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Chen W, Wang Y, Zemlyanska Y, Butani D, Wong NCB, Virabhak S, Matchar DB, Teerawattananon Y. Evaluating the Value for Money of Precision Medicine from Early Cycle to Market Access: A Comprehensive Review of Approaches and Challenges. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1425-1434. [PMID: 37187236 DOI: 10.1016/j.jval.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 04/05/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES This study aimed to perform a comprehensive review of modeling approaches and methodological and policy challenges in the economic evaluation (EE) of precision medicine (PM) across clinical stages. METHODS First, a systematic review was performed to assess the approaches of EEs in the past 10 years. Next, a targeted review of methodological articles was conducted for methodological and policy challenges in performing EEs of PM. All findings were synthesized into a structured framework that focused on patient population, Intervention, Comparator, Outcome, Time, Equity and ethics, Adaptability and Modeling aspects, named the "PICOTEAM" framework. Finally, a stakeholder consultation was conducted to understand the major determinants of decision making in PM investment. RESULTS In 39 methodological articles, we identified major challenges to the EE of PM. These challenges include that PM applications involve complex and evolving clinical decision space, that clinical evidence is sparse because of small subgroups and complex pathways in PM settings, a one-time PM application may have lifetime or intergenerational impacts but long-term evidence is often unavailable, and that equity and ethics concerns are exceptional. In 275 EEs of PM, current approaches did not sufficiently capture the value of PM compared with targeted therapies, nor did they differentiate Early EEs from Conventional EEs. Finally, policy makers perceived the budget impact, cost savings, and cost-effectiveness of PM as the most important determinants in decision making. CONCLUSIONS There is an urgent need to modify existing guidelines or develop a new reference case that fits into the new healthcare paradigm of PM to guide decision making in research and development and market access.
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Affiliation(s)
- Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
| | - Yi Wang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yaroslava Zemlyanska
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Dimple Butani
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Thailand
| | | | | | - David Bruce Matchar
- Precision Health Research (PRECISE), Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Yot Teerawattananon
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Thailand
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2
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Curtit E, Bellanger MM, Nerich V, Hequet D, Frenel JS, Cristeau O, Rouzier R. Genomic signature to guide adjuvant chemotherapy treatment decisions for early breast cancer patients in France: a cost-effectiveness analysis. Front Oncol 2023; 13:1191943. [PMID: 37427133 PMCID: PMC10327821 DOI: 10.3389/fonc.2023.1191943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Chemotherapy (CT) is commonly used as an adjuvant treatment for women with early breast cancer (BC). However, not all patients benefit from CT, while all are exposed to its short- and long-term toxicity. The Oncotype DX® test assesses cancer-related gene expression to estimate the risk of BC recurrence and predict the benefit of chemotherapy. The aim of this study was to estimate, from the French National Health Insurance (NHI) perspective, the cost-effectiveness of the Oncotype DX® test compared to standard of care (SoC; involving clinicopathological risk assessment only) among women with early, hormone receptor-positive, human epidermal growth factor receptor 2-negative BC considered at high clinicopathological risk of recurrence. Methods Clinical outcomes and costs were estimated over a lifetime horizon based on a two-component model that comprised a short-term decision tree representing the adjuvant treatment choice guided by the therapeutic decision support strategy (Oncotype DX® test or SoC) and a Markov model to capture long-term outcomes. Results In the base case, the Oncotype DX® test reduced CT use by 55.2% and resulted in 0.337 incremental quality-adjusted life-years gained and cost savings of €3,412 per patient, compared with SoC. Being more effective and less costly than SoC, Oncotype DX® testing was the dominant strategy. Discussion Widespread implementation of Oncotype DX® testing would improve patient care, provide equitable access to more personalized medicine, and bring cost savings to the health system.
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Affiliation(s)
- Elsa Curtit
- University of Franche-Comté, University Hospital of Besançon J. Minjoz, INSERM, EFS UMR 1098, Besançon, France
| | - Martine Marie Bellanger
- UMR CNRS6051, Ecole des Hautes Etudes en Santé Publique - School of Public Health (EHESP), University of Rennes, Rennes, France
| | - Virginie Nerich
- Department of Pharmacy, University Hospital of Besançon, France; INSERM, EFS-BFC, UMR 1098, University of Franche-Comté, Besançon, France
| | - Delphine Hequet
- Institut Bourdonnais, Clinique Saint Jean de Dieu, Paris, France
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3
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Oliveira LJC, Megid TBC, Rosa DD, Magliano CADS, Assad DX, Argolo DF, Sanches SM, Testa L, Bines J, Kaliks R, Caleffi M, de Melo Gagliato D, Sahade M, Barroso-Sousa R, Corrêa TS, Shimada AK, Batista DN, Musse Gomes D, Cesca MG, Gaudêncio D, Moura LMA, de Araújo JAP, Katz A, Mano MS. Cost-effectiveness analysis of Oncotype DX from a Brazilian private medicine perspective: a GBECAM multicenter retrospective study. Ther Adv Med Oncol 2022; 14:17588359221141760. [PMID: 36601632 PMCID: PMC9806428 DOI: 10.1177/17588359221141760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 12/28/2022] Open
Abstract
Background Oncotype DX (ODX) is a validated assay for the prediction of risk of recurrence and benefit of chemotherapy (CT) in both node negative (N0) and 1-3 positive nodes (N1), hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) early breast cancer (eBC). Due to limited access to genomic assays in Brazil, treatment decisions remain largely driven by traditional clinicopathologic risk factors. ODX has been reported to be cost-effective in different health system, but limited data are available considering the reality of middle-income countries such as Brazil. We aim to evaluate the cost-effectiveness of ODX across strata of clinical risk groups using data from a dataset of patients from Brazilian institutions. Methods Clinicopathologic and ODX information were analyzed for patients with T1-T3, N0-N1, HR+/HER2- eBC who had an ODX performed between 2005 and 2020. Projections of CT indication by clinicopathologic criteria were based on binary clinical risk categorization based on the Adjuvant! Algorithm. The ODX score was correlated with the indication of CT according to TAILORx and RxPONDER data. Two decision-tree models were developed. In the first model, low and high clinical risk patients were included while in the second, only high clinical risk patients were included. The cost for ODX and CT was based on the Brazilian private medicine perspective. Results In all, 645 patients were analyzed; 411 patients (63.7%) had low clinical risk and 234 patients (36.3%) had high clinical risk disease. The ODX indicated low (<11), intermediate (11-25), and high (>25) risk in 119 (18.4%), 415 (64.3%), and 111 (17.2%) patients, respectively. Among 645 patients analyzed in the first model, ODX was effective (5.6% reduction in CT indication) though with an incremental cost of United States Dollar (US$) 2288.87 per patient. Among 234 patients analyzed in the second model (high clinical risk only), ODX led to a 57.7% reduction in CT indication and reduced costs by US$ 4350.66 per patient. Conclusions Our study suggests that ODX is cost-saving for patients with high clinical risk HR+/HER2- eBC and cost-attractive for the overall population in the Brazilian private medicine perspective. Its incorporation into routine practice should be strongly considered by healthcare providers.
