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Stein RC, Dunn JA, Bartlett JMS, Campbell AF, Marshall A, Hall P, Rooshenas L, Morgan A, Poole C, Pinder SE, Cameron DA, Stallard N, Donovan JL, McCabe C, Hughes-Davies L, Makris A. OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer. Health Technol Assess 2016; 20:xxiii-xxix, 1-201. [PMID: 26867046 DOI: 10.3310/hta20100] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is uncertainty about the chemotherapy sensitivity of some oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers. Multiparameter assays that measure the expression of several tumour genes simultaneously have been developed to guide the use of adjuvant chemotherapy for this breast cancer subtype. The assays provide prognostic information and have been claimed to predict chemotherapy sensitivity. There is a dearth of prospective validation studies. The Optimal Personalised Treatment of early breast cancer usIng Multiparameter Analysis preliminary study (OPTIMA prelim) is the feasibility phase of a randomised controlled trial (RCT) designed to validate the use of multiparameter assay directed chemotherapy decisions in the NHS. OBJECTIVES OPTIMA prelim was designed to establish the acceptability to patients and clinicians of randomisation to test-driven treatment assignment compared with usual care and to select an assay for study in the main RCT. DESIGN Partially blinded RCT with adaptive design. SETTING Thirty-five UK hospitals. PARTICIPANTS Patients aged ≥ 40 years with surgically treated ER-positive HER2-negative primary breast cancer and with 1-9 involved axillary nodes, or, if node negative, a tumour at least 30 mm in diameter. INTERVENTIONS Randomisation between two treatment options. Option 1 was standard care consisting of chemotherapy followed by endocrine therapy. In option 2, an Oncotype DX(®) test (Genomic Health Inc., Redwood City, CA, USA) performed on the resected tumour was used to assign patients either to standard care [if 'recurrence score' (RS) was > 25] or to endocrine therapy alone (if RS was ≤ 25). Patients allocated chemotherapy were blind to their randomisation. MAIN OUTCOME MEASURES The pre-specified success criteria were recruitment of 300 patients in no longer than 2 years and, for the final 150 patients, (1) an acceptance rate of at least 40%; (2) recruitment taking no longer than 6 months; and (3) chemotherapy starting within 6 weeks of consent in at least 85% of patients. RESULTS Between September 2012 and 3 June 2014, 350 patients consented to join OPTIMA prelim and 313 were randomised; the final 150 patients were recruited in 6 months, of whom 92% assigned chemotherapy started treatment within 6 weeks. The acceptance rate for the 750 patients invited to participate was 47%. Twelve out of the 325 patients with data (3.7%, 95% confidence interval 1.7% to 5.8%) were deemed ineligible on central review of receptor status. Interviews with researchers and recordings of potential participant consultations made as part of the integral qualitative recruitment study provided insights into recruitment barriers and led to interventions designed to improve recruitment. Patient information was changed as the result of feedback from three patient focus groups. Additional multiparameter analysis was performed on 302 tumour samples. Although Oncotype DX, MammaPrint(®)/BluePrint(®) (Agendia Inc., Irvine, CA, USA), Prosigna(®) (NanoString Technologies Inc., Seattle, WA, USA), IHC4, IHC4 automated quantitative immunofluorescence (AQUA(®)) [NexCourse BreastTM (Genoptix Inc. Carlsbad, CA, USA)] and MammaTyper(®) (BioNTech Diagnostics GmbH, Mainz, Germany) categorised comparable numbers of tumours into low- or high-risk groups and/or equivalent molecular subtypes, there was only moderate agreement between tests at an individual tumour level (kappa ranges 0.33-0.60 and 0.39-0.55 for tests providing risks and subtypes, respectively). Health economics modelling showed the value of information to the NHS from further research into multiparameter testing is high irrespective of the test evaluated. Prosigna is currently the highest priority for further study. CONCLUSIONS OPTIMA prelim has achieved its aims of demonstrating that a large UK clinical trial of multiparameter assay-based selection of chemotherapy in hormone-sensitive early breast cancer is feasible. The economic analysis shows that a trial would be economically worthwhile for the NHS. Based on the outcome of the OPTIMA prelim, a large-scale RCT to evaluate the clinical effectiveness and cost-effectiveness of multiparameter assay-directed chemotherapy decisions in hormone-sensitive HER2-negative early breast would be appropriate to take place in the NHS. TRIAL REGISTRATION Current Controlled Trials ISRCTN42400492. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 10. See the NIHR Journals Library website for further project information. The Government of Ontario funded research at the Ontario Institute for Cancer Research. Robert C Stein received additional support from the NIHR University College London Hospitals Biomedical Research Centre.
