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Parker G, Hunter S, Ghazi S, Hayeems RZ, Rousseau F, Miller FA. Decision impact studies, evidence of clinical utility for genomic assays in cancer: A scoping review. PLoS One 2023; 18:e0280582. [PMID: 36897859 PMCID: PMC10004522 DOI: 10.1371/journal.pone.0280582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 01/03/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Decision impact studies have become increasingly prevalent in cancer prognostic research in recent years. These studies aim to evaluate the impact of a genomic test on decision-making and appear to be a new form of evidence of clinical utility. The objectives of this review were to identify and characterize decision impact studies in genomic medicine in cancer care and categorize the types of clinical utility outcomes reported. METHODS We conducted a search of four databases, Medline, Embase, Scopus and Web of Science, from inception to June 2022. Empirical studies that reported a "decision impact" assessment of a genomic assay on treatment decisions or recommendations for cancer patients were included. We followed scoping review methodology and adapted the Fryback and Thornbury Model to collect and analyze data on clinical utility. The database searches identified 1803 unique articles for title/abstract screening; 269 articles moved to full-text review. RESULTS 87 studies met inclusion criteria. All studies were published in the last 12 years with the majority for breast cancer (72%); followed by other cancers (28%) (lung, prostate, colon). Studies reported on the impact of 19 different proprietary (18) and generic (1) assays. Across all four levels of clinical utility, outcomes were reported for 22 discrete measures, including the impact on provider/team decision-making (100%), provider confidence (31%); change in treatment received (46%); patient psychological impacts (17%); and costing or savings impacts (21%). Based on the data synthesis, we created a comprehensive table of outcomes reported for clinical utility. CONCLUSIONS This scoping review is a first step in understanding the evolution and uses of decision impact studies and their influence on the integration of emerging genomic technologies in cancer care. The results imply that DIS are positioned to provide evidence of clinical utility and impact clinical practice and reimbursement decision-making in cancer care. Systematic review registration: Open Science Framework osf.io/hm3jr.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Samer Ghazi
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Robin Z. Hayeems
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Francois Rousseau
- Department of Molecular Biology, Medical Biochemistry, and Pathology, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Fiona A. Miller
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Jank P, Lindner JL, Lehmann A, Pfitzner BM, Blohmer JU, Horst D, Kronenwett R, Denkert C, Schmitt WD. Comparison of risk assessment in 1652 early ER positive, HER2 negative breast cancer in a real-world data set: classical pathological parameters vs. 12-gene molecular assay (EndoPredict). Breast Cancer Res Treat 2021; 191:327-333. [PMID: 34783927 PMCID: PMC8763835 DOI: 10.1007/s10549-021-06415-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Risk assessment on the molecular level is important in predictive pathology to determine the risk of metastatic disease for ERpos, HER2neg breast cancer. The gene expression test EndoPredict (EP) was trained and validated for prediction of a 10-year risk of distant recurrence to support therapy decisions regarding endocrine therapy alone or in combination with chemotherapy. The EP test provides the 12-gene Molecular Score (MS) and the EPclin-Score (EPclin), which combines the molecular score with tumor size and nodal status. In this project we investigated the correlation of 12-gene MS and EPclin scores with classical pathological markers. METHODS EndoPredict-based gene expression profiling was performed prospectively in a total of 1652 patients between 2017 and 2020. We investigated tumor grading and Ki67 cut-offs of 20% for binary classification as well as 10% and 30% for three classes (low, intermediate, high), based on national and international guidelines. RESULTS 410 (24.8%) of 1652 patients were classified as 12-gene MS low risk and 626 (37.9%) as EPclin low risk. We found significant positive associations between 12-gene MS and grading (p < 0.001), EPclin and grading (p = 0.001), 12-gene MS and Ki67 (p < 0.001), and EPclin and Ki67 (p < 0.001). However, clinically relevant differences between EP test results, Ki67 and tumor grading were observed. For example, 118 (26.3%) of 449 patients with Ki67 > 20% were classified as low risk by EPclin. Same differences were seen comparing EP test results and tumor grading. CONCLUSION In this study we could show that EP risk scores are distributed differentially among Ki67 expression groups, especially in Ki67 low and high tumors with a substantial proportion of patients with EPclin high risk results in Ki67 low tumors and vice versa. This suggests that classical pathological parameters and gene expression parameters are not interchangeable, but should be used in combination for risk assessment.
