Cost-Effectiveness Analyses of the 21-Gene Assay in Breast Cancer: Systematic Review and Critical Appraisal

Proposal for Value-Based, Tiered Reimbursement for Tumor Biomarker Tests to Promote Innovation and Evidence Generation

Cancer precision medicine depends on high-quality tumor biomarker tests (TBTs) for treatment selection. TBT reimbursement within the United States in the current regulatory environment is not tied to premarket evidence of clinical utility, resulting in a vicious cycle wherein low-level evidence of utility leads to poor reimbursement, thereby impeding investment in developing new, clinically valuable TBTs supported by high-level evidence. Rational, value-based TBT pricing presents many practical challenges. Precise one-to-one mapping of reimbursement to cost savings or cost effectiveness is precluded by an absence of formal cost-effectiveness analyses for many emerging TBTs, and for more established TBTs, it has become clear that such analyses may yield wildly variable, subjective estimates. To address these challenges, we propose a system of tiered reimbursement that rewards development of high-quality TBTs within specific use contexts, supported by strong evidence of analytic validity and clinical utility. We propose three use contexts of TBTs, each defined by its influence on treatment decisions relative to the current standard of care-Opt-Out, Opt-In, and the use of appropriate, alternative, effective therapies (Opt-Alt). By ensuring minimum levels of reimbursement, this system provides a return on investment to encourage and support the research and development needed to generate high levels of evidence for claims of clinical utility for TBTs by using a robust, objective, and value-based system. We believe our proposed evaluation system will serve as a practical starting point to raise the bar for TBT quality and utility, which has the potential to redirect health care dollars from futile or ineffective treatment to investment in the development of high-quality TBTs needed for safe and effective precision cancer care.

Integration of Ki-67 index into AJCC 2018 staging provides additional prognostic information in breast tumours candidate for genomic profiling

Background

The Eighth edition of the American Joint Committee on Cancer (AJCC) staging system (2018) for breast cancer (BC) introduced the prognostic stage. Moreover, multigene assessment has been indicated to tailor staging in T1/T2/N0, ER-positive/HER2-negative BC. However, many National Health Systems do not provide reimbursement for routine testing. The aim of this study was to assess whether Ki67 proliferation index is prognostically relevant for patients’ candidacy for molecular testing.

Methods

A retrospective series of 686 ER+/HER2− BC were reclassified using AJCC 2018, and in the group of 521 patients for which AJCC 2018 recommends molecular evaluation, we assessed the prognostic efficacy of a prognostic stage enriched by Ki67 (Ki67-PS), considering Ki67 <20% an alternative to recurrence score <11 provided by Oncotype DX.

Results

We found that a group of BCs (35.6%, 58/163) assigned to IB stage by prognostic score were down classified to IA with Ki67-PS. The outcome of these 58 cases overlapped with that of lesions classified as stage IA using prognostic stage, showing a significantly better prognosis compared to IB tumours (HR = 2.79, p = 0.003).

Conclusions

These data suggest that Ki67 may be a reliable marker to enrich the 2018 AJCC prognostic score in BC patients’ candidacy for genomic profiling.

Cost-utility analysis of 21-gene assay for node-positive early breast cancer

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.

A Value of Information Analysis of Research on the 21-Gene Assay for Breast Cancer Management

OBJECTIVES

The 21-gene assay Oncotype DX (21-GA) shows promise as a guide in deciding when to initiate adjuvant chemotherapy in women with hormone receptor-positive early-stage breast cancer. Nevertheless, its routine use remains controversial, owing to insufficient evidence of its clinical utility and cost-effectiveness. Accordingly, we aim to quantify the value of conducting further research to reduce decision uncertainty in the use of the 21-GA.

METHODS

Using value of information methods, we first generated probability distributions of survival and costs for decision making with and without the 21-GA alongside traditional risk prediction. These served as the input to a comparison of 3 alternative study designs: a retrospective observational study to update risk classification from the 21-GA, a prospective observational study to estimate prevalence of chemotherapy use, and a randomized controlled trial (RCT) of the 21-GA predictive value.

RESULTS

We found that current evidence strongly supports the use of the 21-GA in intermediate- and high-risk women. Further research should focus on low-risk women, among whom the cost-effectiveness findings remained equivocal. For this population, we identified a high value of reducing uncertainty in the 21-GA use for all proposed research studies. The RCT had the greatest potential to efficiently reduce the likelihood of choosing a suboptimal strategy, providing a value between $162 million and $1.1 billion at willingness-to-pay thresholds of $150 000 to $200 000/quality-adjusted life years.

