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Ji JH, Ahn SG, Yoo Y, Park SY, Kim JH, Jeong JY, Park S, Lee I. Prediction of a Multi-Gene Assay (Oncotype DX and Mammaprint) Recurrence Risk Group Using Machine Learning in Estrogen Receptor-Positive, HER2-Negative Breast Cancer-The BRAIN Study. Cancers (Basel) 2024; 16:774. [PMID: 38398165 PMCID: PMC10887075 DOI: 10.3390/cancers16040774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/26/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
This study aimed to develop a machine learning-based prediction model for predicting multi-gene assay (MGA) risk categories. Patients with estrogen receptor-positive (ER+)/HER2- breast cancer who had undergone Oncotype DX (ODX) or MammaPrint (MMP) were used to develop the prediction model. The development cohort consisted of a total of 2565 patients including 2039 patients tested with ODX and 526 patients tested with MMP. The MMP risk prediction model utilized a single XGBoost model, and the ODX risk prediction model utilized combined LightGBM, CatBoost, and XGBoost models through soft voting. Additionally, the ensemble (MMP + ODX) model combining MMP and ODX utilized CatBoost and XGBoost through soft voting. Ten random samples, corresponding to 10% of the modeling dataset, were extracted, and cross-validation was performed to evaluate the accuracy on each validation set. The accuracy of our predictive models was 84.8% for MMP, 87.9% for ODX, and 86.8% for the ensemble model. In the ensemble cohort, the sensitivity, specificity, and precision for predicting the low-risk category were 0.91, 0.66, and 0.92, respectively. The prediction accuracy exceeded 90% in several subgroups, with the highest prediction accuracy of 95.7% in the subgroup that met Ki-67 <20 and HG 1~2 and premenopausal status. Our machine learning-based predictive model has the potential to complement existing MGAs in ER+/HER2- breast cancer.
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Affiliation(s)
- Jung-Hwan Ji
- Department of Surgery, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon 22711, Republic of Korea;
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea;
| | - Youngbum Yoo
- Department of Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Republic of Korea;
| | - Shin-Young Park
- Department of Surgery, Inha University Hospital, College of Medicine, Incheon 22332, Republic of Korea;
| | - Joo-Heung Kim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Republic of Korea;
| | - Ji-Yeong Jeong
- Department of AI Research, Neurodigm, Seoul 04790, Republic of Korea;
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ilkyun Lee
- Department of Surgery, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon 22711, Republic of Korea;
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Turner BM, Finkelman BS, Hicks DG, Numbereye N, Moisini I, Dhakal A, Skinner K, Sanders MAG, Wang X, Shayne M, Schiffhauer L, Katerji H, Zhang H. The Rochester Modified Magee Algorithm (RoMMa): An Outcomes Based Strategy for Clinical Risk-Assessment and Risk-Stratification in ER Positive, HER2 Negative Breast Cancer Patients Being Considered for Oncotype DX ® Testing. Cancers (Basel) 2023; 15:cancers15030903. [PMID: 36765860 PMCID: PMC9913115 DOI: 10.3390/cancers15030903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/19/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Multigene genomic profiling has become the standard of care in the clinical risk-assessment and risk-stratification of ER+, HER2- breast cancer (BC) patients, with Oncotype DX® (ODX) emerging as the genomic profile test with the most support from the international community. The current state of the health care economy demands that cost-efficiency and access to testing must be considered when evaluating the clinical utility of multigene profile tests such as ODX. Several studies have suggested that certain lower risk patients can be identified more cost-efficiently than simply reflexing all ER+, HER2- BC patients to ODX testing. The Magee equationsTM use standard histopathologic data in a set of multivariable models to estimate the ODX recurrence score. Our group published the first outcome data in 2019 on the Magee equationsTM, using a modification of the Magee equationsTM combined with an algorithmic approach-the Rochester Modified Magee algorithm (RoMMa). There has since been limited published outcome data on the Magee equationsTM. We present additional outcome data, with considerations of the TAILORx risk-stratification recommendations. METHODS 355 patients with an ODX recurrence score, and at least five years of follow-up or a BC recurrence were included in the study. All patients received either Tamoxifen or an aromatase inhibitor. None of the patients received adjuvant systemic chemotherapy. RESULTS There was no significant difference in the risk of recurrence in similar risk categories (very low risk, low risk, and high risk) between the average Modified Magee score and ODX recurrence score with the chi-square test of independence (p > 0.05) or log-rank test (p > 0.05). Using the RoMMa, we estimate that at least 17% of individuals can safely avoid ODX testing. CONCLUSION Our study further reinforces that BC patients can be confidently stratified into lower and higher-risk recurrence groups using the Magee equationsTM. The RoMMa can be helpful in the initial clinical risk-assessment and risk-stratification of BC patients, providing increased opportunities for cost savings in the health care system, and for clinical risk-assessment and risk-stratification in less-developed geographies where multigene testing might not be available.
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Affiliation(s)
- Bradley M. Turner
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
- Correspondence: ; Tel.: +1-(585)-275-2228; Fax: +1-(585)-341-6725
| | - Brian S. Finkelman
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - David G. Hicks
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Numbere Numbereye
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ioana Moisini
- M. Health Fairview Ridges, Burnsville, MN 55337, USA
| | - Ajay Dhakal
- Department of Medical Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Kristin Skinner
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Mary Ann G. Sanders
- Norton Healthcare, University of Louisville Department of Pathology, Louisville, KY 40292, USA
| | - Xi Wang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Michelle Shayne
- Department of Medical Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Linda Schiffhauer
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Hani Katerji
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Huina Zhang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14620, USA
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Regier DA, Pollard S, McPhail M, Bubela T, Hanna TP, Ho C, Lim HJ, Chan K, Peacock SJ, Weymann D. A perspective on life-cycle health technology assessment and real-world evidence for precision oncology in Canada. NPJ Precis Oncol 2022; 6:76. [PMID: 36284134 PMCID: PMC9596463 DOI: 10.1038/s41698-022-00316-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/29/2022] [Indexed: 11/09/2022] Open
Abstract
Health technology assessment (HTA) can be used to make healthcare systems more equitable and efficient. Advances in precision oncology are challenging conventional thinking about HTA. Precision oncology advances are rapid, involve small patient groups, and are frequently evaluated without a randomized comparison group. In light of these challenges, mechanisms to manage precision oncology uncertainties are critical. We propose a life-cycle HTA framework and outline supporting criteria to manage uncertainties based on real world data collected from learning healthcare systems. If appropriately designed, we argue that life-cycle HTA is the driver of real world evidence generation and furthers our understanding of comparative effectiveness and value. We conclude that life-cycle HTA deliberation processes must be embedded into healthcare systems for an agile response to the constantly changing landscape of precision oncology innovation. We encourage further research outlining the core requirements, infrastructure, and checklists needed to achieve the goal of learning healthcare supporting life-cycle HTA.
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Affiliation(s)
- Dean A Regier
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Melanie McPhail
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Tania Bubela
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Timothy P Hanna
- Department of Oncology, Queen's University, Kingston, ON, Canada.,Department of Public Health Science, Queen's University, Kingston, ON, Canada
| | - Cheryl Ho
- Department of Medical Oncology, BC Cancer, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Howard J Lim
- Department of Medical Oncology, BC Cancer, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kelvin Chan
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Stuart J Peacock
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, BC, Canada.
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Skarping I, Nilsson K, Dihge L, Fridhammar A, Ohlsson M, Huss L, Bendahl PO, Steen Carlsson K, Rydén L. The implementation of a noninvasive lymph node staging (NILS) preoperative prediction model is cost effective in primary breast cancer. Breast Cancer Res Treat 2022; 194:577-586. [PMID: 35790694 PMCID: PMC9287207 DOI: 10.1007/s10549-022-06636-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
Abstract
Purpose The need for sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) patients is currently questioned. Our objective was to investigate the cost-effectiveness of a preoperative noninvasive lymph node staging (NILS) model (an artificial neural network model) for predicting pathological nodal status in patients with cN0 breast cancer (BC). Methods A health-economic decision-analytic model was developed to evaluate the utility of the NILS model in reducing the proportion of cN0 patients with low predicted risk undergoing SLNB. The model used information from a national registry and published studies, and three sensitivity/specificity scenarios of the NILS model were evaluated. Subgroup analysis explored the outcomes of breast-conserving surgery (BCS) or mastectomy. The results are presented as cost (€) and quality-adjusted life years (QALYs) per 1000 patients. Results All three scenarios of the NILS model reduced total costs (–€93,244 to –€398,941 per 1000 patients). The overall health benefit allowing for the impact of SLNB complications was a net health gain (7.0–26.9 QALYs per 1000 patients). Sensitivity analyses disregarding reduced quality of life from lymphedema showed a small loss in total health benefits (0.4–4.0 QALYs per 1000 patients) because of the reduction in total life years (0.6–6.5 life years per 1000 patients) after reduced adjuvant treatment. Subgroup analyses showed greater cost reductions and QALY gains in patients undergoing BCS. Conclusion Implementing the NILS model to identify patients with low risk for nodal metastases was associated with substantial cost reductions and likely overall health gains, especially in patients undergoing BCS. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06636-x.
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Affiliation(s)
- Ida Skarping
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund, Sweden.
| | | | - Looket Dihge
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Mattias Ohlsson
- Division of Computational Biology and Biological Physics, Department of Astronomy and Theoretical Physics, Lund University, Lund, Sweden
| | - Linnea Huss
- Division of Surgery, Department of Clinical Sciences Helsingborg, Lund University, Lund, Sweden.,Department of Surgery, Helsingborg General Hospital, Helsingborg, Sweden
| | - Pär-Ola Bendahl
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Katarina Steen Carlsson
- The Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Health Economics, Lund University, Malmö, Lund, Sweden
| | - Lisa Rydén
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Surgery and Gastroenterology, Skåne University Hospital, Malmö, Sweden
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5
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McCabe C, Tramonti G, Sutton A, Hall P, Paulden M. Probabilistic One-Way Sensitivity Analysis with Multiple Comparators: The Conditional Net Benefit Frontier. PHARMACOECONOMICS 2021; 39:19-24. [PMID: 33225423 PMCID: PMC7790773 DOI: 10.1007/s40273-020-00983-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 05/27/2023]
Abstract
Although there have been substantial developments in the analysis of uncertainty in economic evaluations of health care programmes, the development of methods for one-way sensitivity analysis has been notably slower. Conditional incremental net benefit was recently proposed as an approach for implementing probabilistic one-way sensitivity analysis for economic evaluations comparing two strategies. In this paper, we generalise this approach to economic evaluations that compare three or more strategies. We find that 'conditional net benefit' may be used to conduct probabilistic one-way sensitivity analysis for economic evaluations comparing any number of strategies. We also propose the 'conditional net benefit frontier', which may be used to identify the most cost-effective of any number of strategies conditional upon the specific value of a parameter of interest.
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Affiliation(s)
- Christopher McCabe
- Institute of Health Economics, 10405 Jasper Avenue, Edmonton, AB, 1200T5J 3N4, Canada.
