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Phung MT, Tin Tin S, Elwood JM. Prognostic models for breast cancer: a systematic review. BMC Cancer 2019; 19:230. [PMID: 30871490 PMCID: PMC6419427 DOI: 10.1186/s12885-019-5442-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 03/06/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Breast cancer is the most common cancer in women worldwide, with a great diversity in outcomes among individual patients. The ability to accurately predict a breast cancer outcome is important to patients, physicians, researchers, and policy makers. Many models have been developed and tested in different settings. We systematically reviewed the prognostic models developed and/or validated for patients with breast cancer. METHODS We conducted a systematic search in four electronic databases and some oncology websites, and a manual search in the bibliographies of the included studies. We identified original studies that were published prior to 1st January 2017, and presented the development and/or validation of models based mainly on clinico-pathological factors to predict mortality and/or recurrence in female breast cancer patients. RESULTS From the 96 articles selected from 4095 citations found, we identified 58 models, which predicted mortality (n = 28), recurrence (n = 23), or both (n = 7). The most frequently used predictors were nodal status (n = 49), tumour size (n = 42), tumour grade (n = 29), age at diagnosis (n = 24), and oestrogen receptor status (n = 21). Models were developed in Europe (n = 25), Asia (n = 13), North America (n = 12), and Australia (n = 1) between 1982 and 2016. Models were validated in the development cohorts (n = 43) and/or independent populations (n = 17), by comparing the predicted outcomes with the observed outcomes (n = 55) and/or with the outcomes estimated by other models (n = 32), or the outcomes estimated by individual prognostic factors (n = 8). The most commonly used methods were: Cox proportional hazards regression for model development (n = 32); the absolute differences between the predicted and observed outcomes (n = 30) for calibration; and C-index/AUC (n = 44) for discrimination. Overall, the models performed well in the development cohorts but less accurately in some independent populations, particularly in patients with high risk and young and elderly patients. An exception is the Nottingham Prognostic Index, which retains its predicting ability in most independent populations. CONCLUSIONS Many prognostic models have been developed for breast cancer, but only a few have been validated widely in different settings. Importantly, their performance was suboptimal in independent populations, particularly in patients with high risk and in young and elderly patients.
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Affiliation(s)
- Minh Tung Phung
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Sandar Tin Tin
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - J. Mark Elwood
- Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
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Van Belle V, Van Calster B, Brouckaert O, Vanden Bempt I, Pintens S, Harvey V, Murray P, Naume B, Wiedswang G, Paridaens R, Moerman P, Amant F, Leunen K, Smeets A, Drijkoningen M, Wildiers H, Christiaens MR, Vergote I, Van Huffel S, Neven P. Qualitative Assessment of the Progesterone Receptor and HER2 Improves the Nottingham Prognostic Index Up to 5 Years After Breast Cancer Diagnosis. J Clin Oncol 2010; 28:4129-34. [DOI: 10.1200/jco.2009.26.4200] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo investigate whether the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) can improve the Nottingham Prognostic Index (NPI) in the classification of patients with primary operable breast cancer for disease-free survival (DFS).Patients and MethodsThe analysis is based on 1,927 patients with breast cancer treated between 2000 and 2005 at the University Hospitals, Leuven. We compared performances of NPI with and without ER, PR and/or HER2. Validation was done on two external data sets containing 862 and 2,805 patients from Oslo (Norway) and Auckland (New Zealand), respectively.ResultsIn the Leuven cohort, median follow-up was 66 months, and 13.7% of patients experienced a breast cancer–related event. Positive staining for ER, PR, and HER2 was detected, respectively, in 86.9%, 75.5%, and 11.9% of patients. Based on multivariate Cox regression modeling, the improved NPI (iNPI) was derived as NPI − PR positivity + HER2 positivity. Validation results showed a risk group reclassification of 20% to 30% of patients when using iNPI with its optimal risk boundaries versus NPI, in a majority of patients to more appropriate risk groups. An additional 10% of patients were classified into the extreme risk groups, where clinical actions are less ambiguous. Survival curves of reclassified patients resembled more closely those for patients in the same iNPI group than those for patients in the same NPI group.ConclusionThe addition of PR and HER2 to NPI increases its 5-year prognostic accuracy. The iNPI can be considered as a clinically useful tool for stratification of patients with breast cancer receiving standard of care.