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Affiliation(s)
- Robert C Stein
- Department of Oncology, University College London Hospitals, London, UK
| | - Janet A Dunn
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Amy F Campbell
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter Hall
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | | | - Sarah E Pinder
- Research Oncology, Division of Cancer Studies, King's College London, London, UK
| | - David A Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Luke Hughes-Davies
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundations Trust, Cambridge, UK
| | - Andreas Makris
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
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Wen HY, Krystel-Whittemore M, Patil S, Pareja F, Bowser ZL, Dickler MN, Norton L, Morrow M, Hudis CA, Brogi E. Breast carcinoma with an Oncotype Dx recurrence score <18: Rate of distant metastases in a large series with clinical follow-up. Cancer 2016; 123:131-137. [PMID: 27526056 DOI: 10.1002/cncr.30271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/19/2016] [Accepted: 07/28/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A 21-gene expression assay (Oncotype DX recurrence score [RS]) that uses reverse transcriptase-polymerase chain reaction is used clinically in patients with early-stage, estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast carcinoma (ER+/HER2- BC) to determine both prognosis with tamoxifen therapy and the usefulness of adding adjuvant chemotherapy. Use of the assay is associated with reductions in overall chemotherapy use. The current study examined the treatments and outcomes in patients with low RS. METHODS The authors reviewed the institutional database to identify patients with lymph node-negative, ER+/HER2- BC who were treated at the study institution between September 2008 and August 2013 and their 21-gene RS results. RESULTS A total of 1406 consecutive patients with lymph node-negative ER+/HER2- BC and a low RS were identified (510 patients had an RS of 0-10 and 896 patients had an RS of 11-17). The median age at the time of diagnosis of BC was 56 years; 63 patients (4%) were aged <40 years. Overall, 1361 patients (97%) received endocrine therapy and 170 patients (12%) received chemotherapy. The median follow-up was 46 months. Six patients (0.4%) developed distant metastases (1 patient with an RS of 5 and 5 patients with an RS of 11-17). In the cohorts of patients with an RS of 11 to 17, the absolute rate of distant metastasis among patients aged <40 years was 7.1% (3 of 42 patients) versus 0.2% among patients aged ≥40 years (2 of 854 patients). CONCLUSIONS The data from the current study document a 0.4% rate of distant metastasis within 5 years of BC diagnosis among patients with lymph node-negative ER+/HER2- BC with an RS <18. Patients aged <40 years at the time of BC diagnosis were observed to have a higher rate of distant metastases. Analysis of data from other studies is necessary to validate this observation further. Cancer 2017;131-137. © 2016 American Cancer Society.
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Affiliation(s)
- Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fresia Pareja
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zenica L Bowser
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maura N Dickler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Larry Norton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Clifford A Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
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O'Neill SC, Isaacs C, Chao C, Tsai HT, Liu C, Ekezue BF, Selvam N, Kessler LG, Schwartz MD, Lobo T, Potosky AL. Adoption of Gene Expression Profiling for Breast Cancer in US Oncology Practice for Women Younger Than 65 Years. J Natl Compr Canc Netw 2016; 13:1216-24. [PMID: 26483061 DOI: 10.6004/jnccn.2015.0150] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A number of practice guidelines incorporate the use of gene expression profiling (GEP) tests for early-stage, hormone receptor-positive, HER2-negative breast tumors. Few studies describe factors associated with GEP testing in US oncology practice. We assessed the relationship between clinical, demographic, and group-level socioeconomic variables and test use in women younger than 65 years. PATIENTS AND METHODS Data from 5 state cancer registries were linked with insurance claims data and GEP test results. We assessed rates of testing and variables associated with test use in an incident cohort of 9,444 commercially insured women younger than 65 years, newly diagnosed with stage I or II hormone receptor-positive breast cancer from 2006 through 2012. RESULTS Rates of testing for women with N0 disease increased from 20.4% in 2006 to 35.2% in 2011. Variables associated with higher rates of testing, beyond clinical factors such as nodal status (P<.001), included being diagnosed from 2008 through 2012 versus 2006 through 2007 (adjusted odds ratio [OR], 1.67; 95% CI, 1.47-1.90), having preexisting comorbidities (adjusted OR, 1.35; 95% CI, 1.14-1.59), and higher out-of-pocket pharmacy costs (adjusted OR, 1.66; 95% CI, 1.40-1.97). Women younger than 50 years were more likely to be tested if they had stage I versus stage II disease (P<.0001). CONCLUSIONS In an insured population of women younger than 65 years, GEP testing increased after its inclusion in clinical practice guidelines and mounting evidence. Additional research is needed to better understand oncologists' decision not to order GEP testing for their patients who are otherwise eligible.