CONCLUSION

Future research to inform 21-GA decision making is of high value. The RCT of the 21-GA predictive value has the greatest potential to efficiently reduce decision uncertainty around 21-GA use in women with low-risk early-stage breast cancer.

Cost effectiveness of Gene Expression Profiling in Patients with Early-Stage Breast Cancer in a Middle-Income Country, Turkey: Results of a Prospective Multicenter Study

Objective

Breast cancer is a heterogenous disease, and genetic profiling helps to individualize adjuvant treatment. The Oncotype DX is a validated test to predict benefit of adjuvant systemic treatment. The aims of this study are to determine the costs of chemotherapy in government hospitals in Turkey and evaluate the cost-effectiveness of the Oncotype DX from the national insurance perspective.

Materials and Methods

A Markov model was developed to make long term projections of distant recurrence, survival, quality adjusted life expectancy, and direct costs for patients with ER+, HER2-, node-negative or up to 3 node-positive early stage breast cancer. Turkish decision impact study patient data were captured for model reference. In that study, ten academic centers across Turkey participated in a prospective trial. Of 165 patients with pT1-3, pN0-N1mic, ER-positive, and HER-2 negative tumors, 57% had low recurrence score (RS), 35% had intermediate RS, and 8% had high RS, respectively. The overall rate of change in chemotherapy treatment decisions following Oncotype DX was 33%.

Results

The cost of adjuvant chemotherapy in public hospitals was estimated at $3.649, and Oncotype Dx test was $5.141. Based on the cost-effectiveness analysis, Oncotype DX testing was estimated to improve life expectancy (+0.86 years) and quality-adjusted life expectancy (+0.68 QALYs) versus standard care. The incremental cost-effectiveness ratio (ICERs) of Oncotype DX was estimated to be $7207.9 per QALY gained and $5720.6 per LY gained versus current clinical practice.

Conclusion

As Oncotype DX was found both cost-effective and life-saving from a national perspective, the test should be introduced to standard care in patients with ER+, HER-2 negative early-stage breast cancer in Turkey.

Progesterone receptor status and tumor grade predict the 21-gene recurrence score of invasive lobular breast cancer

Aim: To assess the association between established clinicopathological variables and the 21-gene recurrence score (RS) stratification of invasive lobular carcinoma (ILC) of the breast. Materials & methods: We identified 9030 ILC patients from the Surveillance, Epidemiology and End Results database. Results: Older age, higher grade tumor and progesterone receptor (PR)-negative disease were independent predictors of high-risk RS stratification. Among patients with PR-positive tumors, 3, 6 and 15% with well-differentiated (G1), moderately-differentiated (G2) and poorly and/or undifferentiated (G3) disease were in the high-risk cohort, respectively. In patients with PR-negative tumors: 16, 24 and 41% of patients with G1, G2 and G3 disease were in the high-risk cohort, respectively. Conclusion: The 21-gene RS testing may not be necessary for patients with PR+/G1-2 ILC.

Risk stratification of ER-positive breast cancer patients: A multi-institutional validation and outcome study of the Rochester Modified Magee algorithm (RoMMa) and prediction of an Oncotype DX® recurrence score <26

The skyrocketing cost of health-care demands that we question when to use multigene assay testing in the planning of treatment for breast cancer patients. A previously published algorithmic model gave recommendations for which cases to send out for Oncotype DX^® (ODX) testing. This study is a multi-institutional validation of that algorithmic model in 620 additional estrogen receptor positive breast cancer cases, with outcome data on 310 cases, named in this study as the Rochester Modified Magee algorithm (RoMMa). RoMMa correctly predicted 85% (140/164) and 100% (17/17) of cases to have a low- or high-risk ODX recurrence score, respectively, consistent with the original publication. Applying our own risk stratification criteria, in patients who received appropriate hormonal therapy, only one of the 45 (2.0%) patients classified as low risk by our original algorithm have been associated with a breast cancer recurrence over 5-10 years of follow-up. Eight of 116 (7.0%) patients classified as low risk by ODX have been associated with a breast cancer recurrence with up to 11 years of follow-up. In addition, 524 of 537 (98%) cases from our total population (n = 903) with an average modified Magee score ≤18 had an ODX recurrence score <26. Patients with an average modified Magee score ≤18 or >30 may not need to be sent out for ODX testing. By avoiding these cases sending out for ODX testing, the potential cost savings to the health-care system in 2018 are estimated to have been over $100,000,000.

