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Freeman JQ, Huo D. Addressing Social Determinants in the Era of Precision Medicine in Breast Cancer: Is It Sufficient to Reduce Disparities? Cancer Epidemiol Biomarkers Prev 2024; 33:635-637. [PMID: 38689576 DOI: 10.1158/1055-9965.epi-24-0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 05/02/2024] Open
Abstract
The Oncotype DX (ODX) assay predicts recurrence risk and demonstrates the benefits of adjuvant therapy in patients with early-stage, hormone receptor (HR)-positive/HER2-negative breast cancer. ODX uptake varies by patients' racial/ethnic backgrounds and socioeconomic status (SES). However, community-level variability remains unknown, and research regarding the association between testing status and receipt of adjuvant chemotherapy is limited. To fill these knowledge gaps, Van Alsten and colleagues found a 6% lower prevalence of ODX uptake among patients residing in high SES-deprived areas than among those residing in low SES-deprived areas. Among patients with low and median ODX recurrence scores, those who underwent testing were 28% and 21% less likely to receive adjuvant chemotherapy than those who did not, respectively. The findings emphasize the role of social determinants of health. However, to further reduce or eliminate racial/ethnic disparities and SES inequities, we would need sufficient and effective multi-level approaches. These involve lower ODX testing costs, health insurance coverage expansion, re-classification and validation of ODX recurrence scores in patients of minority ancestry, and the development of a faster, more accurate, and affordable test. See related article by Van Alsten et al., p. 654.
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Affiliation(s)
- Jincong Q Freeman
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
- Cancer Prevention and Control Program, UChicago Medicine Comprehensive Cancer Center, Chicago, Illinois
| | - Dezheng Huo
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
- Center for Clinical Cancer Genetics & Global Health, University of Chicago, Chicago, Illinois
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2
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Song R, Lee DE, Lee EG, Lee S, Kang HS, Han JH, Lee KS, Sim SH, Chae H, Kwon Y, Woo J, Jung SY. Clinicopathological Factors Associated with Oncotype DX Risk Group in Patients with ER+/HER2- Breast Cancer. Cancers (Basel) 2023; 15:4451. [PMID: 37760420 PMCID: PMC10527468 DOI: 10.3390/cancers15184451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Oncotype DX (ODX), a 21-gene assay, predicts the recurrence risk in early breast cancer; however, it has high costs and long testing times. We aimed to identify clinicopathological factors that can predict the ODX risk group and serve as alternatives to the ODX test. This retrospective study included 547 estrogen receptor-positive, human epidermal growth factor receptor 2-negative, and lymph node-negative breast cancer patients who underwent ODX testing. Based on the recurrence scores, three ODX risk categories (low: 0-15, intermediate: 16-25, and high: 26-100) were established in patients aged ≤50 years (n = 379), whereas two ODX risk categories (low: 0-25 and high: 26-100) were established in patients aged >50 years (n = 168). Factors selected for analysis included body mass index, menopausal status, type of surgery, and pathological and immunohistochemical features. The ODX risk groups showed significant association with histologic grade (p = 0.0002), progesterone receptor expression (p < 0.0001), Ki-67 (p < 0.0001), and p53 expression (p = 0.023) in patients aged ≤50 years. In patients aged >50 years, tumor size (p = 0.022), Ki-67 (p = 0.001), and p53 expression (p = 0.001) were significantly associated with the risk group. Certain clinicopathological factors can predict the ODX risk group and enable decision-making on adjuvant chemotherapy; these factors differ according to age.
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Affiliation(s)
- Ran Song
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - Dong-Eun Lee
- Biostatistics Collaboration Team, Research Core Center, Research Institute of National Cancer Center, Goyang 10408, Republic of Korea
| | - Eun-Gyeong Lee
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - Seeyoun Lee
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - Han-Sung Kang
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - Jai Hong Han
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - Keun Seok Lee
- Department of Medical Oncology, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea
| | - Sung Hoon Sim
- Department of Medical Oncology, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea
| | - Heejung Chae
- Department of Medical Oncology, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea
| | - Youngmee Kwon
- Department of Pathology, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea
| | - Jaeyeon Woo
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
| | - So-Youn Jung
- Department of Surgery, Center of Breast Cancer, National Cancer Center, Goyang 10408, Republic of Korea; (R.S.); (J.W.)
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Lee YW, Ahn SH, Lee YJ, Yoo TK, Kim J, Chung IY, Kim HJ, Ko BS, Lee JW, Son BH, Lee SB. Survey of clinicians on the use of adjuvant therapy for premenopausal women with breast cancer. PLoS One 2023; 18:e0290174. [PMID: 37590284 PMCID: PMC10434887 DOI: 10.1371/journal.pone.0290174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023] Open
Abstract
PURPOSE Considering prognostic and anatomic stages in early-stage premenopausal patients with breast cancer, clinicians decide on performing the multigene assay, adjuvant chemotherapy, or ovarian function suppression (OFS). This decision is also based on genetic information related to hormone receptor-positive and human epidermal growth factor receptor 2 negative results. We aimed to determine the tendency to use adjuvant therapy in clinical practice. METHODS From April to May 2022, clinicians of the Korean Breast Cancer Society responded to a web-based survey. The survey included 62 multiple-choice questions mainly on decision-making under different pathologic conditions. RESULTS Among 92 responding clinicians, 91.3% were breast surgeons. For 35-year-old patients (pT2N0 and Ki-67 50% profile), 96.8% of clinicians selected chemotherapy, whereas 50.7% selected chemotherapy for patients with pT1N0, Ki-67 10%, and without Oncotype Dx (ODX). Only 35.6% selected chemotherapy for 47-year-old patients with the same profiles, while 84.3% and 49.1% chose chemotherapy with ODX recurrence score 21 and 16, respectively. More clinicians selected tamoxifen (TMX) plus OFS than aromatase inhibitor (AI) plus OFS for 5 years of endocrine therapy in patients with adjuvant chemotherapy regardless of genomic and clinical risks. However, for the same patients without adjuvant chemotherapy, more clinicians selected AI plus OFS. A longer duration of additional OFS and TMX was selected in patients with high clinical and genomic risks, and the duration of OFS was relatively shorter in older patients. CONCLUSION The decision regarding adjuvant therapy should be made considering clinical and genomic risks and age, and clinicians should consult with patients about adverse effects and compliance.
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Affiliation(s)
- Young-Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sei-Hyun Ahn
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Young-jin Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Kyung Yoo
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Il Yong Chung
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Angarita FA, Oshi M, Yamada A, Yan L, Matsuyama R, Edge SB, Endo I, Takabe K. Low RUFY3 expression level is associated with lymph node metastasis in older women with invasive breast cancer. Breast Cancer Res Treat 2022; 192:19-32. [PMID: 35018543 PMCID: PMC8844209 DOI: 10.1007/s10549-021-06482-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Sentinel lymph node biopsy is omitted in older women (≥ 70 years old) with clinical lymph node (LN)-negative hormone receptor-positive breast cancer as it does not influence adjuvant treatment decision-making. However, older women are heterogeneous in frailty while the chance of recurrence increase with improving longevity. Therefore, a biomarker that identifies LN metastasis may facilitate treatment decision-making. RUFY3 is associated with cancer progression. We evaluated RUFY3 expression level as a biomarker for LN-positive breast cancer in older women. METHODS Clinical and transcriptomic data of breast cancer patients were obtained from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC, n = 1903) and The Cancer Genome Atlas (TCGA, n = 1046) Pan-cancer study cohorts. RESULTS A total of 510 (METABRIC) and 211 (TCGA) older women were identified. LN-positive breast cancer, which represented 51.4% (METABRIC) and 48.4% (TCGA), demonstrated worse disease-free, disease-specific, and overall survival. RUFY3 levels were significantly lower in LN-positive tumors regardless of age. The area under the curve for the receiver operator characteristic (AUC-ROC) curves showed RUFY3-predicted LN metastasis. Low RUFY3 enriched oxidative phosphorylation, DNA repair, MYC targets, unfolded protein response, and mtorc1 signaling gene sets, was associated with T helper type 1 cell infiltration, and with intratumor heterogeneity and fraction altered. Low RUFY3 expression was associated with LN-positive breast cancer and with worse disease-specific survival among older women. CONCLUSION Older women with breast cancers who had low expression level of RUFY3 were more frequently diagnosed with LN-positive tumors, which translated into worse prognosis.
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Affiliation(s)
- Fernando A. Angarita
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Masanori Oshi
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA;,Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Akimitsu Yamada
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Li Yan
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Stephen B. Edge
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA;,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, New York, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Kazuaki Takabe
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA;,Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan;,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, New York, USA;,Department of Breast Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan;,Department of Breast Surgery and Oncology, Tokyo Medical University, Tokyo, Japan
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5
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Berdunov V, Millen S, Paramore A, Hall P, Perren T, Brown R, Griffin J, Reynia S, Fryer N, Longworth L. Cost-effectiveness analysis of the Oncotype DX Breast Recurrence Score test in node-positive early breast cancer. J Med Econ 2022; 25:591-604. [PMID: 35416089 DOI: 10.1080/13696998.2022.2066399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Given the high rate of adverse events and high cost of adjuvant chemotherapy, it is optimal to avoid its use when endocrine therapy is equally effective at preventing distant recurrence of early breast cancer. The Oncotype DX test is a predictive and prognostic multigene assay used to guide adjuvant chemotherapy decisions in early breast cancer based on a Recurrence Score (RS) result. A model-based cost-effectiveness analysis compared the Oncotype DX test to clinical risk tools alone for HR+/HER2- node-positive (1-3 axillary lymph nodes) early breast cancer patients based on results from the RxPONDER trial. MATERIALS AND METHODS A decision-tree and Markov model was developed in Microsoft Excel. Distributions of patients and distant recurrence probabilities with endocrine and chemo-endocrine therapy were derived from the RxPONDER trial, TransATAC and SWOG-8814. Chemotherapy assignment data were obtained from the Clalit registry. The cost of adjuvant chemotherapy was based on the distribution of treatments used in the UK combined with published drug unit costs in the UK. The cost of distant recurrence and health state utility values were obtained from literature. RESULTS The Oncotype DX test was found to be more effective (with an estimated 0.02 additional QALYs) at a lower estimated cost (-£989) compared to clinical risk tools alone. The results did not substantially change with more conservative clinical and cost scenarios. The RxPONDER trial was restricted to RS 0-25, and data synthesis with other studies was required to inform the analysis, which increased uncertainty. CONCLUSIONS The Oncotype DX test is highly likely to be cost-effective in node-positive early breast cancer. The results were driven by reduction in the use of chemotherapy with consequence avoidance of the costs and harmful effects of chemotherapy. Targeted treatment of a minority (11%) of women with RS 26-100 who benefit from chemotherapy reduced cost and improved survival.
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Affiliation(s)
| | | | | | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
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6
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Magnoni F, Corso G, Gilardi L, Pagan E, Massari G, Girardi A, Ghidinelli F, Bagnardi V, Galimberti V, Grana CM, Veronesi P. Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer? Future Oncol 2021; 18:193-204. [PMID: 34882010 DOI: 10.2217/fon-2021-0470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.
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Affiliation(s)
- Francesca Magnoni
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Giovanni Corso
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy.,Departmentof Oncology & Hemato-Oncology, University of Milan, Milan, 20122, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milano, 20141, Italy
| | - Eleonora Pagan
- Department of Statistics & Quantitative Methods, University of Milan-Bicocca, Milan, 20126, Italy
| | - Giulia Massari
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Antonia Girardi
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | | | - Vincenzo Bagnardi
- Department of Statistics & Quantitative Methods, University of Milan-Bicocca, Milan, 20126, Italy
| | - Viviana Galimberti
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milano, 20141, Italy
| | - Paolo Veronesi
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy.,Departmentof Oncology & Hemato-Oncology, University of Milan, Milan, 20122, Italy
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7
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Schaafsma E, Zhang B, Schaafsma M, Tong CY, Zhang L, Cheng C. Impact of Oncotype DX testing on ER+ breast cancer treatment and survival in the first decade of use. Breast Cancer Res 2021; 23:74. [PMID: 34274003 PMCID: PMC8285794 DOI: 10.1186/s13058-021-01453-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/08/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The Oncotype DX breast recurrence score has been introduced more than a decade ago to aid physicians in determining the need for systemic adjuvant chemotherapy in patients with early-stage, estrogen receptor (ER)+, lymph node-negative breast cancer. METHODS In this study, we utilized data from The Surveillance, Epidemiology, and End Results (SEER) Program to investigate temporal trends in Oncotype DX usage among US breast cancer patients in the first decade after the introduction of the Oncotype DX assay. RESULTS We found that the use of Oncotype DX has steadily increased in the first decade of use and that this increase is associated with a decreased usage of chemotherapy. Patients who utilized the Oncotype DX test tended to have improved survival compared to patients who did not use the assay even after adjusting for clinical variables associated with prognosis. In addition, chemotherapy usage in patients with high-risk scores is associated with significantly longer overall and breast cancer-specific survival compared to high-risk patients who did not receive chemotherapy. On the contrary, patients with low-risk scores who were treated with chemotherapy tended to have shorter overall survival compared to low-risk patients who forwent chemotherapy. CONCLUSION We have provided a comprehensive temporal overview of the use of Oncotype DX in breast cancer patients in the first decade after Oncotype DX was introduced. Our results suggest that the use of Oncotype DX is increasing in ER+ breast cancer and that the Oncotype DX test results provide valuable information for patient treatment and prognosis.