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Affiliation(s)
| | | | - Daniela Dornelles Rosa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | | | - Daniele Xavier Assad
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | - Daniel Fontes Argolo
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica CLION – Grupo CAM, Salvador,
Brazil
| | - Solange Moraes Sanches
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil AC,Camargo Cancer Center, São Paulo, Brazil
| | - Laura Testa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - José Bines
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Rafael Kaliks
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Israelita
Albert Einstein, São Paulo, Brazil
| | - Maira Caleffi
- Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | - Debora de Melo Gagliato
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Beneficência
Portuguesa, São Paulo, Brazil
| | - Marina Sahade
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Romualdo Barroso-Sousa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | | | - Andrea Kazumi Shimada
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
| | - Daniel Negrini Batista
- Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Daniel Musse Gomes
- Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | | | | | | | | | - Artur Katz
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Max Senna Mano
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
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4
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Davey MG, Davey MS, Ryan ÉJ, Boland MR, McAnena PF, Lowery AJ, Kerin MJ. Is radiomic MRI a feasible alternative to OncotypeDX® recurrence score testing? A systematic review and meta-analysis. BJS Open 2021; 5:6388195. [PMID: 34633438 PMCID: PMC8504445 DOI: 10.1093/bjsopen/zrab081] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/03/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND OncotypeDX® recurrence score (RS) aids therapeutic decision-making in oestrogen-receptor-positive (ER+) breast cancer. Radiomics is an evolving field that aims to examine the relationship between radiological features and the underlying genomic landscape of disease processes. The aim of this study was to perform a systematic review of current evidence evaluating the comparability of radiomics and RS. METHODS A systematic review was performed as per PRISMA guidelines. Studies comparing radiomic MRI tumour analyses and RS were identified. Sensitivity, specificity and area under curve (AUC) delineating low risk (RS less than 18) versus intermediate-high risk (equal to or greater than 18) and low-intermediate risk (RS less than 30) and high risk (RS greater than 30) were recorded. Log rate ratios (lnRR) and standard error were determined from AUC and 95 per cent confidence intervals. RESULTS Nine studies including 1216 patients met inclusion criteria; the mean age at diagnosis was 52.9 years. Mean RS was 16 (range 0-75); 401 patients with RS less than 18, 287 patients with RS 18-30 and 100 patients with RS greater than 30. Radiomic analysis and RS were comparable for differentiating RS less than 18 versus RS 18 or greater (RR 0.93 (95 per cent c.i. 0.85 to 1.01); P = 0.010, heterogeneity (I2)=0%) as well as RS less than 30 versus RS 30 or greater (RR 0.76 (95 per cent c.i. 0.70 to 0.83); P < 0.001, I2=0%). MRI sensitivity and specificity for RS less than 18 versus 18 or greater was 0.89 (95 per cent c.i. 0.85 to 0.93) and 0.72 (95 per cent c.i. 0.66 to 0.78) respectively, and 0.79 (95 per cent c.i. 0.72 to 0.86) and 0.74 (95 per cent c.i. 0.68 to 0.80) for RS less than 30 versus 30 or greater. CONCLUSION Radiomic tumour analysis is comparable to RS in differentiating patients into clinically relevant subgroups. For patients requiring MRI, radiomics may complement and enhance RS for prognostication and therapeutic decision making in ER+ breast cancer.
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Affiliation(s)
- M G Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M S Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - É J Ryan
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M R Boland
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - P F McAnena
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - A J Lowery
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M J Kerin
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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5
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Zhou S, Sikorski D, Xu H, Zubarev A, Chergui M, Lagacé F, Miller WH, Redpath M, Ghazal S, Butler MO, Petrella TM, Claveau J, Nessim C, Salopek TG, Gniadecki R, Litvinov IV. Defining the Criteria for Reflex Testing for BRAF Mutations in Cutaneous Melanoma Patients. Cancers (Basel) 2021; 13:2282. [PMID: 34068774 PMCID: PMC8126223 DOI: 10.3390/cancers13092282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022] Open
Abstract
Targeted therapy has been developed through an in-depth understanding of molecular pathways involved in the pathogenesis of melanoma. Approximately ~50% of patients with melanoma have tumors that harbor a mutation of the BRAF oncogene. Certain clinical features have been identified in BRAF-mutated melanomas (primary lesions located on the trunk, diagnosed in patients <50, visibly pigmented tumors and, at times, with ulceration or specific dermatoscopic features). While BRAF mutation testing is recommended for stage III-IV melanoma, guidelines differ in recommending mutation testing in stage II melanoma patients. To fully benefit from these treatment options and avoid delays in therapy initiation, advanced melanoma patients harboring a BRAF mutation must be identified accurately and quickly. To achieve this, clear definition and implementation of BRAF reflex testing criteria/methods in melanoma should be established so that patients with advanced melanoma can arrive to their first medical oncology appointment with a known biomarker status. Reflex testing has proven effective for a variety of cancers in selecting therapies and driving other medical decisions. We overview the pathophysiology, clinical presentation of BRAF-mutated melanoma, current guidelines, and present recommendations on BRAF mutation testing. We propose that reflex BRAF testing should be performed for every melanoma patient with stages ≥IIB.
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Affiliation(s)
- Sarah Zhou
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
| | - Daniel Sikorski
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
| | - Honghao Xu
- Division of Dermatology, Laval University, Quebec City, QC G1V 0A6, Canada; (H.X.); (J.C.)
| | - Andrei Zubarev
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
| | - May Chergui
- Department of Pathology, McGill University, Montreal, QC H3A 0G4, Canada; (M.C.); (M.R.)
| | - François Lagacé
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
| | - Wilson H. Miller
- Departments of Medicine and Oncology, McGill University, Montreal, QC H3A 0G4, Canada;
| | - Margaret Redpath
- Department of Pathology, McGill University, Montreal, QC H3A 0G4, Canada; (M.C.); (M.R.)
| | - Stephanie Ghazal
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
| | - Marcus O. Butler
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University of Toronto, Toronto, ON M5G 2C1, Canada;
| | - Teresa M. Petrella
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Joël Claveau
- Division of Dermatology, Laval University, Quebec City, QC G1V 0A6, Canada; (H.X.); (J.C.)
| | - Carolyn Nessim
- Division of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
| | - Thomas G. Salopek
- Division of Dermatology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (T.G.S.); (R.G.)
| | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (T.G.S.); (R.G.)
| | - Ivan V. Litvinov
- Division of Dermatology, McGill University, Montreal, QC H3A 0G4, Canada; (S.Z.); (D.S.); (A.Z.); (F.L.); (S.G.)
