapy use in more than 50% of Korean estrogen receptor-positive, early breast cancer patients.
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Affiliation(s)
- Moo Hyun Lee
- Center for Breast Cancer, National Cancer Center, Goyang, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ku Sang Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Heeseung Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jongjin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Youn Bae
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Joo Shin
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Sook Lee
- Center for Breast Cancer, National Cancer Center, Goyang, Korea
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Cusumano P, Generali D, Ciruelos E, Manso L, Ghanem I, Lifrange E, Jerusalem G, Klaase J, de Snoo F, Stork-sloots L, Dekker-vroling L, Holzik ML. European inter-institutional impact study of MammaPrint. Breast 2014; 23:423-8. [DOI: 10.1016/j.breast.2014.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 02/25/2014] [Accepted: 02/28/2014] [Indexed: 12/19/2022] Open
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Zanotti L, Bottini A, Rossi C, Generali D, Cappelletti MR. Diagnostic tests based on gene expression profile in breast cancer: from background to clinical use. Tumour Biol 2014; 35:8461-70. [DOI: 10.1007/s13277-014-2366-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 07/15/2014] [Indexed: 12/17/2022] Open
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Abstract
The recurrence score derived from the 21-gene Oncotype DX assay is both prognostic and predictive of adjuvant chemotherapy benefit in node-negative, estrogen-receptor-positive breast cancer patients treated with tamoxifen. This has led to a remarkable shift in the treatment paradigm, with a sizeable number of patients being able to avoid adjuvant chemotherapy. The recurrence score was then analyzed in a large retrospective study with node-positive, estrogen-receptor-positive patients, in which it demonstrated both prognostic and predictive abilities. This review introduces the clinical trials that validated the Oncotype DX assay in the node-negative population, highlights the studies evaluating the utility of the assay in node-positive patients, examines the impact of the assay results on treatment decisions, and discusses the health outcomes and health care expenditures associated with this assay.
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Affiliation(s)
- Sarika Jain
- Division of Hematology/Oncology, Department of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, 676 N. St Clair, Suite 850, Chicago, IL, 60611, USA
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Fried G, Moskovitz M. Treatment decisions in estrogen receptor-positive early breast cancer patients with intermediate oncotype DX recurrence score results. Springerplus 2014; 3:71. [PMID: 24567880 DOI: 10.1186/2193-1801-3-71] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 11/26/2022]
Abstract
This retrospective study evaluated the impact of intermediate Recurrence Score® results on adjuvant treatment decisions in estrogen receptor-positive (ER+) early invasive breast cancer, comparing treatment recommendations pre-testing with actual treatments received post-testing. Of the 111 patients included in the analysis, 78 (70.3%) had hormonal therapy (HT) and 33 (29.7%) had chemohormonal therapy (CHT) recommendations pre-testing. The Recurrence Score was significantly higher in those with a pre-testing CHT recommendation compared with those with a pre-testing HT recommendation (median of 24 vs. 22; P = 0.047; Mann–Whitney–Wilcoxon [MWW] test). Post-testing, treatment of 24 patients (21.6%) was different from their pre-testing recommendation. The difference between CHT recommendation rate pre-testing and the rate of CHT received post-testing was nonsignificant for the entire cohort and for patients’ subgroups (by age, tumor size, and grade) (P >0.17; McNemar’s test). Following classification of the cohort into two Recurrence Score subcategories (low-intermediate, [18-25]; high-intermediate, [26-30]), changes in treatment decisions (pre-testing recommendations vs. actual treatments received post testing) were reported for 16.5% of low-intermediate and 34.4% of high-intermediate patients. Post-testing, the rate of CHT decreased (by 58%) in the low-intermediate subcategory and increased (by 64%) in the high-intermediate subcategory (P <0.01, both subcategories). In logistic regression analyses, the Recurrence Score subcategory was the only significant predictor of changes in treatment decisions (pre-testing recommendations vs. actual treatments received post testing; P <0.01). The only significant difference between the two subsets of patients with such a change (HT to CHT, 11 patients; CHT to HT, 13 patients) was the Recurrence Score (median of 28 vs. 20, respectively; P = 0.0014; MWW test). These findings demonstrate that intermediate Recurrence Score results provide clinically relevant information and impact treatment decisions in ER + early breast cancer.