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Giovanni Tramonti
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, Scotland, UK
| | - Andrew Sutton
- Institute of Health Economics, 10405 Jasper Avenue, Edmonton, AB, 1200T5J 3N4, Canada
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, Scotland, UK
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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6
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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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7
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Masucci L, Torres S, Eisen A, Trudeau M, Tyono I, Saunders H, Chan KW, Isaranuwatchai W. Cost-utility analysis of 21-gene assay for node-positive early breast cancer. ACTA ACUST UNITED AC 2019; 26:307-318. [PMID: 31708649 DOI: 10.3747/co.26.4769] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background For women with lymph node (ln)-positive, estrogen receptor-positive, and her2 (human epidermal growth factor receptor 2)-negative breast cancer (bca), current guidelines recommend treatment with both hormonal therapy and chemotherapy. The 21-gene Recurrence Score (rs) assay might be helpful in selecting patients with bca who can be spared chemotherapy when they have 1-3 positive lns and a lower risk of recurrence. In the present study, we performed a cost-utility analysis comparing use of the 21-gene rs assay with current practice from the perspective of a Canadian health care payer. Methods A Markov model was developed to determine costs and quality-adjusted life-years (qalys) over a patient's lifetime. Patient outcomes in both study groups were examined based on published clinical trials. Costs were derived primarily from published Canadian sources. Costs and outcomes were discounted at 1.5% annually, and costs are reported in 2016 Canadian dollars. A probabilistic analysis was used, and the model parameters were varied in a sensitivity analysis. Results The results indicate that use of the 21-gene rs assay was less costly ($432 less) and more effective (0.22 qalys) than current practice. The probabilistic analysis revealed that 70% of the 10,000 simulated incremental cost-effectiveness ratios were in the southeast quadrant. The results were sensitive to the probability of a low rs and to the probability of receiving chemotherapy in the low-risk rs category and in current practice. Conclusions Use of the 21-gene rs assay could be a cost-effective strategy for Ontario patients with estrogen receptor-positive, her2-negative early bca and 1-3 positive lns.
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Affiliation(s)
- L Masucci
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - S Torres
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - A Eisen
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - M Trudeau
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - I Tyono
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - H Saunders
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - K W Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON
| | - W Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
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8
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Kunst NR, Alarid-Escudero F, Paltiel AD, Wang SY. A Value of Information Analysis of Research on the 21-Gene Assay for Breast Cancer Management. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1102-1110. [PMID: 31563252 PMCID: PMC7343670 DOI: 10.1016/j.jval.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 05/02/2023]
Abstract
OBJECTIVES The 21-gene assay Oncotype DX (21-GA) shows promise as a guide in deciding when to initiate adjuvant chemotherapy in women with hormone receptor-positive early-stage breast cancer. Nevertheless, its routine use remains controversial, owing to insufficient evidence of its clinical utility and cost-effectiveness. Accordingly, we aim to quantify the value of conducting further research to reduce decision uncertainty in the use of the 21-GA. METHODS Using value of information methods, we first generated probability distributions of survival and costs for decision making with and without the 21-GA alongside traditional risk prediction. These served as the input to a comparison of 3 alternative study designs: a retrospective observational study to update risk classification from the 21-GA, a prospective observational study to estimate prevalence of chemotherapy use, and a randomized controlled trial (RCT) of the 21-GA predictive value. RESULTS We found that current evidence strongly supports the use of the 21-GA in intermediate- and high-risk women. Further research should focus on low-risk women, among whom the cost-effectiveness findings remained equivocal. For this population, we identified a high value of reducing uncertainty in the 21-GA use for all proposed research studies. The RCT had the greatest potential to efficiently reduce the likelihood of choosing a suboptimal strategy, providing a value between $162 million and $1.1 billion at willingness-to-pay thresholds of $150 000 to $200 000/quality-adjusted life years. CONCLUSION Future research to inform 21-GA decision making is of high value. The RCT of the 21-GA predictive value has the greatest potential to efficiently reduce decision uncertainty around 21-GA use in women with low-risk early-stage breast cancer.
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Affiliation(s)
- Natalia R Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands; LINK Medical Research, Oslo, Norway.
| | - Fernando Alarid-Escudero
- Drug Policy Program, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Mexico; National Council on Science and Technology (CONACyT), Mexico City, Mexico
| | - A David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA
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9
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Turner BM, Gimenez-Sanders MA, Soukiazian A, Breaux AC, Skinner K, Shayne M, Soukiazian N, Ling M, Hicks DG. Risk stratification of ER-positive breast cancer patients: A multi-institutional validation and outcome study of the Rochester Modified Magee algorithm (RoMMa) and prediction of an Oncotype DX ® recurrence score <26. Cancer Med 2019; 8:4176-4188. [PMID: 31199586 PMCID: PMC6675710 DOI: 10.1002/cam4.2323] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/25/2019] [Accepted: 05/18/2019] [Indexed: 12/15/2022] Open
Abstract
The skyrocketing cost of health-care demands that we question when to use multigene assay testing in the planning of treatment for breast cancer patients. A previously published algorithmic model gave recommendations for which cases to send out for Oncotype DX® (ODX) testing. This study is a multi-institutional validation of that algorithmic model in 620 additional estrogen receptor positive breast cancer cases, with outcome data on 310 cases, named in this study as the Rochester Modified Magee algorithm (RoMMa). RoMMa correctly predicted 85% (140/164) and 100% (17/17) of cases to have a low- or high-risk ODX recurrence score, respectively, consistent with the original publication. Applying our own risk stratification criteria, in patients who received appropriate hormonal therapy, only one of the 45 (2.0%) patients classified as low risk by our original algorithm have been associated with a breast cancer recurrence over 5-10 years of follow-up. Eight of 116 (7.0%) patients classified as low risk by ODX have been associated with a breast cancer recurrence with up to 11 years of follow-up. In addition, 524 of 537 (98%) cases from our total population (n = 903) with an average modified Magee score ≤18 had an ODX recurrence score <26. Patients with an average modified Magee score ≤18 or >30 may not need to be sent out for ODX testing. By avoiding these cases sending out for ODX testing, the potential cost savings to the health-care system in 2018 are estimated to have been over $100,000,000.
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Affiliation(s)
- Bradley M Turner
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | | | | | - Andrea C Breaux
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, Kentucky
| | - Kristin Skinner
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michelle Shayne
- Department of Medical Oncology, University of Rochester, Rochester, New York
| | - Nyrie Soukiazian
- Drexel University College of Medicine Graduate School of Biomedical and Professional Studies, Philadelphia, Pennsylvania
| | - Marilyn Ling
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - David G Hicks
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
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10
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Flight L, Arshad F, Barnsley R, Patel K, Julious S, Brennan A, Todd S. A Review of Clinical Trials With an Adaptive Design and Health Economic Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:391-398. [PMID: 30975389 DOI: 10.1016/j.jval.2018.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/28/2018] [Accepted: 11/07/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE An adaptive design uses data collected as a clinical trial progresses to inform modifications to the trial. Hence, adaptive designs and health economics aim to facilitate efficient and accurate decision making. Nevertheless, it is unclear whether the methods are considered together in the design, analysis, and reporting of trials. This review aims to establish how health economic outcomes are used in the design, analysis, and reporting of adaptive designs. METHODS Registered and published trials up to August 2016 with an adaptive design and health economic analysis were identified. The use of health economics in the design, analysis, and reporting was assessed. Summary statistics are presented and recommendations formed based on the research team's experiences and a practical interpretation of the results. RESULTS Thirty-seven trials with an adaptive design and health economic analysis were identified. It was not clear whether the health economic analysis accounted for the adaptive design in 17/37 trials where this was thought necessary, nor whether health economic outcomes were used at the interim analysis for 18/19 of trials with results. The reporting of health economic results was suboptimal for the (17/19) trials with published results. CONCLUSIONS Appropriate consideration is rarely given to the health economic analysis of adaptive designs. Opportunities to use health economic outcomes in the design and analysis of adaptive trials are being missed. Further work is needed to establish whether adaptive designs and health economic analyses can be used together to increase the efficiency of health technology assessments without compromising accuracy.
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Affiliation(s)
- Laura Flight
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Fahid Arshad
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Rachel Barnsley
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Kian Patel
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Steven Julious
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Alan Brennan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, England, UK
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11
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Haque W, Verma V, Hatch S, Klimberg VS, Butler EB, Teh BS. Omission of chemotherapy for low-grade, luminal A N1 breast cancer: Patterns of care and clinical outcomes. Breast 2018; 41:67-73. [DOI: 10.1016/j.breast.2018.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 06/25/2018] [Indexed: 11/15/2022] Open
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12
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Kang M, Kim E, Chen S, Bentley WE, Kelly DL, Payne GF. Signal processing approach to probe chemical space for discriminating redox signatures. Biosens Bioelectron 2018; 112:127-135. [DOI: 10.1016/j.bios.2018.04.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/03/2018] [Accepted: 04/16/2018] [Indexed: 12/22/2022]
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13
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Wang SY, Dang W, Richman I, Mougalian SS, Evans SB, Gross CP. Cost-Effectiveness Analyses of the 21-Gene Assay in Breast Cancer: Systematic Review and Critical Appraisal. J Clin Oncol 2018; 36:1619-1627. [PMID: 29659329 DOI: 10.1200/jco.2017.76.5941] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Purpose Prior studies examining cost effectiveness of the 21-gene assay (Oncotype DX [ODX]) for women with hormone receptor-positive, early-stage breast cancer have yielded disparate results. We aimed to explore why these analyses may have yielded different conclusions. Methods We conducted a systematic literature review of cost-effectiveness analyses (CEAs) of ODX. We examined the extent to which the structure of CEA modeling, the assumptions of the models, and the selection of input parameters influenced cost-effectiveness estimates. We also explored the prevalence of industry funding and whether industry funding was associated with study designs favoring ODX. Results We identified 27 analyses, 15 of which received industry funding. In 18 studies, the clinical characteristics (eg, tumor size and grade) commonly used to make chemotherapy decisions were not incorporated into simulation modeling; thus, these studies would favor ODX being cost effective and might not reflect clinical practice. Most studies ignored the heterogeneous effect of ODX on chemotherapy use; only five studies assumed that ODX would increase chemotherapy use for clinically low-risk patients but decrease chemotherapy use for clinically high-risk patients. No study used population-based joint distributions of ODX recurrence score and tumor characteristics, and 12 studies inappropriately assumed that chemotherapy would increase distant recurrence for the low recurrence score group; both approaches overestimated the benefits of ODX. Industry-funded studies tended to favor ODX; all five studies that reported ODX as being cost saving were industry funded. In contrast, two studies that reported an incremental cost-effectiveness ratio > $50,000 per quality-adjusted life-year were not funded by industry. Conclusion Although a majority of published analyses indicated that ODX is cost effective, they incorporated study designs that can increase the risk of bias.