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Affiliation(s)
- Suzanne C O'Neill
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Claudine Isaacs
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Calvin Chao
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Huei-Ting Tsai
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Chunfu Liu
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Bola F Ekezue
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Nandini Selvam
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Larry G Kessler
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Marc D Schwartz
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Tania Lobo
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Arnold L Potosky
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
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Boughey JC, Dietz JR. Editorial: Management Based on Risk: Individualizing the Care of the Breast Cancer Patient. Ann Surg Oncol 2016; 23:3083-7. [DOI: 10.1245/s10434-016-5371-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Indexed: 11/18/2022]
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Cyr AE, Tucker N, Ademuyiwa F, Margenthaler JA, Aft RL, Eberlein TJ, Appleton CM, Zoberi I, Thomas MA, Gao F, Gillanders WE. Successful Completion of the Pilot Phase of a Randomized Controlled Trial Comparing Sentinel Lymph Node Biopsy to No Further Axillary Staging in Patients with Clinical T1-T2 N0 Breast Cancer and Normal Axillary Ultrasound. J Am Coll Surg 2016; 223:399-407. [PMID: 27212005 DOI: 10.1016/j.jamcollsurg.2016.04.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/21/2016] [Accepted: 04/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Axillary surgery is not considered therapeutic in patients with clinical T1-T2 N0 breast cancer. The importance of axillary staging is eroding in an era in which tumor biology, as defined by biomarker and gene expression profile, is increasingly important in medical decision making. We hypothesized that axillary ultrasound (AUS) is a noninvasive alternative to sentinel lymph node biopsy (SLNB), and AUS could replace SLNB without compromising patient care. STUDY DESIGN Patients with clinical T1-T2 N0 breast cancer and normal AUS were eligible for enrollment. Subjects were randomized to no further axillary staging (arm 1) vs SLNB (arm 2). Descriptive statistics were used to describe the results of the pilot phase of the randomized controlled trial. RESULTS Sixty-eight subjects were enrolled in the pilot phase of the trial (34 subjects in arm 1, no further staging; 32 subjects in arm 2, SLNB; and 2 subjects voluntarily withdrew from the trial). The median age was 61 years (range 40 to 80 years) in arm 1 and 59 years (range 31 to 81 years) in arm 2, and there were no significant clinical or pathologic differences between the arms. Median follow-up was 17 months (range 1 to 32 months). The negative predictive value (NPV) of AUS for identification of clinically significant axillary disease (>2.0 mm) was 96.9%. No axillary recurrences have been observed in either arm. CONCLUSIONS Successful completion of the pilot phase of the randomized controlled trial confirms the feasibility of the study design, and provides prospective evidence supporting the ability of AUS to exclude clinically significant disease in the axilla. The results provide strong support for a phase 2 randomized controlled trial.
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Affiliation(s)
- Amy E Cyr
- Department of Surgery, Washington University School of Medicine, St Louis, MO.
| | - Natalia Tucker
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Foluso Ademuyiwa
- Department of Medicine, Washington University School of Medicine, St Louis, MO
| | | | - Rebecca L Aft
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Timothy J Eberlein
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | | | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Feng Gao
- Department of Surgery, Washington University School of Medicine, St Louis, MO; Division of Biostatistics, Washington University School of Medicine, St Louis, MO
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Unger JM, Hershman DL, Arnold KB, Loomba R, Chugh R, Hwang JP, O'Rourke MA, Bhadkamkar NA, Wang LX, Siegel AB, Cooley TP, Berenberg JL, Bridges BB, Ramsey SD. Stepwise development of a cancer care delivery research study to evaluate the prevalence of virus infections in cancer patients. Future Oncol 2016; 12:1219-31. [PMID: 26952901 PMCID: PMC4864045 DOI: 10.2217/fon-2015-0076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND SWOG initiated a cancer care delivery research study of virus infection rates among newly diagnosed cancer patients. This study will inform viral screening guidelines in oncology clinics. METHODS In a first step 'vanguard' phase, we evaluated the feasibility of multiple study procedures. Site investigators were surveyed to obtain feedback on study implementation. RESULTS Much higher enrollment occurred at sites where all physicians participated and viral testing was performed as routine practice. These procedures will be required going forward. Additional protocol changes based on site investigator input were implemented. CONCLUSION This multistep protocol design process illustrates how cancer care delivery research studies can adapt to real-world strategies and procedures that exist at community clinics where the predominance of cancer patients are treated.
