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Simons MJHG, Machielsen PM, Spoorendonk JA, Ignacio T, Drost PB, Jacobs T, de Jongh FE. A cost-consequence model of using the 21-gene assay to identify patients with early-stage node-positive breast cancer who benefit from adjuvant chemotherapy in the Netherlands. J Med Econ 2024; 27:445-454. [PMID: 38436289 DOI: 10.1080/13696998.2024.2324612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients with early-stage hormone receptor positive, human epidermal growth factor receptor-2 (HER2) negative invasive breast cancer with 1-3 positive lymph nodes (N1) often undergo surgical excisions followed by adjuvant chemotherapy (ACT). Many patients have no benefit from ACT and receive unnecessary, costly treatment often associated with short- and long-term adverse events (AEs). Gene expression profiling (GEP) assays, such as the 21-gene assay (i.e. the Oncotype DX assay), can identify patients at higher risk for recurrence who may benefit from ACT. However, the budgetary consequence of using the Oncotype DX assay versus no GEP testing in the Netherlands is unknown. Our study therefore assessed it using a cost-consequence model. METHODS A validated model was used to create the N1 model. The model compared the costs and consequences of using the Oncotype DX assay versus no GEP testing and MammaPrint, and subsequent ACT use with corresponding costs for chemotherapy, treatment of AEs, productivity losses, GEP testing, and treatment of recurrences, according to the Oncotype DX results. The model time horizon was 5 years. RESULTS Costs for the total population amounted to €8.0 million (M), €16.2 M, and €9.5 M, and cost per patient amounted to €13,540, €27,455, and €16,154 for using the Oncotype DX assay, no GEP testing, and MammaPrint, respectively. Total cost savings of using the Oncotype DX assay amounted to €8.2 M versus no GEP testing and €1.5 M versus MammaPrint. Using the Oncotype DX assay would result in fewer patients receiving ACT and thus fewer AEs, sick days, and hospitalizations, leading to overall cost savings compared with no GEP testing and MammaPrint. CONCLUSIONS Implementing Oncotype DX testing in this population can prevent unnecessary overtreatment, reducing clinical and economic burden on the patient and Dutch healthcare system.
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Affiliation(s)
| | | | | | - Tim Ignacio
- Evidence & Access, OPEN Health, Rotterdam, The Netherlands
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Berdunov V, Millen S, Paramore A, Griffin J, Reynia S, Fryer N, Brown R, Longworth L. Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score ® Test in Node-Negative Early Breast Cancer. Clinicoecon Outcomes Res 2022; 14:619-633. [PMID: 36157054 PMCID: PMC9505370 DOI: 10.2147/ceor.s360049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/13/2022] [Indexed: 11/23/2022]
Abstract
Background The 21-gene assay (the Oncotype DX Breast Recurrence Score® test) is a validated multigene assay which produces the Recurrence Score® result (RS) to inform decisions on the use of adjuvant chemotherapy in human epidermal growth factor receptor 2-negative (HER2-), hormone receptor positive (HR+) early invasive breast cancer. A model-based economic evaluation estimated the cost-effectiveness of the 21-gene assay against the use of clinical risk tools alone based on the latest evidence from prospective studies. Methods The proportion of patients assigned to chemotherapy conditional on their RS result was obtained from retrospective data from the Clalit registry. The probability of distant recurrence with endocrine and chemo-endocrine therapy conditional on RS result was obtained from TAILORx and NSABP B-20 trials. The cost-effectiveness of the 21-gene assay compared to using clinical risk tools alone was estimated in terms of cost per quality-adjusted life-year (QALY) over a lifetime horizon. Results The 21-gene assay was more effective (0.17 more quality-adjusted life years) at a lower cost (-£519) over a lifetime compared to clinical risk alone. The model results were sensitive to assumptions around the magnitude of benefit of chemotherapy in the high RS result subgroup. Other assumptions underpinning the model, such as the proportion of patients assigned to chemotherapy in the low and mid-range RS result subgroups and long-term distant recurrence probabilities, had a smaller impact on the results. Conclusion The analysis showed that the cost-effectiveness of the 21-gene assay is sensitive to assumptions for chemotherapy sparing for patients with RS 0–25 whose outcomes with endocrine therapy are no worse compared to chemotherapy-assigned patients, and a chemotherapy benefit in the RS 26–100 group. Future studies need to incorporate a wider set of tumour profiling tests other than the 21-gene assay to allow a direct comparison of their cost-effectiveness.
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de Jongh FE, Efe R, Herrmann KH, Spoorendonk JA, Singh A. Cost and Clinical Benefits Associated with Oncotype DX® Test in Patients with Early-Stage HR+/HER2- Node-Negative Breast Cancer in the Netherlands. Int J Breast Cancer 2022; 2022:1-12. [PMID: 36250028 PMCID: PMC9553686 DOI: 10.1155/2022/5909724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives Patients with early-stage HR+/HER2- N0 breast cancer may receive adjuvant chemotherapy in combination with surgery. However, chemotherapy does not always lead to improved survival and incurs high healthcare costs and increased adverse events. To support decision-making regarding adjuvant chemotherapy, genomic profile testing performed with tests such as the Oncotype DX® test can help healthcare practitioners decide whether chemotherapy provides any benefit to these patients. As such, a cost-consequence model was developed with the aim to estimate the economic impact of using different gene expression tests or no testing, in patients with node-negative early-stage breast cancer. Methods A cost-consequence model was developed to estimate the economic impact of three different scenarios in the Dutch setting: (1) Oncotype DX® test, (2) MammaPrint®, and (3) and no genomic profile testing. The model included chemotherapy costs, administration costs, short- and long-term adverse event costs, productivity loss, genomic profiling testing costs, cost of cancer recurrence, and hospitalization costs. Results A treatment paradigm with Oncotype DX resulted in average savings per patient of €6,768 vs. a paradigm with MammaPrint and €13,125 vs. a paradigm with no genomic testing. Furthermore, due to less patients receiving adjuvant chemotherapy through better targeting by the Oncotype DX test, fewer adverse events, sick days, practice visits, and hospitalizations were required compared to MammaPrint and no genomic profiling. Conclusions Testing with Oncotype DX test in Dutch clinical practice in patients with early-stage breast cancer proved to be cost-saving versus MammaPrint and no genomic profiling tests. Introducing the Oncotype DX test to the Dutch setting will likely reduce the economic resources that are required.