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Affiliation(s)
- Shi-Yi Wang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Weixiong Dang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Ilana Richman
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Sarah S Mougalian
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Suzanne B Evans
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Cary P Gross
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
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14
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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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15
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Hall PS, Smith A, Hulme C, Vargas-Palacios A, Makris A, Hughes-Davies L, Dunn JA, Bartlett JMS, Cameron DA, Marshall A, Campbell A, Macpherson IR, Francis A, Earl H, Morgan A, Stein RC, McCabe C. Value of Information Analysis of Multiparameter Tests for Chemotherapy in Early Breast Cancer: The OPTIMA Prelim Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1311-1318. [PMID: 29241890 DOI: 10.1016/j.jval.2017.04.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 04/19/2017] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Precision medicine is heralded as offering more effective treatments to smaller targeted patient populations. In breast cancer, adjuvant chemotherapy is standard for patients considered as high-risk after surgery. Molecular tests may identify patients who can safely avoid chemotherapy. OBJECTIVES To use economic analysis before a large-scale clinical trial of molecular testing to confirm the value of the trial and help prioritize between candidate tests as randomized comparators. METHODS Women with surgically treated breast cancer (estrogen receptor-positive and lymph node-positive or tumor size ≥30 mm) were randomized to standard care (chemotherapy for all) or test-directed care using Oncotype DX™. Additional testing was undertaken using alternative tests: MammaPrintTM, PAM-50 (ProsignaTM), MammaTyperTM, IHC4, and IHC4-AQUA™ (NexCourse Breast™). A probabilistic decision model assessed the cost-effectiveness of all tests from a UK perspective. Value of information analysis determined the most efficient publicly funded ongoing trial design in the United Kingdom. RESULTS There was an 86% probability of molecular testing being cost-effective, with most tests producing cost savings (range -£1892 to £195) and quality-adjusted life-year gains (range 0.17-0.20). There were only small differences in costs and quality-adjusted life-years between tests. Uncertainty was driven by long-term outcomes. Value of information demonstrated value of further research into all tests, with Prosigna currently being the highest priority for further research. CONCLUSIONS Molecular tests are likely to be cost-effective, but an optimal test is yet to be identified. Health economics modeling to inform the design of a randomized controlled trial looking at diagnostic technology has been demonstrated to be feasible as a method for improving research efficiency.
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Affiliation(s)
- Peter S Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK; Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Alison Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Armando Vargas-Palacios
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Andreas Makris
- Department of Clinical Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, Northwood, UK
| | - Luke Hughes-Davies
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet A Dunn
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - David A Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Campbell
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iain R Macpherson
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | - Adele Francis
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Helena Earl
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Robert C Stein
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
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Blok EJ, Bastiaannet E, van den Hout WB, Liefers GJ, Smit VTHBM, Kroep JR, van de Velde CJH. Systematic review of the clinical and economic value of gene expression profiles for invasive early breast cancer available in Europe. Cancer Treat Rev 2017; 62:74-90. [PMID: 29175678 DOI: 10.1016/j.ctrv.2017.10.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/29/2017] [Indexed: 01/12/2023]
Abstract
Gene expression profiles with prognostic capacities have shown good performance in multiple clinical trials. However, with multiple assays available and numerous types of validation studies performed, the added value for daily clinical practice is still unclear. In Europe, the MammaPrint, OncotypeDX, PAM50/Prosigna and Endopredict assays are commercially available. In this systematic review, we aim to assess these assays on four important criteria: Assay development and methodology, clinical validation, clinical utility and economic value. We performed a literature search covering PubMed, Embase, Web of Science and Cochrane, for studies related to one or more of the four selected assays. We identified 147 papers for inclusion in this review. MammaPrint and OncotypeDX both have evidence available, including level IA clinical trial results for both assays. Both assays provide prognostic information. Predictive value has only been shown for OncotypeDX. In the clinical utility studies, a higher reduction in chemotherapy was achieved by OncotypeDX, although the number of available studies differ considerably between tests. On average, economic evaluations estimate that genomic testing results in a moderate increase in total costs, but that these costs are acceptable in relation to the expected improved patient outcome. PAM50/prosigna and EndoPredict showed comparable prognostic capacities, but with less economical and clinical utility studies. Furthermore, for these assays no level IA trial data are available yet. In summary, all assays have shown excellent prognostic capacities. The differences in the quantity and quality of evidence are discussed. Future studies shall focus on the selection of appropriate subgroups for testing and long-term outcome of validation trials, in order to determine the place of these assays in daily clinical practice.
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Affiliation(s)
- E J Blok
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - W B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - J R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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17
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Dzimitrowicz H, Mougalian S, Storms S, Hurd S, Chagpar AB, Killelea BK, Horowitz NR, Lannin DR, Harigopal M, Hofstatter E, DiGiovanna MP, Adelson KB, Silber A, Abu-Khalaf M, Chung G, Zaheer W, Abdelghany O, Hatzis C, Pusztai L, Sanft TB. Impacts of Early Guideline-Directed 21-Gene Recurrence Score Testing on Adjuvant Therapy Decision Making. J Oncol Pract 2017; 13:e1012-e1020. [PMID: 29048991 DOI: 10.1200/jop.2017.022731] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE The 21-gene recurrence score (RS) assay is used to help formulate adjuvant chemotherapy recommendations for patients with estrogen receptor-positive, early-stage breast cancer. Most frequently, medical oncologists order RS after surgery. Results take an additional 2 weeks to return, which can delay decision making. We conducted a prospective quality-improvement project to assess the impact of early guideline-directed RS ordering by surgeons before the first visit with a medical oncologist on adjuvant therapy decision making. MATERIALS AND METHODS Surgical oncologists ordered RS testing following National Comprehensive Cancer Network guidelines at time of diagnosis or at time of surgery between July 1, 2015 and December 31, 2015. We measured the testing rate of patients eligible for RS, time to chemotherapy decisions, rates of chemotherapy use, accrual to RS-based clinical trials, cost, and physician acceptance of the policy and compared the results to patients who met eligibility criteria for early guideline-directed testing during the 6 months before the project. RESULTS Ninety patients met eligibility criteria during the testing period. RS was ordered for 91% of patients in the early testing group compared with 76% of historical controls ( P < .001). Median time to chemotherapy decision was significantly shorter in the early testing group (20 days; 95% CI, 17 to 23 days) compared with historical controls (32 days; 95% CI, 29 to 35 days; P < .001). There were no significant differences in time to chemotherapy initiation, chemotherapy use, RS-based trial enrollment, or calculated costs between the groups. CONCLUSION Early guideline-directed RS testing in selected patients is an effective way to shorten time to treatment decisions.
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Affiliation(s)
- Hannah Dzimitrowicz
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sarah Mougalian
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sherri Storms
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sandra Hurd
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Anees B Chagpar
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Brigid K Killelea
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Nina R Horowitz
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Donald R Lannin
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Malini Harigopal
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Erin Hofstatter
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Michael P DiGiovanna
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Kerin B Adelson
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Andrea Silber
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Maysa Abu-Khalaf
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Gina Chung
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Wajih Zaheer
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Osama Abdelghany
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Christos Hatzis
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Lajos Pusztai
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Tara B Sanft
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
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18
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Lobo JM, Trifiletti DM, Sturz VN, Dicker AP, Buerki C, Davicioni E, Cooperberg MR, Karnes RJ, Jenkins RB, Den RB, Showalter TN. Cost-effectiveness of the Decipher Genomic Classifier to Guide Individualized Decisions for Early Radiation Therapy After Prostatectomy for Prostate Cancer. Clin Genitourin Cancer 2017; 15:e299-e309. [DOI: 10.1016/j.clgc.2016.08.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 01/09/2023]
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McVeigh TP, Kerin MJ. Clinical use of the Oncotype DX genomic test to guide treatment decisions for patients with invasive breast cancer. BREAST CANCER-TARGETS AND THERAPY 2017; 9:393-400. [PMID: 28615971 PMCID: PMC5459968 DOI: 10.2147/bctt.s109847] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Implementation of the Oncotype DX assay has led to a change in the manner in which chemotherapy is utilized in patients with early stage, estrogen receptor (ER)-positive, node-negative breast cancer; ensuring that patients at highest risk of recurrence are prescribed systemic treatment, while at the same time sparing low-risk patients potential adverse events from therapy unlikely to influence their survival. This test generates a recurrence score between 0 and 100, which correlates with probability of distant disease recurrence. Patients with low-risk recurrence scores (0–17) are unlikely to derive significant survival benefit with adjuvant chemotherapy and hormonal agents derived from using adjuvant hormonal therapy only. Conversely, adjuvant chemotherapy has been shown to significantly improve survival in patients with high-risk recurrence scores (≥31). Trials are ongoing to determine how best to manage patients with recurrence scores in the intermediate range. This review outlines the introduction and impact of Oncotype DX testing on practice; ongoing clinical trials investigating its utility; and challenging clinical scenarios where the absolute recurrence score may require careful interpretation. We also performed a bibliometric analysis of publications on the topics of breast cancer and Oncotype DX as a surrogate marker of acceptability and incorporation of the assay into the management of patients with breast cancer.
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Affiliation(s)
- Terri P McVeigh
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Republic of Ireland
| | - Michael J Kerin
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Republic of Ireland
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Trifiletti DM, Sturz VN, Showalter TN, Lobo JM. Towards decision-making using individualized risk estimates for personalized medicine: A systematic review of genomic classifiers of solid tumors. PLoS One 2017; 12:e0176388. [PMID: 28486497 PMCID: PMC5423583 DOI: 10.1371/journal.pone.0176388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/10/2017] [Indexed: 12/16/2022] Open
Abstract
Recent advances in the understanding of the genetic underpinnings of cancer offer the promise to customize cancer treatments to the individual through the use of genomic classifiers (GCs). At present, routine clinical utilization of GCs is uncommon and their current scope and status, in a broad sense, are unknown. As part of a registered review (PROSPERO 2014:CRD42014013371), we systematically reviewed the literature evaluating the utility of commercially available GCs by searching Ovid Medline (PubMed), EMBASE, the Cochrane Database of Systematic Reviews, and CINAHL on September 2, 2014. We excluded articles involving pediatric malignancies, non-solid or non-invasive cancers, hereditary risk of cancer, non-validated GCs, and GCs involving fewer than 3 biomarkers. A total of 3,625 studies were screened, but only 37 met the pre-specified inclusion criteria. Of these, 15 studies evaluated outcomes and clinical utility of GCs through clinical trials, and the remainder through the use of mathematical models. Most studies (29 of 37) were specific to hormone-receptor positive breast cancer, whereas only 4 studies evaluated GCs in non-breast cancer (prostate, colon, and lung cancers). GCs have spurred excitement across disciplines in recent decades. While there are several GCs that have been validated, the general quality of the data are weak. Further research, including prospective validation is needed, particularly in the non-breast cancer GCs.