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Affiliation(s)
- Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Kathryn B Arnold
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rohit Loomba
- University of California - San Diego, La Jolla, CA, USA
| | | | | | - Mark A O'Rourke
- NCORP of the Carolinas/Greenville Health System, Greenville, SC, USA
| | | | - Lili X Wang
- Bay Area Institute NCORP Oakland, CA, USA.,Contra Costa Regional Medical Center, Martinez, CA, USA
| | - Abby B Siegel
- Columbia University Minority Underserved NCORP, New York, NY, USA
| | | | | | - Benjamin B Bridges
- Pacific Cancer Research Consortium NCORP, Seattle, WA, USA.,St Luke's Mountain States Tumor Institute, Boise, ID, USA
| | - Scott D Ramsey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Roberts MC, Weinberger M, Dusetzina SB, Dinan MA, Reeder-Hayes KE, Carey LA, Troester MA, Wheeler SB. Racial Variation in the Uptake of Oncotype DX Testing for Early-Stage Breast Cancer. J Clin Oncol 2015; 34:130-8. [PMID: 26598755 DOI: 10.1200/jco.2015.63.2489] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Oncotype DX (ODX) is a tumor gene-profiling test that aids in adjuvant chemotherapy decision-making. ODX has the potential to improve quality of care; however, if not equally accessible across racial groups, disparities in cancer care quality may persist or worsen. We examined racial disparities in ODX testing uptake. METHODS We used data from the Carolina Breast Cancer Study, phase III, a longitudinal, population-based study of 2,998 North Carolina women who received a diagnosis of breast cancer between 2008 and 2014. Our primary analysis used modified Poisson regression to determine the association between race and whether ODX testing was ordered among two strata: node-negative and node-positive breast cancer. RESULTS A total of 1,468 women with estrogen receptor-positive, human epidermal growth factor receptor-2-negative, stage I or II breast cancer met inclusion criteria. Black patients had higher-grade and larger tumors, more comorbidities, younger age at diagnosis, and lower socioeconomic status than non-black women. Overall, 42% of women had ODX test results in their pathology reports. Compared with those who did not receive ODX testing, women who received ODX testing tended to be younger and have medium tumor size and grade. Our regression analyses indicated no racial disparities in ODX uptake among node-negative patients. However, racial differences were detected among node-positive patients, with black patients being 46% less likely to receive ODX testing than non-black women (adjusted relative risk, 0.54; 95% CI, 0.35 to 0.84; P = .006). CONCLUSION We did not find racial disparities in ODX testing for node-negative patients for whom ODX testing is guideline recommended and widely covered by insurers. However, our findings suggest that a newer, non-guideline-concordant application of ODX testing for node-positive breast cancer was accessed less by black women than by non-black women, reflecting more guideline concordant care among black women.
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Affiliation(s)
- Megan C Roberts
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC.
| | - Morris Weinberger
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stacie B Dusetzina
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Michaela A Dinan
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Katherine E Reeder-Hayes
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Lisa A Carey
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Melissa A Troester
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stephanie B Wheeler
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
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Potosky AL, O'Neill SC, Isaacs C, Tsai HT, Chao C, Liu C, Ekezue BF, Selvam N, Kessler LG, Zhou Y, Schwartz MD. Population-based study of the effect of gene expression profiling on adjuvant chemotherapy use in breast cancer patients under the age of 65 years. Cancer 2015; 121:4062-70. [PMID: 26291519 DOI: 10.1002/cncr.29621] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/23/2015] [Accepted: 07/10/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Gene expression profiling (GEP) testing can help to predict the risk of cancer recurrence and guide decisions about adjuvant chemotherapy for breast cancer (BC). However, no prior US studies have evaluated the relation between GEP testing and the use of adjuvant chemotherapy by women treated in a general oncology practice. METHODS Eligible patients were women under the age 65 of years who were newly diagnosed with their first stage I or II, hormone receptor-positive BC between 2006 and 2011 (n = 9405). This retrospective study was conducted with a data set consisting of registry data, health claims data, and GEP testing results. The distribution of GEP test results was reported in terms of the risk of recurrence predicted, and logistic regression was used to assess the association of test results with chemotherapy use, with adjustments made for multiple patient characteristics. RESULTS The proportions of tested women with low, intermediate, and high recurrence score results were 51%, 39%, and 10%, respectively. Among these women, 11%, 47%, and 88%, respectively, received adjuvant chemotherapy. There was a significant, positive linear relation of assay scores with chemotherapy use within the low and intermediate subgroups after adjustments for all other factors (adjusted odds ratios, 1.17 and 1.20, respectively). CONCLUSIONS Adjuvant chemotherapy use after GEP testing is generally consistent with the recommended test interpretation for women with a high or low predicted risk of recurrence. Chemotherapy use in the intermediate-risk group increased with Recurrence Score values, and evidence from ongoing randomized trials may help to clarify whether this finding reflects optimal interpretation of GEP test results. These results demonstrate the principle that genomic testing, on the basis of research establishing its utility, can be applied appropriately in general practice in accordance with guideline recommendations.
