Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score® Test in Node-Negative Early Breast Cancer

Cost-Utility Analysis of Multigene Assays to Guide Treatment Decisions for Node-Negative Early Breast Cancer

INTRODUCTION

Clinicopathologic and patient factors, such as tumor grade, size, age, and menopausal status, provide limited prognostic and predictive information in hormone receptor positive (HR +), human epidermal growth receptor 2 negative (HER2-), node-negative early-stage breast cancer, leading to potential over- or under-treatment. Multigene expression profile tests used in clinical practice in the USA, including the 21-gene assay, 70-gene assay, 12-gene assay, and 50-gene assay, offer prognostic information beyond traditional clinicopathologic features to improve treatment decisions. This study aimed to estimate the cost-effectiveness of these four multigene assays compared with clinicopathologic risk assessment alone.

METHODS

A decision tree categorized hypothetical patients with HR + /HER2- early-stage invasive breast cancer according to clinical and genomic risk, and integrated clinical expert insights for chemotherapy allocation with literature inputs. A Markov model simulated lifetime costs and outcomes of chemotherapy decisions over a patient's lifetime. The probability of distant breast cancer recurrence was derived from TAILORx (21-gene assay), MINDACT (70-gene assay), and TransATAC (12-gene assay, 50-gene assay) studies. Costs were calculated from a US societal perspective in 2021 US dollars, considering healthcare costs, lost productivity, and patient out-of-pocket expenses.

RESULTS

The 21-gene assay and 50-gene assay were less costly ( -$12,189 and  -$2410, respectively) and more effective [0.23 and 0.07 quality-adjusted life years (QALYs), respectively] compared with clinicopathologic risk alone. Similarly, the 70-gene assay and 12-gene assay are also cost-effective alternatives [incremental cost-effectiveness ratio (ICER): 27,760 and 7942, respectively].

CONCLUSIONS

All four multigene assays were cost-effective from a societal perspective, offering low net lifetime costs or savings with improved outcomes compared with clinicopathologic risk assessment alone. These assays can help refine treatment decisions by providing prognostic risk estimates. In the case of the 21-gene assay, it can also predict chemotherapy benefit leading to the highest lifetime cost savings and greatest QALY gain.

Impact of the 21-gene recurrence score testing on chemotherapy selection and clinical outcomes in T3N0 luminal breast cancer

BACKGROUND

The role of 21-gene recurrence score (RS) testing on chemotherapy decision-making and survival outcomes for T3N0 luminal breast cancer (BC) remains unclear. This study aimed to investigate the effect of RS testing in chemotherapy selection and prognosis in these patients.

RESEARCH DESIGN AND METHODS

Patients diagnosed with T3N0 luminal BC were included from the Surveillance, Epidemiology, and End Results Oncotype database. The likelihood of undergoing chemotherapy was analyzed using the chi-square test and binomial logistic regression. Survival analysis used Kaplan-Meier method and multivariate Cox proportional hazards models.

RESULTS

Of the 3186 patients, 852 (26.7%) underwent RS testing. Those who had RS testing demonstrated a lower probability of chemotherapy receipt than those without RS testing (27.0% vs. 47.5%, p < 0.001). Higher RS correlated with increased the probabilities of chemotherapy receipt. The probabilities of chemotherapy for low-risk, intermediate-risk, and high-risk were 9.8%, 26.7%, and 60.6%, respectively (p < 0.001). RS testing independently improved breast cancer-specific survival (p < 0.001) and overall survival (p < 0.001). In the high-risk cohort, chemotherapy administration was associated with improved overall survival than those who did not (p = 0.038).

CONCLUSIONS

Our study highlights the significant role of RS testing in guiding treatment decisions and improving survival outcomes for patients with T3N0 luminal BC.

Nottingham prognostic x (NPx): a risk stratification tool in ER-positive HER2-negative breast cancer: a validation study

AIMS

In this study, we validate the use of Nottingham Prognostic x (NPx), consisting of tumour size, tumour grade, progesterone receptor (PR) and Ki67 in luminal BC.

MATERIALS AND METHODS

Two large cohorts of luminal early-stage BC (n = 2864) were included. PR and Ki67 expression were assessed using full-face resection samples using immunohistochemistry. NPx was calculated and correlated with clinical variables and outcome, together with Oncotype DX recurrence score (RS), that is frequently used as a risk stratifier in luminal BC.

RESULTS

In the whole cohort, 38% of patients were classified as high risk using NPx which showed significant association with parameters characteristics of aggressive tumour behaviour and shorter survival (P < 0.0001). NPx classified the moderate Nottingham Prognostic Index (NPI) risk group (n = 1812) into two distinct prognostic subgroups. Of the 82% low-risk group, only 3.8% developed events. Contrasting this, 14% of the high-risk patients developed events during follow-up. A strong association was observed between NPx and Oncotype Dx RS (P < 0.0001), where 66% of patients with intermediate risk RS who had subsequent distant metastases also had a high-risk NPx.