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Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Vanessa N. Sturz
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Jennifer M. Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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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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Alarid-Escudero F, Blaes AH, Kuntz KM. Trade-offs Between Efficacy and Cardiac Toxicity of Adjuvant Chemotherapy in Early-Stage Breast Cancer Patients: Do Competing Risks Matter? Breast J 2017; 23:401-409. [DOI: 10.1111/tbj.12757] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Fernando Alarid-Escudero
- Division of Health Policy and Management; University of Minnesota School of Public Health; Minneapolis Minnesota
| | - Anne H. Blaes
- Hematology; Oncology and Transplantation; University of Minnesota; Minneapolis Minnesota
| | - Karen M. Kuntz
- Division of Health Policy and Management; University of Minnesota School of Public Health; Minneapolis Minnesota
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Stein RC, Dunn JA, Bartlett JMS, Campbell AF, Marshall A, Hall P, Rooshenas L, Morgan A, Poole C, Pinder SE, Cameron DA, Stallard N, Donovan JL, McCabe C, Hughes-Davies L, Makris A. OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer. Health Technol Assess 2016; 20:xxiii-xxix, 1-201. [PMID: 26867046 DOI: 10.3310/hta20100] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is uncertainty about the chemotherapy sensitivity of some oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers. Multiparameter assays that measure the expression of several tumour genes simultaneously have been developed to guide the use of adjuvant chemotherapy for this breast cancer subtype. The assays provide prognostic information and have been claimed to predict chemotherapy sensitivity. There is a dearth of prospective validation studies. The Optimal Personalised Treatment of early breast cancer usIng Multiparameter Analysis preliminary study (OPTIMA prelim) is the feasibility phase of a randomised controlled trial (RCT) designed to validate the use of multiparameter assay directed chemotherapy decisions in the NHS. OBJECTIVES OPTIMA prelim was designed to establish the acceptability to patients and clinicians of randomisation to test-driven treatment assignment compared with usual care and to select an assay for study in the main RCT. DESIGN Partially blinded RCT with adaptive design. SETTING Thirty-five UK hospitals. PARTICIPANTS Patients aged ≥ 40 years with surgically treated ER-positive HER2-negative primary breast cancer and with 1-9 involved axillary nodes, or, if node negative, a tumour at least 30 mm in diameter. INTERVENTIONS Randomisation between two treatment options. Option 1 was standard care consisting of chemotherapy followed by endocrine therapy. In option 2, an Oncotype DX(®) test (Genomic Health Inc., Redwood City, CA, USA) performed on the resected tumour was used to assign patients either to standard care [if 'recurrence score' (RS) was > 25] or to endocrine therapy alone (if RS was ≤ 25). Patients allocated chemotherapy were blind to their randomisation. MAIN OUTCOME MEASURES The pre-specified success criteria were recruitment of 300 patients in no longer than 2 years and, for the final 150 patients, (1) an acceptance rate of at least 40%; (2) recruitment taking no longer than 6 months; and (3) chemotherapy starting within 6 weeks of consent in at least 85% of patients. RESULTS Between September 2012 and 3 June 2014, 350 patients consented to join OPTIMA prelim and 313 were randomised; the final 150 patients were recruited in 6 months, of whom 92% assigned chemotherapy started treatment within 6 weeks. The acceptance rate for the 750 patients invited to participate was 47%. Twelve out of the 325 patients with data (3.7%, 95% confidence interval 1.7% to 5.8%) were deemed ineligible on central review of receptor status. Interviews with researchers and recordings of potential participant consultations made as part of the integral qualitative recruitment study provided insights into recruitment barriers and led to interventions designed to improve recruitment. Patient information was changed as the result of feedback from three patient focus groups. Additional multiparameter analysis was performed on 302 tumour samples. Although Oncotype DX, MammaPrint(®)/BluePrint(®) (Agendia Inc., Irvine, CA, USA), Prosigna(®) (NanoString Technologies Inc., Seattle, WA, USA), IHC4, IHC4 automated quantitative immunofluorescence (AQUA(®)) [NexCourse BreastTM (Genoptix Inc. Carlsbad, CA, USA)] and MammaTyper(®) (BioNTech Diagnostics GmbH, Mainz, Germany) categorised comparable numbers of tumours into low- or high-risk groups and/or equivalent molecular subtypes, there was only moderate agreement between tests at an individual tumour level (kappa ranges 0.33-0.60 and 0.39-0.55 for tests providing risks and subtypes, respectively). Health economics modelling showed the value of information to the NHS from further research into multiparameter testing is high irrespective of the test evaluated. Prosigna is currently the highest priority for further study. CONCLUSIONS OPTIMA prelim has achieved its aims of demonstrating that a large UK clinical trial of multiparameter assay-based selection of chemotherapy in hormone-sensitive early breast cancer is feasible. The economic analysis shows that a trial would be economically worthwhile for the NHS. Based on the outcome of the OPTIMA prelim, a large-scale RCT to evaluate the clinical effectiveness and cost-effectiveness of multiparameter assay-directed chemotherapy decisions in hormone-sensitive HER2-negative early breast would be appropriate to take place in the NHS. TRIAL REGISTRATION Current Controlled Trials ISRCTN42400492. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 10. See the NIHR Journals Library website for further project information. The Government of Ontario funded research at the Ontario Institute for Cancer Research. Robert C Stein received additional support from the NIHR University College London Hospitals Biomedical Research Centre.
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Affiliation(s)
- Robert C Stein
- Department of Oncology, University College London Hospitals, London, UK
| | - Janet A Dunn
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Amy F Campbell
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter Hall
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | | | - Sarah E Pinder
- Research Oncology, Division of Cancer Studies, King's College London, London, UK
| | - David A Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Luke Hughes-Davies
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundations Trust, Cambridge, UK
| | - Andreas Makris
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
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de Boer PT, Frederix GWJ, Feenstra TL, Vemer P. Unremarked or Unperformed? Systematic Review on Reporting of Validation Efforts of Health Economic Decision Models in Seasonal Influenza and Early Breast Cancer. PHARMACOECONOMICS 2016; 34:833-845. [PMID: 27129572 PMCID: PMC4980411 DOI: 10.1007/s40273-016-0410-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Transparent reporting of validation efforts of health economic models give stakeholders better insight into the credibility of model outcomes. In this study we reviewed recently published studies on seasonal influenza and early breast cancer in order to gain insight into the reporting of model validation efforts in the overall health economic literature. METHODS A literature search was performed in Pubmed and Embase to retrieve health economic modelling studies published between 2008 and 2014. Reporting on model validation was evaluated by checking for the word validation, and by using AdViSHE (Assessment of the Validation Status of Health Economic decision models), a tool containing a structured list of relevant items for validation. Additionally, we contacted corresponding authors to ask whether more validation efforts were performed other than those reported in the manuscripts. RESULTS A total of 53 studies on seasonal influenza and 41 studies on early breast cancer were included in our review. The word validation was used in 16 studies (30 %) on seasonal influenza and 23 studies (56 %) on early breast cancer; however, in a minority of studies, this referred to a model validation technique. Fifty-seven percent of seasonal influenza studies and 71 % of early breast cancer studies reported one or more validation techniques. Cross-validation of study outcomes was found most often. A limited number of studies reported on model validation efforts, although good examples were identified. Author comments indicated that more validation techniques were performed than those reported in the manuscripts. CONCLUSIONS Although validation is deemed important by many researchers, this is not reflected in the reporting habits of health economic modelling studies. Systematic reporting of validation efforts would be desirable to further enhance decision makers' confidence in health economic models and their outcomes.
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Affiliation(s)
- Pieter T de Boer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands
| | - Geert W J Frederix
- Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
- Centre for Nutrition, Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Pepijn Vemer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands.
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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Plöthner M, Ribbentrop D, Hartman JP, Frank M. Cost-Effectiveness of Pharmacogenomic and Pharmacogenetic Test-Guided Personalized Therapies: A Systematic Review of the Approved Active Substances for Personalized Medicine in Germany. Adv Ther 2016; 33:1461-80. [PMID: 27406232 PMCID: PMC5020122 DOI: 10.1007/s12325-016-0376-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of targeted therapies has recently increased. Pharmacogenetic tests are a useful tool to guide patient treatment and to test a response before administering medicines. Pharmacogenetic tests can predict potential drug resistance and may be used for determining genotype-based drug dosage. However, their cost-effectiveness as a diagnostic tool is often debatable. In Germany, 47 active ingredients are currently approved. A prior predictive test is required for 39 of these and is recommended for eight. The objective of this study was to review the cost-effectiveness (CE) of pharmacogenetic test-guided drug therapy and compare the application of drugs with and without prior genetic testing. METHODS A systematic literature review was conducted to identify the CE and cost-utility of genetic tests. Studies from January 2000 until November 2015 were searched in 16 databases including Medline, Embase, and Cochrane. A quality assessment of the full-text publications was performed using the validated Quality of Health Economic Studies (QHES) instrument. RESULTS In the majority of the included studies, the pharmacogenetic test-guided therapy represents a cost-effective/cost-saving treatment option. Only seven studies lacked a clear statement of CE or cost-savings, because of uncertainty, restriction to specific patient populations, or assumptions for comparative therapy. Moreover, the high quality of the available evidence was evaluated. CONCLUSION Pharmacogenetic testing constitutes an opportunity to improve the CE of pharmacotherapy. The CE of targeted therapies depends on various factors including costs, prevalence of biomarkers, and test sensitivity and specificity. To guarantee the CE comparability of stratified drug therapies, national and international standards for evaluation studies should be defined.
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Affiliation(s)
- Marika Plöthner
- Centre for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover, Germany.
| | - Dana Ribbentrop
- Centre for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover, Germany
| | - Jan-Phillipp Hartman
- Centre for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover, Germany
| | - Martin Frank
- Centre for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover, Germany
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Cost-utility analyses of drug therapies in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:407-24. [PMID: 27572551 DOI: 10.1007/s10549-016-3924-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/20/2016] [Indexed: 01/08/2023]
Abstract
The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.
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O'Neill SC, Isaacs C, Chao C, Tsai HT, Liu C, Ekezue BF, Selvam N, Kessler LG, Schwartz MD, Lobo T, Potosky AL. Adoption of Gene Expression Profiling for Breast Cancer in US Oncology Practice for Women Younger Than 65 Years. J Natl Compr Canc Netw 2016; 13:1216-24. [PMID: 26483061 DOI: 10.6004/jnccn.2015.0150] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A number of practice guidelines incorporate the use of gene expression profiling (GEP) tests for early-stage, hormone receptor-positive, HER2-negative breast tumors. Few studies describe factors associated with GEP testing in US oncology practice. We assessed the relationship between clinical, demographic, and group-level socioeconomic variables and test use in women younger than 65 years. PATIENTS AND METHODS Data from 5 state cancer registries were linked with insurance claims data and GEP test results. We assessed rates of testing and variables associated with test use in an incident cohort of 9,444 commercially insured women younger than 65 years, newly diagnosed with stage I or II hormone receptor-positive breast cancer from 2006 through 2012. RESULTS Rates of testing for women with N0 disease increased from 20.4% in 2006 to 35.2% in 2011. Variables associated with higher rates of testing, beyond clinical factors such as nodal status (P<.001), included being diagnosed from 2008 through 2012 versus 2006 through 2007 (adjusted odds ratio [OR], 1.67; 95% CI, 1.47-1.90), having preexisting comorbidities (adjusted OR, 1.35; 95% CI, 1.14-1.59), and higher out-of-pocket pharmacy costs (adjusted OR, 1.66; 95% CI, 1.40-1.97). Women younger than 50 years were more likely to be tested if they had stage I versus stage II disease (P<.0001). CONCLUSIONS In an insured population of women younger than 65 years, GEP testing increased after its inclusion in clinical practice guidelines and mounting evidence. Additional research is needed to better understand oncologists' decision not to order GEP testing for their patients who are otherwise eligible.