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Affiliation(s)
- Arnold L Potosky
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Huei-Ting Tsai
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Calvin Chao
- Genomic Health, Inc, Redwood City, California
| | | | | | | | - Larry G Kessler
- University of Washington School of Public Health, Seattle, Washington
| | - Yingjun Zhou
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Overmoyer B. Treatment With Adjuvant Endocrine Therapy for Early-Stage Breast Cancer: Is It Forever? J Clin Oncol 2015; 33:823-8. [DOI: 10.1200/jco.2014.58.2361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Sun Z, Prat A, Cheang MCU, Gelber RD, Perou CM. Chemotherapy benefit for 'ER-positive' breast cancer and contamination of nonluminal subtypes—waiting for TAILORx and RxPONDER. Ann Oncol 2015; 26:70-74. [PMID: 25355719 PMCID: PMC7360145 DOI: 10.1093/annonc/mdu493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/14/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Retrospective analyses of NSABP B20 and SWOG 8814 showed a large benefit of chemotherapy in patients with ER-positive tumors and high OncotypeDX Recurrence Score (RS≥31). However, it might be possible that both studies may be contaminated by non-luminal tumors, especially in high-risk RS group. METHODS We conducted simulations in order to obtain a better understanding of how the NSABP B20 and SWOG 8814 results would have been if non-luminal breast cancer would have been excluded. Simulations were done separately for the node-negative and node-positive cohorts. RESULTS AND CONCLUSION The results of the simulations suggest that the non-luminal tumors are augmenting the apparent benefit of chemotherapy, but do not appear to be responsible for the entire effect. These simulations could provide information about the potential influence of contamination by unexpected tumor subtypes on the future results of TAILORx and RxPONDER clinical trials.
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Affiliation(s)
- Z Sun
- IBCSG Statistical Center, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, USA
| | - A Prat
- Translational Genomics Group, Vall D'Hebron Institute of Oncology (VHIO), Barcelona; Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - M C U Cheang
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Belmont, UK
| | - R D Gelber
- IBCSG Statistical Center, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, USA.
| | - C M Perou
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, USA.
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Marrone M, Stewart A, Dotson WD. Clinical utility of gene-expression profiling in women with early breast cancer: an overview of systematic reviews. Genet Med 2014; 17:519-32. [PMID: 25474343 DOI: 10.1038/gim.2014.140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 09/02/2014] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This overview systematically evaluates the clinical utility of using Oncotype DX and MammaPrint gene-expression profiling tests to direct treatment decisions in women with breast cancer. The findings are intended to inform an updated recommendation from the Evaluation of Genomic Applications in Practice and Prevention Working Group. METHODS Evidence reported in systematic reviews evaluating the clinical utility of Oncotype DX and MammaPrint, as well as the ability to predict treatment outcomes, change in treatment decisions, and cost-effectiveness, was qualitatively synthesized. RESULTS Five systematic reviews found no direct evidence of clinical utility for either test. Indirect evidence showed Oncotype DX was able to predict treatment effects of adjuvant chemotherapy, whereas no evidence of predictive value was found for MammaPrint. Both tests influenced a change in treatment recommendations in 21 to 74% of participants. The cost-effectiveness of Oncotype DX varied with the alternative compared. For MammaPrint, lack of evidence of the predictive value led to uncertainty in the cost-effectiveness. CONCLUSION No studies were identified that provided direct evidence that using gene-expression profiling tests to direct treatment decisions improved outcomes in women with breast cancer. Three ongoing studies may provide direct evidence for determining the clinical utility of gene-expression profiling testing.