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Erber R, Angeloni M, Stöhr R, Lux MP, Ulbrich-Gebauer D, Pelz E, Bankfalvi A, Schmid KW, Walter RFH, Vetter M, Thomssen C, Mayr D, Klauschen F, Sinn P, Sotlar K, Stering K, Stenzinger A, Wunderle M, Fasching PA, Beckmann MW, Hoffmann O, Kimmig R, Harbeck N, Wuerstlein R, Ferrazzi F, Hartmann A. Molecular Subtyping of Invasive Breast Cancer Using a PAM50-Based Multigene Expression Test-Comparison with Molecular-Like Subtyping by Tumor Grade/Immunohistochemistry and Influence on Oncologist's Decision on Systemic Therapy in a Real-World Setting. Int J Mol Sci 2022; 23. [PMID: 35955851 DOI: 10.3390/ijms23158716] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
In intermediate risk hormone receptor (HR) positive, HER2 negative breast cancer (BC), the decision regarding adjuvant chemotherapy might be facilitated by multigene expression tests. In all, 142 intermediate risk BCs were investigated using the PAM50-based multigene expression test Prosigna® in a prospective multicentric study. In 119/142 cases, Prosigna® molecular subtyping was compared with local and two central (C1 and C6) molecular-like subtypes relying on both immunohistochemistry (IHC; HRs, HER2, Ki-67) and IHC + tumor grade (IHC+G) subtyping. According to local IHC, 35.4% were Luminal A-like and 64.6% Luminal B-like subtypes (local IHC+G subtype: 31.9% Luminal A-like; 68.1% Luminal B-like). In contrast to local and C1 subtyping, C6 classified >2/3 of cases as Luminal A-like. Pairwise agreement between Prosigna® subtyping and molecular-like subtypes was fair to moderate depending on molecular-like subtyping method and center. The best agreement was observed between Prosigna® (53.8% Luminal A; 44.5% Luminal B) and C1 surrogate subtyping (Cohen’s kappa = 0.455). Adjuvant chemotherapy was suggested to 44.2% and 88.6% of Prosigna® Luminal A and Luminal B cases, respectively. Out of all Luminal A-like cases (locally IHC/IHC+G subtyping), adjuvant chemotherapy was recommended if Prosigna® testing classified as Prosigna® Luminal A at high / intermediate risk or upgraded to Prosigna® Luminal B.
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Seedor RS, Orloff M, Sato T. Genetic Landscape and Emerging Therapies in Uveal Melanoma. Cancers (Basel) 2021; 13:5503. [PMID: 34771666 PMCID: PMC8582814 DOI: 10.3390/cancers13215503] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 12/12/2022] Open
Abstract
Despite successful treatment of primary uveal melanoma, up to 50% of patients will develop systemic metastasis. Metastatic disease portends a poor outcome, and no adjuvant or metastatic therapy has been FDA approved. The genetic landscape of uveal melanoma is unique, providing prognostic and potentially therapeutic insight. In this review, we discuss our current understanding of the molecular and cytogenetic mutations in uveal melanoma, and the importance of obtaining such information. Most of our knowledge is based on primary uveal melanoma and a better understanding of the mutational landscape in metastatic uveal melanoma is needed. Clinical trials targeting certain mutations such as GNAQ/GNA11, BAP1, and SF3B1 are ongoing and promising. We also discuss the role of liquid biopsies in uveal melanoma in this review.
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Affiliation(s)
- Rino S. Seedor
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.O.); (T.S.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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9
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Ahmed S, Pati S, Le D, Haider K, Iqbal N. The prognostic and predictive role of 21-gene recurrence scores in hormone receptor-positive early-stage breast cancer. J Surg Oncol 2020; 122:144-154. [PMID: 32346902 DOI: 10.1002/jso.25952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022]
Abstract
Over the past two decades, gene expression profiling of breast cancer has emerged as an important tool in early-stage breast cancer management. The approach provides important information on underlying biological mechanisms, breast cancer classification, future risk potential of developing recurrent metastatic disease, and provides beneficial clues for adjuvant chemotherapy in hormone receptor (HR) positive breast cancer. Of the commercially available genomic tests for breast cancer, the prognostic and predictive value of 21-gene recurrence score tests have been validated using both retrospective data and prospective clinical trials. In this paper, we reviewed the current evidence on 21-gene expression profiles for HR-positive HER2-negative early-stage breast cancer management. We show that current evidence supports endocrine therapy alone as an appropriate adjuvant systemic therapy for approximately 70% of women with HR-positive, HER2-negative, node-negative breast cancer. Evolving evidence also suggests that 21-gene recurrence scores have predictive values for node-positive breast cancer and that chemotherapy can be avoided in more than half of women with nodes 1 to 3 positive HR-positive breast cancer. Furthermore, retrospective data also supports the predictive role of 21-gene recurrence scores for adjuvant radiation therapy. A prospective trial in this area is ongoing.
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Affiliation(s)
- Shahid Ahmed
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Sukanya Pati
- Department of Pharmacology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Duc Le
- Department of Radiation Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kamal Haider
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nayyar Iqbal
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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10
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Boeri C, Chiappa C, Galli F, De Berardinis V, Bardelli L, Carcano G, Rovera F. Machine Learning techniques in breast cancer prognosis prediction: A primary evaluation. Cancer Med 2020; 9:3234-3243. [PMID: 32154669 PMCID: PMC7196042 DOI: 10.1002/cam4.2811] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/28/2019] [Accepted: 12/13/2019] [Indexed: 01/13/2023] Open
Abstract
More than 750 000 women in Italy are surviving a diagnosis of breast cancer. A large body of literature tells us which characteristics impact the most on their prognosis. However, the prediction of each disease course and then the establishment of a therapeutic plan and follow‐up tailored to the patient is still very complicated. In order to address this issue, a multidisciplinary approach has become widely accepted, while the Multigene Signature Panels and the Nottingham Prognostic Index are still discussed options. The current technological resources permit to gather many data for each patient. Machine Learning (ML) allows us to draw on these data, to discover their mutual relations and to esteem the prognosis for the new instances. This study provides a primary evaluation of the application of ML to predict breast cancer prognosis. We analyzed 1021 patients who underwent surgery for breast cancer in our Institute and we included 610 of them. Three outcomes were chosen: cancer recurrence (both loco‐regional and systemic) and death from the disease within 32 months. We developed two types of ML models for every outcome (Artificial Neural Network and Support Vector Machine). Each ML algorithm was tested in accuracy (=95.29%‐96.86%), sensitivity (=0.35‐0.64), specificity (=0.97‐0.99), and AUC (=0.804‐0.916). These models might become an additional resource to evaluate the prognosis of breast cancer patients in our daily clinical practice. Before that, we should increase their sensitivity, according to literature, by considering a wider population sample with a longer period of follow‐up. However, specificity, accuracy, minimal additional costs, and reproducibility are already encouraging.