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Affiliation(s)
- Suzanne C O'Neill
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Claudine Isaacs
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Calvin Chao
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Huei-Ting Tsai
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Chunfu Liu
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Bola F Ekezue
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Nandini Selvam
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Larry G Kessler
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Marc D Schwartz
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Tania Lobo
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
| | - Arnold L Potosky
- From Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; Genomic Health, Inc, Redwood City, California; HealthCore, Inc., Wilmington, Delaware; and University of Washington School of Public Health, Seattle, Washington
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Marguet S, Mazouni C, Ramaekers BL, Dunant A, Kates R, Jacobs VR, Joore MA, Harbeck N, Bonastre J. European cost-effectiveness study of uPA/PAI-1 biomarkers to guide adjuvant chemotherapy decisions in breast cancer. Eur J Cancer 2016; 63:168-79. [DOI: 10.1016/j.ejca.2016.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/15/2016] [Accepted: 05/14/2016] [Indexed: 12/25/2022]
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Dodson A, Zabaglo L, Yeo B, Miller K, Smith I, Dowsett M. Risk of recurrence estimates with IHC4+C are tolerant of variations in staining and scoring: an analytical validity study. J Clin Pathol 2016; 69:128-35. [PMID: 26281860 DOI: 10.1136/jclinpath-2015-203212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/26/2015] [Indexed: 11/04/2022]
Abstract
AIMS The IHC4+C score combines assessment of oestrogen receptor (ER), progesterone receptor (PgR), HER2 and Ki67 with clinicopathological parameters to identify the risk of distant disease recurrence in patients with breast cancer, so, aiding treatment decision-making on adjuvant chemotherapy. Despite low cost and wide availability, the reported use of IHC4+C remains limited; one explanation for this is the perception that immunohistochemistry (IHC)-based methods and assessment of them lack precision, reproducibility and portability. We examined the effects of decentralised testing and easily reproducible estimate-based scoring methods on IHC4+C scores to determine its suitability for wider adoption. METHODS Sections from a breast cancer tissue micro-array (TMA) were distributed to three centres undertaking diagnostic breast cancer IHC. Centres stained sections using their standard procedures, and returned them for central assessment. The results were compared with those obtained at IHC4+C's originating hospital (Royal Marsden Hospital (RMH)). In parallel, TMA sections stained at RMH were scored by a variety of simplified non-counting-based methods. The results were compared with those produced using counting. RESULTS There was a high degree of correlation between individual IHC results produced by external centres and those of RMH (r: 0.797-0.982), and between risk of distant recurrence scores derived from them (r: 0.972-0.984). Scoring methods for ER and PgR could be adapted to require less precision without significantly affecting correlation with counted results (r: 0.933 and 0.980, respectively), but correlation between estimating and counting for Ki67 was poorer (r: 0.855). CONCLUSIONS IHC4+C is tolerant of variation in staining and scoring methods. Although additional confirmatory comparative studies are required, these data support use of IHC4+C in clinical practice outside RMH.
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Affiliation(s)
- Andrew Dodson
- Academic Department of Biochemistry, Royal Marsden Hospital, London, UK
| | - Lila Zabaglo
- Academic Department of Biochemistry, Royal Marsden Hospital, London, UK The Breakthrough Toby Robins Breast Cancer Research Centre, Institute of Cancer Research, London, UK
| | - Belinda Yeo
- Academic Department of Biochemistry, Royal Marsden Hospital, London, UK Department of Medicine, Royal Marsden Hospital, London, UK
| | - Keith Miller
- UK National External Quality Assessment for Immunocytochemistry and In-situ Hybridisation, University College London, London, UK
| | - Ian Smith
- Department of Medicine, Royal Marsden Hospital, London, UK
| | - Mitch Dowsett
- Academic Department of Biochemistry, Royal Marsden Hospital, London, UK
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Economic Evaluations of Pharmacogenetic and Pharmacogenomic Screening Tests: A Systematic Review. Second Update of the Literature. PLoS One 2016; 11:e0146262. [PMID: 26752539 PMCID: PMC4709231 DOI: 10.1371/journal.pone.0146262] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/15/2015] [Indexed: 01/29/2023] Open
Abstract
Objective Due to extended application of pharmacogenetic and pharmacogenomic screening (PGx) tests it is important to assess whether they provide good value for money. This review provides an update of the literature. Methods A literature search was performed in PubMed and papers published between August 2010 and September 2014, investigating the cost-effectiveness of PGx screening tests, were included. Papers from 2000 until July 2010 were included via two previous systematic reviews. Studies’ overall quality was assessed with the Quality of Health Economic Studies (QHES) instrument. Results We found 38 studies, which combined with the previous 42 studies resulted in a total of 80 included studies. An average QHES score of 76 was found. Since 2010, more studies were funded by pharmaceutical companies. Most recent studies performed cost-utility analysis, univariate and probabilistic sensitivity analyses, and discussed limitations of their economic evaluations. Most studies indicated favorable cost-effectiveness. Majority of evaluations did not provide information regarding the intrinsic value of the PGx test. There were considerable differences in the costs for PGx testing. Reporting of the direction and magnitude of bias on the cost-effectiveness estimates as well as motivation for the chosen economic model and perspective were frequently missing. Conclusions Application of PGx tests was mostly found to be a cost-effective or cost-saving strategy. We found that only the minority of recent pharmacoeconomic evaluations assessed the intrinsic value of the PGx tests. There was an increase in the number of studies and in the reporting of quality associated characteristics. To improve future evaluations, scenario analysis including a broad range of PGx tests costs and equal costs of comparator drugs to assess the intrinsic value of the PGx tests, are recommended. In addition, robust clinical evidence regarding PGx tests’ efficacy remains of utmost importance.
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Safonov A, Wang S, Gross CP, Agarwal D, Bianchini G, Pusztai L, Hatzis C. Assessing cost-utility of predictive biomarkers in oncology: a streamlined approach. Breast Cancer Res Treat 2016; 155:223-34. [PMID: 26749360 DOI: 10.1007/s10549-016-3677-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/02/2016] [Indexed: 10/22/2022]
Abstract
Evaluation of cost-utility is critical in assessing the medical utility of predictive or prognostic biomarkers. Current methods involve complex state-transition models, requiring comprehensive data inputs. We propose a simplified decision-analytic tool to explore the relative effect of factors contributing to the cost-utility of a biomarker. We derived a cost-utility metric, the "test incremental cost-effectiveness ratio" (TICER) for biomarker-guided treatment compared to no biomarker use. This method uses data inputs readily accessible through clinical literature. We compared our results with traditional cost-effectiveness analysis of predictive biomarkers for established (HER2-guided trastuzumab, ALK-guided crizotinib, OncotypeDX-guided adjuvant chemotherapy) and emerging (ROS1-guided crizotinib) targeted treatments. We conducted sensitivity analysis to determine which factors had the greatest impact on TICER estimates. Base case TICER for HER2 was $149,600/quality-adjusted life year (QALY), for ALK was $22,200/QALY, and for OncotypeDX was $11,600/QALY, consistent with literature-reported estimates ($180,000/QALY, $202,800/QALY, $8900/QALY, respectively). Base case TICER for ROS1-guided crizotinib was $205,900/QALY. Generally, when treatment cost is considerably greater than biomarker testing costs, TICER is driven by clinical outcomes and health-related quality of life, while biomarker prevalence and treatment cost have a lesser effect. Our simplified decision-analytic approach produces values consistent with existing cost-effectiveness analyses. Our results suggest that biomarker value is mostly driven by the clinical efficacy of the targeted agent. A user-friendly web tool for complete TICER analysis has been made available for open use at http://medicine.yale.edu/lab/pusztai/ticer/ .
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Affiliation(s)
| | - Shiyi Wang
- Yale School of Public Health, New Haven, USA.,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, New Haven, USA
| | - Cary P Gross
- Yale School of Medicine, New Haven, USA.,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, New Haven, USA.,Yale Cancer Center, Yale University, New Haven, USA
| | | | | | - Lajos Pusztai
- Yale School of Medicine, New Haven, USA.,Yale Cancer Center, Yale University, New Haven, USA
| | - Christos Hatzis
- Yale School of Medicine, New Haven, USA. .,Yale Cancer Center, Yale University, New Haven, USA.
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Jahn B, Rochau U, Kurzthaler C, Hubalek M, Miksad R, Sroczynski G, Paulden M, Kluibenschädl M, Krahn M, Siebert U. Cost effectiveness of personalized treatment in women with early breast cancer: the application of OncotypeDX and Adjuvant! Online to guide adjuvant chemotherapy in Austria. SPRINGERPLUS 2015; 4:752. [PMID: 26693110 PMCID: PMC4666888 DOI: 10.1186/s40064-015-1440-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022]
Abstract
A Breast Cancer Outcomes model was developed at the ONCOTYROL research center to evaluate personalized test-treatment strategies in Austria. The goal was to evaluate the cost-effectiveness of a new 21-gene assay (ODX) when used in conjunction with the Adjuvant! Online (AO) decision aid to support personalized decisions about use of adjuvant chemotherapy in early-stage breast cancer patients in Austria. We applied a validated discrete-event-simulation model to a hypothetical cohort of 50 years old women over a lifetime horizon. The test-treatment strategies of interest were defined using three-letter acronyms. The first (second, third) letter indicates whether patients with a low (intermediate, high) risk according to AO were tested using ODX (Y yes, N no). The main outcomes were life-years gained, quality-adjusted life-years (QALYs), costs and cost effectiveness. Robustness of the results was tested in sensitivity analyses. Results were compared to a Canadian analysis conducted by the Toronto Health Economics and Technology Assessment Collaborative (THETA). Five of eight strategies were dominated (i.e., more costly and less effective: NNY, NYN, YNN, YNY, YYN). The base-case analysis shows that YYY (ODX provided to all patients) is the most effective strategy and is cost effective with an incremental cost-effectiveness ratio of 15,700 EUR per QALY gained. These results are sensitive to changes in the probabilities of distant recurrence, age and costs of chemotherapy. The results of the base-case analysis were comparable to the THETA results. Based on our analyses, using ODX in addition to AO is effective and cost effective in all women in Austria. The development of future genetic tests may require alternative or additional test-treatment strategies to be evaluated.