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Affiliation(s)
- Paul Jank
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM)-Universitätsklinikum Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Judith Lea Lindner
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany
| | - Annika Lehmann
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany
| | | | - Jens-Uwe Blohmer
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Gynecology and Obstetrics, Charitéplatz 1, 10117, Berlin, Germany
| | - David Horst
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany
| | | | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg (UKGM)-Universitätsklinikum Marburg, Baldingerstraße, 35043, Marburg, Germany.
| | - Wolfgang Daniel Schmitt
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany
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Maniez P, Osada M, Reix N, Mathelin C. [uPA/PAI-1 and EPClin®: Comparison of their impact on the management of intermediate-prognosis breast cancers]. ACTA ACUST UNITED AC 2021; 50:298-306. [PMID: 34626849 DOI: 10.1016/j.gofs.2021.10.003] [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: 06/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The uPA/PAI-1 assay and the EPClin® test are useful tools that add to clinico-anatomical characteristics to determine the indication of adjuvant chemotherapy in case of intermediate-prognosis invasive breast cancer. The principal purpose of our study was to analyze the concordance of uPA/PAI-1 and EPClin® in classification of patients into two groups: low and high risk of relapse. METHODS We prospectively included 63 patients treated for intermediate-prognosis invasive breast cancer. All of these patients received a uPA/PAI-1 assay and an EPClin® test. RESULTS The uPA/PAI-1 assay and EPClin® test were consistent for 56.2% and inconsistent for 43.8%. In the event of a discrepancy, the treatment decision was based in 95.2% of patients on the EPClin® test result. In total, 38 patients were selected for adjuvant chemotherapy after achievement of the two tests. The mean time to report results after surgery was 9 days for the uPA/PAI-1 assay and 35 days for the EPClin® test. No cases of recurrence or death were found, with an average follow-up of 32 months. CONCLUSION The EPClin® test resulted in more chemotherapy prescriptions than indicated by uPA/PAI-1. However, we can't conclude to the superiority of one of these two tests, survival data and the effectiveness of our study being insufficient. In general, studies comparing different signatures useful to the therapeutic decision of intermediate prognosis breast cancers should be encouraged.
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Affiliation(s)
- P Maniez
- Hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France; Service de chirurgie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France.
| | - M Osada
- Hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France; Service de chirurgie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - N Reix
- ICube UMR 7357, université de Strasbourg/CNRS, Fédération de médecine translationnelle de Strasbourg (FMTS), Strasbourg, France; Laboratoire de biochimie et biologie moléculaire, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - C Mathelin
- Hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France; Service de chirurgie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France; CNRS UMR7104 Inserm U964, Institut de génétique et de biologie moléculaire et cellulaire (IGBMC), 1, rue Laurent-Fries, 67400 Illkirch-Graffenstaden, France
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Bourien H, Quillien V, Godey F, Perrin C, Le Du F, Guillermet S, Blanchot J, Lavoué V, Campillo-Gimenez B, Brunot A, Crouzet L, De la Motte Rouge T, Diéras V, Lefeuvre-Plesse C. Impact of EPclin on adjuvant therapeutic decision making and comparison of EPclin to the PREDICT tool. Int J Biol Markers 2021; 36:57-63. [PMID: 34027694 DOI: 10.1177/17246008211012424] [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: 02/04/2023]
Abstract
PURPOSE Genomic signatures, such as EndoPredict®, may help clinicians to decide which adjuvant treatment is the most appropriate. METHODS We propose the EndoPredict® assay for unclear cases of adjuvant treatment in patients treated in our comprehensive cancer center. We prospectively and retrospectively report the decision of adjuvant treatment before and after the EndoPredict® assay, respectively, compared to the PREDICT's tool scores. RESULTS From November 2016 to March 2019, 159 breast cancer tumors were analyzed and presented before and after the EndoPredict® assay. Before the EndoPredict® results, clinicians recommended chemotherapy for 57 patients (57/159, 36%). A total of 108 patients (108/159, 68%) were classified as EPclin high-risk score. There was only a slight agreement between clinicians' decisions and EPclin risk score. The EPclin score led to 37% changes in treatment (59/159); chemotherapy was favored in 80% of cases (47/59). The PREDICT tool recommended chemotherapy for 16 high-risk patients (16/159, 10%). CONCLUSION Although genomic tests were developed in order to de-escalate adjuvant treatment, in our comprehensive cancer center the use of the EndoPredict® assay led to an increase in prescribed chemotherapy.