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6
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Davey MG, Ryan ÉJ, Abd Elwahab S, Elliott JA, McAnena PF, Sweeney KJ, Malone CM, McLaughlin R, Barry MK, Keane MM, Lowery AJ, Kerin MJ. Clinicopathological correlates, oncological impact, and validation of Oncotype DX™ in a European Tertiary Referral Centre. Breast J 2021; 27:521-528. [PMID: 33709552 DOI: 10.1111/tbj.14217] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
Oncotype DX™ (ODX) score estimates prognosis and predicts breast cancer recurrence. It also individualizes patient adjuvant chemotherapy prescription in breast cancer. This assay relies on genetic and molecular markers; the clinicopathological phenotype of which are tested routinely. The aim of this study was determine whether clinicopathological and immunohistochemical information predicts ODX recurrence score (RS). Secondly, to assess the impact on adjuvant chemotherapy (AC) and oncological outcome of ODX testing in patients in a European tertiary referral center. Estrogen receptor positive (ER+), human epidermal growth factor receptor-2 negative (HER2-), lymph node negative (LN-), and female breast cancer patients with ODX testing performed between 2007 and 2015 were categorized into low- (<11), intermediate- (11-25), and high-risk (>25) groups. Clinicopathological and immunohistochemical correlates of RS were determined. Predictors of RS were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan-Meier and Cox regression analyses. ODX was performed in 400 consecutive ER+LN- patients. Median follow-up was 74.1 months (3.0-144.4). Low grade (odds ratio [OR]:2.39; 95% confidence interval [CI]:1.04-5.51, p = 0.041) independently predicted low ODX, while high grade (OR:2.04; 95% CI: 1.19-3.49, p = 0.009) and reduced progesterone receptor (PgR) expression (OR: 2.57, 95% CI: 1.42-4.65, p = 0.002) independently predicted high ODX. Omission of AC in intermediate- (p = 0.159) and high-risk (p = 0.702) groups did not negatively impact survival. In conclusion, tumor grade independently predicts low and high RS, while PgR negativity predicts high RS. ODX reduced AC prescription without compromising oncological outcome.
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Affiliation(s)
- Matthew G Davey
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Éanna J Ryan
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Sami Abd Elwahab
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Jessie A Elliott
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Peter F McAnena
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Karl J Sweeney
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Carmel M Malone
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Ray McLaughlin
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Michael K Barry
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Maccon M Keane
- Department of Medical Oncology, Galway University Hospitals, Galway, Ireland
| | - Aoife J Lowery
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Michael J Kerin
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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7
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Giorgi Rossi P, Lebeau A, Canelo-Aybar C, Saz-Parkinson Z, Quinn C, Langendam M, Mcgarrigle H, Warman S, Rigau D, Alonso-Coello P, Broeders M, Graewingholt A, Posso M, Duffy S, Schünemann HJ. Recommendations from the European Commission Initiative on Breast Cancer for multigene testing to guide the use of adjuvant chemotherapy in patients with early breast cancer, hormone receptor positive, HER-2 negative. Br J Cancer 2021; 124:1503-1512. [PMID: 33597715 PMCID: PMC8076250 DOI: 10.1038/s41416-020-01247-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/10/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background Predicting the risk of recurrence and response to chemotherapy in women with early breast cancer is crucial to optimise adjuvant treatment. Despite the common practice of using multigene tests to predict recurrence, existing recommendations are inconsistent. Our aim was to formulate healthcare recommendations for the question “Should multigene tests be used in women who have early invasive breast cancer, hormone receptor-positive, HER2-negative, to guide the use of adjuvant chemotherapy?” Methods The European Commission Initiative on Breast Cancer (ECIBC) Guidelines Development Group (GDG), a multidisciplinary guideline panel including experts and three patients, developed recommendations informed by systematic reviews of the evidence. Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision frameworks were used. Four multigene tests were evaluated: the 21-gene recurrence score (21-RS), the 70-gene signature (70-GS), the PAM50 risk of recurrence score (PAM50-RORS), and the 12-gene molecular score (12-MS). Results Five studies (2 marker-based design RCTs, two treatment interaction design RCTs and 1 pooled individual data analysis from observational studies) were included; no eligible studies on PAM50-RORS or 12-MS were identified and the GDG did not formulate recommendations for these tests. Conclusions The ECIBC GDG suggests the use of the 21-RS for lymph node-negative women (conditional recommendation, very low certainty of evidence), recognising that benefits are probably larger in women at high risk of recurrence based on clinical characteristics. The ECIBC GDG suggests the use of the 70-GS for women at high clinical risk (conditional recommendation, low certainty of evidence), and recommends not using 70-GS in women at low clinical risk (strong recommendation, low certainty of evidence).
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Affiliation(s)
- Paolo Giorgi Rossi
- Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Annette Lebeau
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carlos Canelo-Aybar
- Iberoamerican Cochrane Center, Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, Spain.,Department of Paediatrics, Obstetrics and Gynaecology, Preventive Medicine, and Public Health, PhD Programme in Methodology of Biomedical Research and Public Health, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Zuleika Saz-Parkinson
- European Commission, Joint Research Centre (JRC), Ispra, Italy. .,Instituto de Salud Carlos III, Health Technology Assessment Agency, Avenida Monforte de Lemos 5, Madrid, Spain.
| | - Cecily Quinn
- St. Vincent's University Hospital, Dublin, Ireland
| | - Miranda Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | | | - Sue Warman
- Havyatt Lodge, Havyatt Road, Langford, North Somerset, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Mireille Broeders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands.,Dutch Expert Centre for Screening, Nijmegen, the Netherlands
| | | | - Margarita Posso
- Iberoamerican Cochrane Center, Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, Spain.,Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Research Network on Health Services in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - Stephen Duffy
- Centre for Cancer Prevention, Queen Mary University of London, Charterhouse Square, London, UK
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada and McGRADE Centres; Department of Health Research Methods, Evidence and Impact, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
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8
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Barba D, León-Sosa A, Lugo P, Suquillo D, Torres F, Surre F, Trojman L, Caicedo A. Breast cancer, screening and diagnostic tools: All you need to know. Crit Rev Oncol Hematol 2020; 157:103174. [PMID: 33249359 DOI: 10.1016/j.critrevonc.2020.103174] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/18/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is one of the most frequent malignancies among women worldwide. Methods for screening and diagnosis allow health care professionals to provide personalized treatments that improve the outcome and survival. Scientists and physicians are working side-by-side to develop evidence-based guidelines and equipment to detect cancer earlier. However, the lack of comprehensive interdisciplinary information and understanding between biomedical, medical, and technology professionals makes innovation of new screening and diagnosis tools difficult. This critical review gathers, for the first time, information concerning normal breast and cancer biology, established and emerging methods for screening and diagnosis, staging and grading, molecular and genetic biomarkers. Our purpose is to address key interdisciplinary information about these methods for physicians and scientists. Only the multidisciplinary interaction and communication between scientists, health care professionals, technical experts and patients will lead to the development of better detection tools and methods for an improved screening and early diagnosis.