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Affiliation(s)
- B Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - U Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - C Kurzthaler
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Hubalek
- Department of Obstetrics and Gynaecology, Medical University Innsbruck, Innsbruck, Austria
| | - R Miksad
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - G Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Paulden
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON Canada ; Department of Emergency Medicine, University of Alberta, Edmonton, AB Canada
| | - M Kluibenschädl
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON Canada
| | - U Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria ; Center for Health Decision Science, Department of Health Policy and Management, T.H.Chan Harvard School of Public Health, Boston, MA USA ; Institute for Technology Assessment and Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA USA
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Epstein AJ, Wong YN, Mitra N, Vachani A, Hin S, Yang L, Smith-McLallen A, Armstrong K, Groeneveld PW. Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer. J Clin Oncol 2015; 33:4259-67. [PMID: 26598749 DOI: 10.1200/jco.2015.61.9023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We assessed the associations between the 21-gene recurrence score assay (RS) receipt, subsequent chemotherapy use, and medical expenditures among patients with early-stage breast cancer. PATIENTS AND METHODS Data from the Pennsylvania Cancer Registry were used to assemble a retrospective cohort of women with early-stage breast cancer from 2007 to 2010 who underwent initial surgical treatment. These data were merged with administrative claims from the 12-month periods before and after diagnosis to identify comorbidities, treatments, and expenditures (n = 7,287). Propensity score-weighted regression models were estimated to identify the effects of RS receipt on chemotherapy use and medical spending in the year after diagnosis. RESULTS The associations between RS receipt and outcomes varied markedly by patient age. RS use was associated with lower chemotherapy use among women younger than 55 (19.2% lower; 95% CI, 10.6 to 27.9). RS use was associated with higher chemotherapy use among women 75 to 84 years old (5.7% higher; 95% CI, 0.4 to 11.0). RS receipt was associated with lower adjusted 1-year medical spending among women younger than 55 ($15,333 lower; 95% CI, $2,841 to $27,824) and with higher spending among women who were 75 to 84 years old ($3,489 higher; 95% CI, $857 to $6,122). CONCLUSION RS receipt was associated with reduced use of adjuvant chemotherapy and lower health care spending among women with breast cancer who were younger than 55. Conversely, among women 75 and older, RS testing was associated with a modest increase in chemotherapy use and slightly higher spending. From a population perspective, the impact of RS testing on breast cancer treatment and health care costs is much greater in younger women.
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Affiliation(s)
- Andrew J Epstein
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Yu-Ning Wong
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Nandita Mitra
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Anil Vachani
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Sakhena Hin
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Lin Yang
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Aaron Smith-McLallen
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Katrina Armstrong
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Peter W Groeneveld
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
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Luporsi E, Bellocq JP, Barrière J, Bonastre J, Chetritt J, Le Corroller AG, de Cremoux P, Fina F, Gauchez AS, Lamy PJ, Martin PM, Mazouni C, Peyrat JP, Romieu G, Verdoni L, Mazeau-Woynar V, Kassab-Chahmi D. [uPA/PAI-1, Oncotype DX™, MammaPrint(®). Prognosis and predictive values for clinical utility in breast cancer management]. Bull Cancer 2015; 102:719-29. [PMID: 26235416 DOI: 10.1016/j.bulcan.2015.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Elisabeth Luporsi
- Institut de cancérologie de Lorraine, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy cedex, France
| | | | - Jérôme Barrière
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice, France
| | - Julia Bonastre
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - Jérôme Chetritt
- Institut d'histopathologie, 55, rue Amiral-du-Chaffault, 44100 Nantes, France
| | - Anne-Gaëlle Le Corroller
- UMR 912 Inserm, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | | | - Frédéric Fina
- AP-HM, faculté de médecine-secteur Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | | | - Pierre-Jean Lamy
- Institut régional du cancer, 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Pierre-Marie Martin
- AP-HM, faculté de médecine-secteur Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - Chafika Mazouni
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | | | - Gilles Romieu
- Institut régional du cancer, 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Laetitia Verdoni
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France
| | - Valérie Mazeau-Woynar
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France
| | - Diana Kassab-Chahmi
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France.
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Bonastre J, Marguet S, Lueza B, Michiels S, Delaloge S, Saghatchian M. Reply to V.P. Retèl et al, D. Gauchan et al, and C. Rahilly-Tierney et al. J Clin Oncol 2015; 33:1629-30. [PMID: 25847933 DOI: 10.1200/jco.2014.60.5568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Julia Bonastre
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Sophie Marguet
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Beranger Lueza
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Stefan Michiels
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
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Lobo JM, Dicker AP, Buerki C, Daviconi E, Karnes RJ, Jenkins RB, Patel N, Den RB, Showalter TN. Evaluating the clinical impact of a genomic classifier in prostate cancer using individualized decision analysis. PLoS One 2015; 10:e0116866. [PMID: 25837660 PMCID: PMC4383561 DOI: 10.1371/journal.pone.0116866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Currently there is controversy surrounding the optimal way to treat patients with prostate cancer in the post-prostatectomy setting. Adjuvant therapies carry possible benefits of improved curative results, but there is uncertainty in which patients should receive adjuvant therapy. There are concerns about giving toxicity to a whole population for the benefit of only a subset. We hypothesized that making post-prostatectomy treatment decisions using genomics-based risk prediction estimates would improve cancer and quality of life outcomes. METHODS We developed a state-transition model to simulate outcomes over a 10 year horizon for a cohort of post-prostatectomy patients. Outcomes included cancer progression rates at 5 and 10 years, overall survival, and quality-adjusted survival with reductions for treatment, side effects, and cancer stage. We compared outcomes using population-level versus individual-level risk of cancer progression, and for genomics-based care versus usual care treatment recommendations. RESULTS Cancer progression outcomes, expected life-years (LYs), and expected quality-adjusted life-years (QALYs) were significantly different when individual genomics-based cancer progression risk estimates were used in place of population-level risk estimates. Use of the genomic classifier to guide treatment decisions provided small, but statistically significant, improvements in model outcomes. We observed an additional 0.03 LYs and 0.07 QALYs, a 12% relative increase in the 5-year recurrence-free survival probability, and a 4% relative reduction in the 5-year probability of metastatic disease or death. CONCLUSIONS The use of genomics-based risk prediction to guide treatment decisions may improve outcomes for prostate cancer patients. This study offers a framework for individualized decision analysis, and can be extended to incorporate a wide range of personal attributes to enable delivery of patient-centered tools for informed decision-making.
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Affiliation(s)
- Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Adam P. Dicker
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Elai Daviconi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - R. Jeffrey Karnes
- Department of Urology, Mayo Clinic, Rochester, MN, United States of America
| | - Robert B. Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Nirav Patel
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Robert B. Den
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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A retrospective study of the impact of 21-gene recurrence score assay on treatment choice in node positive micrometastatic breast cancer. Pharmaceuticals (Basel) 2015; 8:107-22. [PMID: 25789420 PMCID: PMC4381203 DOI: 10.3390/ph8010107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/04/2015] [Accepted: 02/09/2015] [Indexed: 12/26/2022] Open
Abstract
To assess clinical utility of the 21-gene assay (Oncotype DX® Recurrence Score®), we determined whether women with HER2(−)/ER+ pN1mi breast cancer with low (<18) Recurrence Scores results are given adjuvant chemotherapy in a lower proportion than those with high scores (≥31). This was a multicenter chart review of ≥18 year old women with pN1mi breast cancer, HER2(−)/ER+ tumors, ductal/lobular/mixed histology, with the assay ordered on or after 1 January 2007. One hundred and eighty one patients had a mean age of 60.7 years; 82.9% had ECOG performance status 0; 33.7% had hypertension, 22.7% had osteoporosis, 18.8% had osteoarthritis, and 8.8% had type-2 diabetes. Mean Recurrence Score was 17.8 (range: 0–50). 48.6% had a mastectomy; 55.8% had a lumpectomy. 19.8% of low-risk group patients were recommended chemotherapy vs. 57.9% in the intermediate-risk group and 100% in the high-risk group (p < 0.001). A total of 80.2% of the low-risk group were recommended endocrine therapy alone, while 77.8% of the high-risk group were recommended both endocrine and chemotherapy (p < 0.001). The Oncotype DX Recurrence Score result provides actionable information that can be incorporated into treatment planning for women with HER2(−)/ER+ pN1mi breast cancer. The Recurrence Score result has clinical utility in treatment planning for HER2(−)/ER+ pN1mi breast cancer patients.
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Blank PR, Filipits M, Dubsky P, Gutzwiller F, Lux MP, Brase JC, Weber KE, Rudas M, Greil R, Loibl S, Szucs TD, Kronenwett R, Schwenkglenks M, Gnant M. Cost-effectiveness analysis of prognostic gene expression signature-based stratification of early breast cancer patients. PHARMACOECONOMICS 2015; 33:179-190. [PMID: 25404424 PMCID: PMC4305105 DOI: 10.1007/s40273-014-0227-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The individual risk of recurrence in hormone receptor-positive primary breast cancer patients determines whether adjuvant endocrine therapy should be combined with chemotherapy. Clinicopathological parameters and molecular tests such as EndoPredict(®) (EPclin) can support decision making in patients with estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative cancer. OBJECTIVE Using a life-long Markov state transition model, we determined the health economic impact and incremental cost effectiveness of EPclin-based risk stratification in combination with clinical guidelines [German-S3, National Comprehensive Cancer Center Network (NCCN), and St. Gallen] to decide on chemotherapy use. METHODS Information on overall and metastasis-free survival came from Austrian Breast & Colorectal Cancer Study Group clinical trials 6/8 (n = 1,619) and published literature. Effectiveness was assessed as quality-adjusted life-years (QALYs). Costs (2010) were assessed from a German third-party payer perspective. RESULTS Lifetime costs per patient ranged from <euro>28,268 (St.Gallen and EPclin) to <euro>33,756 (NCCN). Due to an imperfect prognostic value and differences in chemotherapy use, strategies achieved between 13.165 QALYs (NCCN) and 13.173 QALYs (EPclin alone) per patient. Using German-S3 as reference, three strategies showed dominant results (St. Gallen and EPclin, German-S3 and EPclin, EPclin alone). Compared to German-S3, the addition of EPclin saved <euro>3,388 and gained 0.002 QALYs per patient. Combining guidelines with EPclin remained preferable in sensitivity analysis. CONCLUSION Our study suggests that molecular markers can be sensibly combined with clinical guidelines to determine the risk profile of adjuvant breast cancer patients. Compared with the current German best practice (German-S3), combinations of EPclin with the St. Gallen, German-S3 or NCCN guideline and EPclin alone were dominant from the perspective of the German healthcare system.
