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Record SM, Thomas SM, Tian WM, van den Bruele AB, Chiba A, DiLalla G, DiNome ML, Kimmick G, Rosenberger LH, Woriax HE, Hwang ES, Plichta JK. Anatomy Versus Biology: What Guides Chemotherapy Decisions in Older Patients With Breast Cancer? J Surg Res 2024; 296:654-664. [PMID: 38359680 PMCID: PMC10947834 DOI: 10.1016/j.jss.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION With the increasing utilization of genomic assays, such as the Oncotype DX recurrence score (RS), the relevance of anatomic staging has been questioned for select older patients with breast cancer. We sought to evaluate differences in chemotherapy receipt and/or survival among older patients based on RS and sentinel lymph node biopsy (SLNB) receipt/result. METHODS Patients aged ≥ 65 diagnosed with pT1-2/cN0/M0 hormone-receptor-positive (HR+)/HER2-breast cancer (2010-2019) were selected from the National Cancer Database. Logistic regression was used to identify factors associated with chemotherapy receipt. Cox proportional hazards models were used to estimate the association of RS/SLNB group with overall survival. A cost-benefit study was also performed. RESULTS Of the 75,428 patients included, the majority had an intermediate RS (58.2% versus 27.9% low, 13.8% high) and were SLNB- (85.1% versus 11.6% SLNB+, 3.3% none). Chemotherapy was recommended for 13,442 patients (17.8%). After adjustment, chemotherapy receipt was more likely with higher RS and SLNB+. After adjustment, SLNB receipt/result was only associated with overall survival among those with an intermediate RS. However, returning to the OR for SLNB is not cost-effective. CONCLUSIONS SLNB receipt/result was associated with survival for those with an intermediate RS, but not a low or high RS, suggesting that an SLNB may indeed be unnecessary for select older patients with breast cancer.
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Affiliation(s)
- Sydney M Record
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, North Carolina; Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - William M Tian
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Astrid Botty van den Bruele
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Gayle DiLalla
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Maggie L DiNome
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Gretchen Kimmick
- Duke Cancer Institute, Duke University, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Hannah E Woriax
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Cancer Institute, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina.
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Simons MJHG, Machielsen PM, Spoorendonk JA, Ignacio T, Drost PB, Jacobs T, de Jongh FE. A cost-consequence model of using the 21-gene assay to identify patients with early-stage node-positive breast cancer who benefit from adjuvant chemotherapy in the Netherlands. J Med Econ 2024; 27:445-454. [PMID: 38436289 DOI: 10.1080/13696998.2024.2324612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients with early-stage hormone receptor positive, human epidermal growth factor receptor-2 (HER2) negative invasive breast cancer with 1-3 positive lymph nodes (N1) often undergo surgical excisions followed by adjuvant chemotherapy (ACT). Many patients have no benefit from ACT and receive unnecessary, costly treatment often associated with short- and long-term adverse events (AEs). Gene expression profiling (GEP) assays, such as the 21-gene assay (i.e. the Oncotype DX assay), can identify patients at higher risk for recurrence who may benefit from ACT. However, the budgetary consequence of using the Oncotype DX assay versus no GEP testing in the Netherlands is unknown. Our study therefore assessed it using a cost-consequence model. METHODS A validated model was used to create the N1 model. The model compared the costs and consequences of using the Oncotype DX assay versus no GEP testing and MammaPrint, and subsequent ACT use with corresponding costs for chemotherapy, treatment of AEs, productivity losses, GEP testing, and treatment of recurrences, according to the Oncotype DX results. The model time horizon was 5 years. RESULTS Costs for the total population amounted to €8.0 million (M), €16.2 M, and €9.5 M, and cost per patient amounted to €13,540, €27,455, and €16,154 for using the Oncotype DX assay, no GEP testing, and MammaPrint, respectively. Total cost savings of using the Oncotype DX assay amounted to €8.2 M versus no GEP testing and €1.5 M versus MammaPrint. Using the Oncotype DX assay would result in fewer patients receiving ACT and thus fewer AEs, sick days, and hospitalizations, leading to overall cost savings compared with no GEP testing and MammaPrint. CONCLUSIONS Implementing Oncotype DX testing in this population can prevent unnecessary overtreatment, reducing clinical and economic burden on the patient and Dutch healthcare system.
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Affiliation(s)
| | | | | | - Tim Ignacio
- Evidence & Access, OPEN Health, Rotterdam, The Netherlands
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Park I, Lee Y, Kim JH, Bae SJ, Ahn SG, Jeong J, Cha YJ. YAP1 Expression in HR+HER2- Breast Cancer: 21-Gene Recurrence Score Analysis and Public Dataset Validation. Cancers (Basel) 2023; 15:5034. [PMID: 37894401 PMCID: PMC10605327 DOI: 10.3390/cancers15205034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND YAP1, an oncogene in numerous cancers, is a downstream transcription factor of the Hippo pathway. This study focuses on its relationship with the Oncotype Dx (ODX) test risk score (RS) in patients with hormone-receptor-positive, HER2-negative (HR+HER2-) breast cancer. METHODS We retrospectively analyzed 401 HR+HER2- breast cancer patients from Gangnam Severance Hospital who underwent ODX tests (May 2014-April 2020). YAP1 nuclear localization was evaluated via immunohistochemical staining and its clinical correlation with clinicopathological parameters, including RS, was analyzed. Public datasets TCGA-BRCA and METABRIC validated clinical outcomes. RESULTS YAP1 expression negatively correlated with ODX RS (OR 0.373, p = 0.002). Elevated YAP1 mRNA levels corresponded to better clinical outcomes, specifically in ER-positive patients, with significant results in METABRIC and TCGA-BRCA datasets (p < 0.0001 OS in METABRIC, p = 0.00085 RFS in METABRIC, p = 0.040 DFS in TCGA-BRCA). In subsets with varying ESR1 mRNA expression and pronounced YAP1 expression, superior survival outcomes were consistently observed. CONCLUSION YAP1 may be a valuable prognostic marker and potential therapeutic target in HR+HER2- breast cancer patients.