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Affiliation(s)
- Diego Barba
- Escuela de Medicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Instituto de Investigaciones en Biomedicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Mito-Act Research Consortium, Quito, Ecuador
| | - Ariana León-Sosa
- Escuela de Medicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Instituto de Investigaciones en Biomedicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Mito-Act Research Consortium, Quito, Ecuador
| | - Paulina Lugo
- Hospital de los Valles HDLV, Quito, Ecuador; Fundación Ayuda Familiar y Comunitaria AFAC, Quito, Ecuador
| | - Daniela Suquillo
- Instituto de Investigaciones en Biomedicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Mito-Act Research Consortium, Quito, Ecuador; Ingeniería en Procesos Biotecnológicos, Colegio de Ciencias Biológicas y Ambientales COCIBA, Universidad San Francisco de Quito USFQ, Quito, Ecuador
| | - Fernando Torres
- Escuela de Medicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Hospital de los Valles HDLV, Quito, Ecuador
| | - Frederic Surre
- University of Glasgow, James Watt School of Engineering, Glasgow, G12 8QQ, United Kingdom
| | - Lionel Trojman
- LISITE, Isep, 75006, Paris, France; Universidad San Francisco de Quito USFQ, Colegio de Ciencias e Ingenierías Politécnico - USFQ, Instituto de Micro y Nanoelectrónica, IMNE, USFQ, Quito, Ecuador
| | - Andrés Caicedo
- Escuela de Medicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Instituto de Investigaciones en Biomedicina, Universidad San Francisco de Quito USFQ, Quito, Ecuador; Mito-Act Research Consortium, Quito, Ecuador; Sistemas Médicos SIME, Universidad San Francisco de Quito USFQ, Quito, Ecuador.
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9
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El Khal M, Perrier L, Carretier J, Touillaud M, Hureau M, Pérol D, Fervers B. [The cost of the therapeutic education program "Eat better, move more through nutrition education" in patients with breast cancer]. Bull Cancer 2020; 107:1252-1259. [PMID: 33012504 DOI: 10.1016/j.bulcan.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Since the life expectancy of women with breast cancer has increased, tertiary prevention, through the Therapeutic Patient Education (TPE), is now a part of patient support. The main objective of this pilot study is to evaluate the cost of a nutrition and physical activity TPE program intended to help women with breast cancer in the management of their weight. METHODS This study is a description of costs, based on the micro-costing method, of the first two years of the program, conducted on an outpatient basis, at the Cancer Center Leon Berard, Lyon, France, with the involvement of a dietician and a physical activity trainer. Only the direct costs were taken into account, from the hospital's perspective, in Euro 2016. Sensitivity analyses were also conducted. RESULTS Sixty-five patients were included in the study in 2014/2015. Their mean age was 52 years, the majority of them were in sick leave (65 %). In most cases, they had undergone surgery (95 %) and chemotherapy (71 %). The average cost per patient of the program was 541.04€ (SD 88.44€; 95 % IC [520.06-562.03]) excluding overhead costs, i.e. 687.13€ overhead costs included. The unit cost of the dietician was the most sensitive parameters. CONCLUSION This cost study, an accurate estimate of the production costs, allows to inform the decision-maker in term of pricing of such a program and to make the necessary adjustments in order to optimize the organization of this activity.
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Affiliation(s)
- Mariam El Khal
- Centre Léon-Bérard, département prévention cancer et environnement, 28, rue Laënnec, 69008 Lyon, France
| | - Lionel Perrier
- Université de Lyon, centre Léon-Bérard, GATE L-SE UMR, 5824, 28, rue Laënnec, 69008 Lyon, France; Centre Léon-Bérard, direction de la recherche clinique et de l'innovation, 28, rue Laënnec, 69008 Lyon, France
| | - Julien Carretier
- Centre Léon-Bérard, département prévention cancer et environnement, 28, rue Laënnec, 69008 Lyon, France.
| | - Marina Touillaud
- Centre Léon-Bérard, département prévention cancer et environnement, 28, rue Laënnec, 69008 Lyon, France; Unité Inserm UA8 « radiations : défense, santé, environnement », 28, rue Laënnec, 69008 Lyon, France
| | - Magalie Hureau
- Centre Léon-Bérard, direction de la recherche clinique et de l'innovation, 28, rue Laënnec, 69008 Lyon, France
| | - David Pérol
- Centre Léon-Bérard, direction de la recherche clinique et de l'innovation, 28, rue Laënnec, 69008 Lyon, France
| | - Béatrice Fervers
- Centre Léon-Bérard, département prévention cancer et environnement, 28, rue Laënnec, 69008 Lyon, France; Unité Inserm UA8 « radiations : défense, santé, environnement », 28, rue Laënnec, 69008 Lyon, France
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10
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Harnan S, Tappenden P, Cooper K, Stevens J, Bessey A, Rafia R, Ward S, Wong R, Stein RC, Brown J. Tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer: a systematic review and economic analysis. Health Technol Assess 2020; 23:1-328. [PMID: 31264581 DOI: 10.3310/hta23300] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Breast cancer and its treatment can have an impact on health-related quality of life and survival. Tumour profiling tests aim to identify whether or not women need chemotherapy owing to their risk of relapse. OBJECTIVES To conduct a systematic review of the effectiveness and cost-effectiveness of the tumour profiling tests oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA), MammaPrint® (Agendia, Inc., Amsterdam, the Netherlands), Prosigna® (NanoString Technologies, Inc., Seattle, WA, USA), EndoPredict® (Myriad Genetics Ltd, London, UK) and immunohistochemistry 4 (IHC4). To develop a health economic model to assess the cost-effectiveness of these tests compared with clinical tools to guide the use of adjuvant chemotherapy in early-stage breast cancer from the perspective of the NHS and Personal Social Services. DESIGN A systematic review and health economic analysis were conducted. REVIEW METHODS The systematic review was partially an update of a 2013 review. Nine databases were searched in February 2017. The review included studies assessing clinical effectiveness in people with oestrogen receptor-positive, human epidermal growth factor receptor 2-negative, stage I or II cancer with zero to three positive lymph nodes. The economic analysis included a review of existing analyses and the development of a de novo model. RESULTS A total of 153 studies were identified. Only one completed randomised controlled trial (RCT) using a tumour profiling test in clinical practice was identified: Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) for MammaPrint. Other studies suggest that all the tests can provide information on the risk of relapse; however, results were more varied in lymph node-positive (LN+) patients than in lymph node-negative (LN0) patients. There is limited and varying evidence that oncotype DX and MammaPrint can predict benefit from chemotherapy. The net change in the percentage of patients with a chemotherapy recommendation or decision pre/post test ranged from an increase of 1% to a decrease of 23% among UK studies and a decrease of 0% to 64% across European studies. The health economic analysis suggests that the incremental cost-effectiveness ratios for the tests versus current practice are broadly favourable for the following scenarios: (1) oncotype DX, for the LN0 subgroup with a Nottingham Prognostic Index (NPI) of > 3.4 and the one to three positive lymph nodes (LN1-3) subgroup (if a predictive benefit is assumed); (2) IHC4 plus clinical factors (IHC4+C), for all patient subgroups; (3) Prosigna, for the LN0 subgroup with a NPI of > 3.4 and the LN1-3 subgroup; (4) EndoPredict Clinical, for the LN1-3 subgroup only; and (5) MammaPrint, for no subgroups. LIMITATIONS There was only one completed RCT using a tumour profiling test in