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Affiliation(s)
- Patricia R Blank
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland,
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Vollan HKM, Rueda OM, Chin SF, Curtis C, Turashvili G, Shah S, Lingjærde OC, Yuan Y, Ng CK, Dunning MJ, Dicks E, Provenzano E, Sammut S, McKinney S, Ellis IO, Pinder S, Purushotham A, Murphy LC, Kristensen VN, Brenton JD, Pharoah PDP, Børresen-Dale AL, Aparicio S, Caldas C. A tumor DNA complex aberration index is an independent predictor of survival in breast and ovarian cancer. Mol Oncol 2015; 9:115-27. [PMID: 25169931 PMCID: PMC4286124 DOI: 10.1016/j.molonc.2014.07.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 07/23/2014] [Accepted: 07/25/2014] [Indexed: 01/27/2023] Open
Abstract
Complex focal chromosomal rearrangements in cancer genomes, also called "firestorms", can be scored from DNA copy number data. The complex arm-wise aberration index (CAAI) is a score that captures DNA copy number alterations that appear as focal complex events in tumors, and has potential prognostic value in breast cancer. This study aimed to validate this DNA-based prognostic index in breast cancer and test for the first time its potential prognostic value in ovarian cancer. Copy number alteration (CNA) data from 1950 breast carcinomas (METABRIC cohort) and 508 high-grade serous ovarian carcinomas (TCGA dataset) were analyzed. Cases were classified as CAAI positive if at least one complex focal event was scored. Complex alterations were frequently localized on chromosome 8p (n = 159), 17q (n = 176) and 11q (n = 251). CAAI events on 11q were most frequent in estrogen receptor positive (ER+) cases and on 17q in estrogen receptor negative (ER-) cases. We found only a modest correlation between CAAI and the overall rate of genomic instability (GII) and number of breakpoints (r = 0.27 and r = 0.42, p < 0.001). Breast cancer specific survival (BCSS), overall survival (OS) and ovarian cancer progression free survival (PFS) were used as clinical end points in Cox proportional hazard model survival analyses. CAAI positive breast cancers (43%) had higher mortality: hazard ratio (HR) of 1.94 (95%CI, 1.62-2.32) for BCSS, and of 1.49 (95%CI, 1.30-1.71) for OS. Representations of the 70-gene and the 21-gene predictors were compared with CAAI in multivariable models and CAAI was independently significant with a Cox adjusted HR of 1.56 (95%CI, 1.23-1.99) for ER+ and 1.55 (95%CI, 1.11-2.18) for ER- disease. None of the expression-based predictors were prognostic in the ER- subset. We found that a model including CAAI and the two expression-based prognostic signatures outperformed a model including the 21-gene and 70-gene signatures but excluding CAAI. Inclusion of CAAI in the clinical prognostication tool PREDICT significantly improved its performance. CAAI positive ovarian cancers (52%) also had worse prognosis: HRs of 1.3 (95%CI, 1.1-1.7) for PFS and 1.3 (95%CI, 1.1-1.6) for OS. This study validates CAAI as an independent predictor of survival in both ER+ and ER- breast cancer and reveals a significant prognostic value for CAAI in high-grade serous ovarian cancer.
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Affiliation(s)
- Hans Kristian Moen Vollan
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK; Department of Genetics, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310 Oslo, Norway; The K.G. Jebsen Center for Breast Cancer Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Norway; Department of Oncology, Division for Surgery, Cancer and Transplantation, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310 Oslo, Norway
| | - Oscar M Rueda
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Suet-Feung Chin
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Christina Curtis
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, University of British Colombia, Vancouver, British Colombia V6T 2B5, Canada; Molecular Oncology, British Colombia Cancer Research Center, Vancouver, British Columbia V5Z 1L3, Canada
| | - Sohrab Shah
- Department of Pathology and Laboratory Medicine, University of British Colombia, Vancouver, British Colombia V6T 2B5, Canada; Molecular Oncology, British Colombia Cancer Research Center, Vancouver, British Columbia V5Z 1L3, Canada
| | - Ole Christian Lingjærde
- The K.G. Jebsen Center for Breast Cancer Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Norway; Biomedical Informatics Division, Department of Computer Science, University of Oslo, Oslo, Norway; Center for Cancer Biomedicine, University of Oslo, Norway
| | - Yinyin Yuan
- Division of Molecular Pathology, The Institute of Cancer Research, 237 Fulham Road, SW3 6JB, London, UK
| | - Charlotte K Ng
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Mark J Dunning
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Ed Dicks
- Strangeways Research Laboratories, University of Cambridge, Cambridge CB1 9RN, UK
| | - Elena Provenzano
- Cambridge Experimental Cancer Medicine Centre, Cambridge CB2 0RE, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge CB2 2QQ, UK
| | - Stephen Sammut
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge CB2 2QQ, UK
| | - Steven McKinney
- Molecular Oncology, British Colombia Cancer Research Center, Vancouver, British Columbia V5Z 1L3, Canada
| | - Ian O Ellis
- Department of Histopathology, School of Molecular Medical Sciences, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Sarah Pinder
- King's College London, Breakthrough Breast Cancer Research Unit, London WC2R 2LS, UK; NIHR Comprehensive Biomedical Research Centre at Guy's and St. Thomas NHS Foundation Trust and King's College London, London WC2R 2LS, UK
| | - Arnie Purushotham
- King's College London, Breakthrough Breast Cancer Research Unit, London WC2R 2LS, UK; NIHR Comprehensive Biomedical Research Centre at Guy's and St. Thomas NHS Foundation Trust and King's College London, London WC2R 2LS, UK
| | - Leigh C Murphy
- Manitoba Institute of Cell Biology, CancerCare Manitoba, University of Manitoba, Manitoba R3E 0V9, Canada
| | - Vessela N Kristensen
- Department of Genetics, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310 Oslo, Norway; The K.G. Jebsen Center for Breast Cancer Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Norway; Department of Clinical Molecular Biology (EpiGen), Medical Division, Akershus University Hospital, Lørenskog, Norway
| | - James D Brenton
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK; Department of Oncology, University of Cambridge, Hills Road, Cambridge CB2 2XZ, UK; Cambridge Experimental Cancer Medicine Centre, Cambridge CB2 0RE, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge CB2 2QQ, UK
| | - Paul D P Pharoah
- Department of Oncology, University of Cambridge, Hills Road, Cambridge CB2 2XZ, UK; Strangeways Research Laboratories, University of Cambridge, Cambridge CB1 9RN, UK; Cambridge Experimental Cancer Medicine Centre, Cambridge CB2 0RE, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge CB2 2QQ, UK
| | - Anne-Lise Børresen-Dale
- Department of Genetics, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310 Oslo, Norway; The K.G. Jebsen Center for Breast Cancer Research, Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Samuel Aparicio
- Department of Pathology and Laboratory Medicine, University of British Colombia, Vancouver, British Colombia V6T 2B5, Canada; Molecular Oncology, British Colombia Cancer Research Center, Vancouver, British Columbia V5Z 1L3, Canada.
| | - Carlos Caldas
- Cancer Research UK, Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK; Department of Oncology, University of Cambridge, Hills Road, Cambridge CB2 2XZ, UK; Cambridge Experimental Cancer Medicine Centre, Cambridge CB2 0RE, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust and NIHR Cambridge Biomedical Research Centre, Cambridge CB2 2QQ, UK.
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Marrone M, Stewart A, Dotson WD. Clinical utility of gene-expression profiling in women with early breast cancer: an overview of systematic reviews. Genet Med 2014; 17:519-32. [PMID: 25474343 DOI: 10.1038/gim.2014.140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 09/02/2014] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This overview systematically evaluates the clinical utility of using Oncotype DX and MammaPrint gene-expression profiling tests to direct treatment decisions in women with breast cancer. The findings are intended to inform an updated recommendation from the Evaluation of Genomic Applications in Practice and Prevention Working Group. METHODS Evidence reported in systematic reviews evaluating the clinical utility of Oncotype DX and MammaPrint, as well as the ability to predict treatment outcomes, change in treatment decisions, and cost-effectiveness, was qualitatively synthesized. RESULTS Five systematic reviews found no direct evidence of clinical utility for either test. Indirect evidence showed Oncotype DX was able to predict treatment effects of adjuvant chemotherapy, whereas no evidence of predictive value was found for MammaPrint. Both tests influenced a change in treatment recommendations in 21 to 74% of participants. The cost-effectiveness of Oncotype DX varied with the alternative compared. For MammaPrint, lack of evidence of the predictive value led to uncertainty in the cost-effectiveness. CONCLUSION No studies were identified that provided direct evidence that using gene-expression profiling tests to direct treatment decisions improved outcomes in women with breast cancer. Three ongoing studies may provide direct evidence for determining the clinical utility of gene-expression profiling testing.
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Affiliation(s)
- Michael Marrone
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alison Stewart
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W David Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Bonastre J, Marguet S, Lueza B, Michiels S, Delaloge S, Saghatchian M. Cost Effectiveness of Molecular Profiling for Adjuvant Decision Making in Patients With Node-Negative Breast Cancer. J Clin Oncol 2014; 32:3513-9. [DOI: 10.1200/jco.2013.54.9931] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose To conduct an economic evaluation of the 70-gene signature used to guide adjuvant chemotherapy decision making both in patients with node-negative breast cancer (NNBC) and in the subgroup of estrogen receptor (ER) –positive patients. Patients and Methods We used a mixed approach combining patient-level data from a multicenter validation study of the 70-gene signature (untreated patients) and secondary sources for chemotherapy efficacy, unit costs, and utility values. Three strategies on which to base the decision to administer adjuvant chemotherapy were compared: the 70-gene signature, Adjuvant! Online, and chemotherapy in all patients. In the base-case analysis, costs from the French National Insurance Scheme, life-years (LYs), and quality-adjusted life-years (QALYs) were computed for the three strategies over a 10-year period. Cost-effectiveness acceptability curves using the net monetary benefit were computed, combining bootstrap and probabilistic sensitivity analyses. Results The mean differences in LYs and QALYs were similar between the three strategies. The 70-gene signature strategy was associated with a higher cost, with a mean difference of €2,037 (range, €1,472 to €2,515) compared with Adjuvant! Online and of €657 (95% CI, −€642 to €3,130) compared with systematic chemotherapy. For a €50,000 per QALY willingness-to-pay threshold, the probability of being the most cost-effective strategy was 92% (76% in ER-positive patients) for the Adjuvant! Online strategy, 6% (4% in ER-positive patients) for the systematic chemotherapy strategy, and 2% (20% in ER-positive patients) for the 70-gene strategy. Conclusion Optimizing adjuvant chemotherapy decision making based on the 70-gene signature is unlikely to be cost effective in patients with NNBC.