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Affiliation(s)
| | | | | | | | - Fanny Le Du
- Centre Eugène Marquis, Unicancer, Rennes, France
| | | | | | - Vincent Lavoué
- Centre Eugène Marquis, Unicancer, Rennes, France.,Department of Surgery, CHU Pontchaillou, Unicancer, Rennes, France
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Ettl J, Anders SI, Hapfelmeier A, Paepke S, Noske A, Weichert W, Klein E, Kiechle M. First prospective outcome data for the second-generation multigene test Endopredict in ER-positive/HER2-negative breast cancer. Arch Gynecol Obstet 2020; 302:1461-1467. [PMID: 32902674 PMCID: PMC7584549 DOI: 10.1007/s00404-020-05771-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/24/2020] [Indexed: 01/30/2023]
Abstract
Purpose Prospectively collected outcome data of patients (pts) whose adjuvant systemic therapy recommendation was based on the clinico-molecular test EndoPredict® (EP) are presented. Methods Pts with ER-positive, HER2-negative early breast cancer with 0–3 positive lymph nodes were enrolled. The EP was carried out on all tumor samples. Pts were evaluated for treatment compliance, local recurrence, distant metastases and overall survival. Censored time-to-event outcomes were analysed by Cox proportional hazards models. Additional estimates of the event-free-survival were calculated by the Kaplan–Meier method. Hypothesis testing was conducted on two-sided exploratory 5% significance levels. Results 373 consecutive pts were enrolled. EP classified 238 pts (63.8%) as low risk and 135 pts (36.2%) as high risk. Median follow-up was 41.6 months. Risk for disease recurrence or death in EPclin high-risk patients was twofold higher in comparison with EPclin low-risk patients (hazard ratio (HR) 2.05 (95% CI 0.85–4.96; p = 0.110). Patients with EPclin high risk were at significant higher risk of distant metastases than patients with EPclin low risk (HR 5.18; 95% CI 1.04–25.74; p = 0.0443). EPclin high-risk patients who actually underwent adjuvant CTX had a 3-year-DFS of 96.3% (95% CI 92.2–100) in contrast to EPclin high-risk patients without CTX (3-year-DFS: 91.5% (95% CI 82.7–100%); HR 0.32; 95% CI 0.10–1.05; p = 0.061). Conclusion These first prospective outcome results show that EP, in clinical routine, is a valid clinico-molecular test, to predict DFS and to guide decision of adjuvant CTX use in ER-positive, HER2-negative early breast cancer pts with 0–3 positive lymph nodes. Adjuvant CTX seems to be beneficial for EPclin high-risk patients.
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Affiliation(s)
- Johannes Ettl
- Department of Obstetrics and Gynecology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.
| | - Sophie-Isabelle Anders
- Department of Obstetrics and Gynecology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Stefan Paepke
- Department of Obstetrics and Gynecology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Aurelia Noske
- Institute of Pathology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Wilko Weichert
- Institute of Pathology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Evelyn Klein
- Department of Obstetrics and Gynecology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Marion Kiechle
- Department of Obstetrics and Gynecology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Gupta G, Lee CD, Guye ML, Van Sciver RE, Lee MP, Lafever AC, Pang A, Tang-Tan AM, Winston JS, Samli B, Jansen RJ, Hoefer RA, Tang AH. Unmet Clinical Need: Developing Prognostic Biomarkers and Precision Medicine to Forecast Early Tumor Relapse, Detect Chemo-Resistance and Improve Overall Survival in High-Risk Breast Cancer. ACTA ACUST UNITED AC 2020; 4:48-57. [PMID: 32542231 PMCID: PMC7295150 DOI: 10.36959/739/525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chemo-resistant breast cancer is a major barrier to curative treatment for a significant number of women with breast cancer. Neoadjuvant chemotherapy (NACT) is standard first- line treatment for most women diagnosed with high-risk TNBC, HER2+, and locally advanced ER+ breast cancer. Current clinical prognostic tools evaluate four clinicopathological factors: Tumor size, LN status, pathological stage, and tumor molecular subtype. However, many similarly treated patients with identical residual cancer burden (RCB) following NACT experience distinctly different tumor relapse rates, clinical outcomes and survival. This problem is particularly apparent for incomplete responders with a high-risk RCB classification following NACT. Therefore, there is a pressing need to identify new prognostic and predictive biomarkers, and develop novel curative therapies to augment current standard of care (SOC) treatment regimens to save more lives. Here, we will discuss these unmet needs and clinical challenges that stand in the way of precision medicine and personalized cancer therapy.