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Affiliation(s)
- Carlo Boeri
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Corrado Chiappa
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Federica Galli
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Valentina De Berardinis
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Laura Bardelli
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Giulio Carcano
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
| | - Francesca Rovera
- SSD Breast Unit - ASST-Settelaghi Varese, Senology Research Center, Department of Medicine, University of Insubria, Varese, Italy
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Ibarrondo O, Álvarez-lópez I, Freundlich F, Arrospide A, Galve-calvo E, Gutiérrez-toribio M, Plazaola A, Mar J. Probabilistic cost-utility analysis and expected value of perfect information for the Oncotype multigenic test: a discrete event simulation model. Gaceta Sanitaria 2020; 34:61-8. [DOI: 10.1016/j.gaceta.2018.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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12
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Masucci L, Torres S, Eisen A, Trudeau M, Tyono I, Saunders H, Chan KW, Isaranuwatchai W. Cost-utility analysis of 21-gene assay for node-positive early breast cancer. ACTA ACUST UNITED AC 2019; 26:307-318. [PMID: 31708649 DOI: 10.3747/co.26.4769] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background For women with lymph node (ln)-positive, estrogen receptor-positive, and her2 (human epidermal growth factor receptor 2)-negative breast cancer (bca), current guidelines recommend treatment with both hormonal therapy and chemotherapy. The 21-gene Recurrence Score (rs) assay might be helpful in selecting patients with bca who can be spared chemotherapy when they have 1-3 positive lns and a lower risk of recurrence. In the present study, we performed a cost-utility analysis comparing use of the 21-gene rs assay with current practice from the perspective of a Canadian health care payer. Methods A Markov model was developed to determine costs and quality-adjusted life-years (qalys) over a patient's lifetime. Patient outcomes in both study groups were examined based on published clinical trials. Costs were derived primarily from published Canadian sources. Costs and outcomes were discounted at 1.5% annually, and costs are reported in 2016 Canadian dollars. A probabilistic analysis was used, and the model parameters were varied in a sensitivity analysis. Results The results indicate that use of the 21-gene rs assay was less costly ($432 less) and more effective (0.22 qalys) than current practice. The probabilistic analysis revealed that 70% of the 10,000 simulated incremental cost-effectiveness ratios were in the southeast quadrant. The results were sensitive to the probability of a low rs and to the probability of receiving chemotherapy in the low-risk rs category and in current practice. Conclusions Use of the 21-gene rs assay could be a cost-effective strategy for Ontario patients with estrogen receptor-positive, her2-negative early bca and 1-3 positive lns.
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Affiliation(s)
- L Masucci
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - S Torres
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - A Eisen
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - M Trudeau
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - I Tyono
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - H Saunders
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - K W Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON
| | - W Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
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13
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Lee SB, Kim J, Sohn G, Kim J, Chung IY, Kim HJ, Ko BS, Son BH, Ahn SH, Lee JW, Jung KH. A Nomogram for Predicting the Oncotype DX Recurrence Score in Women with T1-3N0-1miM0 Hormone Receptor‒Positive, Human Epidermal Growth Factor 2 (HER2)‒Negative Breast Cancer. Cancer Res Treat 2018; 51:1073-1085. [PMID: 30384581 PMCID: PMC6639212 DOI: 10.4143/crt.2018.357] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/31/2018] [Indexed: 12/20/2022] Open
Abstract
Purpose This preliminary study was conducted to evaluate the association between Oncotype DX (ODX) recurrence score and traditional prognostic factors. We also developed a nomogram to predict subgroups with low ODX recurrence scores (less than 25) and to avoid additional chemotherapy treatments for those patients. Materials and Methods Clinicopathological and immunohistochemical variables were retrospectively retrieved and analyzed from a series of 485 T1-3N0-1miM0 hormone receptor-positive, human epidermal growth factor 2‒negative breast cancer patients with available ODX test results at Asan Medical Center from 2010 to 2016. One hundred twenty-seven patients (26%) had positive axillary lymph node micrometastases, and 408 (84%) had ODX recurrence scores of ≤25. Logistic regression was performed to build a nomogram for predicting a low-risk subgroup of the ODX assay. Results Multivariate analysis revealed that estrogen receptor (ER) score, progesterone receptor (PR) score, histologic grade, lymphovascular invasion (LVI), and Ki-67 had a statistically significant association with the low-risk subgroup. With these variables, we developed a nomogram to predict the low-risk subgroup with ODX recurrence scores of ≤25. The area under the receiver operating characteristic curve was 0.90 (95% confidence interval [CI], 0.85 to 0.96). When applied to the validation group the nomogram was accurate with an area under the curve = 0.88 (95% CI, 0.83 to 0.95). Conclusion The low ODX recurrence score subgroup can be predicted by a nomogram incorporating five traditional prognostic factors: ER, PR, histologic grade, LVI, and Ki-67. Our nomogram, which predicts a low-risk ODX recurrence score, will be a useful tool to help select patients who may or may not need additional ODX testing.
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Affiliation(s)
- Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Junetae Kim
- Samsung Electronics, Giheung/Hwaseong/Pyeongtaek Complex, Smart IT team, Hwaseong, Korea
| | - Guiyun Sohn
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Il Yong Chung
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sei-Hyun Ahn
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyung Hae Jung
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Chandler Y, Schechter CB, Jayasekera J, Near A, O’Neill SC, Isaacs C, Phelps CE, Ray GT, Lieu TA, Ramsey S, Mandelblatt JS. Cost Effectiveness of Gene Expression Profile Testing in Community Practice. J Clin Oncol 2018; 36:554-562. [PMID: 29309250 PMCID: PMC5815401 DOI: 10.1200/jco.2017.74.5034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Gene expression profile (GEP) testing can support chemotherapy decision making for patients with early-stage, estrogen receptor-positive, human epidermal growth factor 2-negative breast cancers. This study evaluated the cost effectiveness of one GEP test, Onco type DX (Genomic Health, Redwood City, CA), in community practice with test-eligible patients age 40 to 79 years. Methods A simulation model compared 25-year societal incremental costs and quality-adjusted life-years (QALYs) of community Onco type DX use from 2005 to 2012 versus usual care in the pretesting era (2000 to 2004). Inputs included Onco type DX and chemotherapy data from an integrated health care system and national and published data on Onco type DX accuracy, chemotherapy effectiveness, utilities, survival and recurrence, and Medicare and patient costs. Sensitivity analyses varied individual parameters; results were also estimated for ideal conditions (ie, 100% testing and adherence to test-suggested treatment, perfect test accuracy, considering test effects on reassurance or worry, and lowest costs). Results Twenty-four percent of test-eligible patients had Onco type DX testing. Testing was higher in younger patients and patients with stage I disease ( v stage IIA), and 75.3% and 10.2% of patients with high and low recurrence risk scores received chemotherapy, respectively. The cost-effectiveness ratio for testing ( v usual care) was $188,125 per QALY. Considering test effects on worry versus reassurance decreased the cost-effectiveness ratio to $58,431 per QALY. With perfect test accuracy, the cost-effectiveness ratio was $28,947 per QALY, and under ideal conditions, it was $39,496 per QALY. Conclusion GEP testing is likely to have a high cost-effectiveness ratio on the basis of community practice patterns. However, realistic variations in assumptions about key variables could result in GEP testing having cost-effectiveness ratios in the range of other accepted interventions. The differences in cost-effectiveness ratios on the basis of community versus ideal conditions underscore the importance of considering real-world implementation when assessing the new technology.
