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Ning L, Liu Y, He X, Han R, Xin Y, Zhao J, Liu X. Validation of CTS5 Model in Large-scale Breast Cancer Population and Combination of CTS5 and Ki-67 Status to Develop a Novel Nomogram for Prognosis Prediction. Am J Clin Oncol 2024; 47:228-238. [PMID: 38131531 DOI: 10.1097/coc.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND More than half of patients with early-stage estrogen receptor-positive (ER+) breast cancer relapse after completing 5 years of adjuvant endocrine therapy, so it is important to determine which patients are candidates for extended endocrine therapy. The clinical treatment score after 5 years (CTS5) is a prognostic tool developed based on postmenopausal ER+ breast cancer to assess the risk of late distant recurrence (LDR) after 5 years of adjuvant endocrine therapy for breast cancer. We aimed to externally validate the prognostic value of CTS5 in premenopausal and postmenopausal patients and combined with Ki-67 to develop a new model to improve the ability of prognosis prediction. METHODS We included a total of 516 patients with early-stage ER+ breast cancer who had received 5 years of adjuvant endocrine therapy and were recurrence-free for 5 years after surgery. According to menopausal status, we divided the study population into 2 groups: premenopausal and postmenopausal women. The CTS5 of each patient was calculated using a previously published formula, and the patients were divided into low, intermediate, and high CTS5 risk groups according to their CTS5 values. Based on the results of the univariate analysis ( P <0.01), a multivariate COX proportional hazards regression analysis was conducted to establish a nomogram with significant variables ( P <0.05). The discriminative power and accuracy of the nomograms were assessed using the concordance index (C-index), calibration curve, and area under the time-dependent receiver operating characteristic curve. Discrimination and calibration were evaluated by bootstrapping 1000 times. Finally, we utilized decision curve analysis to assess the performance of our novel predictive model in comparison to the CTS5 scoring system with regard to their respective benefits and advantages. RESULTS The median follow-up time was 7 years (6 to 9 years). The 516 women were categorized by CTS5 as follows: 246(47.7%) low risk, 179(34.7%) intermediate risk, and 91(17.6%) high risk. Using the CTS5 score as a continuous variable, patients' risk score was significantly positively associated with recurrence risk in both premenopausal and postmenopausal subgroups. For HER2- premenopausal patients and HER2+ postmenopausal patients, the CTS5 score was positively correlated with LDR risk. Patients with a Ki-67≥20% had a higher risk of LDR regardless of menopausal status. Using the CTS5 score as a categorical variable, the high-risk group of HER2- premenopausal patients had a higher risk of LDR. However, the CTS5 model could not distinguish the risk of LDR in different risk groups for HER2+ postmenopausal patients. In the high-risk group, patients with Ki-67≥20% had a higher risk of LDR, regardless of menopausal status. We developed a new nomogram model by combining the CTS5 model with Ki-67 levels. The C-indexes premenopausal and postmenopausal cohorts were 0.731 and 0.713, respectively. The nomogram model was well calibrated, and the time-dependent ROC curves indicated good specificity and sensitivity. Furthermore, decision curve analysis demonstrated that the new model had a wider and practical range of threshold probabilities, resulting in an increased net benefit compared with the CTS5 model. CONCLUSIONS Our study demonstrated that the CTS5 model can effectively predict the risk of LDR in early-stage ER+ breast cancer patients in both premenopausal and postmenopausal patients. Extended endocrine therapy is recommended for patients with Ki-67≥20% in the CTS5 high-risk group, as well as premenopausal patients with HER2-. Compared with CTS5, the new nomogram model has better identification and calibration capabilities, and further research is required to validate its efficacy in large-scale, multicenter, and prospective studies.