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Affiliation(s)
- Inho Park
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (I.P.); (Y.L.)
- Center for Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Yangkyu Lee
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (I.P.); (Y.L.)
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
| | - Jee Hung Kim
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Soong June Bae
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Sung Gwe Ahn
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Joon Jeong
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Yoon Jin Cha
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (I.P.); (Y.L.)
- Institute of Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul 06273, Republic of Korea; (J.H.K.); (S.J.B.); (S.G.A.); (J.J.)
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Wang T, Dossett LA. Incorporating Value-Based Decisions in Breast Cancer Treatment Algorithms. Surg Oncol Clin N Am 2023; 32:777-797. [PMID: 37714643 DOI: 10.1016/j.soc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.
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Affiliation(s)
- Ton Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Shaw VR, Amos CI, Cheng C. Predicting Chemotherapy Benefit across Different Races in Early-Stage Breast Cancer Patients Using the Oncotype DX Score. Cancers (Basel) 2023; 15:3217. [PMID: 37370827 DOI: 10.3390/cancers15123217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Oncotype DX assay, a multigene molecular test, has been widely used to stratify relapse risk and guide chemotherapy treatment in breast cancer. However, the optimal threshold of the Oncotype DX score in predicting chemotherapy benefit and its racial variation has not been investigated. METHODS In this study, we apply a random forest survival model to the SEER-Oncotype cohort data (Surveillance, Epidemiology, and End Results with Oncotype DX test information for breast cancer patients) and determine chemotherapy benefit thresholds in early-stage, estrogen-receptor-positive (ER+), and HER2-negative (HER2-) patients of different races. RESULTS Our results indicate that early-stage ER+, HER2-, and LN-/LN+ patients may benefit from receiving chemotherapy at a lower Oncotype DX score than current guidelines (Recurrence Score, RS > 25 or RS > 30) suggest. According to the estimated chemotherapy sensitivity thresholds from our models, 2.05-2.72-fold more lymph-node-negative (LN-) and 2.08-5.02-fold more lymph-node-positive (LN+) patients who may not currently be recommended for chemotherapy by their Oncotype DX test result may actually have the potential to benefit from chemotherapy. Furthermore, our models indicate a racial difference in chemotherapy benefit: white, black, and Asian women with early-stage ER+/LN- tumors benefit from chemotherapy when their Oncotype DX scores are greater than 19.9, 37.2, and 18.0, respectively. CONCLUSIONS Our study provides a method for calibrating multigene molecular tests to help guide treatment decisions in racially and ethnically diverse patients with cancer. Specifically, we identify key chemotherapy sensitivity thresholds for the Oncotype DX recurrence score test in breast cancer patients and provide evidence that certain patients may benefit from receiving chemotherapy at a lower threshold than the current clinical guidelines suggest.
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Affiliation(s)
- Vikram R Shaw
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX 77030, USA
| | - Christopher I Amos
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX 77030, USA
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
| | - Chao Cheng
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX 77030, USA
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Knape N, Park JH, Agala CB, Spanheimer P, Morrow M, Downs-Canner S, Baldwin XL. Can We Forgo Sentinel Lymph Node Biopsy in Women Aged ≥ 50 Years with Early-Stage Hormone-Receptor-Positive HER2-Negative Special Histologic Subtype Breast Cancer? Ann Surg Oncol 2023; 30:1042-1050. [PMID: 36217063 DOI: 10.1245/s10434-022-12626-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Breast cancer has significant biologic heterogeneity, which influences treatment decisions. We hypothesized that in postmenopausal women (≥ 50 years) with clinical T1-2, N0, hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer of special histology (mucinous, tubular, cribriform, papillary), information from sentinel lymph node biopsy (SLNB) may not change adjuvant therapy recommendations. PATIENTS AND METHODS We constructed a cohort from the National Cancer Database of women aged ≥ 18 years with cT1-2 N0 HR+ HER2- invasive breast cancer. We calculated the frequency of nodal positivity by histology. We measured the frequency of N2/N3 disease, the distribution of Oncotype DX 21-gene assay recurrence score (ODX RS) across special histology by nodal status, and frequency of chemotherapy use by ODX RS and pathologic N stage. RESULTS In women with cN0 HR+/HER2- special histologic subtype breast cancer, the likelihood of pathologic nodal positivity is less than 5%, and 99.7% of patients had N0 or N1 disease. Among women aged ≥ 50 years with HR+/HER2- special histologic subtype breast cancer, there was low prevalence of high ODX RS > 25 in both N0 and N1 patients (7% overall). Receipt of chemotherapy correlated with Oncotype DX scores as anticipated, with the lowest use in women with a low/intermediate RS (from 2 to 6% for N0 and 6-24% for N1) and the highest use in women with high risk Oncotype scores (from 74 to 92%). CONCLUSIONS Our study suggests that SLNB could potentially be omitted in select postmenopausal women with cT1-2 N0 HR+/HER2- special histologic subtype breast cancer when ODX RS is available.