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Affiliation(s)
- Young Chandler
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Clyde B. Schechter
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jinani Jayasekera
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aimee Near
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suzanne C. O’Neill
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudine Isaacs
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles E. Phelps
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - G. Thomas Ray
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tracy A. Lieu
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott Ramsey
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeanne S. Mandelblatt
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Stemmer SM, Steiner M, Rizel S, Geffen DB, Nisenbaum B, Peretz T, Soussan-Gutman L, Bareket-Samish A, Isaacs K, Rosengarten O, Fried G, McCullough D, Svedman C, Shak S, Liebermann N, Ben-Baruch N. Clinical outcomes in ER+ HER2 -node-positive breast cancer patients who were treated according to the Recurrence Score results: evidence from a large prospectively designed registry. NPJ Breast Cancer 2017; 3:32. [PMID: 28900632 DOI: 10.1038/s41523-017-0033-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 01/25/2023] Open
Abstract
The Recurrence Score® is increasingly used in node-positive ER+ HER2-negative breast cancer. This retrospective analysis of a prospectively designed registry evaluated treatments/outcomes in node-positive breast cancer patients who were Recurrence Score-tested through Clalit Health Services from 1/2006 through 12/2011 (N = 709). Medical records were reviewed to verify treatments/recurrences/survival. Median follow-up, 5.9 years; median age, 62 years; 53.9% grade 2; 69.8% tumors ≤ 2 cm; 84.5% invasive ductal carcinoma; 42.0% N1mi, and 37.2%/15.5%/5.2% with 1/2/3 positive nodes; 53.4% Recurrence Score < 18, 36.4% Recurrence Score 18–30, and 10.2% Recurrence Score ≥ 31. Overall, 26.9% received adjuvant chemotherapy: 7.1%, 39.5%, and 86.1% in the Recurrence Score < 18, 18–30, and ≥ 31 group, respectively. The 5-year Kaplan–Meier estimates for distant recurrence were 3.2%, 6.3%, and 16.9% for these respective groups and the corresponding 5-year breast cancer death estimates were 0.5%, 3.4%, and 5.7%. In Recurrence Score < 18 patients, 5-year distant-recurrence rates for N1mi/1 positive node/2–3 positive nodes were 1.2%/4.4%/5.4%. As patients were not randomized to treatment and treatment decision is heavily influenced by Recurrence Score, analysis of 5-year distant recurrence by chemotherapy use was exploratory and should be interpreted cautiously: In Recurrence Score < 18, recurrence rate was 7.7% in chemotherapy-treated (n = 27) and 2.9% in chemotherapy-untreated patients (n = 352); P = 0.245. In Recurrence Score 18–30, recurrence rate in chemotherapy-treated patients (n = 102) was significantly lower than in untreated patients (n = 156) (1.0% vs. 9.7% P = 0.019); in Recurrence Score ≤ 25 (the RxPONDER study cutoff), recurrence rate was 2.3% in chemotherapy-treated (n = 89) and 4.4% in chemotherapy-untreated patients (n = 488); P = 0.521. In conclusion, our findings support using endocrine therapy alone in ER+ HER2-negative breast cancer patients with micrometastases/1–3 positive nodes and Recurrence Score < 18. Women with breast cancer that has spread to the lymph nodes do well on anti-hormone treatment alone if they score under 18 on OncotypeDX. Salomon Stemmer from Rabin Medical Center in Petah Tikvah, Israel, and colleagues conducted the first analysis of a large prospectively designed registry in which patients with breast cancer cells in the underarm lymph nodes have taken the 21-gene expression analysis known as OncotypeDX to guide their treatment. Among the 709 women with node-positive, ER-positive, HER-negative disease, patients with test scores under 18 did just as well if they received chemotherapy or not in addition to anti-hormone treatment, whereas those with scores of 18 to 30 had significantly lower recurrence rates if they received both therapies. The findings suggest that only women with OncotypeDX scores under 18 can safely forgo chemotherapy.
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Nerich V, Saing S, Gamper EM, Kemmler G, Daval F, Pivot X, Holzner B. Cost-utility analyses of drug therapies in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:407-24. [PMID: 27572551 DOI: 10.1007/s10549-016-3924-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/20/2016] [Indexed: 01/08/2023]
Abstract
The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.
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Marguet S, Mazouni C, Ramaekers BL, Dunant A, Kates R, Jacobs VR, Joore MA, Harbeck N, Bonastre J. European cost-effectiveness study of uPA/PAI-1 biomarkers to guide adjuvant chemotherapy decisions in breast cancer. Eur J Cancer 2016; 63:168-79. [DOI: 10.1016/j.ejca.2016.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/15/2016] [Accepted: 05/14/2016] [Indexed: 12/25/2022]
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Cockburn JG, Hallett RM, Gillgrass AE, Dias KN, Whelan T, Levine MN, Hassell JA, Bane A. The effects of lymph node status on predicting outcome in ER+ /HER2- tamoxifen treated breast cancer patients using gene signatures. BMC Cancer 2016; 16:555. [PMID: 27469239 PMCID: PMC4964078 DOI: 10.1186/s12885-016-2501-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 07/04/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Lymph node (LN) status is the most important prognostic variable used to guide ER positive (+) breast cancer treatment. While a positive nodal status is traditionally associated with a poor prognosis, a subset of these patients respond well to treatment and achieve long-term survival. Several gene signatures have been established as a means of predicting outcome of breast cancer patients, but the development and indication for use of these assays varies. Here we compare the capacity of two approved gene signatures and a third novel signature to predict outcome in distinct LN negative (-) and LN+ populations. We also examine biological differences between tumours associated with LN- and LN+ disease. METHODS Gene expression data from publically available data sets was used to compare the ability of Oncotype DX and Prosigna to predict Distant Metastasis Free Survival (DMFS) using an in silico platform. A novel gene signature (Ellen) was developed by including patients with both LN- and LN+ disease and using Prediction Analysis of Microarrays (PAM) software. Gene Set Enrichment Analysis (GSEA) was used to determine biological pathways associated with patient outcome in both LN- and LN+ tumors. RESULTS The Oncotype DX gene signature, which only used LN- patients during development, significantly predicted outcome in LN- patients, but not LN+ patients. The Prosigna gene signature, which included both LN- and LN+ patients during development, predicted outcome in both LN- and LN+ patient groups. Ellen was also able to predict outcome in both LN- and LN+ patient groups. GSEA suggested that epigenetic modification may be related to poor outcome in LN- disease, whereas immune response may be related to good outcome in LN+ disease. CONCLUSIONS We demonstrate the importance of incorporating lymph node status during the development of prognostic gene signatures. Ellen may be a useful tool to predict outcome of patients regardless of lymph node status, or for those with unknown lymph node status. Finally we present candidate biological processes, unique to LN- and LN+ disease, that may indicate risk of relapse.
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Affiliation(s)
- Jessica G. Cockburn
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - Robin M. Hallett
- Department of Biochemistry and Biomedical Sciences, Centre for Functional Genomics, McMaster University, Hamilton, Canada
| | - Amy E. Gillgrass
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - Kay N. Dias
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - T. Whelan
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - M. N. Levine
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - John A. Hassell
- Department of Biochemistry and Biomedical Sciences, Centre for Functional Genomics, McMaster University, Hamilton, Canada
| | - Anita Bane
- Department of Oncology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
- Department of Pathology, Juravinski Hospital and Cancer Centre, Hamilton, Canada
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Curtis KK, Wong WW, Ross HJ. Past approaches and future directions for targeting tumor hypoxia in squamous cell carcinomas of the head and neck. Crit Rev Oncol Hematol 2016; 103:86-98. [DOI: 10.1016/j.critrevonc.2016.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 04/04/2016] [Accepted: 05/10/2016] [Indexed: 12/27/2022] Open
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Plasseraud KM, Cook RW, Tsai T, Shildkrot Y, Middlebrook B, Maetzold D, Wilkinson J, Stone J, Johnson C, Oelschlager K, Aaberg TM. Clinical Performance and Management Outcomes with the DecisionDx-UM Gene Expression Profile Test in a Prospective Multicenter Study. J Oncol 2016; 2016:5325762. [PMID: 27446211 PMCID: PMC4944073 DOI: 10.1155/2016/5325762] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/04/2016] [Accepted: 05/12/2016] [Indexed: 12/31/2022]
Abstract
Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p = 0.003) with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher's exact test p = 2.1 × 10(-13) and p = 0.04, resp.). The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920).