clinical practice. Except for oncotype DX in the LN0 group with a NPI score of > 3.4 (clinical intermediate risk), evidence surrounding pre- and post-test chemotherapy probabilities is subject to considerable uncertainty. There is uncertainty regarding whether or not oncotype DX and MammaPrint are predictive of chemotherapy benefit. The MammaPrint analysis uses a different data source to the other four tests. The Translational substudy of the Arimidex, Tamoxifen, Alone or in Combination (TransATAC) study (used in the economic modelling) has a number of limitations. CONCLUSIONS The review suggests that all the tests can provide prognostic information on the risk of relapse; results were more varied in LN+ patients than in LN0 patients. There is limited and varying evidence that oncotype DX and MammaPrint are predictive of chemotherapy benefit. Health economic analyses indicate that some tests may have a favourable cost-effectiveness profile for certain patient subgroups; all estimates are subject to uncertainty. More evidence is needed on the prediction of chemotherapy benefit, long-term impacts and changes in UK pre-/post-chemotherapy decisions. STUDY REGISTRATION This study is registered as PROSPERO CRD42017059561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katy Cooper
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alice Bessey
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rachid Rafia
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sue Ward
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert C Stein
- University College London Hospitals Biomedical Research Centre, London, UK.,Research Department of Oncology, University College London, London, UK
| | - Janet Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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11
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Puppe J, Seifert T, Eichler C, Pilch H, Mallmann P, Malter W. Genomic Signatures in Luminal Breast Cancer. Breast Care (Basel) 2020; 15:355-365. [PMID: 32982645 DOI: 10.1159/000509846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 01/22/2023] Open
Abstract
Background Breast cancer is a very heterogeneous disease and luminal breast carcinomas represent the hormone receptor-positive tumors among all breast cancer subtypes. In this context, multigene signatures were developed to gain further prognostic and predictive information beyond clinical parameters and traditional immunohistochemical markers. Summary For early breast cancer patients these molecular tools can guide clinicians to decide on the extension of endocrine therapy to avoid over- and undertreatment by adjuvant chemotherapy. Beside the predictive and prognostic value, a few genomic tests are also able to provide intrinsic subtype classification. In this review, we compare the most frequently used and commercially available molecular tests (OncotypeDX®, MammaPrint®, Prosigna®, EndoPredict®, and Breast Cancer Index<sup>SM</sup>). Moreover, we discuss the clinical utility of molecular profiling for advanced breast cancer of the luminal subtype. Key Messages Multigene assays can help to de-escalate systemic therapy in early-stage breast cancer. Only the Oncotype DX® and MammaPrint®<sup></sup>test are validated by entirely prospective and randomized phase 3 trials. More clinical evidence is needed to support the use of genomic tests in node-positive disease. Recent developments in high-throughput sequencing technology will provide further insights to understand the heterogeneity of luminal breast cancers in early-stage and metastatic disease.
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Affiliation(s)
- Julian Puppe
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tabea Seifert
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Eichler
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Henryk Pilch
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Wolfram Malter
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Dinan MA, Wilson LE, Reed SD. Chemotherapy Costs and 21-Gene Recurrence Score Genomic Testing Among Medicare Beneficiaries With Early-Stage Breast Cancer, 2005 to 2011. J Natl Compr Canc Netw 2020; 17:245-254. [PMID: 30865923 DOI: 10.6004/jnccn.2018.7097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/11/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study examined whether associations between 21-gene recurrence score (RS) genomic testing and lower costs among patients with early-stage, estrogen receptor-positive breast cancer are observable in real-world data from the Medicare population. METHODS A retrospective cohort study was conducted using SEER-Medicare data for a nationally representative sample of Medicare beneficiaries diagnosed from 2005 through 2011. The main outcomes were associations between RS testing and overall and chemotherapy-specific costs. The primary analysis was restricted to patients aged 66 to 75 years. RESULTS The primary analysis comprised 30,058 patients. Mean costs 1 year after diagnosis were $35,940 [SD, $28,894] overall, $51,127 [33,386] for clinically high-risk disease, $33,225 [$27,711] for intermediate-risk disease, and $26,695 [$19,532] for low-risk disease. Chemotherapy-specific costs followed similar trends. In multivariable analyses, RS testing was associated with significantly lower costs among high-risk patients in terms of both relative costs (cost ratio, 0.88; 99% CI, 0.82-0.94) and absolute costs ($6,606; 99% CI, $39,223-$9,290). Higher costs among low-risk and intermediate-risk patients were mainly caused by higher noncancer costs. In sensitivity analyses that included all patients aged ≥66 years (N=64,996), associations between RS testing and costs among high-risk patients were similar but less pronounced because of lower overall use of chemotherapy. CONCLUSIONS RS testing was associated with lower overall and chemotherapy-related costs in patients with high-risk disease, consistent with lower chemotherapy use among these patients. Higher overall costs for patients with intermediate-risk and low-risk disease were driven largely by non-treatment-related costs.
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Affiliation(s)
- Michaela A Dinan
- Duke Clinical Research Institute.,Duke Cancer Institute, and.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Shelby D Reed
- Duke Clinical Research Institute.,Duke Cancer Institute, and.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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13
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Gene Expression Profiling Tests for Early-Stage Invasive Breast Cancer: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2020; 20:1-234. [PMID: 32284770 PMCID: PMC7143374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Breast cancer is a disease in which cells in the breast grow out of control. They often form a tumour that may be seen on an x-ray or felt as a lump.Gene expression profiling (GEP) tests are intended to help predict the risk of metastasis (spread of the cancer to other parts of the body) and to identify people who will most likely benefit from chemotherapy. We conducted a health technology assessment of four GEP tests (EndoPredict, MammaPrint, Oncotype DX, and Prosigna) for people with early-stage invasive breast cancer, which included an evaluation of effectiveness, safety, cost effectiveness, the budget impact of publicly funding GEP tests, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using either the Cochrane Risk of Bias tool, Prediction model Risk Of Bias ASsessment Tool (PROBAST), or Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), depending on the type of study and outcome of interest, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also performed a literature survey of the quantitative evidence of preferences and values of patients and providers for GEP tests.We performed an economic evidence review to identify published studies assessing the cost-effectiveness of each of the four GEP tests compared with usual care or with one another for people with early-stage invasive breast cancer. We