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Differential patterns of recurrence and specific survival between luminal A and luminal B breast cancer according to recent changes in the 2013 St Gallen immunohistochemical classification. Clin Transl Oncol 2014; 17:238-46. [PMID: 25270605 DOI: 10.1007/s12094-014-1220-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/20/2014] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In 2011, the St Gallen panel introduced several changes in breast cancer classification, thereby creating the luminal B Her2- subtype. In 2013, the panel also included Ki67 overexpression and PR <20 % as risk factors, while excluding GH3 in the absence of increased Ki67. We compared the classification of 2011 modified with the new 2013 St Gallen classification. PATIENTS AND METHOD Consecutive breast cancer patients referred to the Breast Unit of the University Hospital Mútua Terrassa and Hospital of Terrassa for surgical treatment of either primary or recurrent tumors were prospectively included between 1997 and 2014. Eventually, 1,874 cases were included for the four-subtype analysis. The median follow-up was of 66 months. RESULTS Using the 2013 St Gallen classification no significant differences were found in specific mortality rates between luminal A and B subtypes. There were significant differences at 5, 10, and, 15 years if we excluded luminal A GH3 patients in the absence of increased Ki67 (p = 0.004, 0.005, and 0.007). Luminal A sub-type patients showed significantly less distant metastases than the rest, including luminal B Her2- patients (p < 0.001). Also, luminal B patients showed significantly less distant metastases than pure Her2 (0.05) and triple negative (TN) (p < 0.001). There were no differences between pure Her2 and TN patients (0.055), neither among the different luminal B sub-types. CONCLUSION GH3, PR, and Ki67 may all be discriminatory factors for metastasis and specific mortality. Therefore, we suggest including GH3 in the luminal B subtype in the absence of Ki67.
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Predictive and prognostic value of the 21-gene recurrence score in hormone receptor-positive, node-positive breast cancer. Am J Clin Oncol 2014; 37:404-10. [PMID: 24853663 PMCID: PMC4162320 DOI: 10.1097/coc.0000000000000086] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The addition of adjuvant chemotherapy to hormonal therapy is recommended for patients with estrogen receptor-positive (ER+), node-positive (N+) early breast cancer (EBC). Some of these patients, however, are not likely to benefit from treatment and may, therefore, be overtreated while also incurring unnecessary treatment-related adverse events and health care costs. The 21-gene Recurrence Score assay has been clinically validated and recommended for use in patients with ER+, node-negative (N0) EBC to assess the 10-year risk of distant disease recurrence and predict the likelihood of response to adjuvant chemotherapy. A growing body of evidence from several large phase III clinical trials reports similar findings in patients with ER+, N+ EBC. A systematic review of published literature from key clinical trials that have used the 21-gene breast cancer assay in patients with ER+, N+ EBC was performed. The Recurrence Score has been shown to be an independent predictor of disease-free survival, overall survival, and distant recurrence-free interval in patients with ER+, N+ EBC. Outcomes from decision impact and health economics studies further indicate that the Recurrence Score affects physician treatment recommendations equally in patients with N+ or N0 disease. It also indicates that a reduction in Recurrence Score-directed chemotherapy is cost-effective. There is a large body of evidence to support the use of the 21-gene assay Recurrence Score in patients with N+ EBC. Use of this assay could help guide treatment decisions for patients who are most likely to receive benefit from chemotherapy.
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[Economic assessment of the routine use of Oncotype DX® assay for early breast cancer in Franche-Comte region]. Bull Cancer 2014; 101:681-9. [PMID: 25091650 DOI: 10.1684/bdc.2014.1923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Oncotype DX® has been validated as quantifying the likelihood of distant recurrence at 10 years and overall chemotherapy benefit in patients with estrogen-receptor-positive and HER-2-negative early breast cancer. In 2012, this genomic signature was routinely available for patients in Franche-Comté, France. Patients eligible for Oncotype DX(®) testing had a ER-positive, HER-2-négative early breast cancer with a nodal involvement limited to 0 or 1 positive-node without extracapsular spread; an adjuvant chemotherapy was indicated based on usual prognostic factors. The aim was to assess the economic impact of Oncotype DX(®) testing in a French region. A cost-minimisation analysis from the French Public Healthcare System perspective was performed. The availability of Oncotype DX(®) in Franche-Comté, France, and its use in clinical routine allowed a decrease of 73 % of adjuvant chemotherapy without increase of the cost of the patients' management and with a potential reduction of the cost for the French Public Healthcare System. This strategy was successful and may allow the reimbursement of this test in France for patients with early breast cancer.
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Mandelblatt JS, Huang K, Makgoeng SB, Luta G, Song JX, Tallarico M, Roh JM, Munneke JR, Houlston CA, McGuckin ME, Cai L, Clarke Hillyer G, Hershman DL, Neugut AI, Isaacs C, Kushi L. Preliminary Development and Evaluation of an Algorithm to Identify Breast Cancer Chemotherapy Toxicities Using Electronic Medical Records and Administrative Data. J Oncol Pract 2014; 11:e1-8. [PMID: 25161127 DOI: 10.1200/jop.2013.001288] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Breast cancer chemotherapy toxicity is not well documented outside of randomized trials. We developed and conducted preliminary evaluation of an algorithm to detect grade 3 and 4 toxicities using electronic data from a large integrated managed care organization. METHODS The algorithm used administrative, pharmacy, and electronic data from outpatient, emergency room, and inpatient records of 99 women diagnosed with breast cancer from 2006 to 2009 who underwent chemotherapy. Data were abstracted for 12 months post-treatment initiation (24 months for trastuzumab recipients). An oncology nurse independently blindly reviewed records; these results were the "gold standard." Sensitivity and specificity were calculated for overall toxicity, categories of toxicities, and toxicity by age or regimen. The algorithm was applied to an independent sample of 1,575 patients with breast cancer diagnosed during the study period to estimate prevalence rates. RESULTS The overall sensitivity for detecting chemotherapy-related toxicity was 89% (95% CI, 77% to 95%). The highest sensitivity was for identification of hematologic toxicities (97%; 95% CI, 84% to 99%). There were good sensitivities for infectious toxicity, but rates dropped for GI and neurological toxicities. Specificity was high within each category (89% to 99%), but when combined to measure any toxicity, it was lower (70%; 95% CI, 57% to 81%). When applied to an independent chemotherapy sample, the algorithm estimates a 26% rate of hematologic toxicity; rates were higher among patients age ≥ 65 years versus less than 65 years. CONCLUSIONS If validated in other samples and health care settings, algorithms to capture toxicity could be useful in comparative and cost-effectiveness evaluations of community practice-delivered treatment.
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Affiliation(s)
- Jeanne S Mandelblatt
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Karl Huang
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Solomon B Makgoeng
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Gheorghe Luta
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Jun X Song
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Michelle Tallarico
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Janise M Roh
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Julie R Munneke
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Cathie A Houlston
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Meghan E McGuckin
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Ling Cai
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Grace Clarke Hillyer
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Dawn L Hershman
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Alfred I Neugut
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Claudine Isaacs
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Larry Kushi
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
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Abu-Khalf M, Pusztai L. Influence of genomics on adjuvant treatments for pre-invasive and invasive breast cancer. Breast 2014; 22 Suppl 2:S83-7. [PMID: 24074799 DOI: 10.1016/j.breast.2013.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION AND AIM Tribute to the improved quality of tumor marker studies all major national and international practice guidelines now recognized the potential clinical value of multivariate genomic prognostic tests. There are several diagnostic companies that offer these products for clinical use. This paper reviews recent trends in genomic prognostic testing in the clinic and briefly discusses future trends. METHODS AND RESULTS Published manuscripts on breast cancer biomarkers, genomic prognostic and predictive tests were reviewed along with abstracts and proceedings of major conferences to extract information on the clinical utility, cost-effectiveness and usage of molecular tests in the management of early stage breast cancers. Genomic test use has steadily increased over the past 5 years, approximately 30%, 13% and 1% of stage I, II and III ER-positive breast cancer breast cancers are tested. Among those who are tested, approximately, 25-30% of the time treatment recommendations change due to test results. Testing is associated with decreased use of chemotherapy overall, however in clinically low risk patients who are tested tend to receive chemotherapy more frequently than low risk patients who are untested. Almost all cost-effectiveness studies concluded that genomic testing is cost effective under a broad range of assumptions when used within current guidelines. Simple immunohistochemistry based assays when performed following a standard operating procedure and combined into a multivariate prognostic model, have the potential to substitute for genomic tests in the future. DISCUSSION AND CONCLUSIONS Genomic testing, when available, is widely used to assist in adjuvant chemotherapy treatment recommendations for clinically intermediate risk (e.g. grade 2, stage I-II) ER-positive breast cancers.
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Affiliation(s)
- Maysa Abu-Khalf
- Yale University School of Medicine, Yale Cancer Center, Section of Breast Medical Oncology, 333 Cedar St, PO Box 208032, New Haven, CT 06520-8032, USA.
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Hatz MHM, Schremser K, Rogowski WH. Is individualized medicine more cost-effective? A systematic review. PHARMACOECONOMICS 2014; 32:443-55. [PMID: 24574059 DOI: 10.1007/s40273-014-0143-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Individualized medicine (IM) is a rapidly evolving field that is associated with both visions of more effective care at lower costs and fears of highly priced, low-value interventions. It is unclear which view is supported by the current evidence. OBJECTIVE Our objective was to systematically review the health economic evidence related to IM and to derive general statements on its cost-effectiveness. DATA SOURCES A literature search of MEDLINE database for English- and German-language studies was conducted. STUDY APPRAISAL AND SYNTHESIS METHOD Cost-effectiveness and cost-utility studies for technologies meeting the MEDLINE medical subject headings (MeSH) definition of IM (genetically targeted interventions) were reviewed. This was followed by a standardized extraction of general study characteristics and cost-effectiveness results. RESULTS Most of the 84 studies included in the synthesis were from the USA (n = 43, 51 %), cost-utility studies (n = 66, 79 %), and published since 2005 (n = 60, 71 %). The results ranged from dominant to dominated. The median value (cost-utility studies) was calculated to be rounded $US22,000 per quality-adjusted life year (QALY) gained (adjusted to $US, year 2008 values), which is equal to the rounded median cost-effectiveness in the peer-reviewed English-language literature according to a recent review. Many studies reported more than one strategy of IM with highly varying cost-effectiveness ratios. Generally, results differed according to test type, and tests for disease prognosis or screening appeared to be more favorable than tests to stratify patients by response or by risk of adverse effects. However, these results were not significant. LIMITATIONS Different definitions of IM could have been used. Quality assessment of the studies was restricted to analyzing transparency. CONCLUSIONS IM neither seems to display superior cost-effectiveness than other types of medical interventions nor to be economically inferior. Instead, rather than 'whether' healthcare was individualized, the question of 'how' it was individualized was of economic relevance.
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Affiliation(s)
- Maximilian H M Hatz
- Hamburg Center for Health Economics, University of Hamburg, 20354, Hamburg, Germany,
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uPA/PAI-1, Oncotype DX™, MammaPrint® Valeurs pronostique et prédictive pour une utilité clinique dans la prise en charge du cancer du sein. ONCOLOGIE 2014. [DOI: 10.1007/s10269-014-2379-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Lamond NWD, Skedgel C, Younis T. Is the 21-gene recurrence score a cost-effective assay in endocrine-sensitive node-negative breast cancer? Expert Rev Pharmacoecon Outcomes Res 2014; 13:243-50. [DOI: 10.1586/erp.13.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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André F, Delaloge S, Guinebretière JM, Petit T, Pierga JY, Zarca D, Zarca K. Prolifération des cancers du sein et biomarqueurs décisionnels en pratique RPC (RPC 2013). ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2341-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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