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Affiliation(s)
- Evelien Schaafsma
- Department of Molecular and Systems Biology, Dartmouth College, Hanover, NH, 03755, USA
| | - Baoyi Zhang
- Department of Chemical and Biomolecular Engineering, Rice University, Houston, TX, 77030, USA
| | - Merit Schaafsma
- Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Chun-Yip Tong
- Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Lanjing Zhang
- Department of Biological Sciences, Rutgers University Newark, Newark, NJ, USA
- Department of Pathology, Princeton Medical Center, Plainsboro, NJ, USA
| | - Chao Cheng
- Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
- The Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, 77030, USA.
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8
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Bartlett JMS, Bayani J, Kornaga E, Xu K, Pond GR, Piper T, Mallon E, Yao CQ, Boutros PC, Hasenburg A, Dunn JA, Markopoulos C, Dirix L, Seynaeve C, van de Velde CJH, Stein RC, Rea D. Comparative survival analysis of multiparametric tests-when molecular tests disagree-A TEAM Pathology study. NPJ Breast Cancer 2021; 7:90. [PMID: 34238931 PMCID: PMC8266887 DOI: 10.1038/s41523-021-00297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
Multiparametric assays for risk stratification are widely used in the management of both node negative and node positive hormone receptor positive invasive breast cancer. Recent data from multiple sources suggests that different tests may provide different risk estimates at the individual patient level. The TEAM pathology study consists of 3284 postmenopausal ER+ve breast cancers treated with endocrine therapy Using genes comprising the following multi-parametric tests OncotypeDx®, Prosigna™ and MammaPrint® signatures were trained to recapitulate true assay results. Patients were then classified into risk groups and survival assessed. Whilst likelihood χ2 ratios suggested limited value for combining tests, Kaplan-Meier and LogRank tests within risk groups suggested combinations of tests provided statistically significant stratification of potential clinical value. Paradoxically whilst Prosigna-trained results stratified Oncotype-trained subgroups across low and intermediate risk categories, only intermediate risk Prosigna-trained cases were further stratified by Oncotype-trained results. Both Oncotype-trained and Prosigna-trained results further stratified MammaPrint-trained low risk cases, and MammaPrint-trained results also stratified Oncotype-trained low and intermediate risk groups but not Prosigna-trained results. Comparisons between existing multiparametric tests are challenging, and evidence on discordance between tests in risk stratification presents further dilemmas. Detailed analysis of the TEAM pathology study suggests a complex inter-relationship between test results in the same patient cohorts which requires careful evaluation regarding test utility. Further prognostic improvement appears both desirable and achievable.
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Affiliation(s)
- John M S Bartlett
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada.
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Edinburgh Cancer Research Centre, Edinburgh, UK.
| | - Jane Bayani
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Elizabeth Kornaga
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
- Translational Laboratories, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Keying Xu
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Greg R Pond
- Department of Oncology, McMaster University, Kingston, ON, Canada
| | - Tammy Piper
- Edinburgh Cancer Research Centre, Edinburgh, UK
| | | | - Cindy Q Yao
- Informatics & Computational Biology, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Paul C Boutros
- Informatics & Computational Biology, Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Canada
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, USA
| | - Annette Hasenburg
- Dept of Gynecology and Obstetrics, University Center Mainz, Mainz, Germany
| | - J A Dunn
- University of Warwick, Coventry, UK
| | | | - Luc Dirix
- St. Augustinus Hospital, Antwerp, Belgium
| | | | | | - Robert C Stein
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
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9
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Chen MY, Gillanders WE. Staging of the Axilla in Breast Cancer and the Evolving Role of Axillary Ultrasound. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:311-323. [PMID: 34040436 PMCID: PMC8139849 DOI: 10.2147/bctt.s273039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/23/2021] [Indexed: 12/15/2022]
Abstract
Axillary lymph nodes have long been recognized as a route for breast cancer to spread systemically. As a result, staging of the axilla has always played a central role in the treatment of breast cancer. Anatomic staging was believed to be important for two reasons: 1) it predicts prognosis and guides medical therapy, and 2) it is a potential therapy for removal of disease in the axilla. This paradigm has now been called into question. Prognostic information is driven increasingly by tumor biology, and trials such as the ACOSOG Z0011 demonstrates removal of axillary disease is not therapeutic. Staging of the axilla has undergone a dramatic de-escalation; however, sentinel lymph node biopsy (SLNB) is still an invasive surgery and represents a large economic burden on the healthcare system. In this review, we outline the changing paradigms of axillary staging in breast cancer from emphasis on anatomic staging to tumor biology, and the evolving role of axillary ultrasound, bringing patients less invasive and more personalized therapy.
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Affiliation(s)
- Michael Y Chen
- Department of Surgery, Washington University, St Louis, MS, USA
| | - William E Gillanders
- Department of Surgery, Washington University, St Louis, MS, USA
- Siteman Cancer Center in St. Louis, St Louis, MS, USA
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10
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Park KU, Gregory M, Bazan J, Lustberg M, Rosenberg S, Blinder V, Sharma P, Pusztai L, Shen C, Partridge A, Thompson A. Neoadjuvant endocrine therapy use in early stage breast cancer during the covid-19 pandemic. Breast Cancer Res Treat 2021; 188:249-258. [PMID: 33651271 PMCID: PMC7921279 DOI: 10.1007/s10549-021-06153-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/16/2021] [Indexed: 11/26/2022]
Abstract
Purpose Physician treatment preferences for early stage, estrogen positive breast cancer (ER + BC) patients were evaluated during the initial surge of the COVID-19 pandemic in the US when neoadjuvant endocrine therapy (NET) was recommended to allow safe deferral of surgery. Methods A validated electronic survey was administered May–June, 2020 to US medical oncologists (MO), radiation oncologists (RO), and surgeons (SO) involved in clinical trials organizations. Questions on NET use included practice patterns for locoregional management following NET. Results 114 Physicians from 29 states completed the survey—42 (37%) MO, 14 (12%) RO, and 58 (51%) SO. Before COVID-19, most used NET ‘rarely’ (49/107, 46%) or ‘sometimes’ (36, 33%) for ER + BC. 46% would delay surgery 2 months without NET. The preferred NET regimen was tamoxifen for premenopausal and aromatase inhibitor for postmenopausal women. 53% planned short term NET until surgery could proceed. Most recommended omitting axillary lymph node dissection (ALND) for one micrometastatic node after 1, 2, or 3 months of NET (1 month, N = 56/93, 60%; 2 months, N = 54/92, 59%; 3 months, N = 48/90, 53%). With longer duration of NET, omission of ALND decreased, regardless of years in practice, percent of practice in BC, practice type, participation in multidisciplinary tumor board, or number of regional COVID-19 cases. Conclusion More physicians preferred NET for ER + BC during the pandemic, compared with pre-pandemic times. As the duration of NET extended, more providers favored ALND in low volume metastatic axillary disease. The Covid-19 pandemic affected practice of ER + BC; it remains to be seen how this may impact outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06153-3.
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Affiliation(s)
- Ko Un Park
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Comprehensive Cancer Center, Columbus, OH, USA.
- The Ohio State University Wexner Medical Center, 410 W 10th Ave, N908 Doan Hall, Columbus, OH, 43210, USA.
| | - Megan Gregory
- Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joey Bazan
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center James Comprehensive Cancer Center, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Medicine, The Ohio State University Wexner Medical Center James Comprehensive Cancer Center, Columbus, OH, USA
| | - Shoshana Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Priyanka Sharma
- Division of Medical Oncology, Department of Medicine, University of Kansas Medical Center, Westwood, KS, USA
| | - Lajos Pusztai
- Section of Medical Oncology, Department of Medicine, Yale University, New Haven, CT, USA
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ann Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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11
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Unger JM, Hershman DL, Till C, Minasian LM, Osarogiagbon RU, Fleury ME, Vaidya R. "When Offered to Participate": A Systematic Review and Meta-Analysis of Patient Agreement to Participate in Cancer Clinical Trials. J Natl Cancer Inst 2021; 113:244-257. [PMID: 33022716 PMCID: PMC7936064 DOI: 10.1093/jnci/djaa155] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/26/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patient participation in clinical trials is vital for knowledge advancement and outcomes improvement. Few adult cancer patients participate in trials. Although patient. decision-making about trial participation has been frequently examined, the participation rate for patients actually offered a trial is unknown. METHODS A systematic review and meta-analysis using 3 major search engines was undertaken. We identified studies from January 1, 2000, to January 1, 2020, that examined clinical trial participation in the United States. Studies must have specified the numbers of patients offered a trial and the number enrolled. A random effects model of proportions was used. All statistical tests were 2-sided. RESULTS We identified 35 studies (30 about treatment trials and 5 about cancer control trials) among which 9759 patients were offered trial participation. Overall, 55.0% (95% confidence interval [CI] = 49.4% to 60.5%) of patients agreed to enroll. Participation rates did not differ between treatment (55.0%, 95% CI = 48.9% to 60.9%) and cancer control trials (55.3%, 95% CI = 38.9% to 71.1%; P = .98). Black patients participated at similar rates (58.4%, 95% CI = 46.8% to 69.7%) compared with White patients (55.1%, 95% CI = 44.3% to 65.6%; P = .88). The main reasons for nonparticipation were treatment choice or lack of interest. CONCLUSIONS More than half of all cancer patients offered a clinical trial do participate. These findings upend several conventional beliefs about cancer clinical trial participation, including that Black patients are less likely to agree to participate and that patient decision-making is the primary barrier to participation. Policies and interventions to improve clinical trial participation should focus more on modifiable systemic structural and clinical barriers, such as improving access to available trials and broadening eligibility criteria.
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Affiliation(s)
- Joseph M Unger
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | | | - Cathee Till
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - Lori M Minasian
- National Cancer Institute, Division of Cancer Prevention, Rockville, MD, USA
| | | | - Mark E Fleury
- American Cancer Society Cancer Action Network Inc, Washington, DC, USA
| | - Riha Vaidya
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- SWOG Statistics and Data Management Center, Seattle, WA, USA
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12
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Prognostic and predictive parameters in breast pathology: a pathologist's primer. Mod Pathol 2021; 34:94-106. [PMID: 33154551 DOI: 10.1038/s41379-020-00704-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022]
Abstract
The pathologist's role in the breast cancer treatment team has evolved from rendering a diagnosis of breast cancer, to providing a growing list of prognostic and predictive parameters such that individualized treatment decisions can be made based on likelihood of benefit from additional treatments and potential benefit from specific therapies. In all stages, ER and HER2 status help segregate breast cancers into treatment groups with similar outcomes and treatment response rates, however, traditional pathologic parameters such as favorable histologic subtype, size, lymph node status, and Nottingham grade also have remained clinically relevant in early stage disease decision-making. This is especially true for the most common subtype of breast cancer; ER positive, HER2 negative disease. For this same group of breast cancers, an ever-expanding list of gene-expression panels also can provide prediction and prognostication about potential chemotherapy benefit beyond standard endocrine therapies, with the 21-gene Recurrence Score, currently the only prospectively validated predictive test for this purpose. In the more aggressive ER-negative cancer subtypes, response to neoadjuvant therapy and` the extent of tumor infiltrating lymphocytes (TILs) are more recently recognized powerful prognostic parameters, and clinical guidelines now offer additional treatment options for those high-risk patients with residual cancer after standard neoadjuvant therapy. In stage four disease, predictive tests like germline BRCA status, tumor PIK3CA mutation status (in ER+ metastatic disease) and PDL-1 status (in triple negative metastatic disease) are now used to determine additional new treatment options. The objective of this review is to describe the latest in prognostic and predictive parameters in breast cancer as they are relevant to standard pathology reporting and how they are used in breast cancer clinical treatment decisions.
