1
|
Zhu E, Zhang L, Wang J, Hu C, Pan H, Shi W, Xu Z, Ai P, Shan D, Ai Z. Deep learning-guided adjuvant chemotherapy selection for elderly patients with breast cancer. Breast Cancer Res Treat 2024; 205:97-107. [PMID: 38294615 DOI: 10.1007/s10549-023-07237-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/29/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE The efficacy of adjuvant chemotherapy in elderly breast cancer patients is currently controversial. This study aims to provide personalized adjuvant chemotherapy recommendations using deep learning (DL). METHODS Six models with various causal inference approaches were trained to make individualized chemotherapy recommendations. Patients who received actual treatment recommended by DL models were compared with those who did not. Inverse probability treatment weighting (IPTW) was used to reduce bias. Linear regression, IPTW-adjusted risk difference (RD), and SurvSHAP(t) were used to interpret the best model. RESULTS A total of 5352 elderly breast cancer patients were included. The median (interquartile range) follow-up time was 52 (30-80) months. Among all models, the balanced individual treatment effect for survival data (BITES) performed best. Treatment according to following BITES recommendations was associated with survival benefit, with a multivariate hazard ratio (HR) of 0.78 (95% confidence interval (CI): 0.64-0.94), IPTW-adjusted HR of 0.74 (95% CI: 0.59-0.93), RD of 12.40% (95% CI: 8.01-16.90%), IPTW-adjusted RD of 11.50% (95% CI: 7.16-15.80%), difference in restricted mean survival time (dRMST) of 12.44 (95% CI: 8.28-16.60) months, IPTW-adjusted dRMST of 7.81 (95% CI: 2.93-11.93) months, and p value of the IPTW-adjusted Log-rank test of 0.033. By interpreting BITES, the debiased impact of patient characteristics on adjuvant chemotherapy was quantified, which mainly included breast cancer subtype, tumor size, number of positive lymph nodes, TNM stages, histological grades, and surgical type. CONCLUSION Our results emphasize the potential of DL models in guiding adjuvant chemotherapy decisions for elderly breast cancer patients.
Collapse
Affiliation(s)
- Enzhao Zhu
- School of Medicine, Tongji University, Shanghai, China
| | - Linmei Zhang
- Department of Periodontics, Stomatological Hospital and Dental School of Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, China
| | - Jiayi Wang
- School of Medicine, Tongji University, Shanghai, China
| | - Chunyu Hu
- School of Medicine, Tenth People's Hospital of Tongji University, Shanghai, China
| | - Huiqing Pan
- School of Medicine, Tongji University, Shanghai, China
| | - Weizhong Shi
- Shanghai Hospital Development Center, Shanghai, China
| | - Ziqin Xu
- Columbia University, New York, NY, USA
| | - Pu Ai
- School of Medicine, Tongji University, Shanghai, China
| | - Dan Shan
- Columbia University, New York, NY, USA
- National University of Ireland, Galway, Ireland
| | - Zisheng Ai
- Department of Medical Statistics, School of Medicine, Tongji University, Shanghai, China.
- Clinical Research Center for Mental Disorders, Chinese-German Institute of Mental Health, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China.
| |
Collapse
|
2
|
Trapani D, Jin Q, Block CC, Freedman RA, Lin NU, Tarantino P, Mittendorf EA, King TA, Lester SC, Brock JE, Tayob N, Bunnell CA, Tolaney SM, Burstein HJ. Identifying Patterns and Barriers in OncotypeDX Recurrence Score Testing in Older Patients With Early-Stage, Estrogen Receptor-Positive Breast Cancer: Implications for Guidance and Reimbursement. JCO Oncol Pract 2023; 19:560-570. [PMID: 37192427 DOI: 10.1200/op.22.00731] [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: 10/28/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To evaluate the clinical patterns of utilization of OncotypeDX Recurrence Score (RS) in early-stage, hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer (BC) at an academic center with previously established internal reflex testing guidelines. METHODS RS testing in accordance with preexisting reflex criteria and predictors of utilization outside of reflex criteria were retrospectively analyzed for the years 2019-2021 in a quality improvement evaluation. Patients were grouped according to OncotypeDX testing within (cohort A) or outside (cohort B) of predefined criteria which included a cap at age older than 65 years. RESULTS Of 1,687 patients whose tumors had RS testing, 1,087 were in cohort A and 600 in cohort B. In cohort B, nearly half of patients were older than 65 years (n = 279; IQR, 67-72 years). For patients older than 65 years, those with RS testing were younger (median age: 69 v 73 years), with higher grade cancers (G2-3: 84.9% v 54.7%) and were more likely to be treated with chemotherapy (15.4% v 4.1%). Issues for implementation of RS testing in older patients were identified, including potential structural barriers related to the current policy on the reimbursements of genomic tests. CONCLUSION Internal guidelines may facilitate standardized utilization of the RS in early-BC. Our data suggest that clinicians preferred broader utilization of RS across the age spectrum, with therapeutically important consequences. Modifying the current policy for reimbursement of RS testing and in internal reflexive testing criteria for those older than 65 years is warranted.