Multi-gene assays: effect on chemotherapy use, toxicity and cost in estrogen receptor-positive early stage breast cancer

Aim: To assess multi-gene assay (MGA) effects on chemotherapy use, toxicities, recurrences, and costs in estrogen receptor-positive early breast cancer. Methods: Meta-analysis performed using data from public databases. Results: Studies included 12,202 women. Relative to no testing, chemotherapy use was higher with 12-gene and 70-gene and lower with PAM50 (commercial) and 21-gene MGAs. Overall, 1643 distant recurrences occurred with no testing, declining by 231 (21-gene), 121 (70-gene), 54 (12-gene) and 94 (PAM50); only the 21-gene assay resulted in no risk of increasing the number of distant recurrences. Relative to ‘no testing’, total cost of care declined only with 21-gene MGA. Conclusion: MGAs differ in chemotherapy use and related outcomes for women with estrogen receptor-positive early breast cancer.

Identification of an eight-gene signature for survival prediction for patients with hepatocellular carcinoma based on integrated bioinformatics analysis

Background

Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related death worldwide. Despite recent advances in imaging techniques and therapeutic intervention for HCC, the low overall 5-year survival rate of HCC patients remains unsatisfactory. This study aims to find a gene signature to predict clinical outcomes in HCC.

Methods

Bioinformatics analysis including Cox’s regression analysis, Kaplan-Meier (KM) and receiver operating characteristic curve (ROC) analysis and the random survival forest algorithm were performed to mine the expression profiles of 553 hepatocellular carcinoma (HCC) patients from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) public database.

Results

We selected a signature comprising eight protein-coding genes (DCAF13, FAM163A, GPR18, LRP10, PVRIG, S100A9, SGCB, and TNNI3K) in the training dataset (AUC = 0.77 at five years, n = 332). The signature stratified patients into high- and low-risk groups with significantly different survival in the training dataset (median 2.20 vs. 8.93 years, log-rank test P < 0.001) and in the test dataset (median 2.68 vs. 4.24 years, log-rank test P = 0.004, n = 221, GSE14520). Further multivariate Cox regression analysis showed that the signature was an independent prognostic factor for patients with HCC. Compared with TNM stage and another reported three-gene model, the signature displayed improved survival prediction power in entire dataset (AUC signature = 0.66 vs. AUC TNM = 0.64 vs. AUC gene model = 0.60, n = 553). Stratification analysis shows that it can be used as an auxiliary marker for many traditional staging models.

Conclusions

We constructed an eight-gene signature that can be a novel prognostic marker to predict the survival of HCC patients.

Second Primary Lung Cancer After Breast Cancer: A Population-Based Study of 6,269 Women

Purpose: Breast cancer (BC) and lung cancer are the most two common cancers with highest morbidity and mortality for women. With prolonged survival, there comes the possibility that BC patients will develop second primary cancers. We evaluate the characteristics, incidence and survival of second primary non-small cell lung cancer (BC-NSCLC) and small cell lung cancer (BC-SCLC) after breast cancer. Patients and methods: Second primary lung cancer risks using standardized incidence ratios (SIRs) [95% confidence intervals (95% CIs)] were calculated among breast cancer patients in SEER-18 (2000-2014). Survival outcomes were also analyzed for both BC-NSCLC and BC-SCLC. Results: A total of 6,269 second lung cancer patients after a localized or regional BC were identified. The incidence rate was modestly higher compared to the general population (SIR = 1.03; 95%CI: 1.00-1.06). For ER-, PR- and HER2- groups, SIRs were 1.26, 1.16, 1.13, respectively (all p < 0.05). Triple negative breast cancer (TNBC) patients have an even higher incidence rate of lung cancer (SIR = 1.59, 95%CI: 1.29-1.94). Elevated SIRs were also observed among the following groups: within 1 year after BC diagnosed, a young age at BC diagnosed, black people, poorly or undifferentiated histological grade of breast cancer. Median survival (MST) after localized, regional and distant BC-NSCLC was 68.0, 26.0, and 6.0m. Five-year survival rates for BC-NSCLC were 53.9, 29.8 and 5.7% in each stage, which were significantly higher compared to first primary NSCLC (all p < 0.001). ER-/PR- or TNBC were unfavorable prognostic factors for BC-NSCLC. The survival rates of BC-SCLC were no significant different compared to first primary SCLC. Conclusion: BC patients, especially for TNBC, are at a high risk of developing second primary lung cancers. BC history may be a favorable prognostic factor for NSCLC (but not SCLC) patients. Clinicians should closely follow up BC patients with high-risk factors.