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81
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Murawa P, Murawa D, Adamczyk B, Połom K. Breast cancer: Actual methods of treatment and future trends. Rep Pract Oncol Radiother 2014; 19:165-72. [PMID: 24936340 DOI: 10.1016/j.rpor.2013.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/04/2013] [Indexed: 01/17/2023] Open
Abstract
The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.
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Affiliation(s)
- Paweł Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland ; Cancer Pathology Department, Oncology Department, Poznań University of Medical Sciences, Poland
| | - Dawid Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Beata Adamczyk
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Karol Połom
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
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Abstract
The developments in gene expression analysis have made it possible to sub-classify hormone receptor-positive (luminal) breast cancer in different prognostic subgroups. This sub-classification is currently used in clinical routine as prognostic signature (e.g. 21-gene Onoctype DX®, 70-gene Mammaprint®). As yet, the optimal method for sub-classification has not been defined. Moreover, there is no evidence from prospective trials. This review explores widely used genomic signatures in luminal breast cancer, making a critical appraisal of evidence from retrospective/prospective trials. It is based on systematic literature search performed using Medline (accessed September 2013) and abstracts presented at the Annual Meeting of American Society of Clinical Oncology and San Antonio Breast Cancer Symposium.
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Affiliation(s)
- Oleg Gluz
- Evangelisches Krankenhaus, Bethesda Mönchengladbach GmbH, Mönchengladbach, Germany
| | - Daniel Hofmann
- Evangelisches Krankenhaus, Bethesda Mönchengladbach GmbH, Mönchengladbach, Germany
| | | | - Cornelia Liedtke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein / Campus Lübeck, Germany
| | - Ulrike Nitz
- Evangelisches Krankenhaus, Bethesda Mönchengladbach GmbH, Mönchengladbach, Germany
| | - Nadia Harbeck
- Brustzentrum, Ludwig-Maximilians-Universität München, Germany
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83
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Yamauchi H, Nakagawa C, Takei H, Chao C, Yoshizawa C, Yagata H, Yoshida A, Hayashi N, Hell S, Nakamura S. Prospective study of the effect of the 21-gene assay on adjuvant clinical decision-making in Japanese women with estrogen receptor-positive, node-negative, and node-positive breast cancer. Clin Breast Cancer 2013; 14:191-7. [PMID: 24321102 DOI: 10.1016/j.clbc.2013.10.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 10/01/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In this study we investigated if the 21-gene assay result affects adjuvant decision-making in Japanese women with ER+ invasive EBC. PATIENTS AND METHODS A total of 124 consecutive eligible patients with ER+, HER2-negative EBC and 0 to 3 positive lymph nodes were enrolled. Treatment recommendations, physicians' confidence and patients' decisional conflict before and after knowledge of the Recurrence Score results of the 21-gene assay were recorded. RESULTS One-hundred four patients (84%) had N0 disease, including micrometastases, and 20 (16%) had N+ disease. Overall, recommendations changed in 33% (95% CI, 24%-43%) of N0 and 65% (95% CI, 41%-85%) of N+ patients. In 27 of 48 (56%) of N0 and 13 of 15 (87%) of N+ patients an initial recommendation for chemohormonal therapy was revised to only hormonal therapy after assay results, and in 7 of 56 (13%) of N0 and 0 of 5 N+ patients from only hormonal to combined chemohormonal therapy. Decisions appeared to follow the Recurrence Score results for low and high values. For patients with intermediate Recurrence Score values, overall recommendations for chemohormonal treatment tended to decrease after assay results. Physicians' confidence increased in 106 of 124 (85.5%; 95% CI, 78%-91%) cases. Patients' decisional conflict significantly improved as indicated by changes in the total score and the 5 defined subscores (P = .014 for Informed Subscore; P < .001 for all others). CONCLUSION Results from this prospective study in a Japanese population confirm an effect of the 21-gene assay results on adjuvant treatment decision-making, consistent with reported experiences from the United States and Europe.