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Affiliation(s)
| | | | - Tony Tsai
- Retinal Consultants, Sacramento, CA 95819, USA
| | | | | | | | | | - John Stone
- Castle Biosciences, Friendswood, TX 77546, USA
| | | | | | - Thomas M. Aaberg
- Michigan State University Medical School and Retina Specialists of Michigan, Grand Rapids, MI 49546, USA
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Augustovski F, Soto N, Caporale J, Gonzalez L, Gibbons L, Ciapponi A. Decision-making impact on adjuvant chemotherapy allocation in early node-negative breast cancer with a 21-gene assay: systematic review and meta-analysis. Breast Cancer Res Treat 2015; 152:611-25. [PMID: 26126971 DOI: 10.1007/s10549-015-3483-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/18/2015] [Indexed: 01/10/2023]
Abstract
Risk stratification based on results provided by a 21-gene assay (Oncotype DX(®)) in early stage breast cancer can help optimize hormone therapy (HT) and/or chemotherapy (CT) decisions. We performed a systematic review and meta-analysis of decision impact (DI) and net change in CT use before and after assay results, both in the whole studies' population and by recurrence risk score (RS) strata. A systematic search of studies with prospective data collection reported physician's decision on treatment allocation in early stage node-negative breast cancer was performed. DI reflects the proportion of patients whose management was changed, and net change focuses on CT change. A random-effects model is reported. Fifteen studies (N = 2229) met our inclusion criteria: 50.09, 37.35, and 13.38 % of patients with low, intermediate, and high RS. Treatment decision changed in 29.5 % (95 % CI 26.29-32.86). Net reduction of CT use was 12 % (8-17 %). It was 16 % (12.00-19.00) in the low RS group, 0 % (-3.00 to 3.00) in the intermediate RS group, and increased by 2 % (-1.00 to 3.00) in the high RS group. Use of a 21-gene assay showed a significant impact on treatment decisions. From 100 women tested, 30 could have their treatment optimized, and 12 could avoid CT. Its main effects consist of sparing chemotherapy in low risk patients and slightly increasing it in the high risk category. DI could be higher in selected patient populations with greater uncertainty regarding initial treatment decisions.
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Affiliation(s)
- Federico Augustovski
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024 (1414), Ciudad Autónoma de Buenos Aires, Argentina,
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Turner BM, Skinner KA, Tang P, Jackson MC, Soukiazian N, Shayne M, Huston A, Ling M, Hicks DG. Use of modified Magee equations and histologic criteria to predict the Oncotype DX recurrence score. Mod Pathol 2015; 28:921-31. [PMID: 25932962 DOI: 10.1038/modpathol.2015.50] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/03/2015] [Accepted: 02/04/2015] [Indexed: 11/09/2022]
Abstract
Oncotype DX (Genomic Health, Redwood City, CA, USA, current list price $4,350.00) is a multigene quantitative reverse transcription-polymerase chain reaction-based assay that estimates the risk of distant recurrence and predicts chemotherapy benefit for patients with estrogen receptor (ER)-positive breast cancers. Studies have suggested that standard histologic variables can provide similar information. Klein and Dabbs et al have shown that Oncotype DX recurrence scores can be estimated by incorporating standard histologic variables into equations (Magee equations). Using a simple modification of the Magee equation, we predict the Oncotype DX recurrence score in an independent set of 283 cases. The Pearson correlation coefficient (r) for the Oncotype DX and average modified Magee recurrence scores was 0.6644 (n=283; P<0.0001). 100% of cases with an average modified Magee recurrence score>30 (n=8) or an average modified Magee recurrence score<9 (with an available Ki-67, n=5) would have been correctly predicted to have a high or low Oncotype DX recurrence score, respectively. 86% (38/44) of cases with an average modified Magee recurrence score≤12, and 89% (34/38) of low grade tumors (NS<6) with an ER and PR≥150, and a Ki-67<10%, would have been correctly predicted to have a low Oncotype DX recurrence score. Using an algorithmic approach to eliminate high and low risk cases, between 5% and 23% of cases would potentially not have been sent by our institution for Oncotype DX testing, creating a potential cost savings between $56,550.00 and $282,750.00. The modified Magee recurrence score along with histologic criteria may be a cost-effective alternative to the Oncotype DX in risk stratifying certain breast cancer patients. The information needed is already generated by many pathology laboratories during the initial assessment of primary breast cancer, and the equations are free.
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Affiliation(s)
- Bradley M Turner
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Kristin A Skinner
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ping Tang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary C Jackson
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Nyrie Soukiazian
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Michelle Shayne
- Department of Medical Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Alissa Huston
- Department of Medical Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Marilyn Ling
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - David G Hicks
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
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25
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Gligorov J, Pivot XB, Jacot W, Naman HL, Spaeth D, Misset JL, Largillier R, Sautiere JL, de Roquancourt A, Pomel C, Rouanet P, Rouzier R, Penault-Llorca FM. Prospective Clinical Utility Study of the Use of the 21-Gene Assay in Adjuvant Clinical Decision Making in Women With Estrogen Receptor-Positive Early Invasive Breast Cancer: Results From the SWITCH Study. Oncologist 2015; 20:873-9. [PMID: 26112003 DOI: 10.1634/theoncologist.2014-0467] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The 21-gene Oncotype DX Recurrence Score assay is a validated assay to help decide the appropriate treatment for estrogen receptor-positive (ER+), early-stage breast cancer (EBC) in the adjuvant setting. The choice of adjuvant treatments might vary considerably in different countries according to various treatment guidelines. This prospective multicenter study is the first to assess the impact of the Oncotype DX assay in the French clinical setting. METHODS A total of 100 patients with ER+, human epidermal growth factor receptor 2-negative EBC, and node-negative (pN0) disease or micrometastases in up to 3 lymph nodes (pN1mi) were enrolled. Treatment recommendations, physicians' confidence before and after knowing the Recurrence Score value, and physicians' perception of the assay were recorded. RESULTS Of the 100 patients, 95 were evaluable (83 pN0, 12 pN1mi). Treatment recommendations changed in 37% of patients, predominantly from chemoendocrine to endocrine treatment alone. The proportion of patients recommended chemotherapy decreased from 52% pretest to 25% post-test. Of patients originally recommended chemotherapy, 61% were recommended endocrine treatment alone after receiving the Recurrence Score result. For both pN0 and pN1mi patients, post-test recommendations appeared to follow the Recurrence Score result for low and high values. Physicians' confidence improved significantly. CONCLUSION These are the first prospective data on the impact of the Oncotype DX assay on adjuvant treatment decisions in France. Using the assay was associated with a significant change in treatment decisions and an overall reduction in chemotherapy use. These data are consistent with those presented from European and non-European studies.