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13
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Gordon-Craig S, Parks RM, Cheung KL. The Potential Use of Tumour-Based Prognostic and Predictive Tools in Older Women with Primary Breast Cancer: A Narrative Review. Oncol Ther 2020; 8:231-250. [PMID: 32700048 PMCID: PMC7366554 DOI: 10.1007/s40487-020-00123-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 01/09/2023] Open
Abstract
A move is under way towards personalised cancer treatment, where tumour biology of an individual patient is examined to give unique predictive and prognostic information. This is extremely important in the setting of older women, who have treatment-specific goals which may differ from their younger counterparts, and may include conservation of quality of life rather than curative intent of treatment. One method employed to assist with this is the use of tumour-based prognostic and predictive tools. This article explores six of the most common tumour-based tools currently available on the market: MammaPrint, Oncotype DX, Mammostrat, Prosigna, EndoPredict, IHC4. The article discusses the creation and validation of these tools, their use and validation in older women, and future directions in the field. With the exception of Oncotype Dx, which has also been licensed for prediction of response from adjuvant chemotherapy, these tools have been licensed for use as prognostic tools only, mainly in the setting of adjuvant therapy following surgery. The evidence base for use in older women is strongest for Mammostrat and PAM50, although overall the evidence is much weaker than that in younger women. Where older women have been included in validation studies, this is often in small numbers, or the exact proportion of older women is unknown. In practice, all six of the tools are recommended to be utilised on surgical excision specimens, as well as in core needle biopsy (CNB) specimens in all of the tools except Mammostrat. This is extremely important in the setting of older women, of whom a large proportion do not undergo surgery. The suggested nature of the sample is formalin-fixed paraffin-embedded in all the tools except MammaPrint, which can also be performed on fresh-frozen samples. Future development of prognostic tools in older women with breast cancer should focus on treatment dilemmas specific to this population. This includes the decision of primary treatment between surgery or endocrine therapy and decisions regarding adjuvant therapy, in particular, chemotherapy.
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Affiliation(s)
- Sophie Gordon-Craig
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
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14
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Harnan S, Tappenden P, Cooper K, Stevens J, Bessey A, Rafia R, Ward S, Wong R, Stein RC, Brown J. Tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer: a systematic review and economic analysis. Health Technol Assess 2020; 23:1-328. [PMID: 31264581 DOI: 10.3310/hta23300] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Breast cancer and its treatment can have an impact on health-related quality of life and survival. Tumour profiling tests aim to identify whether or not women need chemotherapy owing to their risk of relapse. OBJECTIVES To conduct a systematic review of the effectiveness and cost-effectiveness of the tumour profiling tests oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA), MammaPrint® (Agendia, Inc., Amsterdam, the Netherlands), Prosigna® (NanoString Technologies, Inc., Seattle, WA, USA), EndoPredict® (Myriad Genetics Ltd, London, UK) and immunohistochemistry 4 (IHC4). To develop a health economic model to assess the cost-effectiveness of these tests compared with clinical tools to guide the use of adjuvant chemotherapy in early-stage breast cancer from the perspective of the NHS and Personal Social Services. DESIGN A systematic review and health economic analysis were conducted. REVIEW METHODS The systematic review was partially an update of a 2013 review. Nine databases were searched in February 2017. The review included studies assessing clinical effectiveness in people with oestrogen receptor-positive, human epidermal growth factor receptor 2-negative, stage I or II cancer with zero to three positive lymph nodes. The economic analysis included a review of existing analyses and the development of a de novo model. RESULTS A total of 153 studies were identified. Only one completed randomised controlled trial (RCT) using a tumour profiling test in clinical practice was identified: Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) for MammaPrint. Other studies suggest that all the tests can provide information on the risk of relapse; however, results were more varied in lymph node-positive (LN+) patients than in lymph node-negative (LN0) patients. There is limited and varying evidence that oncotype DX and MammaPrint can predict benefit from chemotherapy. The net change in the percentage of patients with a chemotherapy recommendation or decision pre/post test ranged from an increase of 1% to a decrease of 23% among UK studies and a decrease of 0% to 64% across European studies. The health economic analysis suggests that the incremental cost-effectiveness ratios for the tests versus current practice are broadly favourable for the following scenarios: (1) oncotype DX, for the LN0 subgroup with a Nottingham Prognostic Index (NPI) of > 3.4 and the one to three positive lymph nodes (LN1-3) subgroup (if a predictive benefit is assumed); (2) IHC4 plus clinical factors (IHC4+C), for all patient subgroups; (3) Prosigna, for the LN0 subgroup with a NPI of > 3.4 and the LN1-3 subgroup; (4) EndoPredict Clinical, for the LN1-3 subgroup only; and (5) MammaPrint, for no subgroups. LIMITATIONS There was only one completed RCT using a tumour profiling test in clinical practice. Except for oncotype DX in the LN0 group with a NPI score of > 3.4 (clinical intermediate risk), evidence surrounding pre- and post-test chemotherapy probabilities is subject to considerable uncertainty. There is uncertainty regarding whether or not oncotype DX and MammaPrint are predictive of chemotherapy benefit. The MammaPrint analysis uses a different data source to the other four tests. The Translational substudy of the Arimidex, Tamoxifen, Alone or in Combination (TransATAC) study (used in the economic modelling) has a number of limitations. CONCLUSIONS The review suggests that all the tests can provide prognostic information on the risk of relapse; results were more varied in LN+ patients than in LN0 patients. There is limited and varying evidence that oncotype DX and MammaPrint are predictive of chemotherapy benefit. Health economic analyses indicate that some tests may have a favourable cost-effectiveness profile for certain patient subgroups; all estimates are subject to uncertainty. More evidence is needed on the prediction of chemotherapy benefit, long-term impacts and changes in UK pre-/post-chemotherapy decisions. STUDY REGISTRATION This study is registered as PROSPERO CRD42017059561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katy Cooper
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alice Bessey
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rachid Rafia
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sue Ward
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert C Stein
- University College London Hospitals Biomedical Research Centre, London, UK.,Research Department of Oncology, University College London, London, UK
| | - Janet Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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15
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Beyond Chemotherapies: Recent Strategies in Breast Cancer Treatment. Cancers (Basel) 2020; 12:cancers12092634. [PMID: 32947780 PMCID: PMC7565588 DOI: 10.3390/cancers12092634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/04/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022] Open
Abstract
In 2018, about 2.1 million women have been diagnosed with breast cancer worldwide. Treatments include-among others-surgery, chemotherapy, radiotherapy, or endocrine therapy. The current policy of care tends rather at therapeutic de-escalation, and systemic treatment such as chemotherapies alone are not systematically considered as the best option anymore. With recent advances in the understanding of cancer biology, and as a complement to anatomic staging, some biological factors (assessed notably via gene-expression signatures) are taken into account to evaluate the benefit of a chemotherapy regimen. The first aim of this review will be to summarize when chemotherapies can be avoided or used only combined with other treatments. The second aim will focus on molecules that can be used instead of chemotherapeutic drugs or used in combination with chemotherapeutic drugs to improve treatment outcomes. These therapeutic molecules have emerged from the collaboration between fundamental and clinical research, and include molecules, such as tyrosine kinase inhibitors, CDK4/6 inhibitors, and monoclonal antibodies (such as anti-PD-L1). In the fight against cancer, new tools aiding decision making are of the utmost importance: gene-expression signatures have proven to be valuable in the clinic, notably, to know when chemotherapies can be avoided. When substitution treatments are also available, a big step can be made toward personalized medicine for the patient's benefit.
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16
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Ibraheem A, Olopade OI, Huo D. Propensity score analysis of the prognostic value of genomic assays for breast cancer in diverse populations using the National Cancer Data Base. Cancer 2020; 126:4013-4022. [PMID: 32521056 PMCID: PMC7423613 DOI: 10.1002/cncr.32956] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/28/2019] [Accepted: 12/08/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Genomic assays such as Oncotype Dx (ODX) and MammaPrint are used for risk-adapted treatment decisions among patients with early breast cancer. However, to the authors' knowledge, concordance between genomic assays is modest. Using real-world data, the authors performed a comparative analysis of ODX and MammaPrint. METHODS A cohort of women diagnosed with early-stage, hormone receptor-positive breast cancer who received ODX or MammaPrint was established using the National Cancer Data Base (NCDB) for 2010 through 2016. Using the propensity score matching method, 2 groups of patients with similar clinical and demographic characteristics were defined: one group received ODX and the other received MammaPrint. The authors examined the association between use of the ODX or MammaPrint assays and overall survival using Cox models. RESULTS Of the 451,693 eligible patients, approximately 45.3% received ODX and 1.8% received MammaPrint testing. The use of ODX increased from 36.1% in 2010 to 49.9% in 2016, whereas use of MammaPrint increased from 0.5% in 2010 to 3.3% in 2016. The authors matched 5042 patients who received ODX with 5042 patients who received MammaPrint. The 5-year risks of death for the MammaPrint low-risk group and the ODX low-risk group were 3.4% and 4.7%, respectively. The prognostic value of MammaPrint was similar to that of ODX; the C-index was 0.614 (95% confidence interval, 0.572-0.657) for MammaPrint and 0.581 (95% confidence interval, 0.530-0.631) for ODX. There was a difference in the performance of the ODX assay observed across racial and/or ethnic groups (P < .001), with a slightly better performance noted among white compared with African American and Hispanic individuals. CONCLUSIONS Both the ODX and MammaPrint tests are good at identifying low-risk individuals who could be spared chemotherapy. The suboptimal performance of ODX in ethnic minority individuals deserves further investigation.
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Affiliation(s)
- Abiola Ibraheem
- Section of Hematology Oncology, Center for Clinical Cancer Genetics & Global Health, The University of Chicago
| | - Olufunmilayo I. Olopade
- Section of Hematology Oncology, Center for Clinical Cancer Genetics & Global Health, The University of Chicago
| | - Dezheng Huo
- Section of Hematology Oncology, Center for Clinical Cancer Genetics & Global Health, The University of Chicago
- Department of Public Health Sciences, University of Chicago
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17
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McEvoy AM, Poplack S, Nickel K, Olsen MA, Ademuyiwa F, Zoberi I, Odom E, Yu J, Chang SH, Gillanders WE. Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound. Breast Cancer Res Treat 2020; 183:251-262. [PMID: 32651755 DOI: 10.1007/s10549-020-05768-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS. METHODS We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR+/HER2- breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed. RESULTS Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients. CONCLUSION Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR+/HER2- breast cancer and negative AUS.
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Affiliation(s)
- Aubriana M McEvoy
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Steven Poplack
- Department of Diagnostic Radiology, Section of Breast Imaging, Washington, University St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, St. Louis, MO, USA
| | - Katelin Nickel
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
| | - Margaret A Olsen
- Siteman Cancer Center, St. Louis, MO, USA
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - Foluso Ademuyiwa
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Medical Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Imran Zoberi
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Radiation Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic Surgery, Washington, University St. Louis, St. Louis, MO, USA
| | - Jennifer Yu
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
| | - Su-Hsin Chang
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - William E Gillanders
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA.
- Siteman Cancer Center, St. Louis, MO, USA.
- Department of Surgery, Washington University School of Medicine, Campus Box 8109, 4590 Children's Place, Suite 9600, St. Louis, MO, 63110, USA.
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18
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Turashvili G, Wen HY. Multigene testing in breast cancer: What have we learned from the 21-gene recurrence score assay? Breast J 2020; 26:1199-1207. [PMID: 32458521 DOI: 10.1111/tbj.13859] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/28/2022]
Abstract
Most invasive breast cancers express hormone receptors (HR) and typically have a favorable prognosis following endocrine therapy. Patients at a higher risk of recurrence can be identified by multigene prognostic classifiers such as the 21-gene recurrence score (RS) assay, 70-gene prognostic signature, PAM-50, 12-gene molecular score, and others. The 21-gene RS assay (Oncotype Dx™, Genomic Health, Redwood City, CA) has level I clinical evidence and is the most widely used multigene assay in North America. The RS assay is based on reverse transcriptase polymerase chain reaction that can be performed on the RNA isolated from formalin-fixed paraffin-embedded tissue. It evaluates the expression of 16 cancer-related genes developed based on a multi-step approach. Due to its ability to assess recurrence risk and predict potential benefit from chemotherapy, the assay is recommended for patients with node-negative, HR-positive, and human epidermal growth factor receptor 2 (HER2)-negative breast cancer by the American Society of Clinical Oncology, National Comprehensive Cancer Network clinical practice guidelines in oncology, European Society for Medical Oncology clinical practice guidelines, and St. Gallen consensus panel guidelines. The RS assay has also been incorporated in the prognostic stage groups in the 8th edition of the American Joint Commission of Cancer staging manual in order to provide essential genomic information for optimal treatment decisions. This review will focus on the utility of the RS assay in HR-positive and HER2-negative breast cancer patients, including risk of distant and locoregional recurrence in node-negative and node-positive tumors, association with radiotherapy, special subtypes of breast cancer, practical issues related to selecting tumors for testing, and overview of the recently published TailorX (Trial Assigning IndividuaLized Options for treatment [Rx]) results.