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Affiliation(s)
- Hideko Yamauchi
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan.
| | - Chizuko Nakagawa
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan
| | - Hiroyuki Takei
- Saitama Cancer Center, Division of Breast Surgery, Saitama, Japan
| | | | | | - Hiroshi Yagata
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan
| | - Atsushi Yoshida
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan
| | - Naoki Hayashi
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan
| | | | - Seigo Nakamura
- St Luke's International Hospital, Department of Breast Surgery, Tokyo, Japan; Department of Breast Surgery, Showa University, Tokyo, Japan
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84
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Abstract
Breast cancer is a heterogeneous disease. For the past decades, new technical tools have been developed for biomarkers at the DNA, RNA and protein levels to better understand the biology of breast cancer. This progress is essential to classify the disease into clinically relevant subtypes, which may lead to new therapeutic opportunities. Novel biomarker development is paramount to deliver personalized cancer therapies. Further, tumor evolution, being natural or under treatment pressure, should be monitored and "liquid biopsies" by detecting circulating tumor cells or circulating free tumor DNA in blood samples will become an important option. This paper reviews the new generation of biomarkers and the current evidence to demonstrate their analytical validity, clinical validity and clinical utility.
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Affiliation(s)
- Fanny Le Du
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA ; Department of Medical Oncology, Eugène Marquis Cancer Center, Rennes, France
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ana M Gonzalez-Angulo
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA ; Department of Systems Biology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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85
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Boer RH, Baker C, Speakman D, Chao CY, Yoshizawa C, Mann GB. The impact of a genomic assay (Oncotype DX) on adjuvant treatment recommendations in early breast cancer. Med J Aust 2013; 199:205-8. [DOI: 10.5694/mja12.11334] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 03/04/2013] [Indexed: 12/20/2022]
Affiliation(s)
- Richard H Boer
- Royal Melbourne Hospital, Melbourne, VIC
- Breast Service, Royal Melbourne Hospital and Royal Women's Hospital, Melbourne, VIC
| | | | | | | | | | - G Bruce Mann
- Breast Service, Royal Melbourne Hospital and Royal Women's Hospital, Melbourne, VIC
- Department of Surgery, University of Melbourne, Melbourne, VIC
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86
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Paulden M, Franek J, Pham B, Bedard PL, Trudeau M, Krahn M. Cost-effectiveness of the 21-gene assay for guiding adjuvant chemotherapy decisions in early breast cancer. Value Health 2013; 16:729-739. [PMID: 23947965 DOI: 10.1016/j.jval.2013.03.1625] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Adjuvant chemotherapy decisions in early breast cancer are complex. The 21-gene assay can potentially aid such decisions, but costs US $4175 per patient. Adjuvant! Online is a freely available decision aid. We evaluate the cost-effectiveness of using the 21-gene assay in conjunction with Adjuvant! Online, and of providing adjuvant chemotherapy conditional upon risk classification. METHODS A probabilistic Markov decision model simulated risk classification, treatment, and the natural history of breast cancer in a hypothetical cohort of 50-year-old women with lymph node-negative, estrogen receptor- and/or progesterone receptor-positive, human epidermal growth factor receptor 2/neu-negative early breast cancer. Cost-effectiveness was considered from an Ontario public-payer perspective by deriving the lifetime incremental cost (2012 Canadian dollars) per quality-adjusted life-year (QALY) for each strategy, and the probability each strategy is cost-effective, assuming a willingness-to-pay of $50,000 per QALY. RESULTS The 21-gene assay has an incremental cost per QALY in patients at low, intermediate, or high Adjuvant Online! risk of $22,440 (probability cost-effective 78.46%), $2,526 (99.40%), or $1,111 (99.82%), respectively. In patients at low (high) 21-gene assay risk, adjuvant chemotherapy increases (reduces) costs and worsens (improves) health outcomes. For patients at intermediate 21-gene assay risk and low, intermediate, or high Adjuvant! Online risk, chemotherapy has an incremental cost per QALY of $44,088 (50.59%), $1,776 (77.65%), or $1,778 (82.31%), respectively. CONCLUSIONS The 21-gene assay appears cost-effective, regardless of Adjuvant! Online risk. Adjuvant chemotherapy appears cost-effective for patients at intermediate or high 21-gene assay risk, although this finding is uncertain in patients at intermediate 21-gene assay and low Adjuvant! Online risk.