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Affiliation(s)
- Gagan Gupta
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Caroline Dasom Lee
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Mary L Guye
- Sentara Surgery Specialists, Sentara CarePlex Hospital, USA.,Sentara Cancer Network, Sentara Hospital Systems, USA
| | - Robert E Van Sciver
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Michael P Lee
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Alex C Lafever
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Anthony Pang
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
| | - Angela M Tang-Tan
- Department of Molecular and Cell Biology, University of California, USA
| | - Janet S Winston
- Department of Pathology, Pathology Sciences Medical Group, Sentara Norfolk General Hospital, USA
| | - Billur Samli
- Department of Pathology, Pathology Sciences Medical Group, Sentara Norfolk General Hospital, USA
| | - Rick J Jansen
- Department of Public Health, North Dakota State University, USA
| | - Richard A Hoefer
- Sentara Cancer Network, Sentara Hospital Systems, USA.,Dorothy G. Hoefer Foundation, Sentara CarePlex Hospital, USA
| | - Amy H Tang
- Department of Microbiology and Molecular Cell Biology, Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School, USA
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Villarreal-Garza C, Lopez-Martinez EA, Deneken-Hernandez Z, Maffuz-Aziz A, Muñoz-Lozano JF, Barragan-Carrillo R, Ramos-Elias P, Moreno B, Diaz-Perez H, Peña-Curiel O, Curiel-Valdez JDJ, Bautista-Piña V. Change in therapeutic management after the EndoPredict assay in a prospective decision impact study of Mexican premenopausal breast cancer patients. PLoS One 2020; 15:e0228884. [PMID: 32160201 PMCID: PMC7065749 DOI: 10.1371/journal.pone.0228884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/24/2020] [Indexed: 01/09/2023] Open
Abstract
Objective To evaluate the change in adjuvant therapeutic decision in a cohort of young women with breast cancer discussed by a multidisciplinary team, before and after EndoPredict testing. Patients and methods 99 premenopausal women with hormone receptor-positive, HER2-negative, T1-T2, and N0-N1 breast cancer were included. Clinicopathological characteristics were recorded and cases were presented in a multidisciplinary tumor board. Consensual therapeutic decisions before and after EndoPredict results were registered. Medical records were reviewed at six-month follow-up to determine physicians’ adherence to therapeutic recommendations. Pearson chi-square and McNemar’s tests were used to analyze differences between groups and changes in treatment recommendations, respectively. Results Median age at diagnosis was 43 years. The most frequent tumor size was pT2 (53.5%) and 27% of patients had 1–3 positive lymph nodes. 46% of patients had a low-risk EPclin result. Nodal status and tumor grade were significantly associated with EPclin result (p < .00001 and p = .0110, respectively), while Ki67 levels and age ≤40 years were not. A change in chemotherapy decision was registered in 19.2% of patients (p = .066), with the greatest impact in de-escalation (9% net reduction). A change in chemotherapy or endocrine therapy regimen was suggested in 19% and 20% of cases, respectively, after EPclin results were available. A significant difference was found in the median EPclin score between patients with a low- vs. high-intensity chemotherapy and endocrine therapy regimen recommendation (p = 0.049 and p = 0.0001, respectively). Tumor board treatment recommendation adherence with the EndoPredict result was 95% and final treatment adherence to EPclin result was 93%. Conclusions The EndoPredict test successfully assisted the clinical decision-making process in premenopausal patients, with a clinically significant change in overall decision-making, with the greatest impact seen in chemotherapy reduction, and a high rate of therapeutic adherence.