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Affiliation(s)
- Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kittaneh M, Badve S, Caldera H, Coleman R, Goetz MP, Mahtani R, Mamounas E, Kalinsky K, Lower E, Pegram M, Press MF, Rugo HS, Schwartzberg L, Traina T, Vogel C. Case-Based Review and Clinical Guidance on the Use of Genomic Assays for Early-Stage Breast Cancer: Breast Cancer Therapy Expert Group (BCTEG). Clin Breast Cancer 2020; 20:183-193. [PMID: 32014370 DOI: 10.1016/j.clbc.2020.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/21/2019] [Accepted: 01/01/2020] [Indexed: 12/18/2022]
Abstract
In addition to classical clinicopathologic factors, such as hormone receptor positivity, human epidermal growth factor receptor 2 (HER2) status, and tumor size, grade, and lymph node status, a number of commercially available genomic tests may be used to help inform treatment decisions for early breast cancer patients. Although these tests improve our understanding of breast cancer and help to individualize treatment decisions, clinicians face challenges when deciding on the most appropriate test to order, and the advantages, if any, of one test over another. The Breast Cancer Therapy Expert Group (BCTEG) recently convened a roundtable meeting to discuss issues surrounding the use of genomic testing in early breast cancer, with the goal of providing practical guidance on the use of these tests by the community oncologist, for whom breast cancer may be only one of many tumor types they treat. The group recognizes that genomic testing can provide important prognostic (eg, risk for recurrence), and in some cases predictive, information (eg, benefit of chemotherapy, or extended adjuvant endocrine therapy), which can be used to help guide treatment decisions in breast cancer. The available tests differ in the types of information they provide, and in the patient populations and clinical trials that were conducted to validate them. We summarize the discussion of the BCTEG on this topic, and we also consider several patient cases and clinical scenarios in which genomic testing may, or may not, be useful to guide treatment decisions for the practicing community oncologist.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Hope S Rugo
- University of California San Francisco, San Francisco, CA
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20
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Collin LJ, Yan M, Jiang R, Ward KC, Crawford B, Torres MA, Gogineni K, Subhedar PD, Puvanesarajah S, Gaudet MM, McCullough LE. Oncotype DX recurrence score implications for disparities in chemotherapy and breast cancer mortality in Georgia. NPJ Breast Cancer 2019; 5:32. [PMID: 31583272 PMCID: PMC6763428 DOI: 10.1038/s41523-019-0129-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 08/21/2019] [Indexed: 12/29/2022] Open
Abstract
Among women diagnosed with stage I-IIIa, node-negative, hormone receptor (HR)-positive breast cancer (BC), Oncotype DX recurrence scores (ODX RS) inform chemotherapy treatment decisions. Differences in recurrence scores or testing may contribute to racial disparities in BC mortality among women with HR+ tumors. We identified 12,081 non-Hispanic White (NHW) and non-Hispanic Black (NHB) BC patients in Georgia (2010-2014), eligible to receive an ODX RS. Logistic regression was used to estimate the odds of chemotherapy receipt by race and ODX RS. Cox proportional hazard regression was used to calculate the hazard ratios (HRs) comparing BC mortality rates by race and recurrence score. Receipt of Oncotype testing was consistent between NHB and NHW women. Receipt of chemotherapy was generally comparable within strata of ODX RS-although NHB women with low scores were slightly more likely to receive chemotherapy (OR = 1.16, 95% CI 0.77, 1.75), and NHB women with high scores less likely to receive chemotherapy (OR = 0.77, 95% CI 0.48, 1.24), than NHW counterparts. NHB women with a low recurrence score had the largest hazard of BC mortality (HR = 2.47 95% CI 1.22, 4.99) compared to NHW women. Our data suggest that additional tumor heterogeneity, or other downstream treatment factors, not captured by ODX, may be drivers of racial disparities in HR+ BC.
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Affiliation(s)
- Lindsay J. Collin
- Department of Epidemiology, Emory University Atlanta, Atlanta, GA 30322 USA
| | - Ming Yan
- Department of Epidemiology, Emory University Atlanta, Atlanta, GA 30322 USA
| | - Renjian Jiang
- Department of Epidemiology, Emory University Atlanta, Atlanta, GA 30322 USA
| | - Kevin C. Ward
- Department of Epidemiology, Emory University Atlanta, Atlanta, GA 30322 USA
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA 30322 USA
| | - Brittany Crawford
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC 29208 USA
| | - Mylin A. Torres
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA 30322 USA
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Keerthi Gogineni
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA 30322 USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Preeti D. Subhedar
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA 30322 USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322 USA
| | | | | | - Lauren E. McCullough
- Department of Epidemiology, Emory University Atlanta, Atlanta, GA 30322 USA
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA 30322 USA
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21
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Zhang QH, Zhang WW, Wang J, Lian CL, Sun JY, He ZY, Wu SG. Impact of the 21-gene recurrence score assay on chemotherapy decision making and outcomes for breast cancer patients with four or more positive lymph nodes. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:446. [PMID: 31700882 PMCID: PMC6803245 DOI: 10.21037/atm.2019.08.82] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/08/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND To assess the impact of the 21-gene recurrence score (RS) on chemotherapy decision making and survival outcomes for breast cancer patients with >4 positive lymph nodes. METHODS Patients with non-metastatic estrogen receptor-positive breast cancer with >4 positive lymph nodes diagnosed between 2004 and 2013 were identified using the Surveillance, Epidemiology, and End Results database. The relationships between the 21-gene RS value and survival outcomes, chemotherapy decision-making, and chemotherapy benefit were analyzed. RESULTS A total of 410 patients were identified, including 191 (46.6%), 164 (40.0%), and 55 (13.4%) in the low-, intermediate-, and high-risk RS groups, respectively. The 21-gene RS assay results were independently related to chemotherapy receipt. A total of 59.0%, 68.0%, and 78.0% of patients received chemotherapy in the low-, intermediate-, and high-risk RS groups, respectively. The 21-gene RS was an independent indicator of breast cancer specific survival (BCSS) and overall survival (OS). Intermediate-risk [BCSS: hazards ratio (HR), 2.832, 95% confidence interval (CI): 1.160-6.910, P=0.022; OS: HR, 3.704, 95% CI: 1.750-7.836, P=0.001] and high-risk RS (BCSS: HR, 6.440, 95% CI: 2.597-15.974, P<0.001; OS: HR, 5.053, 95% CI: 2.199-11.608, P<0.001) cohorts had significantly lower survival outcomes compared to low-risk RS cohort. The 5-year BCSS were 92.7%, 88.3%, and 70.7% in patients in the low-, intermediate-, and high-risk RS cohorts, respectively (P<0.001), and the 5-year OS were 92.1%, 80.6%, and 66.6%, respectively (P<0.001). CONCLUSIONS The 21-gene RS is an independent predictor of chemotherapy receipt and survival outcomes for breast cancer patients with > 4 positive lymph nodes.
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Affiliation(s)
- Qing-Hong Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - Jun Wang
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Chen-Lu Lian
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - San-Gang Wu
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
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22
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Deverka PA, Bangs R, Kreizenbeck K, Delaney DM, Hershman DL, Blanke CD, Ramsey SD. A New Framework for Patient Engagement in Cancer Clinical Trials Cooperative Group Studies. J Natl Cancer Inst 2019; 110:553-559. [PMID: 29684151 DOI: 10.1093/jnci/djy064] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/09/2018] [Indexed: 11/14/2022] Open
Abstract
For the past two decades, the National Cancer Institute (NCI) has supported the involvement of patient advocates in both internal advisory activities and funded research projects to provide a patient perspective. Implementation of the inclusion of patient advocates has varied considerably, with inconsistent involvement of patient advocates in key phases of research such as concept development. Despite this, there is agreement that patient advocates have improved the patient focus of many cancer research studies. This commentary describes our experience designing and pilot testing a new framework for patient engagement at SWOG, one of the largest cancer clinical trial network groups in the United States and one of the four adult groups in the NCI's National Clinical Trials Network (NCTN). Our goal is to provide a roadmap for other clinical trial groups that are interested in bringing the patient voice more directly into clinical trial conception and development. We developed a structured process to engage patient advocates more effectively in the development of cancer clinical trials and piloted the process in four SWOG research committees, including implementation of a new Patient Advocate Executive Review Form that systematically captures patient advocates' input at the concept stage. Based on the positive feedback to our approach, we are now developing training and evaluation metrics to support meaningful and consistent patient engagement across the SWOG clinical trial life cycle. Ultimately, the benefits of more patient-centered cancer trials will be measured in the usefulness, relevance, and speed of study results to patients, caregivers, and clinicians.
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Affiliation(s)
| | - Rick Bangs
- SWOG Patient Advocate Committee, Portland, OR
| | - Karma Kreizenbeck
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Deborah M Delaney
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
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23
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Barger S, Sullivan SD, Bell-Brown A, Bott B, Ciccarella AM, Golenski J, Gorman M, Johnson J, Kreizenbeck K, Kurttila F, Mason G, Myers J, Seigel C, Wade JL, Walia G, Watabayashi K, Lyman GH, Ramsey SD. Effective stakeholder engagement: design and implementation of a clinical trial (SWOG S1415CD) to improve cancer care. BMC Med Res Methodol 2019; 19:119. [PMID: 31185918 PMCID: PMC6560751 DOI: 10.1186/s12874-019-0764-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/04/2019] [Indexed: 01/21/2023] Open
Abstract
Background The Fred Hutchinson Cancer Research Center has engaged an External Stakeholder Advisory Group (ESAG) in the planning and implementation of the TrACER Study (S1415CD), a five-year pragmatic clinical trial assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention. The trial is being conducted by SWOG through the National Cancer Institute Community Oncology Research Program in 45 clinics. The ESAG includes ten patient partners, two payers, two pharmacists, two guideline experts, four providers and one medical ethicist. This manuscript describes the ESAG’s role and impact on the trial. Methods During early trial development, the research team assembled the ESAG to inform plans for each phase of the trial. ESAG members provide feedback and engage in problem solving to improve trial implementation. Each year, members participate in one in-person meeting, web conferences and targeted email discussion. Additionally, they complete a survey that assesses their satisfaction with communication and collaboration. The research team collected and reviewed stakeholder input from 2014 to 2018 for impact on the trial. Results The ESAG has informed trial design, implementation and dissemination planning. The group advised the trial’s endpoints, regimen list and development of cohort and usual care arms. Based on ESAG input, the research team enhanced patient surveys and added pharmacy-related questions to the component application to assess order entry systems. ESAG patient partners collaborated with the research team to develop a patient brochure and study summary for clinic staff. In addition to identifying recruitment strategies and patient-oriented platforms for publicly sharing results, ESAG members participated as co-authors on this manuscript and a conference poster presentation highlighting stakeholder influence on the trial. The annual satisfaction survey results suggest that ESAG members were satisfied with the methods, frequency and target areas of their engagement in the trial during project years 1–3. Conclusions Diverse stakeholder engagement has been essential in optimizing the design, implementation and planned dissemination of the TrACER Study. The lessons described in the manuscript may assist others to effectively partner with stakeholders on clinical research.
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Affiliation(s)
- Sarah Barger
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, 98195, USA.
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Brad Bott
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Anne Marie Ciccarella
- Independent Patient Research Partner and SWOG Digital Engagement Committee Member, New York, NY, USA
| | - John Golenski
- Kairoi Healthcare Strategies, San Francisco, CA, USA
| | - Mark Gorman
- Cancer Survivor Advisor, Silver Spring, MD, USA
| | - Judy Johnson
- SWOG Lung Committee Patient Advocate, St. Louis, MO, USA
| | | | | | - Ginny Mason
- SWOG Breast Committee Patient Advocate, West Lafayette, IN, USA
| | - Jamie Myers
- University of Kansas, School of Nursing, Kansas City, KS, USA
| | - Carole Seigel
- SWOG GI (Pancreatic Cancer) Committee, Patient Advocate, Boston, MA, USA
| | | | | | - Kate Watabayashi
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
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24
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Dubrovsky E, Raymond S, Chun J, Fong A, Patel N, Guth A, Schnabel F. Genomic testing in early stage invasive male breast cancer: An NCDB analysis from 2008 to 2014. Breast J 2019; 25:425-433. [DOI: 10.1111/tbj.13235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Affiliation(s)
| | - Samantha Raymond
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
| | - Jennifer Chun
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
| | - Amy Fong
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
| | - Nisha Patel
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
| | - Amber Guth
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
| | - Freya Schnabel
- NYU Perlmutter Cancer Center, Department of Surgery New York University Langone Health New York New York
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25
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Survival outcome of adjuvant endocrine therapy alone for patients with lymph node-positive, hormone-responsive, HER2-negative breast cancer. Asian J Surg 2019; 42:914-921. [PMID: 30833157 DOI: 10.1016/j.asjsur.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/12/2018] [Accepted: 01/04/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE The prognosis of hormone receptor-positive and HER2-negative breast cancer is better than that of other subtypes. Current guidelines recommend chemotherapy for N1 breast cancer patients. However, this has the possibility to be over-treatment. METHODS This was a retrospective study of 18,549 patients who were surgically treated for invasive breast cancer, at a single center in South Korea, between January 1993 and December 2012. N1 stage breast cancer patients who were hormone receptor-positive and HER2-negative were enrolled, and propensity score matching was performed to compare patients treated with anti-hormonal therapy alone (N = 83) and those treated with chemotherapy followed by anti-hormonal therapy (N = 85). RESULTS In survival analysis, the survival parameters of the endocrine therapy-only group and the chemotherapy with endocrine therapy group were respectively 96.1% and 94.0% for 5-year recurrence free survival (RFS), 89.6% and 94.0% for 10-year RFS, 97.4% and 94.0% for 5-year distant metastasis-free survival (DMFS), 93.2% and 94.0% for 10-year DMFS, 98.7% and 98.8% for 10-year breast cancer-specific survival (BCSS), and 98.7% and 98.8% for 10-year overall survival (OS). There were no significant differences in RFS (p = 0.871), DMFS (p = 0.491), BCSS (p = 0.569) and OS (p = 0.731) between the two groups. CONCLUSION Several patients with clinicopathologic features like hormone receptor positivity and HER2 negativity can avoid chemotherapy even with lymph node metastasis. Future studies with a long-term follow-up and a larger number of patients are required for validating our results.