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Affiliation(s)
- Mike Paulden
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON, Canada.
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Müller BM, Keil E, Lehmann A, Winzer KJ, Richter-Ehrenstein C, Prinzler J, Bangemann N, Reles A, Stadie S, Schoenegg W, Eucker J, Schmidt M, Lippek F, Jöhrens K, Pahl S, Sinn BV, Budczies J, Dietel M, Denkert C. The EndoPredict Gene-Expression Assay in Clinical Practice - Performance and Impact on Clinical Decisions. PLoS One 2013; 8:e68252. [PMID: 23826382 PMCID: PMC3694878 DOI: 10.1371/journal.pone.0068252] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/28/2013] [Indexed: 12/11/2022] Open
Abstract
The validated EndoPredict assay is a novel tool to predict the risk of metastases of patients with estrogen receptor positive, HER2 negative breast cancer treated with endocrine therapy alone. It has been designed to integrate genomic and clinical information and includes clinico-pathological factors such as tumor size and nodal status. The test is feasible in a decentral setting in molecular pathology laboratories. In this project, we investigated the performance of this test in clinical practice, and performed a retrospective evaluation of its impact on treatment decisions in breast cancer. During one year, EndoPredict assays from 167 patients could be successfully performed. For retrospective evaluation of treatment decisions, a questionnaire was sent to the clinical partner. Regarding the molecular EP class, samples from 56 patients (33.5%) had a low-risk, whereas 111 patients (66.5%) showed a high-risk gene profile. After integration of the clinicopathological factors the combined clinical and molecular score (EPclin) resulted in a low-risk group of 77 patients (46.4%), while 89 (53.6%) had a high risk EPclin score. The EPclin-based estimated median 10-year-risk for metastases with endocrine therapy alone was 11% for the whole cohort. The median handling time averaged three days (range: 0 to 11 days), 59.3% of the tests could be performed in three or less than three days. Comparison of pre- and post-test therapy decisions showed a change of therapy in 37.7% of patients. 16 patients (12.3%) had a change to an additional chemotherapy while 25.4% of patients (n = 33) changed to an endocrine therapy alone. In 73 patients (56.2%) no change of therapy resulted. In 6.1% of patients (n = 8), the patients did not agree to the recommendation of the tumor board. Our results show that the EndoPredict assay could be routinely performed in decentral molecular pathology laboratories and the results markedly change treatment decisions.