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Affiliation(s)
- Lizhi Ning
- Department of Medical Oncology, Xianyang Central Hospital, Shanxi
| | - Yaobang Liu
- Department of Surgical Oncology, General Hospital of Ningxia Medical University
| | - Xuefang He
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
| | - Rui Han
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
| | - Yuanfang Xin
- Breast Disease Diagnosis and Treatment Center of Affiliated Hospital of Qinghai University & Affiliated Cancer Hospital of Qinghai University, Xining, China
| | - Jiuda Zhao
- Breast Disease Diagnosis and Treatment Center of Affiliated Hospital of Qinghai University & Affiliated Cancer Hospital of Qinghai University, Xining, China
| | - Xinlan Liu
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan
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Dejthevaporn T, Patanayindee P. Clinical Treatment Score Post-5 Years as a Tool for Risk Estimation of Late Recurrence in Thai Patients With Estrogen-Receptor-Positive, Early Breast Cancer: A Validation Study. Breast Cancer (Auckl) 2023; 17:11782234231186869. [PMID: 37533837 PMCID: PMC10392218 DOI: 10.1177/11782234231186869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 06/22/2023] [Indexed: 08/04/2023] Open
Abstract
Background The risk of late distant recurrence (LDR) of estrogen receptor (ER)-positive breast cancer continues even after 5 years of endocrine treatment. Clinical Treatment Score after 5 years (CTS5) was developed and validated as a tool to assess the risk of LDR using data from Tamoxifen, Arimidex Alone or in Combinations (ATAC) and Breast International Group 1-98 (BIG1-98) trials. This study aimed to externally validate CTS5 in a real-world cohort of patients treated at an academic center in Thailand. Methods The study was a retrospective analytical research study of early-stage, ER-positive breast cancer patients. The primary endpoint was LDR. The risk of LDR was determined using the CTS5 calculator. Cox regression model and Kaplan-Meier survival analysis were applied for prognostic validation of CTS5. Calibration was performed by comparing observed LDR to expected LDR using the Hosmer-Lemeshow (H-L) test. Results A total of 323 women were included with a median follow-up period of 11.6 years. The rate of LDR was 10.8%. The CTS5 was prognostic for LDR. C-index of the area under the ROC curve was 0.672. There was no significant difference between actual and expected numbers of LDR with an observed (O) LDR events to expected (E) number of LDR events ratio of 0.99 (0.86-1.12) (H-L P = .79) indicating a proper calibration in this cohort. Conclusions Our study validated that CTS5 is accurate in predicting the risk of LDR in ER-positive breast cancer cases in Thai patients. Its performance seemed to be better in postmenopausal patients. CTS5 could be applied in routine clinical practice to improve decisions regarding prolonged endocrine therapy, particularly in resource-limited countries where molecular profiling are inaccessible.
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Affiliation(s)
- Thitiya Dejthevaporn
- Division of Medical Oncology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panchanin Patanayindee
- Division of Medical Oncology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Medical Oncology Unit, Department of Medicine, Faculty of Medicine, Thammasat University, Bangkok, Thailand
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Shah S, Shaing C, Khatib J, Lodrigues W, Dreadin-Pulliam J, Anderson BB, Unni N, Farr D, Li HC, Sadeghi N, Syed S. The Utility of Breast Cancer Index (BCI) Over Clinical Prognostic Tools for Predicting the Need for Extended Endocrine Therapy: A Safety Net Hospital Experience. Clin Breast Cancer 2022; 22:823-827. [PMID: 36089460 DOI: 10.1016/j.clbc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Extended endocrine therapy (EET) benefits select patients with early-stage hormone-receptor positive (HR+) breast cancer (BC) but also incurs side effects and cost. The Clinical Treatment Score at Five Years (CTS5) is a free tool that estimates risks of late relapse in estrogen-receptor positive (ER+) BC using clinicopathologic factors. The Breast Cancer Index (BCI) incorporates 2 genomic assays to estimate late relapse risk and likelihood of benefit from EET. This retrospective study assesses the utility of BCI in selecting EET candidates in a safety net hospital. MATERIALS AND METHODS We performed a retrospective chart review on 69 women with early-stage HR+, HER2- BC diagnosed at our institution from December 2009 to February 2016 on whom BCI was submitted. The CTS5 score was also calculated to assess clinical risk of late relapse. RESULTS Median age was 53 years. All patients included in our analysis had early ER+ HER2-negative BC. Roughly half of the patients (55%) were postmenopausal and 61% were of Hispanic origin. A total of 34 patients (49%) were deemed high-risk (>5%) for late relapse by CTS5, compared to 42 (61%) by BCI. BCI identified 31 (45%) patients that would benefit from EET and of those, 74%% were advised EET. 16 (47%) clinical high-risk patients were advised against EET due to low benefit predicted by BCI. In the clinical low risk group, 9 (26%) were recommended EET based on high benefit predicted by BCI. CONCLUSION BCI is reasonable to consider in early-stage HR+ BC and offered clinically relevant information over clinical pathologic information alone.
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Affiliation(s)
| | - Christine Shaing
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX
| | - Jude Khatib
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX
| | | | | | | | - Nisha Unni
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX
| | - Deborah Farr
- UT Southwestern Medical Center, Department of Surgery, Dallas, TX
| | - Hsiao-Ching Li
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX
| | - Navid Sadeghi
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX
| | - Samira Syed
- UT Southwestern Medical Center, Division of Hematology Oncology, Dallas, TX.