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26
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Caudle AS, Smith BD. Do Internal Mammary Nodes Matter? Ann Surg Oncol 2019; 26:930-932. [PMID: 30617872 DOI: 10.1245/s10434-018-07152-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Abigail S Caudle
- The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1434, Houston, TX, 77030, USA.
| | - Benjamin D Smith
- The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1434, Houston, TX, 77030, USA
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27
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Tevis SE, Bassett R, Bedrosian I, Barcenas CH, Black DM, Caudle AS, DeSnyder SM, Fitzsullivan E, Hunt KK, Kuerer HM, Lucci A, Meric-Bernstam F, Mittendorf EA, Park K, Teshome M, Thompson AM, Hwang RF. OncotypeDX Recurrence Score Does Not Predict Nodal Burden in Clinically Node Negative Breast Cancer Patients. Ann Surg Oncol 2018; 26:815-820. [PMID: 30556120 DOI: 10.1245/s10434-018-7059-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND OncotypeDX recurrence score (RS)® has been found to predict recurrence and disease-free survival in patients with node negative breast cancer. Whether RS is useful in guiding locoregional therapy decisions is unclear. We sought to evaluate the relationship between RS and lymph node burden. METHODS Patients with invasive breast cancer who underwent sentinel lymph node dissection from 2010 to 2015 were identified from a prospectively maintained database. Patients were excluded if they were clinically node positive or if they received neoadjuvant chemotherapy. RS was classified as low (< 18), intermediate (18-30), or high (> 30). The association between RS, lymph node burden, and disease recurrence was evaluated. Statistical analyses were performed in R version 3.4.0; p < 0.05 was considered significant. RESULTS A positive SLN was found in 168 (15%) of 1121 patients. Completion axillary lymph node dissection was performed in 84 (50%) of SLN-positive patients. The remaining 84 (50%) patients had one to two positive SLNs and did not undergo further axillary surgery. RS was low in 58.5%, intermediate in 32.6%, and high in 8.9%. RS was not associated with a positive SLN, number of positive nodes, maximum node metastasis size, or extranodal extension. The median follow-up was 23 months. High RS was not associated with locoregional recurrence (p = 0.07) but was significantly associated with distant recurrence (p = 0.0015). CONCLUSIONS OncotypeDX RS is not associated with nodal burden in women with clinically node-negative breast cancer, suggesting that RS is not useful to guide decisions regarding extent of axillary surgery for these patients.
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Affiliation(s)
- S E Tevis
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - R Bassett
- Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - I Bedrosian
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - C H Barcenas
- Department of Breast Medical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - D M Black
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - A S Caudle
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - S M DeSnyder
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - E Fitzsullivan
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - K K Hunt
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - H M Kuerer
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - A Lucci
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - F Meric-Bernstam
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - E A Mittendorf
- Department of Surgery, Brigham and Women's Hospital, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - K Park
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - M Teshome
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - A M Thompson
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - R F Hwang
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
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28
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Ibraheem AF, Press DJ, Olopade OI, Huo D. Community clinical practice patterns and mortality in patients with intermediate oncotype DX recurrence scores: Who benefits from chemotherapy? Cancer 2018; 125:213-222. [PMID: 30387876 DOI: 10.1002/cncr.31818] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/16/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Oncotype DX recurrence score (RS) is used as a tool for making decisions about chemotherapy for patients who have hormone receptor (estrogen receptor or progesterone receptor)-positive, HER2-negative breast cancer. There is no benefit from chemotherapy among patients aged ≥50 years who have lymph node-negative disease and an RS from 11 to 25, but the benefit of chemotherapy in the lymph node-positive group remains unknown. METHODS On the basis of data from the National Cancer Data Base between 2010 and 2014, a nationwide, retrospective cohort study included 73,185 women who had stage I through IIIA breast cancer and an RS between 11 and 30. RESULTS Receipt of chemotherapy was associated with a reduced risk of death among patients who had lymph node-positive breast cancer (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.45-0.74; P < .001) after adjusting for other prognostic factors in a multivariable Cox model. The 5-year survival gain ranged from 1.3% (RS 11-17 subgroup), to 3.3% (RS 18-25 subgroup), and to 6.7% (RS 26-30 subgroup). Among patients who had lymph node-negative disease, chemotherapy was associated with a reduced risk of death for those with an RS from 25 to 30 (HR, 0.68; 95% CI, 0.48-0.96; P = .03; 5-year survival gain, 1.8%), but there was no benefit from chemotherapy for patients who had an RS from 11 to 17 (HR, 0.97; 95% CI, 0.61-1.55; P = .90), and there was a marginally significant benefit for women who had an RS from 18 to 25 (HR, 0.79; 95% CI, 0.62-1.00; P = .05). Similar results were observed using propensity score-matching method. CONCLUSIONS The benefit of chemotherapy for patients with breast cancer who have an intermediate RS is driven in a nonlinear fashion by RS: the higher the RS, the larger the absolute benefit. Findings from this study underscore the utility of real-world data to inform joint decision making in practice.
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Affiliation(s)
- Abiola F Ibraheem
- Section of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - David J Press
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Olufunmilayo I Olopade
- Section of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Dezheng Huo
- Section of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, Illinois.,Department of Public Health Sciences, University of Chicago, Chicago, Illinois
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29
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Ohara AM, Naoi Y, Shimazu K, Kagara N, Shimoda M, Tanei T, Miyake T, Kim SJ, Noguchi S. PAM50 for prediction of response to neoadjuvant chemotherapy for ER-positive breast cancer. Breast Cancer Res Treat 2018; 173:533-543. [DOI: 10.1007/s10549-018-5020-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/17/2018] [Indexed: 01/04/2023]
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30
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Bello DM, Russell C, McCullough D, Tierno M, Morrow M. Lymph Node Status in Breast Cancer Does Not Predict Tumor Biology. Ann Surg Oncol 2018; 25:2884-2889. [PMID: 29968028 PMCID: PMC6123264 DOI: 10.1245/s10434-018-6598-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND/OBJECTIVE The 21-gene Oncotype DX® Breast Recurrence Score® (RS) assay has been prospectively validated as prognostic and predictive in node-negative, estrogen receptor-positive (ER+)/HER2- breast cancer patients. Less is known about its prognostic role in node-positive breast cancer. We compared RS results among patients with lymph node-negative (N0), micrometastatic (N1mi), and macrometastatic (N+) breast cancer to determine if nodal metastases are associated with more aggressive biology, as determined by RS. METHODS Overall, 610,350 tumor specimens examined by the Genomic Health laboratory from February 2004 to August 2017 were studied. Histology was classified centrally, while lymph node status was determined locally. RS distribution (low: < 18; intermediate: 18-30; high: ≥ 31) was compared by nodal status. RESULTS Eighty percent (n = 486,013) of patients were N0, 4% (n = 24,325) were N1mi, 9% (n = 56,100) were N+, and 7% (n = 43,912) had unknown nodal status. Mean RS result was 18, 16.7, 17.3 and 18.9 in the N0, N1mi, N+, and unknown groups, respectively. An RS ≥ 31 was seen in 10% of N0 patients, 7% of N1mi patients, and 8.0% of N+ patients. The likelihood of an RS ≥ 31 in N1mi and N+ patients varied with tumor histology, with only 2% of patients with classic infiltrating lobular cancer having an RS ≥ 31, versus 7-9% of those with ductal carcinoma. CONCLUSIONS RS distribution among N0, N1mi, and N+ patients is similar, suggesting a spectrum of biology and potential chemotherapy benefit exists among node-negative and node-positive ER+/HER2- breast cancer patients. If RxPONDER does not show a chemotherapy benefit in N+ patients with a low RS result, our findings indicate that substantial numbers of patients could be spared the burden of chemotherapy.
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MESH Headings
- Aged
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/genetics
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/genetics
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Lobular/genetics
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/secondary
- Female
- Follow-Up Studies
- Gene Expression Profiling/methods
- Humans
- Lymph Nodes/metabolism
- Lymph Nodes/pathology
- Lymphatic Metastasis
- Middle Aged
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/metabolism
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Prospective Studies
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
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Affiliation(s)
- Danielle M Bello
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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31
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Vieira AF, Schmitt F. An Update on Breast Cancer Multigene Prognostic Tests-Emergent Clinical Biomarkers. Front Med (Lausanne) 2018; 5:248. [PMID: 30234119 PMCID: PMC6131478 DOI: 10.3389/fmed.2018.00248] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
Multigene signatures generate crucial prognostic information particularly useful for cancer patients where clinical parameters and traditional immunohistochemical markers alone lead to equivocal prognosis. Clinicians are now provided with molecular tools that assist in the outline of adjuvant therapies, namely helping decide on the extension of adjuvant endocrine therapy or on suppressing adjuvant chemotherapy in patients were toxic effects are particularly deleterious or when this treatment is fundamentally not needed. The importance of cancer multigene prognostic signatures is well elucidated in the guidelines for adjuvant systemic therapy in early-stage breast cancer and the guidelines on disease staging that are progressively integrating gene expression assays as classification biomarkers. In addition to the predictive and prognostic value, some genetic tests provide intrinsic subtyping classification. Herewith, we compare the molecular tests OncotypeDX, MammaPrint, Prosigna, EndoPredict, Breast Cancer Index, Mammostrat, and IHC4 and report the eligibility of each one in the suitable setting. Through to now, there is not a commercially available multigene test that makes recommendations regarding adjuvant treatment for HER-2 and triple negative breast cancers. Thus, these patients still receive adjuvant chemotherapy. Importantly, triple negative carcinomas are very heterogeneous regarding prognosis and new molecular signatures that decipher this very heterogeneous subgroup of breast cancer may improve the clinical management of the disease.
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Affiliation(s)
- André Filipe Vieira
- IPATIMUP - Epithelial Interactions in Cancer Group, Instituto de Patologia e Imunologia Molecular, Universidade do Porto, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Fernando Schmitt
- IPATIMUP - Epithelial Interactions in Cancer Group, Instituto de Patologia e Imunologia Molecular, Universidade do Porto, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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32
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Tadros AB, Wen HY, Morrow M. Breast Cancers of Special Histologic Subtypes Are Biologically Diverse. Ann Surg Oncol 2018; 25:3158-3164. [PMID: 30094484 DOI: 10.1245/s10434-018-6687-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND/OBJECTIVE Cancers classified as "special histologic subtypes" are felt to have a good prognosis. We used the 21-gene Oncotype DX Breast Recurrence Score® multigene assay to examine prognostic variation within special histologic subtypes. We also examined the Recurrence Score® (RS) distribution among the more common ductal (IDC) and lobular (ILC) cancers. METHODS 610,350 tumor specimens examined in the Genomic Health clinical laboratory from 2/2004 to 8/2017 were included. Specimen histology was classified centrally using a single H&E slide and World Health Organization criteria. RS distribution (low < 18, intermediate 18-30, and high ≥ 31) was compared among histologic subtypes. RESULTS Median patient age was 60 years (IQR 51-67); 80% were node negative. Most patients had low RS results (59.2%); only 9.5% had high results. The lowest mean RS was seen in the papillary subtype (11); the highest in the IDC group (18.4). Mean RS for all special subtypes was lower than that of IDC patients. When the high RS threshold was decreased from 31 to 25, as used in the TAILORx and RxPONDER trials, the number of high RS-result patients increased from 9.5% to 16.8%. Patients with ILC had a lower mean RS result than patients with IDC, 16.5 versus 18.4. CONCLUSION There is substantial diversity in predicted prognosis among patients with cancers classified as special histologic subtypes, with 12-25% having intermediate RS results and 0.5-9% having high RS results. Pending further definition of the role of chemotherapy for patients with intermediate RS results by TAILORx and RxPONDER, the RS result may help to inform systemic therapy decisions in these patients.