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Affiliation(s)
- Joseph Gligorov
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Xavier B Pivot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - William Jacot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Hervé L Naman
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Dominique Spaeth
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Louis Misset
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Rémy Largillier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Loup Sautiere
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Anne de Roquancourt
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Christophe Pomel
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Philippe Rouanet
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Roman Rouzier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Frederique M Penault-Llorca
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
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Lobo JM, Dicker AP, Buerki C, Daviconi E, Karnes RJ, Jenkins RB, Patel N, Den RB, Showalter TN. Evaluating the clinical impact of a genomic classifier in prostate cancer using individualized decision analysis. PLoS One 2015; 10:e0116866. [PMID: 25837660 PMCID: PMC4383561 DOI: 10.1371/journal.pone.0116866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Currently there is controversy surrounding the optimal way to treat patients with prostate cancer in the post-prostatectomy setting. Adjuvant therapies carry possible benefits of improved curative results, but there is uncertainty in which patients should receive adjuvant therapy. There are concerns about giving toxicity to a whole population for the benefit of only a subset. We hypothesized that making post-prostatectomy treatment decisions using genomics-based risk prediction estimates would improve cancer and quality of life outcomes. METHODS We developed a state-transition model to simulate outcomes over a 10 year horizon for a cohort of post-prostatectomy patients. Outcomes included cancer progression rates at 5 and 10 years, overall survival, and quality-adjusted survival with reductions for treatment, side effects, and cancer stage. We compared outcomes using population-level versus individual-level risk of cancer progression, and for genomics-based care versus usual care treatment recommendations. RESULTS Cancer progression outcomes, expected life-years (LYs), and expected quality-adjusted life-years (QALYs) were significantly different when individual genomics-based cancer progression risk estimates were used in place of population-level risk estimates. Use of the genomic classifier to guide treatment decisions provided small, but statistically significant, improvements in model outcomes. We observed an additional 0.03 LYs and 0.07 QALYs, a 12% relative increase in the 5-year recurrence-free survival probability, and a 4% relative reduction in the 5-year probability of metastatic disease or death. CONCLUSIONS The use of genomics-based risk prediction to guide treatment decisions may improve outcomes for prostate cancer patients. This study offers a framework for individualized decision analysis, and can be extended to incorporate a wide range of personal attributes to enable delivery of patient-centered tools for informed decision-making.
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Affiliation(s)
- Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Adam P. Dicker
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Elai Daviconi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - R. Jeffrey Karnes
- Department of Urology, Mayo Clinic, Rochester, MN, United States of America
| | - Robert B. Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Nirav Patel
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Robert B. Den
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Munkácsy G, Szász MA, Menyhárt O. Gene expression-based prognostic and predictive tools in breast cancer. Breast Cancer 2015; 22:245-52. [PMID: 25874688 DOI: 10.1007/s12282-015-0594-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/27/2015] [Indexed: 12/21/2022]
Abstract
Genomic assays measuring the expression of multiple genes have made their way into clinical practice and their utilization is now recommended by major international guidelines. A basic property of these tests is their capability to sub-divide patients into high- and low-risk cohorts thereby providing prognostic, and in certain settings, predictive decision support. Here, we summarize commercially available assays for breast cancer including RT-PCR and gene chip-based tests. Given the relative uncertainty in cancer treatment, multigene tests have the potential for a significant cost reduction as they can pinpoint those patients for whom chemotherapy proves to be unnecessary. However, concordance of risk assessment for an individual patient is still far from optimal. Additionally, emerging multigene approaches focus on predicting therapy response, which is a black spot of current tests. Promising techniques include the homologous recombination deficiency score, utilization of massive parallel sequencing to identify driver genes, employment of internet-based meta-analysis tools and investigation of miRNA expression signatures. Combination of multiple simultaneous analyses at diagnosis, including classical histopathological diagnostics, monogenic markers, genomic signatures and clinical parameters will most likely bring maximal benefit for patients. As the main driving force behind such genomic tests is the power to achieve cost reduction due to avoiding unnecessary systemic treatment, the future is most likely to hold a further proliferation of such assays.
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Blank PR, Filipits M, Dubsky P, Gutzwiller F, Lux MP, Brase JC, Weber KE, Rudas M, Greil R, Loibl S, Szucs TD, Kronenwett R, Schwenkglenks M, Gnant M. Cost-effectiveness analysis of prognostic gene expression signature-based stratification of early breast cancer patients. Pharmacoeconomics 2015; 33:179-190. [PMID: 25404424 PMCID: PMC4305105 DOI: 10.1007/s40273-014-0227-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The individual risk of recurrence in hormone receptor-positive primary breast cancer patients determines whether adjuvant endocrine therapy should be combined with chemotherapy. Clinicopathological parameters and molecular tests such as EndoPredict(®) (EPclin) can support decision making in patients with estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative cancer. OBJECTIVE Using a life-long Markov state transition model, we determined the health economic impact and incremental cost effectiveness of EPclin-based risk stratification in combination with clinical guidelines [German-S3, National Comprehensive Cancer Center Network (NCCN), and St. Gallen] to decide on chemotherapy use. METHODS Information on overall and metastasis-free survival came from Austrian Breast & Colorectal Cancer Study Group clinical trials 6/8 (n = 1,619) and published literature. Effectiveness was assessed as quality-adjusted life-years (QALYs). Costs (2010) were assessed from a German third-party payer perspective. RESULTS Lifetime costs per patient ranged from <euro>28,268 (St.Gallen and EPclin) to <euro>33,756 (NCCN). Due to an imperfect prognostic value and differences in chemotherapy use, strategies achieved between 13.165 QALYs (NCCN) and 13.173 QALYs (EPclin alone) per patient. Using German-S3 as reference, three strategies showed dominant results (St. Gallen and EPclin, German-S3 and EPclin, EPclin alone). Compared to German-S3, the addition of EPclin saved <euro>3,388 and gained 0.002 QALYs per patient. Combining guidelines with EPclin remained preferable in sensitivity analysis. CONCLUSION Our study suggests that molecular markers can be sensibly combined with clinical guidelines to determine the risk profile of adjuvant breast cancer patients. Compared with the current German best practice (German-S3), combinations of EPclin with the St. Gallen, German-S3 or NCCN guideline and EPclin alone were dominant from the perspective of the German healthcare system.