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Affiliation(s)
- Nicole Knape
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ji-Hye Park
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Philip Spanheimer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Monica Morrow
- Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Xavier L Baldwin
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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da Luz FAC, Araújo BJ, de Araújo RA. The current staging and classification systems of breast cancer and their pitfalls: Is it possible to integrate the complexity of this neoplasm into a unified staging system? Crit Rev Oncol Hematol 2022; 178:103781. [PMID: 35953011 DOI: 10.1016/j.critrevonc.2022.103781] [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: 03/30/2022] [Revised: 06/21/2022] [Accepted: 08/06/2022] [Indexed: 11/29/2022] Open
Abstract
Breast cancer is one of the leading causes of cancer death in women worldwide due to its variable aggressiveness and high propensity to develop distant metastases. The staging can be performed clinically or pathologically, generating the stage stratification by the TNM (T - tumor size; N- lymph node metastasis; M - distant organ metastasis) system. However, cancers with virtually identical TNM characteristics can present highly contrasting behaviors due to the divergence of molecular profiles. This review focuses on the histopathological nuances and molecular understanding of breast cancer through the profiling of gene and protein expression, culminating in improvements promoted by the integration of this information into the traditional staging system. As a culminating point, it will highlight predictive statistical tools for genomic risks and decision algorithms as a possible solution to integrate the various systems because they have the potential to reduce the indications for such tests, serving as a funnel in association with staging and previous classification.
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Affiliation(s)
- Felipe Andrés Cordero da Luz
- Center for Cancer Prevention and Research, Uberlandia Cancer Hospital, Av Amazonas nº 1996, Umuarama, Uberlândia, Minas Gerais, MG 38405-302, Brazil
| | - Breno Jeha Araújo
- São Paulo State Cancer Institute of the Medical School of the University of São Paulo, Av. Dr. Arnaldo 251, São Paulo, São Paulo, SP 01246-000, Brazil
| | - Rogério Agenor de Araújo
- Medical Faculty, Federal University of Uberlandia, Av Pará nº 1720, Bloco 2U, Umuarama, Uberlândia, Minas Gerais, MG 38400-902, Brazil.
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The impact of age and nodal status on variations in oncotype DX testing and adjuvant treatment. NPJ Breast Cancer 2022; 8:27. [PMID: 35232996 PMCID: PMC8888624 DOI: 10.1038/s41523-022-00394-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Oncotype DX (ODX) recurrence score (RS) is a validated tool to guide the use of adjuvant chemotherapy (AC) in hormone receptor+/HER2- breast cancer. In this analysis, we examine (1) characteristics associated with ODX testing and (2) the association between ODX RS and receipt of AC across age and nodal status. Women with HR+/HER2–, early-stage (T1-2, N0-1) breast cancers from 2010–2017 in the National Cancer Database were included. 530,125 met inclusion and 255,971 received ODX testing. Older women were less likely to receive testing; however, nodal positivity increased use of testing. High ODX RS was associated with increased mortality, though the association was not consistent across age and was most strongly associated with mortality among younger, node-negative women. Older women with high ODX RS, regardless of nodal status, were less likely to receive AC. Clinicians may be employing ODX RS to support treatment decisions against the receipt of AC.
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Magnoni F, Corso G, Gilardi L, Pagan E, Massari G, Girardi A, Ghidinelli F, Bagnardi V, Galimberti V, Grana CM, Veronesi P. Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer? Future Oncol 2021; 18:193-204. [PMID: 34882010 DOI: 10.2217/fon-2021-0470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.
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Affiliation(s)
- Francesca Magnoni
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Giovanni Corso
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy.,Departmentof Oncology & Hemato-Oncology, University of Milan, Milan, 20122, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milano, 20141, Italy
| | - Eleonora Pagan
- Department of Statistics & Quantitative Methods, University of Milan-Bicocca, Milan, 20126, Italy
| | - Giulia Massari
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Antonia Girardi
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | | | - Vincenzo Bagnardi
- Department of Statistics & Quantitative Methods, University of Milan-Bicocca, Milan, 20126, Italy
| | - Viviana Galimberti
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milano, 20141, Italy
| | - Paolo Veronesi
- Breast Cancer Surgery Division, European Institute of Oncology, IRCCS, Milan, 20141, Italy.,Departmentof Oncology & Hemato-Oncology, University of Milan, Milan, 20122, Italy
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Braun M, Kriegmair A, Szeterlak N, Andrulat A, Schrodi S, Kriner M, Hanusch C, Hamann M, Stoetzer O, Pölcher M. Validation of the 21-Gene Recurrence Score Assay in Patients with Hormone Receptor-Positive, HER2-Negative Breast Cancer and 0 to 3 Positive Lymph Nodes – Risk Pattern and Outcomes on a Community Level. Breast Care (Basel) 2021; 17:288-295. [DOI: 10.1159/000521096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/19/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction
The aim of the present study was to analyze the performance of Oncotype DX® multigene assay (ODX) in patients with 0-3 lymph nodes in a high volume community hospital.
Methods
Patients with non-metastatic HR+/HER2- EBC and 0-3 positive lymph nodes, who underwent primary surgery at the Red Cross Hospital Munich, Germany and consecutively had ODX testing were included in this retrospective study. The distribution of clinico-pathologic characteristics, recurrence score (RS) risk and use of systemic therapy were compared among patients without positive lymph nodes (N0) and patients with micrometastases or 1 to 3 positive lymph nodes (N1). Disease free survival (DFS) and overall survival (OS) were estimated.