CONCLUSION

NPx is a reliable prognostic index in patients with luminal early-stage BC, and in selected patients may be used to guide adjuvant chemotherapy recommendations.

Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score® Test from a US Societal Perspective

Background and Objectives

The 21-gene assay (the Oncotype DX Breast Recurrence Score® test) estimates the 10-year risk of distant recurrence in hormone receptor positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) early-stage breast cancer to inform adjuvant chemotherapy decisions. The cost-effectiveness of the 21-gene assay compared against standard clinical-pathological risk tools alone for HR+/HER2- early-stage breast cancer was assessed using an economic model informed by evidence from randomized controlled trials.

Materials and Methods

A cost-effectiveness model consisted of a decision-tree to stratify patients according to their Recurrence Score (RS) results and the use of adjuvant chemotherapy, followed by a Markov component to estimate the long-term costs and outcomes of the chosen treatment. Distributions of patients and distant recurrence probabilities were derived from the TAILORx (N0) and RxPONDER (N1) trials. The model was evaluated from a healthcare payer and societal perspective. Endocrine therapy and chemotherapy use were informed using clinical expert opinion to reflect US clinical practice and were combined with Medicare drug costs (2021) to estimate the cost of treatment. Societal costs included lost productivity and patient out-of-pocket costs obtained from literature.

Results

The Oncotype DX test generated more quality-adjusted life-years (QALYs) (N0: 0.25; N1: 0.08) at a lower cost (N0: -$13,395; N1: -$2526) compared to clinical-pathological risk alone from a societal cost perspective. The overall conclusions from the model did not change when considering a payer perspective. The main cost drivers were avoidance of distant recurrence for N0 (-$12,578), and the cost of adjuvant chemotherapy for N1 (-$2133). Lost productivity had a major impact in the societal perspective analysis (N0: -$4607; N1: -$1586).

Conclusion

Adjuvant chemotherapy decisions based on the RS result led to more life year gains and lower healthcare costs (dominant) compared to using clinical-pathological risk factors alone among patients with HR+/HER2- N0 and N1 early-stage breast cancer.

A UK prospective multicentre decision impact, decision conflict and economic evaluation of the 21-gene assay in women with node+ve, hormone receptor+ve, HER2-ve breast cancer

BACKGROUND

For a tumour profiling test to be of value, it needs to demonstrate that it is changing clinical decisions, improving clinical confidence, and of economic benefit. This trial evaluated the use of the Oncotype DX Breast Recurrence Score® assay against these criteria in 680 women with hormone receptor-positive (HR+), HER2-negative early breast cancer with 1-3 lymph nodes positive (LN+) in the UK National Health Service (NHS).

METHODS

Prior to receipt of the Recurrence Score (RS) result, both the physician and the patient were asked to state their preference for or against chemotherapy and their level of confidence on a scale of 1-5. Following receipt of the RS result, the physician and patient were asked to make a final decision regarding chemotherapy and record their post-test level of confidence.

RESULTS

Receipt of the RS result led to a 51.5% (95% CI, 47.2-55.8%) reduction in chemotherapy, significantly increased the relative and absolute confidence for both physicians and patients and led to an estimated saving to the NHS of £787 per patient.

CONCLUSION

The use of the Oncotype DX assay fulfils the criteria of changing clinical decisions, improving confidence and saving money.

Socioeconomic Impact of OncotypeDX on Breast Cancer Treatment: Preliminary Results

BACKGROUND/AIM

Breast cancer (BC) is the most prevalent oncological diagnosis worldwide. Molecular subtyping has provided valuable insights for treatment decisions, but challenges remain in adjuvant treatment for hormone receptor (HR)-positive/HER2-negative luminal BC (LBC). Multigene markers like Oncotype DX have emerged to provide more precise prognostic information. This study aimed to evaluate the influence of gene expression panels on fear of cancer recurrence (FCR), quality of life (QoL), and healthcare-related greenhouse emissions.

PATIENTS AND METHODS

A monocentric retrospective analysis was conducted using a prospective database of patients undergoing Oncotype DX. QoL assessments were performed using the Short Breast Health Perception Questionnaire (BHPQ) and Life Satisfaction Questionnaire (LSQ-32). Reductions in hospital visits and travel distance were analyzed.

RESULTS

Twenty-eight patients underwent Oncotype DX testing. Of these, 17.85% received adjuvant chemotherapy based on the recurrence score (RS). The implementation of Oncotype DX resulted in a significant reduction in hospital visits, travel distance, and healthcare-related greenhouse gas emissions. QoL assessments using BHPQ and LSQ-32 showed lower levels of FCR and improved QoL in various domains for patients who received hormone therapy (HT) alone.

CONCLUSION

The implementation of Oncotype DX in clinical practice has the potential to reduce overtreatment, decrease healthcare-related greenhouse gas emissions, and improve QoL. Lower levels of FCR and improved QoL were observed in patients who received HT-only based on the RS score.