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Affiliation(s)
- Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Kurian AW, Bondarenko I, Jagsi R, Friese CR, McLeod MC, Hawley ST, Hamilton AS, Ward KC, Hofer TP, Katz SJ. Recent Trends in Chemotherapy Use and Oncologists' Treatment Recommendations for Early-Stage Breast Cancer. J Natl Cancer Inst 2018; 110:493-500. [PMID: 29237009 PMCID: PMC5946952 DOI: 10.1093/jnci/djx239] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/10/2017] [Accepted: 10/11/2017] [Indexed: 12/27/2022] Open
Abstract
Background There is growing concern about overtreatment of breast cancer as outcomes have improved over time. However, little is known about how chemotherapy use and oncologists' recommendations have changed in recent years. Methods We surveyed 5080 women (70% response rate) diagnosed with breast cancer between 2013 and 2015 and accrued through two Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles) about chemotherapy receipt and their oncologists' chemotherapy recommendations. We surveyed 504 attending oncologists (60.3% response rate ) about chemotherapy recommendations in node-negative and node-positive case scenarios. We conducted descriptive statistics of chemotherapy use and patients' report of oncologists' recommendations and used a generalized linear mixed model of chemotherapy use according to time and clinical factors. All statistical tests were two-sided. Results The analytic sample was 2926 patients with stage I-II, estrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. From 2013 to 2015, keeping other factors constant, chemotherapy use was estimated to decline from 34.5% (95% confidence interval [CI] = 30.8% to 38.3%) to 21.3% (95% CI = 19.0% to 23.7%, P < .001). Estimated decline in chemotherapy use was from 26.6% (95% CI = 23.0% to 30.7%) to 14.1% (95% CI = 12.0% to 16.3%) for node-negative/micrometastasis patients and from 81.1% (95% CI = 76.6% to 85.0%) to 64.2% (95% CI = 58.6% to 69.6%) for node-positive patients. Use of the 21-gene recurrence score (RS) did not change among node-negative/micrometastasis patients, and increasing RS use in node-positive patients accounted for one-third of the chemotherapy decline. Patients' report of oncologists' recommendations for chemotherapy declined from 44.9% (95% CI = 40.2% to 49.7%) to 31.6% (95% CI = 25.9% to 37.9%), controlling for other factors. Oncologists were much more likely to order RS if patient preferences were discordant with their recommendations (67.4%, 95% CI = 61.7% to 73.0%, vs 17.5%, 95% CI = 13.1% to 22.0%, concordant), and they adjusted recommendations based on patient preferences and RS results. Conclusions For both node-negative/micrometastasis and node-positive patients, chemotherapy receipt and oncologists' recommendations for chemotherapy declined markedly over time, without substantial change in practice guidelines. Results of ongoing trials will be essential to confirm the quality of this approach to breast cancer care.
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Affiliation(s)
- Allison W Kurian
- Department of Medicine and Health Research and Policy, Stanford University, Stanford, CA
| | | | - Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine
| | | | | | - Sarah T Hawley
- Department of Health Management and Policy, School of Public Health
- Division of General Medicine, Department of Internal Medicine
- Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, MI
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kevin C Ward
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
| | - Timothy P Hofer
- Veterans Administration Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation, and Department of Internal Medicine
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health
- Division of General Medicine, Department of Internal Medicine
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Qu F, Chen X, Fei X, Lin L, Gao W, Zong Y, Wu J, Huang O, He J, Zhu L, Chen W, Li Y, Shen K. A nomogram to predict adjuvant chemotherapy recommendation in breast cancer patients with intermediate recurrence score. Chin J Cancer Res 2018; 30:222-230. [PMID: 29861607 PMCID: PMC5953958 DOI: 10.21147/j.issn.1000-9604.2018.02.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 12/09/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The indication of adjuvant chemotherapy recommendation (ACR) in breast cancer patients with intermediate recurrence score (RS) is controversial. This study investigated the relationship between routine clinicopathological indicators and ACR, and established a nomogram for predicting the probability of ACR in this subset of patients. METHODS Data for a total of 504 consecutive patients with intermediate RS from January 2014 to December 2016 were retrospectively reviewed. A nomogram was constructed using a multivariate logistic regression model based on data from a training set (378 cases) and validated in an independent validation set (126 cases). A Youden-derived cut-off value was assigned to the nomogram for accuracy evaluation. RESULTS The multivariate logistic regression analysis identified that age, histological grade, tumor size, lymph node (LN) status, molecular subtype, and RS were independent predictors of ACR. A nomogram based on these predictors performed well. The P value of the Hosmer-Lemeshow test for the prediction model was 0.286. The area under the curve (AUC) values were 0.905 [95% confidence interval (95% CI): 0.876-0.934] and 0.883 (95% CI: 0.824-0.942) in the training and validation sets, respectively. The accuracies of the nomogram for ACR were 84.4% in the training set and 82.1% in the validation set. CONCLUSIONS We developed a nomogram to predict the probability of ACR in breast cancer patients with intermediate RS. This model may aid the individual risk assessment and guide treatment decisions in clinical practice.
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Affiliation(s)
- Feilin Qu
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xiaosong Chen
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiaochun Fei
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Lin Lin
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weiqi Gao
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yu Zong
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jiayi Wu
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ou Huang
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jianrong He
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Li Zhu
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weiguo Chen
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yafen Li
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kunwei Shen
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Chandler Y, Schechter CB, Jayasekera J, Near A, O’Neill SC, Isaacs C, Phelps CE, Ray GT, Lieu TA, Ramsey S, Mandelblatt JS. Cost Effectiveness of Gene Expression Profile Testing in Community Practice. J Clin Oncol 2018; 36:554-562. [PMID: 29309250 PMCID: PMC5815401 DOI: 10.1200/jco.2017.74.5034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Gene expression profile (GEP) testing can support chemotherapy decision making for patients with early-stage, estrogen receptor-positive, human epidermal growth factor 2-negative breast cancers. This study evaluated the cost effectiveness of one GEP test, Onco type DX (Genomic Health, Redwood City, CA), in community practice with test-eligible patients age 40 to 79 years. Methods A simulation model compared 25-year societal incremental costs and quality-adjusted life-years (QALYs) of community Onco type DX use from 2005 to 2012 versus usual care in the pretesting era (2000 to 2004). Inputs included Onco type DX and chemotherapy data from an integrated health care system and national and published data on Onco type DX accuracy, chemotherapy effectiveness, utilities, survival and recurrence, and Medicare and patient costs. Sensitivity analyses varied individual parameters; results were also estimated for ideal conditions (ie, 100% testing and adherence to test-suggested treatment, perfect test accuracy, considering test effects on reassurance or worry, and lowest costs). Results Twenty-four percent of test-eligible patients had Onco type DX testing. Testing was higher in younger patients and patients with stage I disease ( v stage IIA), and 75.3% and 10.2% of patients with high and low recurrence risk scores received chemotherapy, respectively. The cost-effectiveness ratio for testing ( v usual care) was $188,125 per QALY. Considering test effects on worry versus reassurance decreased the cost-effectiveness ratio to $58,431 per QALY. With perfect test accuracy, the cost-effectiveness ratio was $28,947 per QALY, and under ideal conditions, it was $39,496 per QALY. Conclusion GEP testing is likely to have a high cost-effectiveness ratio on the basis of community practice patterns. However, realistic variations in assumptions about key variables could result in GEP testing having cost-effectiveness ratios in the range of other accepted interventions. The differences in cost-effectiveness ratios on the basis of community versus ideal conditions underscore the importance of considering real-world implementation when assessing the new technology.
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Affiliation(s)
- Young Chandler
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Clyde B. Schechter
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jinani Jayasekera
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aimee Near
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suzanne C. O’Neill
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudine Isaacs
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles E. Phelps
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - G. Thomas Ray
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tracy A. Lieu
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott Ramsey
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeanne S. Mandelblatt
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
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Tsai M, Lo S, Audeh W, Qamar R, Budway R, Levine E, Whitworth P, Mavromatis B, Zon R, Oldham D, Untch S, Treece T, Blumencranz L, Soliman H. Association of 70-Gene Signature Assay Findings With Physicians' Treatment Guidance for Patients With Early Breast Cancer Classified as Intermediate Risk by the 21-Gene Assay. JAMA Oncol 2018; 4:e173470. [PMID: 29075751 DOI: 10.1001/jamaoncol.2017.3470] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Importance Among patients who undergo the 21-gene assay (21-GA), 39% to 67% receive an intermediate risk result and may receive ambiguous treatment guidance. The 70-gene signature assay (70-GS) may be associated with physicians' treatment decisions in this population with early breast cancer. Objective To determine whether 70-GS findings are associated with physicians' decisions about adjuvant treatment and confidence in their recommendations and to evaluate the dichotomous (high- vs low-risk) and continuous distribution of 70-GS indices among this group of patients with intermediate risk. Design, Setting, and Participants The Prospective Study of MammaPrint in Breast Cancer Patients With an Intermediate Recurrence Score (PROMIS trial) was an impact study conducted from May 20, 2012, through December 31, 2015, that enrolled 840 patients with early-stage breast cancer and a 21-gene assay recurrence score of 18 to 30. Patients were treated in 58 US institutions. Interventions The 70-GS result was given to physicians before adjuvant treatment. Main Outcomes and Measures Change in physician treatment decision before vs after receiving the 70-GS result. With a treatment change of greater than 20%, the odds ratio (OR) was applied. Results Among the 840 patients who underwent 70-GS classification (mean age, 59 years; range, 27-93 years), 374 (44.5%) had a low-risk and 466 (55.5%) had a high-risk result. The distribution of 70-GS indices did not correlate with recurrence score within the 21-GA intermediate range, with 70-GS low- and high-risk patients observed at every recurrence score. A significant change in adjuvant treatment was associated with receiving the 70-GS classifications with an OR of 0.64 (95% CI, 0.50-0.82; McNemar test, P < .001) for all patients. Among the low-risk patients, 108 of 374 (28.9%) had chemotherapy removed from their treatment recommendation; among the high-risk patients, 171 of 466 (36.7%) had chemotherapy added. Results of the 70-GS were associated with the physician's adjuvant treatment recommendation; 409 high-risk patients (87.8%) were recommended to receive adjuvant chemotherapy, and 339 low-risk patients (90.6%) were recommended no chemotherapy. Physicians reported having greater confidence in their treatment recommendation in 660 cases (78.6%) based on 70-GS results. Conclusions and Relevance The 70-GS provides clinically actionable information regarding patients classified as intermediate risk by the 21-GA and was associated with a change in treatment decision in 282 of these patients (33.6%). Chemotherapy was added or withheld by the treating physician based on the results of the 70-GS test. Physicians reported more confidence with their treatment recommendation after receiving 70-GS results.
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Affiliation(s)
- Michaela Tsai
- Virginia Piper Cancer Center, Minneapolis, Minnesota
| | - Shelly Lo
- Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, Maywood, Illinois
| | | | - Rubina Qamar
- Aurora Advanced Healthcare, Milwaukee, Wisconsin
| | - Raye Budway
- St Clair Hospital, Bethel Park, Pennsylvania
| | - Ellis Levine
- Roswell Park Cancer Institute, Buffalo, New York
| | | | - Blanche Mavromatis
- Western Maryland Health System Schwab Family Cancer Center, Cumberland, Maryland
| | - Robin Zon
- Northern Indiana Cancer Research Consortium, South Bend, Indiana
| | | | | | | | - Lisa Blumencranz
- Agendia, Inc, Irvine, California.,Department of Biochemistry and Molecular Biology, Miller School of Medicine, University of Miami, Miami, Florida
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Turashvili G, Brogi E, Morrow M, Dickler M, Norton L, Hudis C, Wen HY. Breast carcinoma with 21-gene recurrence score lower than 18: rate of locoregional recurrence in a large series with clinical follow-up. BMC Cancer 2018; 18:42. [PMID: 29304773 PMCID: PMC5756373 DOI: 10.1186/s12885-017-3985-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/27/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The 21-gene recurrence score (RS) assay determines the benefit of adding chemotherapy to endocrine therapy for patients with early stage, estrogen receptor (ER)-positive, HER2-negative breast cancer. The RS risk groups predict the likelihood of distant recurrence and have recently been associated with an increased risk of locoregional recurrence (LRR). This study analyzed clinicopathologic features of patients with low RS and LRR. METHODS In our institutional database, we identified 1396 consecutive female patients with lymph node negative, ER+/HER2- invasive breast carcinoma and low RS (<18) results, treated at our center from 2008 to 2013. We collected data on clinicopathologic features, treatment and outcome. RESULTS The median patient age was 57 years (range 22-90). The median tumor size was 1.2 cm (range 0.3-5.8). Overall, 66.6% (930/1396) women were treated with breast conserving surgery (BCS) and radiation therapy, 3.4% (48/1396) with BCS alone, 29.7% (414/1396) with total mastectomy, and 0.3% (4/1396) with total mastectomy and radiation therapy. Most patients (84.8%; 1184/1396) received endocrine therapy alone, 12.1% (169/1396) were treated with chemotherapy plus endocrine therapy, and only 3.1% (43/1396) received no systemic therapy. At a median follow-up of 52 months, 0.9% (13/1396) of patients developed LRR. Sites of LRR included the ipsilateral breast (n = 8), chest wall (n = 3), axillary node (n = 1), and internal mammary node (n = 1). All patients with LRR had negative resection margins at the initial surgery. The rate of LRR in patients treated with adjuvant endocrine therapy alone was 0.7% (8/1184). All eight patients received standard local treatment. Three patients had lymphovascular invasion but no other significant risk factors for LRR were identified. CONCLUSIONS Our study of node negative, ER+/HER2- breast cancer patients with low RS observed extremely low rates of LRR: 0.9% (13/1396) in the whole cohort and 0.7% (8/1184) in patients treated with endocrine therapy alone. As the largest series to date, we report detailed clinicopathologic data and clinical outcomes of this cohort and provide a comprehensive characterization of patients who developed LRR.