Results
From 2012 to2017 ODX was consecutively performed in 575 (16.4%) of 3492 women with HR+/ HER- EBC, of which 553 were eligible for this analysis (N0: 60.8%; N1: 39.2%). Among the patients included, 441 (79.7%) had a RS of 0 to 25 and 112 (20.3%) had a RS of 26 or higher. In patients with RS 0 to 25 the rate of chemotherapy use was low, independent from nodal status (N0: 17.1% and N1: 19.1%) and 5y-DFS was 90.5% and 91.7% for N0 and N1 patients, respectively. There was no significant difference in DFS (90.5% vs. 93.3%; p= 0.101) or OS (97.2% vs. 96.0%; p= 0.737) for patients with a RS 0 to 25 when treated with chemo-endocrine therapy or endocrine therapy alone, independent from nodal status.
Conclusions
The results of the study confirm the observations from randomized studies on the use of the ODX in a real world population in terms of risk distribution and patient outcome. Adjuvant chemotherapy could be safely omitted in patients with HR+/HER2- breast cancer with 0-3 positive lymph nodes and RS<25.
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11
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Yamamoto S, Chishima T, Shibata Y, Harada F, Takeuchi H, Yamada A, Narui K, Misumi T, Ishikawa T, Endo I. Clinical Impact of a Novel Model Predictive of Oncotype DX Recurrence Score in Breast Cancer. In Vivo 2021; 35:2439-2444. [PMID: 34182528 DOI: 10.21873/invivo.12522] [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: 03/02/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Oncotype DX recurrence score (RS) for breast cancer is a useful tool for determining chemotherapy indication but it is expensive and time-consuming. We determined whether four immuno-histochemical markers, namely human epidermal growth factor 2 (HER2), estrogen receptor (ER), progesterone receptor (PgR), and Ki-67, are predictive of an RS ≥26 in Japanese patients. PATIENTS AND METHODS The study included 95 Japanese patients evaluated for RS. A predictive model was created using logistic regression analysis. RESULTS The discriminant function was calculated as follows: p=1/{1+exp [-(4.611+1.2342×HER2-0.0813×ER- 0.0489 ×PgR+0.0857×Ki67)]}. Using a probability of 0.5 as the cutoff, the accuracy, sensitivity, specificity, positive predictive and negative predictive values were 90.5%, 72.2%, 94.8%, 76.4% and 93.5%, respectively. CONCLUSION The model had a high negative predictive value in predicting RS ≥26 in Japanese patients, indicating that Oncotype DX testing may be omitted in patients with a negative result according to the predictive model.
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Affiliation(s)
- Shinya Yamamoto
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Japan.,Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Takashi Chishima
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Japan;
| | - Yukako Shibata
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Fumi Harada
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Hideki Takeuchi
- Department of Breast Surgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Akimitsu Yamada
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Toshihiro Misumi
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takashi Ishikawa
- Department of Breast Surgery and Oncology, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Alkushi A, Omair A, Masuadi E, Alamri G, Abusanad A, Abdelhafiez N, Mohamed AE, Abulkhair O. The Level of Agreement Among Medical Oncologists on Adjuvant Chemotherapy Decision for Breast Cancer in Pre and Post-Oncotype DX Settings. Cureus 2021; 13:e13298. [PMID: 33738150 PMCID: PMC7958828 DOI: 10.7759/cureus.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The Oncotype DX assay plays an important role in the identification of the specific subset of hormone receptor (HR)-positive and node-negative breast cancer (BC) patients, who would benefit the most from adjuvant chemotherapy. The current study aimed at assessing the level of agreement among medical oncologists on adjuvant chemotherapy decisions before and after Oncotype DX, as well as the intra-observer agreement of each medical oncologist's decision of prescribing adjuvant chemotherapy based on clinicopathological and immunohistochemical parameters only and followed by Oncotype DX recurrence score (RS) results. METHODS A retrospective analysis of data related to clinicopathological and immunohistochemical parameters, and Oncotype DX RS result for 145 female, estrogen receptor (ER)-positive, HER2 negative, and both node-negative and positive BC patients was performed. Initially, the data without Oncotype DX RS was sent to 16 oncologists in multiple centers in the Middle East. After one week, the same data with the shuffling of cases were sent to the oncologists with the addition of the Oncotype DX RS result for each patient. The inter and intra-observer agreement (kappa and Fleiss multi-rater kappa) among oncologists' decision of prescribing adjuvant chemotherapy pre and post-Oncotype DX RS results were assessed. Oncotype DX risk scores were used as continuous variables as well as based on old RS grouping, categorized into low (0-17), intermediate (18-30), and high risk (≥ 31) groups. A test with a p-value of < 0 .05 will be considered statistically significant. RESULTS The mean age ± SD of the cohort was 51.9 ± 9.4 years. Sixty-nine patients (47.6%) were premenopausal whereas 76 patients (52.4%) were postmenopausal. The mean Oncotype DX RS was 17.8 ± 8.6 and 54.5% had low recurrence risk (RR), 37.9% had intermediate RR and only 7.6% had high RR. The majority of our cases were grade two (53.1%) and T stage one (49%), whereas 29.7% had positive one to three lymph nodes. The addition of Oncotype DX results improved the agreement among oncologists' decision from fair to moderate (kappa = 0.52; p <0.001). On average, an oncologist's decision of prescribing adjuvant chemotherapy pre and post-Oncotype DX had an agreement in 70.6% of the cases, with agreement observed mostly for cases where the initial decision of adjuvant chemotherapy was (no) and it was retained with post-Oncotype DX assay (46.1%), compared to 24.5% cases where the initial decision was (yes) and it was retained with post-Oncotype DX assay (kappa = 0.39; p <0.001). The addition of the Oncotype DX RS result avoided chemotherapy in 20.4% of cases and identified 9% of cases as candidates for adjuvant chemotherapy (kappa = 0.38; p <0.001). The disagreement was highest among cases with intermediate RR (33.6%) followed by high and low RR (31.3% and 21.6%) with a statistical significance of <0.001. CONCLUSION We conclude that the Oncotype DX RS significantly influenced the decision to prescribe adjuvant chemotherapy among HR-positive, HER2 negative, and both node-negative and positive patients, as it increased the level of agreement among oncologists and led to a decrease in the use of adjuvant chemotherapy compared to the pre-Oncotype recommendations.