adapted a decision-analytic model to compare the costs and outcomes of care that includes a GEP test with usual care without a GEP test over a lifetime horizon. We also estimated the budget impact of publicly funding GEP tests to be conducted in Ontario, compared with funding tests conducted through the out-of-country program and compared with no funding of tests in any location.To contextualize the potential value of GEP tests, we spoke with people who have been diagnosed with early-stage invasive breast cancer. RESULTS We included 68 studies in the clinical evidence review. Within the lymph-node-negative (LN-) population, GEP tests can prognosticate the risk of distant recurrence (GRADE: Moderate) and may predict chemotherapy benefit (GRADE: Low). The evidence for prognostic and predictive ability (ability to indicate the risk of an outcome and ability to predict who will benefit from chemotherapy, respectively) was lower for the lymph-node-positive (LN+) population (GRADE: Very Low to Low). GEP tests may also lead to changes in treatment (GRADE: Low) and generally may increase physician confidence in treatment recommendations (GRADE: Low).Our economic evidence review showed that GEP tests are generally cost-effective compared with usual care.Our primary economic evaluation showed that all GEP test strategies were more effective (led to more quality-adjusted life-years [QALYs]) than usual care and can be considered cost-effective below a willingness-to-pay of $20,000 per QALY gained. There was some uncertainty in our results. At a willingness-to-pay of $50,000 per QALY gained, the probability of each test being cost-effective compared to usual care was 63.0%, 89.2%, 89.2%, and 100% for EndoPredict, MammaPrint, Oncotype DX, and Prosigna, respectively.Sensitivity analyses showed our results were robust to variation in subgroups considered (i.e., LN+ and premenopausal), discount rates, age, and utilities. However, cost parameter assumptions did influence our results. Our scenario analysis comparing tests showed Oncotype DX was likely cost-effective compared with MammaPrint, and Prosigna was likely cost-effective compared with EndoPredict. When the GEP tests were compared with a clinical tool, the cost-effectiveness of the tests varied. Assuming a higher uptake of GEP tests, we estimated the budget impact to publicly fund GEP tests in Ontario would be between $1.29 million (Year 1) and $2.22 million (Year 5) compared to the current scenario of publicly funded GEP tests through the out-of-country program.Gene expression profiling tests are valued by patients and physicians for the additional information they provide for treatment decision-making. Patients are satisfied with what they learn from GEP tests and feel GEP tests can help reduce decisional uncertainty and anxiety. CONCLUSIONS Gene expression profiling tests can likely prognosticate the risk of distant recurrence and some tests may also predict chemotherapy benefit. In people with breast cancer that is ER+, LN-, and human epidermal growth factor receptor 2 (HER2)-negative, GEP tests are likely cost-effective compared with no testing. The GEP tests are also likely cost-effective in LN+ and premenopausal people. Compared with funding GEP tests through the out-of-country program, publicly funding GEP tests in Ontario would cost an additional $1 million to $2 million annually, assuming a higher uptake of tests. GEP tests are valued by both patients and physicians for chemotherapy treatment decision-making.
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14
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Probabilistic cost-utility analysis and expected value of perfect information for the Oncotype multigenic test: a discrete event simulation model. GACETA SANITARIA 2020; 34:61-68. [DOI: 10.1016/j.gaceta.2018.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/06/2018] [Accepted: 07/14/2018] [Indexed: 01/01/2023]
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15
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Jayasekera J, Mandelblatt JS. Systematic Review of the Cost Effectiveness of Breast Cancer Prevention, Screening, and Treatment Interventions. J Clin Oncol 2019; 38:332-350. [PMID: 31804858 DOI: 10.1200/jco.19.01525] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jinani Jayasekera
- Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Jeanne S Mandelblatt
- Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
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Olsson-Brown A, Piskilidis P, O'Hagan J, Thorp N, Robson P, Innes H, Wong H, Cicconi S, Jackson R, Kiernan T, Holcombe C, O'Reilly S, Palmieri C. The impact of the 21-gene recurrence score (Oncotype DX) on concordance of adjuvant therapy decision making as measured by the Liverpool Systemic Therapy Adjuvant Decision Tool. Breast 2019; 44:94-100. [PMID: 30703670 DOI: 10.1016/j.breast.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/09/2019] [Accepted: 01/17/2019] [Indexed: 01/18/2023] Open
Abstract
PURPOSE The 21-gene recurrence score (Oncotype DX) (RS) informs systemic therapy decision making in ER-positive HER2-negative early breast cancer (BC). To date no study has described the more nuanced discussions that take place regarding systemic therapy or the impact of the RS on concordance in such decision making. Here we utilized a novel decision making tool to assess the impact of the RS on decision making as well as concordance of treatment recommendations. PATIENTS AND METHODS The clinicopathological information (CPI) of 50 BCs without and with the RS were presented to a panel of breast oncologists in a simulated MDT. The Liverpool Adjuvant Systemic Therapy Decision Tool (LASTDT) was developed and used to categorize treatment recommendations. Outcome measures included the impact of the RS on decisiveness and concordance in decision making and its impact on treatment recommendations. RESULTS Availability of the RS increased definitive decision making from 8% (4/50) to 56% (28/50) [χ2 = 79.35, p < 0.001] and altered the LASTDT category in 68% (34/50) of cases (p < 0.001), 74% of which were to forgo chemotherapy. With knowledge of RS, universal concordance rose from 14% to 64% [K = 0.328: K = 0.729]. CONCLUSIONS The RS improves certainty of decision making as well as concordance amongst oncologists. This provides evidence that the availability of the RS can improve consistency of decision making amongst oncologists and thus helps to ensure patients are managed consistently. This is particularly important when patients are managed in a loco-regional, multidisciplinary team manner where heterogeneous decisions can lead to disparity in care.
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Affiliation(s)
- Anna Olsson-Brown
- The University of Liverpool, Department of Molecular and Pharmacology, Institute of Translational Medicine, Liverpool, L69 3GE, UK; The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK.
| | - Pavlos Piskilidis
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Julie O'Hagan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Nicky Thorp
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Peter Robson
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Helen Innes
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Helen Wong
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Silvia Cicconi
- The University of Liverpool, Liverpool Cancer Trials Unit, Liverpool, L69 3GE, UK
| | - Richard Jackson
- The University of Liverpool, Liverpool Cancer Trials Unit, Liverpool, L69 3GE, UK
| | - Tamara Kiernan
- St Helens and Knowsley NHS Trust, St Helens, Merseyside, WA10 1ED, UK
| | - Christopher Holcombe
- The Royal Liverpool and Broadgreen University Teaching Hospitals NHS Trust, Liverpool, L7 8XP, UK
| | - Susan O'Reilly
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
| | - Carlo Palmieri
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK; The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool, L69 3GE, UK; Liverpool and Merseyside Academic Breast Unit, Clatterbridge Cancer Centre-The Linda McCartney Centre, Liverpool, L7 8XP, UK.