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Affiliation(s)
- Berit Maria Müller
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
- * E-mail:
| | - Elke Keil
- Breast Center, Park Clinic Weissensee, Berlin, Germany
| | - Annika Lehmann
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | | | | | - Judith Prinzler
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Nikola Bangemann
- Breast Center, Charité University Hospital, Campus Mitte, Berlin, Germany
| | | | - Sylvia Stadie
- Breast Center, Park Clinic Weissensee, Berlin, Germany
| | | | - Jan Eucker
- Department of Internal Medicine, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Marcus Schmidt
- Breast Center, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Korinna Jöhrens
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Stefan Pahl
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Bruno Valentin Sinn
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Jan Budczies
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Manfred Dietel
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Carsten Denkert
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
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88
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Stemmer SM, Klang SH, Ben-Baruch N, Geffen DB, Steiner M, Soussan-Gutman L, Merling S, Svedman C, Rizel S, Lieberman N. The impact of the 21-gene Recurrence Score assay on clinical decision-making in node-positive (up to 3 positive nodes) estrogen receptor-positive breast cancer patients. Breast Cancer Res Treat 2013; 140:83-92. [PMID: 23801158 PMCID: PMC3706725 DOI: 10.1007/s10549-013-2603-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/08/2013] [Indexed: 12/17/2022]
Abstract
Oncotype DX testing is reimbursed in Israel for node-negative and node-positive (N1+; up to 3 positive nodes including micrometastases), estrogen receptor positive (ER+), breast cancer patients. This retrospective study evaluated the impact of Oncotype DX testing on treatment decisions in N1+/ER+ breast cancer patients. To this end, we compared treatments for all N+ patients for whom testing had been ordered with treatments for patients with similar characteristics where the test had not been available. The retrospective analysis included 951 patients (282 Oncotype DX, 669 controls), all of whom received endocrine therapy with or without chemotherapy. In Oncotype DX patients, 7.1, 37.0, and 100 % of those with low, intermediate, and high Recurrence Score results (Oncotype DX summary score) received chemotherapy, respectively (P < 0.0001, all comparisons). Chemotherapy use was lower in Oncotype DX patients versus controls (24.5 vs. 70.1 %). In a multivariate logistic regression analysis in which the probability of receiving chemotherapy was modeled as a function of Oncotype DX testing, age, tumor size, tumor grade, nodal status, and the interactions between Oncotype DX testing and the other covariates, Oncotype DX testing was associated with significantly lower odds of receiving chemotherapy (odds ratio 0.16; 95 % CI 0.11–0.24; P < 0.0001). In summary, our findings suggest that Oncotype DX testing has a significant impact on reducing chemotherapy use in N1+/ER+ breast cancer patients in Israel.
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Affiliation(s)
- Salomon M Stemmer
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva/Sackler Faculty of Medicine, 39 Jabotinski St., Petah Tikva, Israel.
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89
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Holt S, Bertelli G, Humphreys I, Valentine W, Durrani S, Pudney D, Rolles M, Moe M, Khawaja S, Sharaiha Y, Brinkworth E, Whelan S, Jones S, Bennett H, Phillips CJ. A decision impact, decision conflict and economic assessment of routine Oncotype DX testing of 146 women with node-negative or pNImi, ER-positive breast cancer in the U.K. Br J Cancer 2013; 108:2250-8. [PMID: 23695023 PMCID: PMC3681004 DOI: 10.1038/bjc.2013.207] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Tumour gene expression analysis is useful in predicting adjuvant chemotherapy benefit in early breast cancer patients. This study aims to examine the implications of routine Oncotype DX testing in the UK. Methods: Women with oestrogen receptor positive (ER+), pNO or pN1mi breast cancer were assessed for adjuvant chemotherapy and subsequently offered Oncotype DX testing, with changes in chemotherapy decisions recorded. A subset of patients completed questionnaires about their uncertainties regarding chemotherapy decisions pre- and post-testing. All patients were asked to complete a diary of medical interactions over the next 6 months, from which economic data were extracted to model the cost-effectiveness of testing. Results: Oncotype DX testing resulted in changes in chemotherapy decisions in 38 of 142 (26.8%) women, with 26 of 57 (45.6%) spared chemotherapy and 12 of 85 (14.1%) requiring chemotherapy when not initially recommended (9.9% reduction overall). Decision conflict analysis showed that Oncotype DX testing increased patients' confidence in treatment decision making. Economic analysis showed that routine Oncotype DX testing costs £6232 per quality-adjusted life year gained. Conclusion: Oncotype DX decreased chemotherapy use and increased confidence in treatment decision making in patients with ER+ early-stage breast cancer. Based on these findings, Oncotype DX is cost-effective in the UK setting.