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Affiliation(s)
- Abdulmohsen Alkushi
- Pathology, King Abdulaziz Medical City of National Guard, Riyadh, SAU.,Pathology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences & King Abdullah International Medical Research Center, Riyadh, SAU
| | - Ahmad Omair
- Pathology, College of Science & Health Professions, King Saud bin Abdulaziz University for Health Sciences & King Abdullah International Medical Research Center, Riyadh, SAU
| | - Emad Masuadi
- Research Unit/Biostatistics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences & King Abdullah International Medical Research Center, Riyadh, SAU
| | - Ghaida Alamri
- Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences & King Abdullah International Medical Research Center, Riyadh, SAU
| | | | - Nafisa Abdelhafiez
- Medical Oncology, King Abdulaziz Medical City of National Guard, Riyadh, SAU
| | - Amin E Mohamed
- Medical Oncology, King Abdulaziz Medical City of National Guard, Riyadh, SAU
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13
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Immune Cell-Associated Protein Expression Helps to Predict Survival in Muscle-Invasive Urothelial Bladder Cancer Patients after Radical Cystectomy and Optional Adjuvant Chemotherapy. Cells 2021; 10:cells10010159. [PMID: 33467469 PMCID: PMC7829767 DOI: 10.3390/cells10010159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/12/2020] [Accepted: 12/24/2020] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Adjuvant chemotherapy following radical cystectomy is a common therapy for muscle invasive bladder cancer (MIBC) patients. No applicable biomarkers exist to predict which patients will benefit from chemotherapy. Three immune cell markers, the chemokine CC motif ligand 2 (CCL2), the pan macrophage marker CD68, and the M2 macrophage marker CD163, were examined using immunohistochemistry to determine their predictive value for chemotherapy responses in different nodal stage and tumor stage subgroups. The presence of tumor-infiltrating immune cells, characterized by the markers CD68, CD163, and CCL2, was associated with a superior prognosis, and chemotherapy may not add an advantage for prognosis. However, a depleted immune microenvironment, here represented as a reduction or loss of macrophages, helped to predict the benefit of chemotherapy in N1 + 2 stage patients. Altogether, it is meaningful to consider the abundance of immune cells, such as macrophages, to better predict the response to chemotherapy for bladder cancer (BCa) patients after radical treatment. Abstract Bladder cancer (BCa) is the tenth most commonly diagnosed malignant cancer worldwide. Although adjuvant chemotherapy following radical cystectomy is a common therapy for muscle invasive bladder cancer patients, no applicable biomarkers exist to predict which patients will benefit from chemotherapy. In this study, we examined three immune cell markers, the chemokine CC motif ligand 2 (CCL2), the pan macrophage marker cluster of differentiation 68 (CD68) and the M2 macrophage marker cluster of differentiation 163 (CD163), using immunohistochemistry to determine their predictive value for the chemotherapy response in different nodal stage (pN0 vs. pN1 + 2) and tumor stage subgroups (pT2 vs. pT3 + 4). The prognosis was studied in terms of the overall survival (OS), disease-specific survival (DSS), and recurrence-free-survival (RFS) in 168 muscle invasive BCa patients. Chemotherapy was associated with a poorer prognosis in patients with a higher expression of the immune markers CCL2 (RFS), CD68 (DSS and RFS), and CD163 (DSS and RFS) in the N0 group and with poorer survival in patients with a higher expression of the immune markers CCL2 (OS, DSS, and RFS), CD68 (OS, DSS, and RFS), and CD163 (OS, DSS, and RFS) in the pT2 group when compared with treatments without chemotherapy. In contrast, chemotherapy was associated with a better prognosis in patients with a low expression of the immune markers CCL2 (DSS and RFS), CD68 (OS, DSS, and RFS), and CD163 (OS) in the N1 + 2 group. In addition, chemotherapy was associated with improved survival in patients with a low expression of the immune marker CD68 (OS and DSS) and there was a trend for a better prognosis in patients with a low expression of CD163 (OS) in the pT3 + 4 group compared to patients not treated with chemotherapy. Interestingly, CD68 appeared to be the most applicable immune marker to stratify patients by the outcome of chemotherapy in the nodal stage and tumor stage groups. Overall, we suggest that, in addition to the clinical factors of tumor stage and nodal stage, it is also meaningful to consider the abundance of immune cells, such as macrophages, to better predict the response to chemotherapy for BCa patients after radical treatment.