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Saponaro M, Annunziata L, Turla A, Viganò I, De Laurentiis M, Giuliano M, Del Mastro L, Montemurro F, Puglisi F, De Angelis C, Buono G, Schettini F, Arpino G. Extended Adjuvant Endocrine Treatment in Luminal Breast Cancers in the Era of Genomic Tests. Int J Mol Sci 2022; 23:13604. [PMID: 36362392 PMCID: PMC9656848 DOI: 10.3390/ijms232113604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 10/21/2023] Open
Abstract
In patients with early-stage endocrine receptor-positive (ER+) breast cancer (BC), adjuvant endocrine therapy (ET) for 5 years is the standard of care. However, for some patients, the risk of recurrence remain high for up to 15 years after diagnosis and extended ET beyond 5 years may be a reasonable option. Nevertheless, this strategy significantly increases the occurrence of side effects. Here we summarize the available evidence from randomized clinical trials on the efficacy and safety profile of extended ET and discuss available clinical and genomic tools helpful to select eligible patients in daily clinical practice.
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Affiliation(s)
- Mariarosaria Saponaro
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80100 Naples, Italy
| | - Luigi Annunziata
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80100 Naples, Italy
| | - Antonella Turla
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Medical Oncology, ASST Spedali Civili, 25100 Brescia, Italy
| | - Ilaria Viganò
- Medical Oncology, Ospedale Valduce, 22100 Como, Italy
| | - Michele De Laurentiis
- Department of Breast and Thoracic Oncology, National Cancer Institute, Fondazione G. Pascale, 80100 Naples, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80100 Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, 80100 Naples, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, IRCCS Ospedale Policlinico San Martino, 16100 Genova, Italy
| | | | - Fabio Puglisi
- CRO Aviano, National Cancer Institute, IRCCS, 33081 Aviano, Italy
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Carmine De Angelis
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80100 Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, 80100 Naples, Italy
| | - Giuseppe Buono
- Department of Breast and Thoracic Oncology, National Cancer Institute, Fondazione G. Pascale, 80100 Naples, Italy
| | - Francesco Schettini
- Medical Oncology Department, IDIBAPS, Hospital Clinic of Barcelona, 08000 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08000 Barcelona, Spain
| | - Grazia Arpino
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80100 Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, 80100 Naples, Italy
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OUP accepted manuscript. Br J Surg 2022; 109:411-417. [DOI: 10.1093/bjs/znac008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/17/2021] [Accepted: 01/01/2022] [Indexed: 11/14/2022]
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Park YH, Karantza V, Calhoun SR, Park S, Lee S, Kim JY, Yu JH, Kim SW, Lee JE, Nam SJ, Aktan G, Marsico M. Prevalence, treatment patterns, and prognosis of low estrogen receptor-positive (1% to 10%) breast cancer: a single institution's experience in Korea. Breast Cancer Res Treat 2021; 189:653-663. [PMID: 34487293 DOI: 10.1007/s10549-021-06309-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE To determine prevalence, clinicopathological characteristics, initial treatments, and outcomes associated with low estrogen receptor (ER)-expressing invasive breast cancer. METHODS This retrospective, non-interventional database study included patients undergoing surgery with curative intent for invasive ductal or lobular breast cancer. Patients were treated between January 2003-December 2012. Demographics, clinicopathological characteristics, initial treatments, and outcomes were abstracted from patient records. Patients were categorized using immunohistochemistry to determine ER, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) levels. ER-positive patients were subclassified as ER-low (1% to 10%) and ER-high (> 10%) according to the Allred Proportion Score. Disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared among groups by log-rank test. RESULTS 5930 patients were included (median follow-up, 80.9 months). Of all patients included, 117 (2.0%) had ER-low tumors: 63 (53.8%) of whom had HER2- tumors and 54 (46.2%) HER2+ tumors. Five-year DFS and OS were highest in the ER-high/HER2- cohort (94.0% and 98.6%, respectively) and lowest in the triple-negative breast cancer (TNBC; 81.3% and 90.1%) and ER-low/HER2- (85.7% and 92.1%) cohorts. Menopausal status, elevated Ki-67, higher nuclear grade, higher tumor stage, presence of lymphovascular invasion, greater regional lymph node involvement, and larger tumor size were all potential prognostic factors for shorter DFS and OS. CONCLUSION Patients with ER-low/HER2- breast cancer had similar clinicopathological characteristics, treatments, and outcomes as patients with TNBC irrespective of disease setting. Further research is needed to understand predictive and prognostic factors associated with ER-low/HER2- disease.
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Affiliation(s)
- Yeon Hee Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-Gu, Seoul, 06351, South Korea.
| | | | | | - Seri Park
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sohee Lee
- Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
| | - Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-Gu, Seoul, 06351, South Korea
| | - Jong Han Yu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Won Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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