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Affiliation(s)
- Vanya Van Belle
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Ben Van Calster
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Olivier Brouckaert
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Isabelle Vanden Bempt
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Saskia Pintens
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Vernon Harvey
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Paula Murray
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Björn Naume
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Gro Wiedswang
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Robert Paridaens
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Philippe Moerman
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Frederic Amant
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Karin Leunen
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Ann Smeets
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Maria Drijkoningen
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Hans Wildiers
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Marie-Rose Christiaens
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Ignace Vergote
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Sabine Van Huffel
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
| | - Patrick Neven
- From the Katholieke Universiteit Leuven; Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven; Virga Jesse Hospital, Hasselt, Belgium; Auckland Breast Cancer Registry, Greenlane Clinical Centre; Regional Cancer Centre, Auckland City Hospital, Auckland, New Zealand; Ullevål University; and Norwegian Radium Hospital, Oslo, Norway
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Callagy GM, Pharoah PD, Pinder SE, Hsu FD, Nielsen TO, Ragaz J, Ellis IO, Huntsman D, Caldas C. Bcl-2 is a prognostic marker in breast cancer independently of the Nottingham Prognostic Index. Clin Cancer Res 2006; 12:2468-75. [PMID: 16638854 DOI: 10.1158/1078-0432.ccr-05-2719] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Prognostication of breast cancer using clinicopathologic variables, although useful, remains imperfect. Many reports suggest that gene expression profiling can refine the current approach. Alternatively, it has been shown that panels of proteins assessed by immunohistochemistry might also be useful in this regard. We evaluate the prognostic potential of a panel of markers by immunohistochemistry in a large case series to establish if either a single marker or a panel could improve the prognostic power of the Nottingham Prognostic Index (NPI). We validated the results in an independent series. EXPERIMENTAL DESIGN AND RESULTS The expression of 13 biomarkers was evaluated in 930 breast cancers on a tissue microarray. Eight markers [estrogen receptor (ER), progesterone receptor (PR), Bcl-2, cyclin E, p53, MIB-1, cytokeratin 5/6, and HER2] showed a significant association with survival at 10 years on univariate analysis. On multivariate analysis that included these eight markers and the NPI, only the NPI [hazard ratio (HR), 1.35; 95% confidence interval (95% CI), 1.16-1.56; P = 0.0005], ER (HR, 0.59; 95% CI, 0.39-0.88; P = 0.011), and Bcl-2 (HR, 0.68; 95% CI, 0.46-0.99; P = 0.055) were significant. In a subsequent multivariate analysis that included the NPI, ER, and Bcl-2, only Bcl-2 (HR, 0.62; 95% CI, 0.44-0.87; P = 0.006) remained independent of NPI (HR, 1.50; 95% CI, 1.16-1.56; P = 0.004). In addition, Bcl-2, used as a single marker, was more powerful than the use of a panel of markers. Based on these results, an independent series was used to validate the prognostic significance of Bcl-2. ER and PR were also evaluated in this validation series. Bcl-2 (HR, 0.83; 95% CI, 0.71-0.96; P = 0.018) retained prognostic significance independent of the NPI (HR, 2.04; 95% CI, 1.67-2.51; P < 0.001) with an effect that was maximal in the first 5 years. CONCLUSION Bcl-2 is an independent predictor of breast cancer outcome and seems to be useful as a prognostic adjunct to the NPI, particularly in the first 5 years after diagnosis.
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Affiliation(s)
- Grace M Callagy
- Cancer Genomics Program, Department of Oncology, Hutchison-Medical Research Council Research Centre, University of Cambridge, United Kingdom
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Santiago RJ, Wu L, Harris E, Fox K, Schultz D, Glick J, Solin LJ. Fifteen-year results of breast-conserving surgery and definitive irradiation for Stage I and II breast carcinoma: the University of Pennsylvania experience. Int J Radiat Oncol Biol Phys 2004; 58:233-40. [PMID: 14697443 DOI: 10.1016/s0360-3016(03)01460-3] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine the 15-year outcomes for women with early stage breast cancer after breast conservation therapy. METHODS AND MATERIALS Between 1977 and 1990, 937 women with Stage I and II breast carcinoma (55% T1N0, 16% T2N0, 18% T1N1, and 11% T2N1) underwent lumpectomy, axillary lymphadenectomy, and definitive irradiation. The median patient age was 52 years. Of the 937 patients, 375 (40%) received adjuvant chemotherapy and/or hormonal therapy, including 249 (92%) of the 270 women with pathologically positive nodes. The median follow-up was 10.1 years. RESULTS For the overall group, the 15-year overall survival rate was 71%, and the rate of freedom from distant metastases was 76%. The 15-year local failure rate was 19%. The 15-year contralateral breast cancer rate was 12%. The most common first events were distant failure (13%), local failure (10%), contralateral breast cancer (7%), and second malignant neoplasms (6%). The local failure rate at 10 years for favorable subsets of tumors characterized by mammographic detection, resection with negative margins, treatment with chemotherapy, and treatment with hormones was 8%, 10%, 10%, and 7%, respectively. Local failures were most commonly observed within (true recurrence), or just outside (marginal miss), the primary tumor bed (66%, 85 of 128). The rate of true recurrence or marginal miss at 5, 10, and 15 years was 5%, 10%, and 12%, respectively. CONCLUSION These high rates of survival and local control confirm that breast conservation therapy yields favorable results in women with early breast cancer into the second decade after treatment.
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Affiliation(s)
- Roberto J Santiago
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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