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Natsuhara KH, Losk K, King TA, Lin NU, Camuso K, Golshan M, Pochebit S, Brock JE, Bunnell CA, Freedman RA. Impact of Genomic Assay Testing and Clinical Factors on Chemotherapy Use After Implementation of Standardized Testing Criteria. Oncologist 2018; 24:595-602. [PMID: 30076279 DOI: 10.1634/theoncologist.2018-0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/14/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND For clinically appropriate early-stage breast cancer patients, reflex criteria for Oncotype DX ordering ("the intervention") were implemented at our comprehensive cancer center, which reduced time-to-adjuvant chemotherapy initiation. Our objective was to evaluate Oncotype DX ordering practices and chemotherapy use before and after implementation of the intervention. MATERIALS AND METHODS We examined medical records for 498 patients who had definitive breast cancer surgery at our center. The post-intervention cohort consisted of 232 consecutive patients who had Oncotype DX testing after reflex criteria implementation. This group was compared to a retrospective cohort of 266 patients who were diagnosed and treated prior to reflex criteria implementation, including patients who did and did not have Oncotype DX ordered. Factors associated with Oncotype DX ordering pre- and post-intervention were examined. We used multivariate logistic regression to evaluate factors associated with chemotherapy receipt among patients with Oncotype DX testing. RESULTS The distribution of Oncotype DX scores, the proportion of those having Oncotype DX testing (28.9% vs. 34.1%) and those receiving chemotherapy (14.3% vs. 19.4%), did not significantly change between pre- and post-intervention groups. Age ≤65 years, stage II, grade 2, 1-3+ nodes, and tumor size >2 cm were associated with higher odds of Oncotype DX testing. Among patients having Oncotype DX testing, node status and Oncotype DX scores were significantly associated with chemotherapy receipt. CONCLUSION Our criteria for reflex Oncotype DX ordering appropriately targeted patients for whom Oncotype DX would typically be ordered by providers. No significant change in the rate of Oncotype DX ordering or chemotherapy use was observed after reflex testing implementation. IMPLICATIONS FOR PRACTICE This study demonstrates that implementing multidisciplinary consensus reflex criteria for Oncotype DX ordering maintains a stable Oncotype DX ordering rate and chemotherapy rate, mirroring what was observed in a specific clinical practice, while decreasing treatment delays due to additional testing. These reflex criteria appropriately capture patients who would likely have had Oncotype DX ordered by their providers and for whom the test results are predicted to influence management. This intervention serves as a potential model for other large integrated, multidisciplinary oncology centers to institute processes targeting patient populations most likely to benefit from genomic assay testing, while mitigating treatment delays.
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Affiliation(s)
| | - Katya Losk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tari A King
- Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kristen Camuso
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mehra Golshan
- Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Stephen Pochebit
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jane E Brock
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Craig A Bunnell
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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18
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Wang SY, Dang W, Richman I, Mougalian SS, Evans SB, Gross CP. Cost-Effectiveness Analyses of the 21-Gene Assay in Breast Cancer: Systematic Review and Critical Appraisal. J Clin Oncol 2018; 36:1619-1627. [PMID: 29659329 DOI: 10.1200/jco.2017.76.5941] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Purpose Prior studies examining cost effectiveness of the 21-gene assay (Oncotype DX [ODX]) for women with hormone receptor-positive, early-stage breast cancer have yielded disparate results. We aimed to explore why these analyses may have yielded different conclusions. Methods We conducted a systematic literature review of cost-effectiveness analyses (CEAs) of ODX. We examined the extent to which the structure of CEA modeling, the assumptions of the models, and the selection of input parameters influenced cost-effectiveness estimates. We also explored the prevalence of industry funding and whether industry funding was associated with study designs favoring ODX. Results We identified 27 analyses, 15 of which received industry funding. In 18 studies, the clinical characteristics (eg, tumor size and grade) commonly used to make chemotherapy decisions were not incorporated into simulation modeling; thus, these studies would favor ODX being cost effective and might not reflect clinical practice. Most studies ignored the heterogeneous effect of ODX on chemotherapy use; only five studies assumed that ODX would increase chemotherapy use for clinically low-risk patients but decrease chemotherapy use for clinically high-risk patients. No study used population-based joint distributions of ODX recurrence score and tumor characteristics, and 12 studies inappropriately assumed that chemotherapy would increase distant recurrence for the low recurrence score group; both approaches overestimated the benefits of ODX. Industry-funded studies tended to favor ODX; all five studies that reported ODX as being cost saving were industry funded. In contrast, two studies that reported an incremental cost-effectiveness ratio > $50,000 per quality-adjusted life-year were not funded by industry. Conclusion Although a majority of published analyses indicated that ODX is cost effective, they incorporated study designs that can increase the risk of bias.
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Affiliation(s)
- Shi-Yi Wang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Weixiong Dang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Ilana Richman
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Sarah S Mougalian
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Suzanne B Evans
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Cary P Gross
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
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19
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Siow ZR, De Boer RH, Lindeman GJ, Mann GB. Spotlight on the utility of the Oncotype DX ® breast cancer assay. Int J Womens Health 2018; 10:89-100. [PMID: 29503586 PMCID: PMC5827461 DOI: 10.2147/ijwh.s124520] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Oncotype DX® assay was developed to address the need for optimizing the selection of adjuvant systemic therapy for patients with estrogen receptor (ER)-positive, lymph node-negative breast cancer. It has ushered in the era of genomic-based personalized cancer care for ER-positive primary breast cancer and is now widely utilized in various parts of the world. Together with several other genomic assays, Oncotype DX has been incorporated into clinical practice guidelines on biomarker use to guide treatment decisions. The Oncotype DX result is presented as the recurrence score which is a continuous score that predicts the risk of distant disease recurrence. The assay, which provides information on clinicopathological factors, has been validated for use in the prognostication and prediction of degree of adjuvant chemotherapy benefit in both lymph node-positive and lymph node-negative early breast cancers. Clinical studies have consistently shown that the Oncotype DX has a significant impact on decision making in adjuvant therapy recommendations and appears to be cost-effective in diverse health care settings. In this article, we provide an overview of the validation and clinical impact studies for the Oncotype DX assay. We also discuss its potential use in the neoadjuvant setting, as well as the more recent prospective validation trials, and the economic and utility implications of studies that use a lower cutoff score to define low-risk disease.
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Affiliation(s)
- Zhen Rong Siow
- ACRF Stem Cells and Cancer Division, Walter and Eliza Hall Institute of Medical Research.,Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital
| | - Richard H De Boer
- Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital
| | - Geoffrey J Lindeman
- ACRF Stem Cells and Cancer Division, Walter and Eliza Hall Institute of Medical Research.,Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - G Bruce Mann
- Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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20
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Blok EJ, Bastiaannet E, van den Hout WB, Liefers GJ, Smit VTHBM, Kroep JR, van de Velde CJH. Systematic review of the clinical and economic value of gene expression profiles for invasive early breast cancer available in Europe. Cancer Treat Rev 2017; 62:74-90. [PMID: 29175678 DOI: 10.1016/j.ctrv.2017.10.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/29/2017] [Indexed: 01/12/2023]
Abstract
Gene expression profiles with prognostic capacities have shown good performance in multiple clinical trials. However, with multiple assays available and numerous types of validation studies performed, the added value for daily clinical practice is still unclear. In Europe, the MammaPrint, OncotypeDX, PAM50/Prosigna and Endopredict assays are commercially available. In this systematic review, we aim to assess these assays on four important criteria: Assay development and methodology, clinical validation, clinical utility and economic value. We performed a literature search covering PubMed, Embase, Web of Science and Cochrane, for studies related to one or more of the four selected assays. We identified 147 papers for inclusion in this review. MammaPrint and OncotypeDX both have evidence available, including level IA clinical trial results for both assays. Both assays provide prognostic information. Predictive value has only been shown for OncotypeDX. In the clinical utility studies, a higher reduction in chemotherapy was achieved by OncotypeDX, although the number of available studies differ considerably between tests. On average, economic evaluations estimate that genomic testing results in a moderate increase in total costs, but that these costs are acceptable in relation to the expected improved patient outcome. PAM50/prosigna and EndoPredict showed comparable prognostic capacities, but with less economical and clinical utility studies. Furthermore, for these assays no level IA trial data are available yet. In summary, all assays have shown excellent prognostic capacities. The differences in the quantity and quality of evidence are discussed. Future studies shall focus on the selection of appropriate subgroups for testing and long-term outcome of validation trials, in order to determine the place of these assays in daily clinical practice.