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14
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Losk K, Freedman RA, Laws A, Kantor O, Mittendorf EA, Tan-Wasielewski Z, Trippa L, Lin NU, Winer EP, King TA. Oncotype DX testing in node-positive breast cancer strongly impacts chemotherapy use at a comprehensive cancer center. Breast Cancer Res Treat 2020; 185:215-227. [PMID: 32939592 DOI: 10.1007/s10549-020-05931-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE In 2016, we initiated standardized "reflex" Oncotype DX Recurrence Score (RS) testing for patients ≤ 65 years with pT1-2N0-1 HR+/HER2- breast cancer. Here, we examine RS testing patterns, RS distribution, and factors associated with chemotherapy use in patients with pN1 breast cancer. METHODS Patients with stage I-III HR+/HER2- pN1 breast cancer treated with upfront surgery from February 2016 to March 2019 were identified. Clinical characteristics were compared between patients meeting reflex RS testing criteria, those with RS ordered outside of reflex criteria, and those without RS testing. RS was categorized as low (< 18), intermediate (18-30), and high (≥ 31). Multivariate logistic regression was performed to identify factors associated with adjuvant chemotherapy receipt. We examined 3-year recurrence-free survival (RFS) and overall survival (OS) stratified by chemotherapy use. RESULTS We identified 347 HR+/HER2- pN1 patients; 272 (78.4%) received RS testing, and 194 (71.3%) met reflex criteria. RS was < 18 in 164 (61.4%) patients, 18-30 in 89 (32.7%) patients, and ≥ 31 in 16 (5.9%) patients. On multivariate analysis, RS < 18 (OR 0.47, 95% CI 0.24-0.92) was associated with lower odds of chemotherapy use, whereas presence of lymphovascular invasion (OR 1.77, 95% CI 1.03-3.07) and lobular subtype (OR 2.40, 95% CI 1.21-4.78) were associated with higher odds. No differences in 3-year RFS (p = 0.97) or OS (p = 0.19) based on chemotherapy receipt were observed. CONCLUSION Most RS-tested HR+/HER2- pN1 patients at our center had low genomic risk. A low RS independently influenced chemotherapy omission and in RS-tested patients, short-term outcomes were excellent. Our study demonstrates increased use of RS in guiding adjuvant treatment decisions in node-positive disease.
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Affiliation(s)
- Katya Losk
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Lorenzo Trippa
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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15
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Walter VP, Taran FA, Wallwiener M, Bauer A, Grischke EM, Walter CB, Hahn M, Brucker SY, Hartkopf AD. Distribution of the 21-Gene Breast Recurrence Score in Patients with Primary Breast Cancer in Germany. Geburtshilfe Frauenheilkd 2020; 80:619-627. [PMID: 32565552 PMCID: PMC7299682 DOI: 10.1055/a-1111-8734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 02/02/2020] [Indexed: 12/16/2022] Open
Abstract
Background
Multigene assays are being used increasingly to aid in decision-making about chemotherapy in breast cancer. Here, we present the 21-gene recurrence score (RS) of patients tested in routine clinical practice in Germany.
Patients and Methods
In a retrospective analysis, 4695 patients with hormone receptor-positive and HER2-negative early breast cancer (pT1 – 3, pN0 – 1, M0) were included in whom RS testing was conducted in Germany between November 2015 and July 2018. RS groups as defined in the TAILORx trial (RS result 0 – 10; 11 – 25; 26 – 100) were used.
Results
Of these patients, 21% were assigned to the low RS group, 63% to the midrange RS group, and 15% to the high RS group. 1772 (81%) of 2175 node-negative patients over 50 years of age were grouped either into the low RS group or the midrange RS group. The portion of patients with a low or midrange RS was 90% among node-positive patients (1284 of 1432 patients), 79% among patients with Ki-67-high (≥ 20%) tumors (1829 of 2310 patients), 86% vs. 70% among patients with G2 and G3 tumors (3244 of 3762 patients and 368 of 522 patients), respectively, 88% among patients with a tumor size of > 5 cm (140 of 159 patients), and 82% among node-negative patients at high clinical risk (1110 of 1352).
Conclusions
The distribution of the 21-gene RS in German patients that were tested in routine clinical practice indicates that, according to the results of the TAILORx trial, chemotherapy may not be beneficial in most of these.
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Affiliation(s)
- Vincent P Walter
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | | | - Markus Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | - Armin Bauer
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | | | | | - Markus Hahn
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | - Sara Y Brucker
- Department of Women's Health, University of Tübingen, Tübingen, Germany
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16
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Louie RJ, Ollila DW. ASO Author Reflections: More Isn't Always Best-Shaping the Dialogue to Decrease Overtreatment of the Axilla in the Elderly. Ann Surg Oncol 2020; 27:3434-3435. [PMID: 32270419 DOI: 10.1245/s10434-020-08423-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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17
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Louie RJ, Gaber CE, Strassle PD, Gallagher KK, Downs-Canner SM, Ollila DW. Trends in Surgical Axillary Management in Early Stage Breast Cancer in Elderly Women: Continued Over-Treatment. Ann Surg Oncol 2020; 27:3426-3433. [PMID: 32215758 DOI: 10.1245/s10434-020-08388-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In the past two decades, three prospective randomized trials demonstrated that elderly women with early stage hormone positive breast cancer had equivalent disease-specific mortality regardless of axillary surgery. In 2016, the Choosing Wisely campaign encouraged patients and providers to reconsider the role of axillary surgery in this population. We sought to identify factors that contribute to adopting non-operative management of the axilla in these patients. MATERIALS AND METHODS We performed a retrospective analysis of women ≥ 70 years old with cT1/T2, hormone positive invasive ductal carcinoma who underwent partial or total mastectomy, with/without axillary surgery, and did not receive adjuvant chemotherapy from the National Cancer Database from 2004 to 2015. We used multivariable log-binomial regression to model the risk of undergoing axillary surgery across region, care setting, and Charlson-Deyo scores, and analyzed temporal trends using Poisson regression. From 2004 to 2015, 87,342 of 99,940 women who met inclusion criteria (83%) had axillary surgery. Over time, axillary surgery increased from 78% to 88% (p < 0.001). This rise was consistent across region (p = 0.81) and care setting (p = 0.09), but flattened as age increased (p < 0.001). Omitting axillary surgery was more likely in patients treated in New England (RR 0.88, 95% CI 0.86, 0.89) and patients ≥ 85 (RR 0.66, 95% CI 0.65, 0.67). CONCLUSIONS Axillary surgery continues to be the preferred option of axillary management in elderly women with early stage, clinically node negative, hormone-positive, invasive breast cancer despite no survival benefit. Identifying factors to improve patient selection and dissemination of current recommendations can improve adoption of current evidence on axillary surgery in the elderly.