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Affiliation(s)
- S Holt
- Department of Breast Surgery, Prince Philip Hospital, Llanelli, Wales SA14 8QF, UK.
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90
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Davidson JA, Cromwell I, Ellard SL, Lohrisch C, Gelmon KA, Shenkier T, Villa D, Lim H, Sun S, Taylor S, Taylor M, Czerkawski B, Hayes M, Ionescu DN, Yoshizawa C, Chao C, Peacock S, Chia SK. A prospective clinical utility and pharmacoeconomic study of the impact of the 21-gene Recurrence Score® assay in oestrogen receptor positive node negative breast cancer. Eur J Cancer 2013; 49:2469-75. [PMID: 23611660 DOI: 10.1016/j.ejca.2013.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 03/02/2013] [Accepted: 03/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The primary purpose of this study was to measure the impact of the 21-gene Recurrence Score® result on systemic treatment recommendations and to perform a prospective health economic analysis in stage I-II, node-negative, oestrogen receptor positive (ER+) breast cancer. METHODS Consenting patients with ER+ node negative invasive breast cancer and their treating medial oncologists were asked to complete questionnaires about treatment preferences, level of confidence in those preferences and a decisional conflict scale (patients only) after a discussion of their diagnosis and risk without knowledge of the Recurrence Score. At a subsequent visit, the assay result and final treatment recommendations were discussed prior to both parties completing a second set of questionnaires. A Markov health state transition model was constructed, simulating the costs and outcomes experienced by a hypothetical 'assay naïve' population and an 'assay informed' population. RESULTS One hundred and fifty-six patients across two cancer centres were enrolled. Of the 150 for whom successful assay results were obtained, physicians changed their chemotherapy recommendations in 45 cases (30%; 95% confidence interval (CI) 22.8-38.0%); either to add (10%; 95% CI 5.7-16.0%) or omit (20%; 95% CI 13.9-27.3%) adjuvant chemotherapy. There was an overall significant improvement in physician confidence post-assay (p<0.001). Patient decisional conflict also significantly decreased following the assay (p<0.001). The simulation model found an incremental cost-effectiveness ratio of Canadian Dollars (CAD) $6630/quality-adjusted life years (QALY). CONCLUSION Within the context of a publicly funded health care system, the Recurrence Score assay significantly affects adjuvant treatment recommendations and is cost effective in ER+ node negative breast cancer.
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Affiliation(s)
- J A Davidson
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - I Cromwell
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Research Centre, Vancouver, Canada
| | | | - C Lohrisch
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - K A Gelmon
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - T Shenkier
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - D Villa
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - H Lim
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - S Sun
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - S Taylor
- Medical Oncology, BCCA, Kelowna, Canada
| | - M Taylor
- Medical Oncology, BCCA, Kelowna, Canada
| | | | - M Hayes
- Pathology, BCCA, Vancouver, Canada
| | | | | | - C Chao
- Genomic Health Inc., Redwood City, CA, USA
| | - S Peacock
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Research Centre, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - S K Chia
- Medical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada.
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91
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Al-Allak A, Lewis PD, Bertelli G. Decision-making tools to assist prognosis and treatment choices in early breast cancer: a review. Expert Rev Anticancer Ther 2013; 12:1033-43. [PMID: 23030223 DOI: 10.1586/era.12.83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Breast cancer remains the most common type of cancer affecting women worldwide with an estimated lifetime risk of 1:8. With developments in adjuvant treatment and the identification of breast cancer subtypes, rising expectation of 'personalized' and 'targeted' therapy, decisions on systemic therapy have become increasingly more difficult. In a bid to assist clinicians in correctly selecting patients in whom systemic adjuvant therapy would be of most benefit, a number of decision-making tools have been developed. In this article, the authors will review some of these tools, explore how they were developed and assess the impact they have had on daily clinical practice.