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Affiliation(s)
- E J Blok
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - W B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - J R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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21
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Losk K, Freedman RA, Lin NU, Golshan M, Pochebit SM, Lester SC, Natsuhara K, Camuso K, King TA, Bunnell CA. Implementation of Surgeon-Initiated Gene Expression Profile Testing (Onco type DX) Among Patients With Early-Stage Breast Cancer to Reduce Delays in Chemotherapy Initiation. J Oncol Pract 2017; 13:e815-e820. [PMID: 28858535 DOI: 10.1200/jop.2017.023788] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Delays to adjuvant chemotherapy initiation in breast cancer may adversely affect clinical outcomes and patient satisfaction. We previously identified an association between genomic testing (Onco type DX) and delayed chemotherapy initiation. We sought to reduce the interval between surgery and adjuvant chemotherapy initiation by developing standardized criteria and workflows for Onco type DX testing. METHODS Criteria for surgeon-initiated reflex Onco type DX testing, workflows for communication between surgeons and medical oncologists, and a streamlined process for receiving and processing Onco type DX requests in pathology were established by multidisciplinary consensus. Criteria for surgeon-initiated testing included patients ≤ 65 years old with T1cN0 (grade 2 or 3), T2N0 (grade 1 or 2), or T1/T2N1 (grade 1 or 2) breast cancer on final surgical pathology. Medical oncologists could elect to initiate Onco type testing for cases falling outside the criteria. We then examined 720 consecutive patients with breast cancer who underwent Onco type DX testing postoperatively between January 1, 2014 and November 28, 2016 and measured intervals between date of surgery, Onco type DX order date, result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. RESULTS The introduction of standardized criteria and workflows reduced time between surgery and Onco type DX ordering, and time from surgery to receipt of result, by 7.3 days ( P < .001) and 6.3 days ( P < .001), respectively. The mean number of days between surgery and initiation of chemotherapy was also reduced by 6.4 days ( P = .004). CONCLUSION Developing consensus on Onco type DX testing criteria and implementing streamlined workflows has led to clinically significant reductions in wait times to chemotherapy decision making and initiation.
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Affiliation(s)
- Katya Losk
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Rachel A Freedman
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Nancy U Lin
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Mehra Golshan
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Stephen M Pochebit
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Susan C Lester
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kelsey Natsuhara
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kristen Camuso
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Tari A King
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Craig A Bunnell
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
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22
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Plun-Favreau J, Immonen-Charalambous K, Steuten L, Strootker A, Rouzier R, Horgan D, Lawler M. Enabling Equal Access to Molecular Diagnostics: What Are the Implications for Policy and Health Technology Assessment? Public Health Genomics 2016; 19:144-52. [PMID: 27237607 DOI: 10.1159/000446532] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Molecular diagnostics can offer important benefits to patients and are a key enabler of the integration of personalised medicine into health care systems. However, despite their promise, few molecular diagnostics are embedded into clinical practice (especially in Europe) and access to these technologies remains unequal across countries and sometimes even within individual countries. If research translation and the regulatory environments have proven to be more challenging than expected, reimbursement and value assessment remain the main barriers to providing patients with equal access to molecular diagnostics. Unclear or non-existent reimbursement pathways, together with the lack of clear evidence requirements, have led to significant delays in the assessment of molecular diagnostics technologies in certain countries. Additionally, the lack of dedicated diagnostics budgets and the siloed nature of resource allocation within certain health care systems have significantly delayed diagnostics commissioning. This article will consider the perspectives of different stakeholders (patients, health care payers, health care professionals, and manufacturers) on the provision of a research-enabled, patient-focused molecular diagnostics platform that supports optimal patient care. Through the discussion of specific case studies, and building on the experience from countries that have successfully integrated molecular diagnostics into clinical practice, this article will discuss the necessary evolutions in policy and health technology assessment to ensure that patients can have equal access to appropriate molecular diagnostics.
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23
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Orucevic A, Heidel RE, Bell JL. Utilization and impact of 21-gene recurrence score assay for breast cancer in clinical practice across the United States: lessons learned from the 2010 to 2012 National Cancer Data Base analysis. Breast Cancer Res Treat 2016; 157:427-35. [PMID: 27206678 PMCID: PMC4903105 DOI: 10.1007/s10549-016-3833-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/09/2016] [Indexed: 01/01/2023]
Abstract
The aim of our study is to investigate patient selection for the 21-gene recurrence score assay (RS) for breast cancer (BC) and the RS impact on chemotherapy administration (Chemo) in clinical practice across the United States through the retrospective observational study of National Cancer Data Base (NCDB) patients from 2010 to 2012. NCDB captures ~70 % of all newly diagnosed malignancies in the USA annually. The 2010–2012 period depicts data from the beginning of the NCDB that required recording of molecular assays and their data release in April 2015. De-identified demographic and clinical variables of patients that had RS results were analyzed. 513,080 patients had BC; 406,525 were estrogen receptor-positive (ER+). 74,334/91,651 patients with RS recorded as a numerical value (0–100) were analyzed (18.2 % of ER+). Patients’ ages ranged from 18 to 90 (mean = 58.8, median = 59); 99.1 % were females. Patients of Caucasian race, from regions with <7 % having no high school education, and >$63,000 median household income were more likely to be tested than patients of other races, education, or income (p < 0.001). 58.1 % of tests were performed in ER+/lymph node-negative/>1 cm tumors; 16.4 % included ≥N1 disease; 9.9 % included T1a, T3, Stage III and IV, or HER2-positive cancers. Low-risk RS result had 92.2 % negative predictive value for no Chemo. Intermediate-risk RS result had 40.1 % positive predictive value (PPV); high-risk RS had 81.2 % PPV for Chemo. RS is obtained in ~1/5 of ER + BC patients across the USA. Further studies investigating influence and implementation of the newest evidence-based management guidelines regarding patients’ selection for RS test and chemotherapy administration upon obtaining of test results are warranted.
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Affiliation(s)
- Amila Orucevic
- Department of Pathology, University of Tennessee Medical Center at Knoxville, 1924 Alcoa Hwy, Knoxville, TN, 37920, USA.
| | - Robert E Heidel
- Department of Surgery, University of Tennessee Medical Center at Knoxville, 1924 Alcoa Hwy, Knoxville, TN, 37920, USA
| | - John L Bell
- Department of Surgery, University of Tennessee Medical Center at Knoxville, 1924 Alcoa Hwy, Knoxville, TN, 37920, USA
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24
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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]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 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] [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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