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Affiliation(s)
- Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico
- Research and Breast Cancer Department, Instituto Nacional de Cancerologia, Mexico City, Mexico
- * E-mail:
| | | | | | | | | | | | - Pier Ramos-Elias
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico
| | - Brizio Moreno
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico
| | - Hector Diaz-Perez
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico
| | - Omar Peña-Curiel
- Breast Cancer Center, Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico
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Gene Expression Profiling Tests for Early-Stage Invasive Breast Cancer: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2020; 20:1-234. [PMID: 32284770 PMCID: PMC7143374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Breast cancer is a disease in which cells in the breast grow out of control. They often form a tumour that may be seen on an x-ray or felt as a lump.Gene expression profiling (GEP) tests are intended to help predict the risk of metastasis (spread of the cancer to other parts of the body) and to identify people who will most likely benefit from chemotherapy. We conducted a health technology assessment of four GEP tests (EndoPredict, MammaPrint, Oncotype DX, and Prosigna) for people with early-stage invasive breast cancer, which included an evaluation of effectiveness, safety, cost effectiveness, the budget impact of publicly funding GEP tests, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using either the Cochrane Risk of Bias tool, Prediction model Risk Of Bias ASsessment Tool (PROBAST), or Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), depending on the type of study and outcome of interest, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also performed a literature survey of the quantitative evidence of preferences and values of patients and providers for GEP tests.We performed an economic evidence review to identify published studies assessing the cost-effectiveness of each of the four GEP tests compared with usual care or with one another for people with early-stage invasive breast cancer. We adapted a decision-analytic model to compare the costs and outcomes of care that includes a GEP test with usual care without a GEP test over a lifetime horizon. We also estimated the budget impact of publicly funding GEP tests to be conducted in Ontario, compared with funding tests conducted through the out-of-country program and compared with no funding of tests in any location.To contextualize the potential value of GEP tests, we spoke with people who have been diagnosed with early-stage invasive breast cancer. RESULTS We included 68 studies in the clinical evidence review. Within the lymph-node-negative (LN-) population, GEP tests can prognosticate the risk of distant recurrence (GRADE: Moderate) and may predict chemotherapy benefit (GRADE: Low). The evidence for prognostic and predictive ability (ability to indicate the risk of an outcome and ability to predict who will benefit from chemotherapy, respectively) was lower for the lymph-node-positive (LN+) population (GRADE: Very Low to Low). GEP tests may also lead to changes in treatment (GRADE: Low) and generally may increase physician confidence in treatment recommendations (GRADE: Low).Our economic evidence review showed that GEP tests are generally cost-effective compared with usual care.Our primary economic evaluation showed that all GEP test strategies were more effective (led to more quality-adjusted life-years [QALYs]) than usual care and can be considered cost-effective below a willingness-to-pay of $20,000 per QALY gained. There was some uncertainty in our results. At a willingness-to-pay of $50,000 per QALY gained, the probability of each test being cost-effective compared to usual care was 63.0%, 89.2%, 89.2%, and 100% for EndoPredict, MammaPrint, Oncotype DX, and Prosigna, respectively.Sensitivity analyses showed our results were robust to variation in subgroups considered (i.e., LN+ and premenopausal), discount rates, age, and utilities. However, cost parameter assumptions did influence our results. Our scenario analysis comparing tests showed Oncotype DX was likely cost-effective compared with MammaPrint, and Prosigna was likely cost-effective compared with EndoPredict. When the GEP tests were compared with a clinical tool, the cost-effectiveness of the tests varied. Assuming a higher uptake of GEP tests, we estimated the budget impact to publicly fund GEP tests in Ontario would be between $1.29 million (Year 1) and $2.22 million (Year 5) compared to the current scenario of publicly funded GEP tests through the out-of-country program.Gene expression profiling tests are valued by patients and physicians for the additional information they provide for treatment decision-making. Patients are satisfied with what they learn from GEP tests and feel GEP tests can help reduce decisional uncertainty and anxiety. CONCLUSIONS Gene expression profiling tests can likely prognosticate the risk of distant recurrence and some tests may also predict chemotherapy benefit. In people with breast cancer that is ER+, LN-, and human epidermal growth factor receptor 2 (HER2)-negative, GEP tests are likely cost-effective compared with no testing. The GEP tests are also likely cost-effective in LN+ and premenopausal people. Compared with funding GEP tests through the out-of-country program, publicly funding GEP tests in Ontario would cost an additional $1 million to $2 million annually, assuming a higher uptake of tests. GEP tests are valued by both patients and physicians for chemotherapy treatment decision-making.