Collapse
Affiliation(s)
- Dario Trapani
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Qingchun Jin
- Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Caroline C Block
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Rachel A Freedman
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nancy U Lin
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Paolo Tarantino
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Tari A King
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Susan C Lester
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
- Breast Pathology, Brigham and Women's Hospital, Boston, MA
| | - Jane E Brock
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
- Breast Pathology, Brigham and Women's Hospital, Boston, MA
| | - Nabihah Tayob
- Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Craig A Bunnell
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sara M Tolaney
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Harold J Burstein
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| |
Collapse
|
3
|
Trapani D. Adjuvant Chemotherapy in Older Women With Early Breast Cancer. J Clin Oncol 2023; 41:1652-1658. [PMID: 36716418 DOI: 10.1200/jco.22.02477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.The clinical discussion on the adjuvant chemotherapy in older patients with breast cancer (BC) should routinely include comprehensive considerations of the health implications of competitive comorbidities, the safety of the treatment itself, and the likelihood that an appropriate dose intensity will be received (ie, relative dose intensity > 85%). All these factors have prognostic implications, as recently confirmed in the secondary analysis of the Hurria Older PatiEnts clinical trial. Full-informed, shared decision making is essential to provide best care. Our clinical approach for women with BC age ≥ 65 years is based on a standardized screening for frailty, triggering comprehensive geriatric assessment, as appropriate. We only recommend evidence-based regimens that have showed to reduce the risk of cancer recurrence and potentially increase overall survival. We frequently prefer docetaxel-cyclophosphamide, for hormone receptor-positive BC, on the basis of the subgroup analysis of the USOR-9735 study in older population. We avoid single agents (eg, capecitabine or weekly docetaxel), as showed to be inferior treatments in the CALGB-49907 and ELDA trials, and modified nonstandard regimens, for the lack of strong evidence in support.
Collapse
Affiliation(s)
- Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, IEO, IRCCS, Milan, Italy.,Department of Oncology and Haemato-Oncology, University of Milano, Milan, Italy
| |
Collapse
|
4
|
Lemij AA, Baltussen JC, de Glas NA, Kroep JR, Derks MGM, Liefers GJ, Portielje JEA. Gene expression signatures in older patients with breast cancer: A systematic review. Crit Rev Oncol Hematol 2023; 181:103884. [PMID: 36442749 DOI: 10.1016/j.critrevonc.2022.103884] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/15/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Gene expression signatures have emerged to predict prognosis and guide the use of adjuvant therapy in patients with hormone receptor-positive breast cancer. The objective of this systematic review was to evaluate the prognostic and predictive value of commercially available gene expression signatures as a tool in adjuvant treatment decision-making in older patients with breast cancer. METHODS PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, and Emcare were reviewed for relevant articles published before December 2021. Eligible studies were randomised trials and cohort studies that externally validated commercially available gene expression signatures in patients aged 65 years and older, including studies that presented subanalyses of this age group. Data extraction and risk of bias assessment was performed independently by two investigators. RESULTS Fifteen studies were included. Most studies investigated Oncotype DX, while results from other gene expression signatures were limited. Several studies underlined the prognostic performance of Oncotype DX and Prosigna Risk of Recurrence in older patients. Moreover, Oncotype DX was predictive for older patients with an intermediate-risk recurrence score; chemotherapy could be spared in both lymph node-positive and lymph node-negative disease. CONCLUSIONS Prognostic performance has been demonstrated in older patients for several gene expression signatures. However, additional validation in patients with high-risk tumours is needed before gene expression signatures can be implemented in clinical practice as a prediction tool for adjuvant chemotherapy decision-making in the older age group.
Collapse
Affiliation(s)
- A A Lemij
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J C Baltussen
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - N A de Glas
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - J R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - M G M Derks
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|