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Affiliation(s)
- Gulisa Turashvili
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Maura Dickler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Larry Norton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Clifford Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Ohri N, Sittig MP, Tsai CJ, Hwang ESS, Mittendorf EA, Shi W, Zhang Z, Ho AY. Trends and variations in postmastectomy radiation therapy for breast cancer in patients with 1 to 3 positive lymph nodes: A National Cancer Data Base analysis. Cancer 2017; 124:482-490. [PMID: 29112227 DOI: 10.1002/cncr.31080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND High-level evidence is lacking to guide treatment decisions about postmastectomy radiation therapy (PMRT) in patients who have breast cancer with 1 to 3 positive lymph nodes who receive contemporary systemic therapies, leading to potential variations in PMRT delivery. The objective of this study was to examine nationwide trends in PMRT use in this group. METHODS The National Cancer Data Base (NCDB) was used to identify 93,372 women who had T1-T2N1 breast cancer diagnosed between 2003 and 2012. Patients who received neoadjuvant chemotherapy or radiation therapy (RT) and those who had bilateral breast cancers were excluded. Time trends were evaluated using the Cochrane-Armitage test and correlated the receipt of PMRT with various patient demographic, facility, clinicopathologic, and treatment variables using multivariable logistic regression. A second analysis was performed for patients who were diagnosed during 2010 and included radiation oncologist density as an additional covariate. P values < .0001 were considered statistically significant. RESULTS Overall, 22.5% of the study population received PMRT, representing an increase from 19.1% in 2003 to 30.3% in 2012. Factors associated with greater PMRT use included younger age, lower Charlson-Deyo comorbidity scores, shorter distance to the treating facility, treatment at a comprehensive cancer program, facility location in the New England Census division, and higher density of radiation oncologists. Increased PMRT use was associated with later year of diagnosis, receipt of chemotherapy, receipt of hormone therapy, higher grade disease, larger tumor size, greater numbers of positive lymph nodes, positive margins, and absence of immediate breast reconstruction (all P < .0001). CONCLUSIONS The receipt of PMRT by patients with breast cancer who have 1 to 3 positive lymph nodes has increased over time, with wide variability in practice patterns in the United States. Cancer 2018;124:482-90. © 2017 American Cancer Society.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Mark P Sittig
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Elizabeth Ann Mittendorf
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Weiji Shi
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Y Ho
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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Peethambaram PP, Hoskin TL, Day CN, Goetz MP, Habermann EB, Boughey JC. Use of 21-gene recurrence score assay to individualize adjuvant chemotherapy recommendations in ER+/HER2- node positive breast cancer-A National Cancer Database study. NPJ Breast Cancer 2017; 3:41. [PMID: 29067357 PMCID: PMC5648884 DOI: 10.1038/s41523-017-0044-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/28/2022] Open
Abstract
The 21-gene Recurrence Score (RS) assay is prognostic and predictive of adjuvant chemotherapy benefit in node positive (N+) breast cancer (BC). We sought to evaluate use patterns of RS assay in N+, ER+/HER2- BC and the impact of RS on recommendations for adjuvant chemotherapy. Patients with T1-T4c,N1mi-N3, ER+/HER2- BC diagnosed 2010-2013 in the National Cancer Database were analyzed. Multivariable logistic regression assessed factors influencing RS testing and chemotherapy recommendations based on RS. Among 72,897 patients, RS was obtained in 20.6%, increasing from 15.0% in 2010 to 24.5% in 2013 (p < 0.001). RS testing was most common in N1mi (43.7%) followed by N1 (22.1%) and rare in N2/N3 (3.3%). Of the 12,536 with quantitative RS results, 61.1% were low RS, 32.3% intermediate RS and 6.6% high RS. Chemotherapy was recommended less frequently in patients with RS testing (50.4%) vs. those not tested (81.0%, p < 0.001). In N1mi/N1 patients, chemotherapy recommendation varied by RS; however, in N2/N3 patients, chemotherapy was recommended in the majority (70.9-87.5%) regardless of RS. Most patients (>85%) with RS ≥ 26 were recommended chemotherapy regardless of nodal stage. For patients with RS < 26, chemotherapy recommendations increased with higher N and T stage, grade, and younger age (p < 0.001). Histology was not associated with chemotherapy recommendation in any RS subset. The RS assay is frequently and increasingly being used for decision making in node positive ER+/HER2- breast cancer patients and its use is associated with lower rates of adjuvant chemotherapy.
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Affiliation(s)
| | | | | | | | - Elizabeth B. Habermann
- Health Care Policy and Research and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN USA
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Phillips KA, Deverka PA, Sox HC, Khoury MJ, Sandy LG, Ginsburg GS, Tunis SR, Orlando LA, Douglas MP. Making genomic medicine evidence-based and patient-centered: a structured review and landscape analysis of comparative effectiveness research. Genet Med 2017; 19:1081-1091. [PMID: 28406488 PMCID: PMC5629101 DOI: 10.1038/gim.2017.21] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/24/2017] [Indexed: 01/15/2023] Open
Abstract
Comparative effectiveness research (CER) in genomic medicine (GM) measures the clinical utility of using genomic information to guide clinical care in comparison to appropriate alternatives. We summarized findings of high-quality systematic reviews that compared the analytic and clinical validity and clinical utility of GM tests. We focused on clinical utility findings to summarize CER-derived evidence about GM and identify evidence gaps and future research needs. We abstracted key elements of study design, GM interventions, results, and study quality ratings from 21 systematic reviews published in 2010 through 2015. More than half (N = 13) of the reviews were of cancer-related tests. All reviews identified potentially important clinical applications of the GM interventions, but most had significant methodological weaknesses that largely precluded any conclusions about clinical utility. Twelve reviews discussed the importance of patient-centered outcomes, although few described evidence about the impact of genomic medicine on these outcomes. In summary, we found a very limited body of evidence about the effect of using genomic tests on health outcomes and many evidence gaps for CER to address.Genet Med advance online publication 13 April 2017.
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Affiliation(s)
- Kathryn A. Phillips
- Department of Clinical Pharmacy, Center
for Translational and Policy Research on Personalized Medicine (TRANSPERS), UCSF
Philip R. Lee Institute for Health Policy and UCSF Helen Diller Family
Comprehensive Cancer Center, University of California at San Francisco,
San Francisco, California, USA
| | | | - Harold C. Sox
- Patient-Centered Outcomes Research
Institute, Washington, DC, USA
| | - Muin J. Khoury
- Office of Public Health Genomics, US
Centers for Disease Control and Prevention, Atlanta,
Georgia, USA
| | | | - Geoffrey S. Ginsburg
- Duke Center for Applied Genomics and
Precision Medicine, Duke University Medical Center, Durham,
North Carolina, USA
| | - Sean R. Tunis
- Center for Medical Technology
Policy, Baltimore, Maryland, USA
| | - Lori A. Orlando
- Division of General Internal Medicine,
Department of Medicine, Duke University Medical Center, Durham,
North Carolina, USA
| | - Michael P. Douglas
- University of California at San
Francisco, Department of Clinical Pharmacy, Center for Translational and Policy
Research on Personalized Medicine (TRANSPERS), San Francisco,
California, USA
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Turashvili G, Chou JF, Brogi E, Morrow M, Dickler M, Norton L, Hudis C, Wen HY. 21-Gene recurrence score and locoregional recurrence in lymph node-negative, estrogen receptor-positive breast cancer. Breast Cancer Res Treat 2017; 166:69-76. [PMID: 28702894 DOI: 10.1007/s10549-017-4381-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE The 21-gene recurrence score (RS) assay evaluates the likelihood of distant recurrence and benefit of chemotherapy in lymph node-negative, estrogen receptor (ER)-positive, HER2-negative breast cancer patients. The RS categories are associated with the risk of locoregional recurrence (LRR) in some, but not all studies. METHODS We reviewed the institutional database to identify consecutive female patients with node-negative, ER+/HER2- breast carcinoma tested for the 21-gene RS assay and treated at our center from 2008 to 2013. We collected data on clinicopathologic features, treatment, and outcome. Statistical analysis was performed using SAS version 9.4 or R version 3.3.2. RESULTS Of 2326 patients, 60% (1394) were in the low RS group, 33.4% (777) in the intermediate RS group, and 6.6% (155) in the high RS group. Median follow-up was 53 months. A total of 44 LRRs were observed, with a cumulative incidence of 0.17% at 12 months and 1.6% at 48 months. The cumulative incidence of LRR at 48 months was 0.84%, 2.72% and 2.80% for low, intermediate, and high RS groups, respectively (p < 0.01). Univariate analysis showed that the risk of LRR was associated with the RS categories (p < 0.01), T stage (p < 0.01) and lymphovascular invasion (LVI) (p = 0.009). There was no difference in LRR rates by initial local treatment (total mastectomy vs. breast-conserving surgery plus radiation therapy). The RS remained significantly associated with LRR after adjusting for LVI and T stage. Compared to patients with low RS, the risk of LRR was increased more than 4-fold (hazard ratio: 4.61, 95% CI 1.90-11.19, p < 0.01), and 3-fold (hazard ratio: 2.81, 95% CI 1.41-5.56, p < 0.01) for high and intermediate risk categories, respectively. CONCLUSIONS Our study confirms that RS is significantly associated with the risk of LRR in node-negative, ER+/HER2- breast cancer patients. Our findings suggest that in addition to its value for prognostic stage grouping and decision-making regarding adjuvant systemic therapy, the role of the RS in identifying patients not requiring radiotherapy should be studied.
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Affiliation(s)
- Gulisa Turashvili
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Joanne F Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, 10017, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Maura Dickler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Larry Norton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Clifford Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, USA
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Lal S, McCart Reed AE, de Luca XM, Simpson PT. Molecular signatures in breast cancer. Methods 2017; 131:135-146. [PMID: 28669865 DOI: 10.1016/j.ymeth.2017.06.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 12/12/2022] Open
Abstract
The use of molecular signatures to add value to standard clinical and pathological parameters has impacted clinical practice in many cancer types, but perhaps most notably in the breast cancer field. This is, in part, due to the considerable complexity of the disease at the clinical, morphological and molecular levels. The adoption of molecular profiling of DNA, RNA and protein continues to reveal important differences in the intrinsic biology between molecular subtypes and has begun to impact the way patients are managed. Several bioinformatic tools have been developed using DNA or RNA-based signatures to stratify the disease into biologically and/or clinically meaningful subgroups. Here, we review the approaches that have been used to develop gene expression signatures into currently available diagnostic assays (e.g., OncotypeDX® and Mammaprint®), plus we describe the latest work on genome sequencing, the methodologies used in the discovery process of mutational signatures, and the potential of these signatures to impact the clinic.
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Affiliation(s)
- Samir Lal
- The University of Queensland, Centre for Clinical Research, Faculty of Medicine, Herston, QLD 4029, Australia
| | - Amy E McCart Reed
- The University of Queensland, Centre for Clinical Research, Faculty of Medicine, Herston, QLD 4029, Australia
| | - Xavier M de Luca
- The University of Queensland, Centre for Clinical Research, Faculty of Medicine, Herston, QLD 4029, Australia
| | - Peter T Simpson
- The University of Queensland, Centre for Clinical Research, Faculty of Medicine, Herston, QLD 4029, Australia.
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The 21-gene recurrence score in special histologic subtypes of breast cancer with favorable prognosis. Breast Cancer Res Treat 2017; 165:65-76. [PMID: 28577081 DOI: 10.1007/s10549-017-4326-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE The 21-gene recurrence score (RS) assay predicts the likelihood of distant recurrence and chemotherapy benefit in early-stage, estrogen receptor (ER)-positive, HER2-negative breast cancer. Data on the RS of special histologic subtypes of invasive breast carcinoma with favorable prognosis are limited. METHODS We reviewed our institutional database to identify patients with special histologic subtypes of breast cancer associated with favorable prognosis and available RS results. Our cohort consists of fifty-seven women: thirty-three patients with pure mucinous carcinoma (MC), ten with tubular carcinoma (TC), nine with encapsulated papillary carcinoma (EPC), and five with solid papillary carcinoma (SPC). RESULTS Most (44/57, 77.2%) carcinomas had low RS (≤17), and none had high RS (≥31). All EPCs had low RS, but other subtypes had RS 18-30. Higher RS was associated with lower progesterone receptor (PR) expression by immunohistochemistry and lower PR mRNA scores (P ≤ 0.007). No morphologic feature (tumor grade, biopsy site changes, cellular stroma, inflammatory cells) was associated with RS ≥ 18. At a median follow-up of 40 months, the distant recurrence-free survival was 100%. One patient with SPC developed locoregional recurrence at 22 months. CONCLUSIONS As the largest series to date, our study raises the question of whether the RS assay is necessary for breast cancers with favorable histology. Reflex testing of node-negative, ER+/HER2- breast cancers may be deferred for these special histologic subtypes, emphasizing the need for multidisciplinary discussions between breast pathologists and other members of the breast cancer team.