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Affiliation(s)
- Patricia R Blank
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland,
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Zanotti L, Bottini A, Rossi C, Generali D, Cappelletti MR. Diagnostic tests based on gene expression profile in breast cancer: from background to clinical use. Tumour Biol 2014; 35:8461-70. [DOI: 10.1007/s13277-014-2366-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 07/15/2014] [Indexed: 12/17/2022] Open
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André F, Delaloge S, Guinebretière JM, Petit T, Pierga JY, Zarca D, Zarca K. Prolifération des cancers du sein et biomarqueurs décisionnels en pratique RPC (RPC 2013). ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2341-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Gnant M, Filipits M, Greil R, Stoeger H, Rudas M, Bago-Horvath Z, Mlineritsch B, Kwasny W, Knauer M, Singer C, Jakesz R, Dubsky P, Fitzal F, Bartsch R, Steger G, Balic M, Ressler S, Cowens JW, Storhoff J, Ferree S, Schaper C, Liu S, Fesl C, Nielsen TO. Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 Risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone. Ann Oncol 2013; 25:339-45. [PMID: 24347518 DOI: 10.1093/annonc/mdt494] [Citation(s) in RCA: 256] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND PAM50 is a 50-gene test that is designed to identify intrinsic breast cancer subtypes and generate a Risk of Recurrence (ROR) score. It has been developed to be carried out in qualified routine hospital pathology laboratories. PATIENTS AND METHODS One thousand four hundred seventy-eight postmenopausal women with estrogen receptor (ER)+ early breast cancer (EBC) treated with tamoxifen or tamoxifen followed by anastrozole from the prospective randomized ABCSG-8 trial were entered into this study. Patients did not receive adjuvant chemotherapy. RNA was extracted from paraffin blocks and analyzed using the PAM50 test. Both intrinsic subtype (luminal A/B, HER2-enriched, basal-like) and ROR score were calculated. The primary analysis was designed to test whether the continuous ROR score adds prognostic value in predicting distant recurrence (DR) over and above standard clinical variables. RESULTS In all tested subgroups, ROR score significantly adds prognostic information to the clinical predictor (P<0.0001). PAM50 assigns an intrinsic subtype to all cases, and the luminal A cohort had a significantly lower ROR at 10 years compared with Luminal B (P<0.0001). Significant and clinically relevant discrimination between low- and high-risk groups occurred also within all tested subgroups. CONCLUSION(S) The results of the primary analysis, in combination with recently published results from the ATAC trial, constitute Level 1 evidence for clinical validity of the PAM50 test for predicting the risk of DR in postmenopausal women with ER+ EBC. A 10-year metastasis risk of <3.5% in the ROR low category makes it unlikely that additional chemotherapy would improve this outcome-this finding could help to avoid unwarranted overtreatment. CLINICAL TRIAL NUMBER ABCSG 8: NCT00291759.
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Affiliation(s)
- M Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Harbeck N, Sotlar K, Wuerstlein R, Doisneau-Sixou S. Molecular and protein markers for clinical decision making in breast cancer: today and tomorrow. Cancer Treat Rev 2013; 40:434-44. [PMID: 24138841 DOI: 10.1016/j.ctrv.2013.09.014] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/18/2013] [Accepted: 09/20/2013] [Indexed: 01/31/2023]
Abstract
In early breast cancer (eBC), established clinicopathological factors are not sufficient for clinical decision making particularly regarding adjuvant chemotherapy since substantial over- or undertreatment may occur. Thus, novel protein- and molecular markers have been put forward as decision aids. Since these potential prognosis and/or predictive tests differ substantially regarding their methodology, analytical and clinical validation, this review attempts to summarize the essential facts for clinicians. This review focuses on those markers which are the most advanced so far in their development towards routine clinical application, i.e. two protein markers (i.e. uPA/PAI-1 and IHC4) and six molecular multigene tests (i.e. Mammaprint®, Oncotype DX®, PAM50, Endopredict®, the 97-gene genomic grade, and 76 gene Rotterdam signatures). Next to methodological aspects, we summarized the clinical evidences, in particular the main prospective clinical trials which have already been fully recruited (i.e. MINDACT, TAILORx, WSG PLAN B) or are still ongoing (i.e. RxPONDER/SWOG S1007, WSG-ADAPT). Last but not least, this review points out the key elements for clinicians to select one test among the wide panel of proposed assays, for a specific population of patients in term of level of evidence, analytical and clinical validity as well as cost effectiveness.
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Affiliation(s)
- Nadia Harbeck
- Brustzentrum, Universitätsfrauenklinik, Klinikum Großhadern, Marchioninistr. 15, München, Germany.
| | - Karl Sotlar
- Pathologisches Institut, Ludwig-Maximilians-Universität München, Thalkirchner Strasse. 36, München, Germany.
| | - Rachel Wuerstlein
- Brustzentrum, Klinikum der Universität München, Maistraße 11, 80337 Munich, Germany.
| | - Sophie Doisneau-Sixou
- Brustzentrum, Klinikum der Universität München, Maistraße 11, 80337 Munich, Germany; Université Paul Sabatier Toulouse III, Faculté des Sciences Pharmaceutiques, 31062 Toulouse Cedex 09, France.
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Goldhirsch A, Winer EP, Coates AS, Gelber RD, Piccart-Gebhart M, Thürlimann B, Senn HJ. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol 2013; 24:2206-23. [PMID: 23917950 PMCID: PMC3755334 DOI: 10.1093/annonc/mdt303] [Citation(s) in RCA: 2395] [Impact Index Per Article: 217.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 02/07/2023] Open
Abstract
The 13th St Gallen International Breast Cancer Conference (2013) Expert Panel reviewed and endorsed substantial new evidence on aspects of the local and regional therapies for early breast cancer, supporting less extensive surgery to the axilla and shorter durations of radiation therapy. It refined its earlier approach to the classification and management of luminal disease in the absence of amplification or overexpression of the Human Epidermal growth factor Receptor 2 (HER2) oncogene, while retaining essentially unchanged recommendations for the systemic adjuvant therapy of HER2-positive and 'triple-negative' disease. The Panel again accepted that conventional clinico-pathological factors provided a surrogate subtype classification, while noting that in those areas of the world where multi-gene molecular assays are readily available many clinicians prefer to base chemotherapy decisions for patients with luminal disease on these genomic results rather than the surrogate subtype definitions. Several multi-gene molecular assays were recognized as providing accurate and reproducible prognostic information, and in some cases prediction of response to chemotherapy. Cost and availability preclude their application in many environments at the present time. Broad treatment recommendations are presented. Such recommendations do not imply that each Panel member agrees: indeed, among more than 100 questions, only one (trastuzumab duration) commanded 100% agreement. The various recommendations in fact carried differing degrees of support, as reflected in the nuanced wording of the text below and in the votes recorded in supplementary Appendix S1, available at Annals of Oncology online. Detailed decisions on treatment will as always involve clinical consideration of disease extent, host factors, patient preferences and social and economic constraints.
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Affiliation(s)
- A Goldhirsch
- International Breast Cancer Study Group, Division of Medical Oncology, European Institute of Oncology, Milan, Italy.