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Affiliation(s)
- Michael Marrone
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alison Stewart
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W David Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Sheppard VB, O'Neill SC, Dilawari A, Horton S, Hirpa FA, Isaacs C. Patterns of 21-gene assay testing and chemotherapy use in black and white breast cancer patients. Clin Breast Cancer 2014; 15:e83-92. [PMID: 25555816 DOI: 10.1016/j.clbc.2014.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/20/2014] [Accepted: 11/25/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND In women with early stage, hormone receptor (HR)-positive (HR(+)) breast cancer, the 21-gene recurrence score (RS) assay quantifies recurrence risk and predicts chemotherapy responsiveness. Recent data suggest that not all women with early-stage, HR(+) disease receive this testing. We examined sociodemographic, clinical, and attitudinal factors associated with RS testing receipt and the RS testing effect on chemotherapy use in black and white patients. PATIENTS AND METHODS Women with newly diagnosed invasive, nonmetastatic breast cancer were recruited and interviewed to collect sociocultural and health care process data; clinical data were collected from charts. Of the sample (n = 359), 270 had HR(+) disease. Primary analysis focused on those with HR(+) node-negative disease (n = 143); secondary analyses included node-positive women. Logistic regression models evaluated factors associated with receipt of RS testing and chemotherapy. RESULTS Among women eligible for the 21-gene assay, 62 patients [43%] received RS testing. In multivariable analysis, older age (odds ratio, 1.04 per 1 year increase; 95% confidence interval, 1.01-1.08) was associated with RS testing after adjustment for covariates. Chemotherapy use was 23%. In multivariable analysis, positive attitudes about chemotherapy and greater risk of recurrence were associated with chemotherapy use (P < .05). CONCLUSION Patterns of genomic testing might vary according to age. Efforts to understand factors associated with low testing rates will be important.
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Affiliation(s)
- Vanessa B Sheppard
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC.
| | - Suzanne C O'Neill
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC
| | - Asma Dilawari
- Medstar Georgetown University Hospital, Washington, DC
| | - Sara Horton
- Department of Oncology, Howard University Hospital, Washington, DC
| | - Fikru A Hirpa
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC
| | - Claudine Isaacs
- Breast Cancer Program, Lombardi Comprehensive Cancer Center and Departments of Oncology and Medicine, Georgetown University School of Medicine, Medstar Georgetown University Hospital, Washington, DC
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Khokher S, Qureshi MU, Mahmood S, Nagi AH. Association of immunohistochemically defined molecular subtypes with clinical response to presurgical chemotherapy in patients with advanced breast cancer. Asian Pac J Cancer Prev 2014; 14:3223-8. [PMID: 23803108 DOI: 10.7314/apjcp.2013.14.5.3223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Gene expression profiling (GEP) has identified several molecular subtypes of breast cancer, with different clinico-pathologic features and exhibiting different responses to chemotherapy. However, GEP is expensive and not available in the developing countries where the majority of patients present at advanced stage. The St Gallen Consensus in 2011 proposed use of a simplified, four immunohistochemical (IHC) biomarker panel (ER, PR, HER2, Ki67/Tumor Grade) for molecular classification. The present study was conducted in 75 newly diagnosed patients of breast cancer with large (>5cm) tumors to evaluate the association of IHC surrogate molecular subtype with the clinical response to presurgical chemotherapy, evaluated by the WHO criteria, 3 weeks after the third cycle of 5 flourouracil, adriamycin, cyclophosphamide (FAC regimen). The subtypes of luminal, basal-like and HER2 enriched were found to account for 36.0 % (27/75), 34.7 % (26/75) and 29.3% (22/75) of patients respectively. Ten were luminal A and 14 luminal B (8 HER2 negative and 6HER2 positive). The triple negative breast cancer (TNBC) was most sensitive to chemotherapy with 19% achieving clinical-complete-response (cCR) followed by HER2 enriched (2/22 (9%) cCR), luminal B (1/6 (7%) cCR) and luminal A (0/10 (0%) cCR). Heterogeneity was observed within each subgroup, being most marked in the TNBC although the most responding tumors, 8% developing clinical-progressive-disease. The study supports association of molecular subtypes with response to chemotherapy in patients with advanced breast cancer and the existence of further heterogeneity within subtypes.
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Predictive and prognostic value of the 21-gene recurrence score in hormone receptor-positive, node-positive breast cancer. Am J Clin Oncol 2014; 37:404-10. [PMID: 24853663 PMCID: PMC4162320 DOI: 10.1097/coc.0000000000000086] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The addition of adjuvant chemotherapy to hormonal therapy is recommended for patients with estrogen receptor-positive (ER+), node-positive (N+) early breast cancer (EBC). Some of these patients, however, are not likely to benefit from treatment and may, therefore, be overtreated while also incurring unnecessary treatment-related adverse events and health care costs. The 21-gene Recurrence Score assay has been clinically validated and recommended for use in patients with ER+, node-negative (N0) EBC to assess the 10-year risk of distant disease recurrence and predict the likelihood of response to adjuvant chemotherapy. A growing body of evidence from several large phase III clinical trials reports similar findings in patients with ER+, N+ EBC. A systematic review of published literature from key clinical trials that have used the 21-gene breast cancer assay in patients with ER+, N+ EBC was performed. The Recurrence Score has been shown to be an independent predictor of disease-free survival, overall survival, and distant recurrence-free interval in patients with ER+, N+ EBC. Outcomes from decision impact and health economics studies further indicate that the Recurrence Score affects physician treatment recommendations equally in patients with N+ or N0 disease. It also indicates that a reduction in Recurrence Score-directed chemotherapy is cost-effective. There is a large body of evidence to support the use of the 21-gene assay Recurrence Score in patients with N+ EBC. Use of this assay could help guide treatment decisions for patients who are most likely to receive benefit from chemotherapy.