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Affiliation(s)
- Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles E Gaber
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula D Strassle
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristalyn K Gallagher
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie M Downs-Canner
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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18
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Downs-Canner SM, Gaber CE, Louie RJ, Strassle PD, Gallagher KK, Muss HB, Ollila DW. Nodal positivity decreases with age in women with early-stage, hormone receptor-positive breast cancer. Cancer 2019; 126:1193-1201. [PMID: 31860136 DOI: 10.1002/cncr.32668] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/01/2019] [Accepted: 11/20/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite data demonstrating the safety of omitting axillary surgery in older women with early-stage breast cancer, the incidence of axillary surgery remains high. It was hypothesized that the prevalence of nodal positivity would decrease with advancing age. METHODS The National Cancer Data Base was used to construct a cohort of adult women with early-stage, clinically node-negative, estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative breast cancer treated between 2013 and 2015. Multivariable logistic regression was used to assess the relationship between age and nodal positivity, and this was stratified by the axillary surgery category. Modified Poisson regression was used to estimate the proportion of women receiving adjuvant therapy according to age and nodal status. RESULTS The incidence of axillary surgery among women aged 70 and older (n = 51,917) remained high nationwide (86%). There was a significant decrease in nodal positivity with advancing age in women with early-stage, ER+, clinically node-negative breast cancer from the youngest cohort up to patients aged 70 to 89 years, and this was independent of histologic subtype (ductal vs lobular), race, comorbidities, and socioeconomic factors. Overall, less than 10% of women aged 70 or older who underwent surgery had node-positive disease, regardless of axillary surgery type, and almost 95% of node-positive patients aged 70 or older were at pathological stage N1mi or N1. CONCLUSIONS Axillary surgery may be safely omitted for many older women with ER+, clinically node-negative, early-stage breast cancer. Nodal positivity declines with advancing age, and this suggests varied biology in older patients versus younger patients.
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Affiliation(s)
- Stephanie M Downs-Canner
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Charles E Gaber
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Paula D Strassle
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristalyn K Gallagher
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hyman B Muss
- Department of Medical Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Zhang QH, Zhang WW, Wang J, Lian CL, Sun JY, He ZY, Wu SG. Impact of the 21-gene recurrence score assay on chemotherapy decision making and outcomes for breast cancer patients with four or more positive lymph nodes. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:446. [PMID: 31700882 DOI: 10.21037/atm.2019.08.82] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background To assess the impact of the 21-gene recurrence score (RS) on chemotherapy decision making and survival outcomes for breast cancer patients with >4 positive lymph nodes. Methods Patients with non-metastatic estrogen receptor-positive breast cancer with >4 positive lymph nodes diagnosed between 2004 and 2013 were identified using the Surveillance, Epidemiology, and End Results database. The relationships between the 21-gene RS value and survival outcomes, chemotherapy decision-making, and chemotherapy benefit were analyzed. Results A total of 410 patients were identified, including 191 (46.6%), 164 (40.0%), and 55 (13.4%) in the low-, intermediate-, and high-risk RS groups, respectively. The 21-gene RS assay results were independently related to chemotherapy receipt. A total of 59.0%, 68.0%, and 78.0% of patients received chemotherapy in the low-, intermediate-, and high-risk RS groups, respectively. The 21-gene RS was an independent indicator of breast cancer specific survival (BCSS) and overall survival (OS). Intermediate-risk [BCSS: hazards ratio (HR), 2.832, 95% confidence interval (CI): 1.160-6.910, P=0.022; OS: HR, 3.704, 95% CI: 1.750-7.836, P=0.001] and high-risk RS (BCSS: HR, 6.440, 95% CI: 2.597-15.974, P<0.001; OS: HR, 5.053, 95% CI: 2.199-11.608, P<0.001) cohorts had significantly lower survival outcomes compared to low-risk RS cohort. The 5-year BCSS were 92.7%, 88.3%, and 70.7% in patients in the low-, intermediate-, and high-risk RS cohorts, respectively (P<0.001), and the 5-year OS were 92.1%, 80.6%, and 66.6%, respectively (P<0.001). Conclusions The 21-gene RS is an independent predictor of chemotherapy receipt and survival outcomes for breast cancer patients with > 4 positive lymph nodes.