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Axillary Ultrasound Accurately Excludes Clinically Significant Lymph Node Disease in Patients With Early Stage Breast Cancer. Ann Surg 2017; 264:1098-1102. [PMID: 26779976 DOI: 10.1097/sla.0000000000001549] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess the performance characteristics of axillary ultrasound (AUS) for accurate exclusion of clinically significant axillary lymph node (ALN) disease. BACKGROUND Sentinel lymph node biopsy (SLNB) is currently the standard of care for staging the axilla in patients with clinical T1-T2, N0 breast cancer. AUS is a noninvasive alternative to SLNB for staging the axilla. METHODS Patients were identified using a prospectively maintained database. Sensitivity, specificity, and negative predictive value (NPV) were calculated by comparing AUS findings to pathology results. Multivariate analyses were performed to identify patient and/or tumor characteristics associated with false negative (FN) AUS. A blinded review of FN and matched true negative cases was performed by 2 independent medical oncologists to compare treatment recommendations and actual treatment received. Recurrence-free survival was described using Kaplan-Meier product limit methods. RESULTS A total of 647 patients with clinical T1-T2, N0 breast cancer underwent AUS between January 2008 and March 2013. AUS had a sensitivity of 70%, NPV of 84%, and PPV of 56% for the detection of ALN disease. For detection of clinically significant disease (>2.0 mm), AUS had a sensitivity of 76% and NPV of 89%. FN AUS did not significantly impact adjuvant medical decision making. Patients with FN AUS had recurrence-free survival equivalent to patients with pathologic N0 disease. CONCLUSIONS AUS accurately excludes clinically significant ALN disease in patients with clinical T1-T2, N0 breast cancer. AUS may be an alternative to SLNB in these patients, where axillary surgery is no longer considered therapeutic, and predictors of tumor biology are increasingly used to make adjuvant therapy decisions.
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Park S, Lee SK, Paik HJ, Ryu JM, Kim I, Bae SY, Yu J, Kim SW, Lee JE, Nam SJ. Adjuvant endocrine therapy alone in patients with node-positive, luminal A type breast cancer. Medicine (Baltimore) 2017; 96:e6777. [PMID: 28562530 PMCID: PMC5459695 DOI: 10.1097/md.0000000000006777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Luminal A breast cancer has a much better prognosis than other subtypes, with a low risk of local or regional recurrence. However, there is controversy around under- versus overtreatment with regard to adjuvant treatment of node-positive, luminal A breast cancer. The purpose of this study was to identify whether adjuvant systemic chemotherapy has any benefit in node-positive, luminal A breast cancer and to evaluate feasibility of endocrine therapy without chemotherapy in this group.This was a retrospective study of 11,025 patients who were surgically treated for invasive breast cancer at Samsung Medical Center between January 2004 and December 2013. Luminal A subtype was defined as ER+, HER2-, and Ki-67 < 14%. We compared AC based (AC: doxorubicin or epirubicin, plus cyclophosphamide) adjuvant chemotherapy versus endocrine therapy without chemotherapy in patients with node-positive, luminal A breast cancer.We performed 1: n matching, with a maximum n of 8 on endocrine therapy group (n = 50) to chemotherapy group (n = 642). The median age of the patients in each group at the time of surgery was 58.3 ± 9.5 years in the chemotherapy group and 58.7 ± 11.7 in the endocrine therapy only group. The median follow-up time was 51.9 months (range, 1-125 months). In multivariable analysis, omission of adjuvant chemotherapy in luminal A cancer had no influence on OS and DFS. Axillary lymph node metastasis and progesterone receptor (PR) status were significantly different between the endocrine therapy alone group and the chemotherapy group in terms of OS. Nuclear grade, PR status, and adjuvant radiotherapy were significantly different between the endocrine therapy alone group and the chemotherapy group with regard to DFS. In survival analysis, there were no differences in OS (P = .137) and DFS (P = .225) between the 2 groups.Adjuvant chemotherapy could provide little benefit to postmenopausal patients with luminal A, node-positive breast cancer, and endocrine therapy alone may help reduce morbidity. Future studies with a large number of patients and longer follow-up time are necessary to determine whether chemotherapy might be avoided in this patient population.
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Affiliation(s)
- Sungmin Park
- Department of Surgery, Chungbuk National University Hospital, College of Medicine, Chungbuk National University, Cheong-ju, Republic of Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyungkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun-June Paik
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Isaac Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Youn Bae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyungkwan University School of Medicine, Seoul, Republic of Korea
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Xin L, Liu YH, Martin TA, Jiang WG. The Era of Multigene Panels Comes? The Clinical Utility of Oncotype DX and MammaPrint. World J Oncol 2017; 8:34-40. [PMID: 29147432 PMCID: PMC5649994 DOI: 10.14740/wjon1019w] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 11/15/2022] Open
Abstract
The AJCC Cancer Staging Manual, eighth edition published in late 2016, will become the new global guideline for cancer diagnosis and treatment from January 1, 2018. The new edition for the tumor staging system has numerous updates, including building up the prognostic stage group of tumors for the first time and adding a large number of non-anatomical factors into the prognostic evaluation. Oncotype DX and MammaPrint are two of the genomic predictors that will be part of routine clinical practice in the future. Numerous studies have proved the clinical utility of multigene panels in predicting clinical outcome and treatment response. Here we present our review of the studies on these multigene panels and their application to breast cancer.
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Affiliation(s)
- Ling Xin
- Department of Breast Disease, Peking University First Hospital, Xishiku Street, Xicheng District, Beijing 100034, China.,Cardiff China Medical Research Collaborative (CCMRC), School of Medicine, Cardiff University, Ground Floor, Henry Welcome Building, Heath Park, Cardiff CF14 4XN, UK
| | - Yin-Hua Liu
- Department of Breast Disease, Peking University First Hospital, Xishiku Street, Xicheng District, Beijing 100034, China
| | - Tracey A Martin
- Cardiff China Medical Research Collaborative (CCMRC), School of Medicine, Cardiff University, Ground Floor, Henry Welcome Building, Heath Park, Cardiff CF14 4XN, UK
| | - Wen G Jiang
- Cardiff China Medical Research Collaborative (CCMRC), School of Medicine, Cardiff University, Ground Floor, Henry Welcome Building, Heath Park, Cardiff CF14 4XN, UK
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Felts JL, Zhu J, Han B, Smith SJ, Truica CI. An Analysis of Oncotype DX Recurrence Scores and Clinicopathologic Characteristics in Invasive Lobular Breast Cancer. Breast J 2017; 23:677-686. [DOI: 10.1111/tbj.12751] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Junjia Zhu
- Department of Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania
| | - Bing Han
- Department of Pathology; Penn State Hershey Medical Center; Hershey Pennsylvania
| | - Stanley J. Smith
- Department of Surgery; Penn State Hershey Medical Center; Hershey Pennsylvania
| | - Cristina I. Truica
- Department of Hematology Oncology; Penn State Cancer Institute; Hershey Pennsylvania
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Algorithms for prediction of the Oncotype DX recurrence score using clinicopathologic data: a review and comparison using an independent dataset. Breast Cancer Res Treat 2017; 162:1-10. [PMID: 28064383 DOI: 10.1007/s10549-016-4093-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/23/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Given the potential savings in cost and resource utilization, several algorithms have been proposed to predict Oncotype DX recurrence score (ODX RS) using commonly acquired histopathologic variables. Although it is promising, additional independent validation of these surrogate markers is needed prior to guide the patient management. METHODS In this retrospective study, we analyzed 305 patients with invasive breast cancer at our institution who had ODX RS available. We selected five equations that provide a surrogate measure of ODX as previously published by Klein et al. (Magee equations 1-3), Gage et al., and Tang et al. All equations used estrogen receptor status and progesterone receptor status along with different combinations of grade, proliferation indices (Ki-67, mitotic rate), HER2 status, and tumor size. RESULTS Of all surrogate scores tested, the Magee equation 2 provided the highest correlation with ODX both with regard to raw score (Pearson's correlation coefficient = 0.66 95% CI 0.59-0.72) and categorical correlation (Cohen's kappa = 0.43, 95% CI 0.33-0.53). Although Magee equation 2 provided a way to reliably identify high-risk disease by assigning 95% of the patients with high ODX RS to either the intermediate- or high-risk group, it was unable to reliably identify the potential for patients to have intermediate- or high-risk disease by ODX (66% of such patients identified). CONCLUSIONS Although commonly available surrogates for ODX appear to predict high-risk ODX RS, they are unable to reliably rule out the presence of patients with intermediate-risk disease by ODX. Given the potential benefit of adjuvant chemotherapy in women with intermediate-risk disease by ODX, current surrogates are unable to safely substitute for ODX. Characterizing the true recurrence risk in patients with intermediate-risk disease by ODX is critical to the clinical adoption of current surrogate markers and is an area of ongoing clinical trials.
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Sparano JA, Gray R, Oktay MH, Entenberg D, Rohan T, Xue X, Donovan M, Peterson M, Shuber A, Hamilton DA, D’Alfonso T, Goldstein LJ, Gertler F, Davidson NE, Condeelis J, Jones J. A metastasis biomarker (MetaSite Breast™ Score) is associated with distant recurrence in hormone receptor-positive, HER2-negative early-stage breast cancer. NPJ Breast Cancer 2017; 3:42. [PMID: 29138761 PMCID: PMC5678158 DOI: 10.1038/s41523-017-0043-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 08/24/2017] [Accepted: 09/22/2017] [Indexed: 12/16/2022] Open
Abstract
Metastasis is the primary cause of death in early-stage breast cancer. We evaluated the association between a metastasis biomarker, which we call "Tumor Microenviroment of Metastasis" (TMEM), and risk of recurrence. TMEM are microanatomic structures where invasive tumor cells are in direct contact with endothelial cells and macrophages, and which serve as intravasation sites for tumor cells into the circulation. We evaluated primary tumors from 600 patients with Stage I-III breast cancer treated with adjuvant chemotherapy in trial E2197 (NCT00003519), plus endocrine therapy for hormone receptor (HR)+ disease. TMEM were identified and enumerated using an analytically validated, fully automated digital pathology/image analysis method (MetaSite Breast™), hereafter referred to as MetaSite Score (MS). The objectives were to determine the association between MS and distant relapse free interval (DRFI) and relapse free interval (RFI). MS was not associated with tumor size or nodal status, and correlated poorly with Oncotype DX Recurrence Score (r = 0.29) in 297 patients with HR+/HER2- disease. Proportional hazards models revealed a significant positive association between continuous MS and DRFI (p = 0.001) and RFI (p = 0.00006) in HR+/HER2- disease in years 0-5, and by MS tertiles for DRFI (p = 0.04) and RFI (p = 0.01), but not after year 5 or in triple negative or HER2+ disease. Multivariate models in HR+/HER- disease including continuous MS, clinical covariates, and categorical Recurrence Score (<18, 18-30, > 30) showed MS is an independent predictor for 5-year RFI (p = 0.05). MetaSite Score provides prognostic information for early recurrence complementary to clinicopathologic features and Recurrence Score.
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Affiliation(s)
- Joseph A. Sparano
- 0000 0001 2152 0791grid.240283.fMontefiore Medical Center, Albert Einstein College of Medicine, 1695 Eastchester Road, 10461 Bronx, NY USA
| | | | - Maja H. Oktay
- 0000 0001 2152 0791grid.240283.fMontefiore Medical Center, Albert Einstein College of Medicine, 1695 Eastchester Road, 10461 Bronx, NY USA
| | - David Entenberg
- 0000 0001 2152 0791grid.240283.fAlbert Einstein College of Medicine, Bronx, NY USA
| | - Thomas Rohan
- 0000 0001 2152 0791grid.240283.fAlbert Einstein College of Medicine, Bronx, NY USA
| | - Xiaonan Xue
- 0000 0001 2152 0791grid.240283.fAlbert Einstein College of Medicine, Bronx, NY USA
| | - Michael Donovan
- 0000 0001 0670 2351grid.59734.3cMt. Sinai School of Medicine, New York, NY USA
| | | | | | | | | | - Lori J. Goldstein
- 0000 0004 0456 6466grid.412530.1Fox Chase Cancer Center, Philadelphia, PA USA
| | - Frank Gertler
- 0000 0001 2341 2786grid.116068.8Massachusetts Institute of Technology, Boston, MA USA
| | - Nancy E. Davidson
- 0000 0004 0456 9819grid.478063.eUniversity of Pittsburgh Cancer Institute, Pittsburgh, PA USA
| | - John Condeelis
- 0000 0001 2152 0791grid.240283.fAlbert Einstein College of Medicine, Bronx, NY USA
| | - Joan Jones
- 0000 0001 2152 0791grid.240283.fAlbert Einstein College of Medicine, Bronx, NY USA
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