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Reimers MS, Kuppen PJK, Lee M, Lopatin M, Tezcan H, Putter H, Clark-Langone K, Liefers GJ, Shak S, van de Velde CJH. Validation of the 12-gene colon cancer recurrence score as a predictor of recurrence risk in stage II and III rectal cancer patients. J Natl Cancer Inst 2014; 106:dju269. [PMID: 25261968 DOI: 10.1093/jnci/dju269] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The 12-gene Recurrence Score assay is a validated predictor of recurrence risk in stage II and III colon cancer patients. We conducted a prospectively designed study to validate this assay for prediction of recurrence risk in stage II and III rectal cancer patients from the Dutch Total Mesorectal Excision (TME) trial. METHODS RNA was extracted from fixed paraffin-embedded primary rectal tumor tissue from stage II and III patients randomized to TME surgery alone, without (neo)adjuvant treatment. Recurrence Score was assessed by quantitative real time-polymerase chain reaction using previously validated colon cancer genes and algorithm. Data were analysed by Cox proportional hazards regression, adjusting for stage and resection margin status. All statistical tests were two-sided. RESULTS Recurrence Score predicted risk of recurrence (hazard ratio [HR] = 1.57, 95% confidence interval [CI] = 1.11 to 2.21, P = .01), risk of distant recurrence (HR = 1.50, 95% CI = 1.04 to 2.17, P = .03), and rectal cancer-specific survival (HR = 1.64, 95% CI = 1.15 to 2.34, P = .007). The effect of Recurrence Score was most prominent in stage II patients and attenuated with more advanced stage (P(interaction) ≤ .007 for each endpoint). In stage II, five-year cumulative incidence of recurrence ranged from 11.1% in the predefined low Recurrence Score group (48.5% of patients) to 43.3% in the high Recurrence Score group (23.1% of patients). CONCLUSION The 12-gene Recurrence Score is a predictor of recurrence risk and cancer-specific survival in rectal cancer patients treated with surgery alone, suggesting a similar underlying biology in colon and rectal cancers.
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Affiliation(s)
- Marlies S Reimers
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Peter J K Kuppen
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Mark Lee
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Margarita Lopatin
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Haluk Tezcan
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Hein Putter
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Kim Clark-Langone
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Gerrit Jan Liefers
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Steve Shak
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS)
| | - Cornelis J H van de Velde
- Department of Surgery (MSR, PJKK, GJL, CJHvdV) and Department of Medical Statistics (HP), Leiden University Medical Center, Leiden, the Netherlands; Genomic Health Inc., Redwood City, CA (MLe, MLo, HT, KCL, SS).
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Steuten LMG, Ramsey SD. Improving early cycle economic evaluation of diagnostic technologies. Expert Rev Pharmacoecon Outcomes Res 2014; 14:491-8. [PMID: 24766321 DOI: 10.1586/14737167.2014.914435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The rapidly increasing range and expense of new diagnostics, compels consideration of a different, more proactive approach to health economic evaluation of diagnostic technologies. Early cycle economic evaluation is a decision analytic approach to evaluate technologies in development so as to increase the return on investment as well as patient and societal impact. This paper describes examples of 'early cycle economic evaluations' as applied to diagnostic technologies and highlights challenges in its real-time application. It shows that especially in the field of diagnostics, with rapid technological developments and a changing regulatory climate, early cycle economic evaluation can have a guiding role to improve the efficiency of the diagnostics innovation process. In the next five years the attention will move beyond the methodological and analytic challenges of early cycle economic evaluation towards the challenge of effectively applying it to improve diagnostic research and development and patient value. Future work in this area should therefore be 'strong on principles and soft on metrics', that is, the metrics that resonate most clearly with the various decision makers in this field.