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Affiliation(s)
- Asmaa Al-Allak
- SW Wales Cancer Institute, Department of Oncology, Singleton Hospital, Sketty Lane, Swansea, SA2 8QA, UK
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92
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Varga Z, Sinn P, Fritzsche F, von Hochstetter A, Noske A, Schraml P, Tausch C, Trojan A, Moch H. Comparison of EndoPredict and Oncotype DX test results in hormone receptor positive invasive breast cancer. PLoS One 2013; 8:e58483. [PMID: 23505515 DOI: 10.1371/journal.pone.0058483] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/04/2013] [Indexed: 12/19/2022] Open
Abstract
Aim Several multigene expression-based tests offering prognostic and predictive information in hormone-receptor positive early breast cancer were established during the last years. These tests provide prognostic information on distant recurrences and can serve as an aid in therapy decisions. We analyzed the recently validated reverse-transcription-quantitative-real-time PCR-based multigene-expression Endopredict (EP)-test on 34 hormone-receptor positive breast-cancer cases and compared the EP scores with the Oncotype DX Recurrence-scores (RS) obtained from the same cancer samples. Methods Formalin-fixed, paraffin-embedded invasive breast-cancer tissues from 34 patients were analyzed by the EP-test. Representative tumor blocks were analyzed with Oncotype DX prior to this study. Tumor tissue was removed from unstained slides, total-RNA was isolated and EP-analysis was performed blinded to Oncotype DX results. Results Extraction of sufficient amounts of RNA and generation of valid EP-scores were possible for all 34 samples. EP classified 11 patients as low-risk and 23 patients as high-risk. RS Score defined 15 patients as low-risk, 10 patients as intermediate-risk in and 9 patients as high-risk. Major-discrepancy occurred in 6 of 34 cases (18%): Low-risk RS was classified as high-risk by EP in 6 cases. Combining the RS intermediate-risk and high-risk groups to a common group, the concordance between both tests was 76%. Correlation between continuous EP and RS-scores was moderate (Pearson-coefficient: 0.65 (p<0.01). Conclusion We observed a significant but moderate concordance (76%) and moderate correlation (0.65) between RS and EP Score. Differences in results can be explained by different weighting of biological motives covered by the two tests. Further studies are needed to explore the clinical relevance of discrepant test results with respect of outcome.
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93
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Bartlett J, Canney P, Campbell A, Cameron D, Donovan J, Dunn J, Earl H, Francis A, Hall P, Harmer V, Higgins H, Hillier L, Hulme C, Hughes-Davies L, Makris A, Morgan A, McCabe C, Pinder S, Poole C, Rea D, Stallard N, Stein R. Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial. Clin Oncol (R Coll Radiol) 2012; 25:109-16. [PMID: 23267818 DOI: 10.1016/j.clon.2012.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 09/19/2012] [Accepted: 10/19/2012] [Indexed: 11/26/2022]
Abstract
The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.
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Affiliation(s)
- J Bartlett
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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94
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Eiermann W, Rezai M, Kümmel S, Kühn T, Warm M, Friedrichs K, Schneeweiss A, Markmann S, Eggemann H, Hilfrich J, Jackisch C, Witzel I, Eidtmann H, Bachinger A, Hell S, Blohmer J. The 21-gene recurrence score assay impacts adjuvant therapy recommendations for ER-positive, node-negative and node-positive early breast cancer resulting in a risk-adapted change in chemotherapy use. Ann Oncol 2012; 24:618-24. [PMID: 23136233 PMCID: PMC3574549 DOI: 10.1093/annonc/mds512] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background We carried out a prospective clinical study to evaluate the impact of the Recurrence Score (RS) on treatment decisions in early breast cancer (EBC). Patients and methods A total of 379 eligible women with estrogen receptor positive (ER+), HER2-negative EBC and 0–3 positive lymph nodes were enrolled. Treatment recommendations, patients' decisional conflict, physicians' confidence before and after knowledge of the RS and actual treatment data were recorded. Results Of the 366 assessable patients 244 were node negative (N0) and 122 node positive (N+). Treatment recommendations changed in 33% of all patients (N0 30%, N+ 39%). In 38% of all patients (N0 39%, N+ 37%) with an initial recommendation for chemoendocrine therapy, the post-RS recommendation changed to endocrine therapy, in 25% (N0 22%, N+ 39%) with an initial recommendation for endocrine therapy only to combined chemoendocrine therapy, respectively. A patients' decisional conflict score improved by 6% (P = 0.028) and physicians' confidence increased in 45% (P < 0.001) of all cases. Overall, 33% (N0 29%, N+ 38%) of fewer patients actually received chemotherapy as compared with patients recommended chemotherapy pre-test. Using the test was cost-saving versus current clinical practice. Conclusion RS-guided chemotherapy decision-making resulted in a substantial modification of adjuvant chemotherapy usage in node-negative and node-positive ER+ EBC.