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Affiliation(s)
- Qing-Hong Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - Jun Wang
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Chen-Lu Lian
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - San-Gang Wu
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
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20
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Matikas A, Foukakis T, Swain S, Bergh J. Avoiding over- and undertreatment in patients with resected node-positive breast cancer with the use of gene expression signatures: are we there yet? Ann Oncol 2019; 30:1044-1050. [PMID: 31131397 PMCID: PMC6695578 DOI: 10.1093/annonc/mdz126] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prediction of benefit from adjuvant chemotherapy following resection of early breast cancer and, as a result, proper selection of candidates remains an elusive goal since the relative magnitude of benefit is the same regardless of the presence of clinicopathologic factors. Multiple studies, including randomized trials, establish the role of certain gene expression signatures in node-negative disease since they predict the risk of breast cancer relapse being so low that adjuvant chemotherapy can be omitted. In contrast, more limited data are available in higher risk, node-positive breast cancer patients, making the exclusion of adjuvant chemotherapy potentially hazardous. 'Prospective-retrospective' studies and limited prospective data show that several signatures, namely Oncotype Dx, MammaPrint, Prosigna, EndoPredict and Breast Cancer Index, select with different levels of success node-positive patients at very low risk for distant recurrence despite not receiving chemotherapy, although the long-term follow-up is still awaited. Pending, however the publication of the results from ongoing randomized studies which enroll patients with node-positive disease, major caution is warranted. Improper use and misinterpretation of these transcriptomic profiles can lead to undertreatment and exposure of patients to unnecessary risks resulting in increased breast cancer mortality for patients with axillary node-positive disease. With this review we critically discuss the available data on gene expression signatures that are used in clinical practice and offer practical recommendations regarding the management of patients with ER-positive, human epidermal growth factor receptor 2 (HER2)-negative, node-positive breast cancer.
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Affiliation(s)
- A Matikas
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm; Breast Center, Theme Cancer, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - T Foukakis
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm; Breast Center, Theme Cancer, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - S Swain
- Georgetown Lombardi Comprehensive Cancer Center, Washington; MedStar Health, Washington, USA
| | - J Bergh
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm; Breast Center, Theme Cancer, Karolinska University Hospital, Solna, Stockholm, Sweden
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21
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Dieci MV, Guarneri V, Zustovich F, Mion M, Morandi P, Bria E, Merlini L, Bullian P, Oliani C, Gori S, Giarratano T, Orvieto E, Griguolo G, Michieletto S, Saibene T, Del Bianco P, De Salvo GL, Conte P. Impact of 21-Gene Breast Cancer Assay on Treatment Decision for Patients with T1-T3, N0-N1, Estrogen Receptor-Positive/Human Epidermal Growth Receptor 2-Negative Breast Cancer: Final Results of the Prospective Multicenter ROXANE Study. Oncologist 2019; 24:1424-1431. [PMID: 31152079 DOI: 10.1634/theoncologist.2019-0103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/08/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The ROXANE Italian prospective study evaluated the impact of the 21-gene Recurrence Score (RS) results on adjuvant treatment decision for patients with early breast cancer. MATERIALS AND METHODS Nine centers participated. Physicians used the RS test whenever unsure about adjuvant treatment recommendation for patients with estrogen receptor-positive/human epidermal growth receptor 2-negative, T1-T3, N0-N1 early breast cancer. Pre-RS and post-RS treatment recommendations were collected. RESULTS A total of 251 patients were included. N0 patients (61%) showed higher grade (p < .001) and higher Ki67 (p = .001) and were more frequently progesterone receptor negative (p = .012) as compared with N1 patients. RS results were as follows: <11, n = 63 (25.1%); 11-25, n = 143 (57%); and ≥26, n = 45 (17.9%). Higher RS was found in N0 vs. N1 patients (p = .001) and in cases of G3 (p < .001) and higher Ki67 (p < .001). The rate of change in treatment decision was 30% (n = 75), mostly from chemotherapy (CT) plus hormone therapy (CT + HT) to hormone therapy (HT; 76%, n = 57/75). The proportion of patients recommended to CT + HT was significantly reduced from pre-RS to post-RS (52% to 36%, p < .0001). CT use reduction was more evident for N1 patients (55% to 27%) than for N0 patients (50% to 42%) and was observed only in cases of RS ≤17. CONCLUSION Physicians predominantly used the 21-gene assay in N0 patients with a more aggressive biology or in N1 patients showing more indolent biology. In this selected patient population, the use of RS testing led to a 30% rate of change in treatment decision. In the N1 patient subgroup, the use of RS testing contributed to reduce CT use by more than half. IMPLICATIONS FOR PRACTICE This study shows that, even in a context in which physicians recommend a high proportion of patients to endocrine treatment alone before knowing the results of the Recurrence Score (RS) assay, the use of the RS test, whenever uncertainty regarding adjuvant treatment recommendation is present, significantly contributes in further reducing the use of chemotherapy, especially for N1 patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biological Assay
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/genetics
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Lobular/drug therapy
- Carcinoma, Lobular/genetics
- Carcinoma, Lobular/pathology
- Chemotherapy, Adjuvant
- Clinical Decision-Making
- Female
- Follow-Up Studies
- Gene Expression Profiling
- Humans
- Italy
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Prospective Studies
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Survival Rate
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Affiliation(s)
- Maria Vittoria Dieci
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - Valentina Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - Fable Zustovich
- Medical Oncology, Ulss 1, San Martino Hospital, Belluno, Italy
| | - Marta Mion
- Medical Oncology, Ulss 6 Euganea, Ospedale Civile, Camposampiero, Italy
| | - Paolo Morandi
- Medical Oncology Department, Ulss 3 Serenissima, Angelo General Hospital, Mestre and SS Giovanni e Paolo General Hospital, Venezia, Italy
| | - Emilio Bria
- UOC Oncology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura Merlini
- Medical Oncology, Ulss 8 Berica, Ospedale Civile S. Bortolo, Vicenza, Italy
| | | | | | - Stefania Gori
- Oncology Unit, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Tommaso Giarratano
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | | | - Gaia Griguolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | | | - Tania Saibene
- Breast Surgery, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - Paola Del Bianco
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - Gian Luca De Salvo
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
| | - PierFranco Conte
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Medical Oncology 2, Istituto Oncologico Veneto IOV - IRCCS, Padova, Italy
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