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Boer RH, Baker C, Speakman D, Chao CY, Yoshizawa C, Mann GB. The impact of a genomic assay (Oncotype DX) on adjuvant treatment recommendations in early breast cancer. Med J Aust 2013; 199:205-8. [DOI: 10.5694/mja12.11334] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 03/04/2013] [Indexed: 12/20/2022]
Affiliation(s)
- Richard H Boer
- Royal Melbourne Hospital, Melbourne, VIC
- Breast Service, Royal Melbourne Hospital and Royal Women's Hospital, Melbourne, VIC
| | | | | | | | | | - G Bruce Mann
- Breast Service, Royal Melbourne Hospital and Royal Women's Hospital, Melbourne, VIC
- Department of Surgery, University of Melbourne, Melbourne, VIC
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Müller BM, Keil E, Lehmann A, Winzer KJ, Richter-Ehrenstein C, Prinzler J, Bangemann N, Reles A, Stadie S, Schoenegg W, Eucker J, Schmidt M, Lippek F, Jöhrens K, Pahl S, Sinn BV, Budczies J, Dietel M, Denkert C. The EndoPredict Gene-Expression Assay in Clinical Practice - Performance and Impact on Clinical Decisions. PLoS One 2013; 8:e68252. [PMID: 23826382 PMCID: PMC3694878 DOI: 10.1371/journal.pone.0068252] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/28/2013] [Indexed: 12/11/2022] Open
Abstract
The validated EndoPredict assay is a novel tool to predict the risk of metastases of patients with estrogen receptor positive, HER2 negative breast cancer treated with endocrine therapy alone. It has been designed to integrate genomic and clinical information and includes clinico-pathological factors such as tumor size and nodal status. The test is feasible in a decentral setting in molecular pathology laboratories. In this project, we investigated the performance of this test in clinical practice, and performed a retrospective evaluation of its impact on treatment decisions in breast cancer. During one year, EndoPredict assays from 167 patients could be successfully performed. For retrospective evaluation of treatment decisions, a questionnaire was sent to the clinical partner. Regarding the molecular EP class, samples from 56 patients (33.5%) had a low-risk, whereas 111 patients (66.5%) showed a high-risk gene profile. After integration of the clinicopathological factors the combined clinical and molecular score (EPclin) resulted in a low-risk group of 77 patients (46.4%), while 89 (53.6%) had a high risk EPclin score. The EPclin-based estimated median 10-year-risk for metastases with endocrine therapy alone was 11% for the whole cohort. The median handling time averaged three days (range: 0 to 11 days), 59.3% of the tests could be performed in three or less than three days. Comparison of pre- and post-test therapy decisions showed a change of therapy in 37.7% of patients. 16 patients (12.3%) had a change to an additional chemotherapy while 25.4% of patients (n = 33) changed to an endocrine therapy alone. In 73 patients (56.2%) no change of therapy resulted. In 6.1% of patients (n = 8), the patients did not agree to the recommendation of the tumor board. Our results show that the EndoPredict assay could be routinely performed in decentral molecular pathology laboratories and the results markedly change treatment decisions.
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Affiliation(s)
- Berit Maria Müller
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
- * E-mail:
| | - Elke Keil
- Breast Center, Park Clinic Weissensee, Berlin, Germany
| | - Annika Lehmann
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | | | | | - Judith Prinzler
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Nikola Bangemann
- Breast Center, Charité University Hospital, Campus Mitte, Berlin, Germany
| | | | - Sylvia Stadie
- Breast Center, Park Clinic Weissensee, Berlin, Germany
| | | | - Jan Eucker
- Department of Internal Medicine, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Marcus Schmidt
- Breast Center, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Korinna Jöhrens
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Stefan Pahl
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Bruno Valentin Sinn
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Jan Budczies
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Manfred Dietel
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
| | - Carsten Denkert
- Institute of Pathology, Charité University Hospital, Campus Mitte, Berlin, Germany
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Holt S, Bertelli G, Humphreys I, Valentine W, Durrani S, Pudney D, Rolles M, Moe M, Khawaja S, Sharaiha Y, Brinkworth E, Whelan S, Jones S, Bennett H, Phillips CJ. A decision impact, decision conflict and economic assessment of routine Oncotype DX testing of 146 women with node-negative or pNImi, ER-positive breast cancer in the U.K. Br J Cancer 2013; 108:2250-8. [PMID: 23695023 PMCID: PMC3681004 DOI: 10.1038/bjc.2013.207] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Tumour gene expression analysis is useful in predicting adjuvant chemotherapy benefit in early breast cancer patients. This study aims to examine the implications of routine Oncotype DX testing in the UK. Methods: Women with oestrogen receptor positive (ER+), pNO or pN1mi breast cancer were assessed for adjuvant chemotherapy and subsequently offered Oncotype DX testing, with changes in chemotherapy decisions recorded. A subset of patients completed questionnaires about their uncertainties regarding chemotherapy decisions pre- and post-testing. All patients were asked to complete a diary of medical interactions over the next 6 months, from which economic data were extracted to model the cost-effectiveness of testing. Results: Oncotype DX testing resulted in changes in chemotherapy decisions in 38 of 142 (26.8%) women, with 26 of 57 (45.6%) spared chemotherapy and 12 of 85 (14.1%) requiring chemotherapy when not initially recommended (9.9% reduction overall). Decision conflict analysis showed that Oncotype DX testing increased patients' confidence in treatment decision making. Economic analysis showed that routine Oncotype DX testing costs £6232 per quality-adjusted life year gained. Conclusion: Oncotype DX decreased chemotherapy use and increased confidence in treatment decision making in patients with ER+ early-stage breast cancer. Based on these findings, Oncotype DX is cost-effective in the UK setting.
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Affiliation(s)
- S Holt
- Department of Breast Surgery, Prince Philip Hospital, Llanelli, Wales SA14 8QF, UK.
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Eiermann W, Rezai M, Kümmel S, Kühn T, Warm M, Friedrichs K, Schneeweiss A, Markmann S, Eggemann H, Hilfrich J, Jackisch C, Witzel I, Eidtmann H, Bachinger A, Hell S, Blohmer J. The 21-gene recurrence score assay impacts adjuvant therapy recommendations for ER-positive, node-negative and node-positive early breast cancer resulting in a risk-adapted change in chemotherapy use. Ann Oncol 2012; 24:618-24. [PMID: 23136233 PMCID: PMC3574549 DOI: 10.1093/annonc/mds512] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background We carried out a prospective clinical study to evaluate the impact of the Recurrence Score (RS) on treatment decisions in early breast cancer (EBC). Patients and methods A total of 379 eligible women with estrogen receptor positive (ER+), HER2-negative EBC and 0–3 positive lymph nodes were enrolled. Treatment recommendations, patients' decisional conflict, physicians' confidence before and after knowledge of the RS and actual treatment data were recorded. Results Of the 366 assessable patients 244 were node negative (N0) and 122 node positive (N+). Treatment recommendations changed in 33% of all patients (N0 30%, N+ 39%). In 38% of all patients (N0 39%, N+ 37%) with an initial recommendation for chemoendocrine therapy, the post-RS recommendation changed to endocrine therapy, in 25% (N0 22%, N+ 39%) with an initial recommendation for endocrine therapy only to combined chemoendocrine therapy, respectively. A patients' decisional conflict score improved by 6% (P = 0.028) and physicians' confidence increased in 45% (P < 0.001) of all cases. Overall, 33% (N0 29%, N+ 38%) of fewer patients actually received chemotherapy as compared with patients recommended chemotherapy pre-test. Using the test was cost-saving versus current clinical practice. Conclusion RS-guided chemotherapy decision-making resulted in a substantial modification of adjuvant chemotherapy usage in node-negative and node-positive ER+ EBC.
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Affiliation(s)
- W Eiermann
- Interdisciplinary Oncology Center, Munich.
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