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Affiliation(s)
- Lotte M G Steuten
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Abstract
The use of biomarkers to identify patients who can benefit from treatment with a specific anticancer agent has the potential to both improve patient care and accelerate drug development. The development of targeted agents and their accompanying biomarkers frequently occurs contemporaneously, and confidence in a putative biomarker's performance might, therefore, be insufficient to restrict the definitive testing of a new agent to the subgroup of biomarker-positive patients. This Review considers which clinical trial designs and analysis strategies are appropriate for use in phase III, biomarker-driven, randomized clinical trials, on the basis of pre-existing evidence that the biomarker can successfully identify patients who will respond to the treatment in question. The types of interim monitoring that are appropriate for these trials are also discussed. In addition, enrichment strategies based on the use of prognostic biomarkers to separate a population into subgroups with better and worse outcomes, regardless of treatment, are described. Finally, the possibility of formally using a biomarker during phase II drug development, to select what type of biomarker-driven strategy should be used in the phase III trial, is discussed.
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Le Du F, Ueno NT, Gonzalez-Angulo AM. Breast Cancer Biomarkers: Utility in Clinical Practice. CURRENT BREAST CANCER REPORTS 2013; 5. [PMID: 24416469 DOI: 10.1007/s12609-013-0125-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Breast cancer is a heterogeneous disease. For the past decades, new technical tools have been developed for biomarkers at the DNA, RNA and protein levels to better understand the biology of breast cancer. This progress is essential to classify the disease into clinically relevant subtypes, which may lead to new therapeutic opportunities. Novel biomarker development is paramount to deliver personalized cancer therapies. Further, tumor evolution, being natural or under treatment pressure, should be monitored and "liquid biopsies" by detecting circulating tumor cells or circulating free tumor DNA in blood samples will become an important option. This paper reviews the new generation of biomarkers and the current evidence to demonstrate their analytical validity, clinical validity and clinical utility.
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Affiliation(s)
- Fanny Le Du
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA ; Department of Medical Oncology, Eugène Marquis Cancer Center, Rennes, France
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ana M Gonzalez-Angulo
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA ; Department of Systems Biology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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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] [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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Ramsey SD, Sullivan SD, Reed SD, Tina Shih YC, Schaecher K, Dhanda R, Patt D, Pendergrass K, Walker M, Malin J, Schwartzberg L, Neumann K, Yu E, Ravelo A, Small A. Oncology comparative effectiveness research: a multistakeholder perspective on principles for conduct and reporting. Oncologist 2013; 18:760-7. [PMID: 23650020 DOI: 10.1634/theoncologist.2012-0386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Comparative effectiveness research (CER) can assist patients, clinicians, purchasers, and policy makers in making more informed decisions that will improve cancer care and outcomes. Despite its promise, the factors that distinguish CER from other types of evidence remain mysterious to many oncologists. One concern is whether CER studies will improve decision making in oncology or only add to the massive amount of research information that decision makers must sift through as part of their professional responsibilities. In this report, we highlight several issues that distinguish CER from the most common way evidence is generated for cancer therapy-phase I-III clinical trials. To identify the issues that are most relevant to busy decision makers, we assembled a panel of active professionals with a wide range of roles in cancer care delivery. This panel identified five themes that they considered most important for CER in oncology, as well as fundamental threats to the validity of individual CER studies-threats they termed the "kiss of death" for their applicability to practice. In discussing these concepts, we also touched upon the notion of whether cancer is special among health issues with regard to how evidence is generated and used.
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Affiliation(s)
- Scott D Ramsey
- Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA.
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Medford RM, Dagi TF, Rosenson RS, Offermann MK. Biomarkers and Sustainable Innovation in Cardiovascular Drug Development: Lessons from Near and Far Afield. Curr Atheroscler Rep 2013; 15:321. [DOI: 10.1007/s11883-013-0321-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Despite many recent advances, breast cancer remains a clinical challenge. Current issues include improving prognostic evaluation and increasing therapeutic options for women whose tumors are refractory to current frontline therapies. Iron metabolism is frequently disrupted in breast cancer, and may offer an opportunity to address these challenges. Iron enhances breast tumor initiation, growth and metastases. Iron may contribute to breast tumor initiation by promoting redox cycling of estrogen metabolites. Up-regulation of iron import and down-regulation of iron export may enable breast cancer cells to acquire and retain excess iron. Alterations in iron metabolism in macrophages and other cells of the tumor microenvironment may also foster breast tumor growth. Expression of iron metabolic genes in breast tumors is predictive of breast cancer prognosis. Iron chelators and other strategies designed to limit iron may have therapeutic value in breast cancer. The dependence of breast cancer on iron presents rich opportunities for improved prognostic evaluation and therapeutic intervention.
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Affiliation(s)
- Suzy V. Torti
- Department of Molecular, Microbial and Structural Biology, University of Connecticut Health Center, Farmington Connecticut, 06030
| | - Frank M. Torti
- Department of Internal Medicine, University of Connecticut Health Center, Farmington Connecticut, 06030
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