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Affiliation(s)
- W Eiermann
- Interdisciplinary Oncology Center, Munich.
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95
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Sulayman N, Spellman E, Graves KD, Peshkin BN, Isaacs C, Schwartz MD, O'Neill SC. Psychosocial and Quality of Life in Women Receiving the 21-Gene Recurrence Score Assay: The Impact of Decision Style in Women with Intermediate RS. J Cancer Epidemiol 2012; 2012:728290. [PMID: 22899924 DOI: 10.1155/2012/728290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/07/2012] [Accepted: 06/12/2012] [Indexed: 11/23/2022] Open
Abstract
Multigene assays such as the 21-gene recurrence score (RS) quantify risk for recurrence and potential benefit from chemotherapy in early-stage, ER+ breast cancers. Few studies have assessed the impact of testing on patient-reported outcomes such as cancer-related distress or quality of life. The few studies that have assessed these outcomes do not consider potential modifiers, such as the patients' level of involvement in the treatment decision-making process. In the current study, 81 breast cancer patients who received the RS assay completed cross-sectional surveys. We used linear multiple regression to assess whether test result, decision-making role (passive versus shared/active), and their interaction contributed to current levels of distress, quality of life, and decisional conflict. There were no associations between these variables and test result or decision-making role. However, women who received an intermediate RS and took a passive role in their care reported higher-cancer-related distress and cancer worry and lower quality of life than those who took a shared or active role. These data should be confirmed in prospective samples, as these poorer outcomes could be amenable to intervention.
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96
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Barnadas A. Is there any role for new prognostic markers in breast cancer? Clin Transl Oncol 2012; 14:161-2. [DOI: 10.1007/s12094-012-0778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Affiliation(s)
- Shelly S Lo
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, Illinois 60153, USA.
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98
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Abstract
Epithelial breast malignancies are a group of several disease entities that vary in their biology and response to specific therapies. Historically, classification of different molecular types of breast cancer was done through the use of conventional methods such as tumor morphology, grade, and immunophenotyping for estrogen, progesterone, and HER-2/neu receptor expression. Such techniques, although helpful, are not sufficient to accurately predict biologic behavior of breast cancers. Over the last several years, much progress has been made in more precise identification of molecular breast cancer subtypes. Such advances hold a great promise in improving estimation of prognosis and assigning most appropriate therapies. Thanks to use of cDNA microarrays expression technology and quantitative reverse transcriptase polymerase chain reaction (RT-PCR), tumors with specific gene expression patterns can now be identified. This process is presently reshaping perceptions of how breast cancer should be classified and treated. Categorization of breast cancers by gene expression is only beginning to make its way into the daily clinical practice and likely will complement, but not replace, the conventional methods of classification.
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Affiliation(s)
- Robert Wesolowski
- Division of Medical Oncology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Bhuvaneswari Ramaswamy
- Division of Medical Oncology, College of Medicine, The Ohio State University, Columbus, OH, USA
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