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Noske A, Anders SI, Ettl J, Hapfelmeier A, Steiger K, Specht K, Weichert W, Kiechle M, Klein E. Risk stratification in luminal-type breast cancer: Comparison of Ki-67 with EndoPredict test results. Breast 2020; 49:101-107. [PMID: 31786414 PMCID: PMC7375593 DOI: 10.1016/j.breast.2019.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Adjuvant chemotherapy decision in patients with hormone receptor positive, HER2 negative breast cancer (BC) is challenging. Ki-67 is widely used for adjuvant therapy decision in BC. The multigene assay EndoPredict (EP) has shown to provide valid and additional information about the risk of recurrence compared to traditional pathological factors. In this study, we compared Ki-67 with EP assay generated risk groups. METHODS We analyzed the results from prospective EP testing (n = 373) and tumor proliferation assessed by Ki-67 staining in luminal breast cancer. We statistically investigated the association of both parameters and probed for equivalence in risk stratification. RESULTS Evaluation of Ki-67 was feasible in 307 (82%) BC specimens with known EP test results. The EPscore (now called 12-gene molecular score) delineated 140 low and 167 high scores. After combining the EPscore with pathological tumor stage and nodal status, we received 203 EPclin low-risk and 104 EPclin high-risk classifications. EPscore and EPclin were significantly associated with Ki-67 indices and tumor grade (p < 0.001). Overall, we observed a moderate correlation between Ki-67 and the EPscore (r = 0.63) as well as the EPclin score (r = 0.59). CONCLUSION Ki-67 values above 25% partly overlap with EP test results and therefore indicate a high-risk profile. In these cases, the additional prognostic information from EP testing might be rather low. However, low and intermediate Ki-67 values (less than 25%) alone were not reliable in predicting a low risk EP profile, indicating that EP testing is useful in this subgroup.
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Affiliation(s)
- Aurelia Noske
- Institute of Pathology, Technical University of Munich, School of Medicine, Germany.
| | - Sophie-Isabelle Anders
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johannes Ettl
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Katja Steiger
- Institute of Pathology, Technical University of Munich, School of Medicine, Germany
| | - Katja Specht
- Institute of Pathology, Technical University of Munich, School of Medicine, Germany
| | - Wilko Weichert
- Institute of Pathology, Technical University of Munich, School of Medicine, Germany
| | - Marion Kiechle
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Evelyn Klein
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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10
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Penault-Llorca F, Kwiatkowski F, Arnaud A, Levy C, Leheurteur M, Uwer L, Derbel O, Le Rol A, Jacquin JP, Jouannaud C, Quenel-Tueux N, Girre V, Foa C, Guardiola E, Lortholary A, Catala S, Guiu S, Valent A, Boinon D, Lemonnier J, Delaloge S. Decision of adjuvant chemotherapy in intermediate risk luminal breast cancer patients: A prospective multicenter trial assessing the clinical and psychological impact of EndoPredict® (EpClin) use (UCBG 2-14). Breast 2020; 49:132-140. [PMID: 31790959 PMCID: PMC7375561 DOI: 10.1016/j.breast.2019.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/13/2019] [Accepted: 10/25/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Genomic tests can identify ER-positive HER2-negative localized breast cancer patients who may not benefit from adjuvant chemotherapy. Such tests seem especially interesting in "intermediate" clinico-pathological risk categories. The psychological impact of the decision uncertainty in these women remains largely unexplored. We assessed the clinical and psychological impact of EndoPredict® (EpClin), a clinico-genomic test, in these patients. METHODS This multicenter, single arm prospective study (NCT02773004) enrolled patients for which adjuvant chemotherapy was uncertain, based on predefined criteria. The primary endpoint was the proportion of change between initial adjuvant decision and final administration of chemotherapy. Secondary endpoints included post-test (Day 17) and 1-year patient reported outcomes. RESULTS One third of 200 evaluable patients had a high EpClin score (≥3.32867; 10 years cumulative risk of distance failure ≥10%). The overall change rate of chemotherapy decision was 72/200 (35.8%, 95% CI 29.2-42.4). Chemotherapy was withdrawn in 57 cases (28.4% [22.2-34.8]) and added in 15 (7.5% [3.8-11.2]. 6 changes (8%) were based on patients' decisions. Anxiety and distress levels increased at Day 17 when adding chemotherapy after the test result (p < 10-7 and 0.00022 respectively), while stable in other situations. At 1-year, all patients had returned to the baseline anxiety and distress levels (mean anxiety 51.5, +/- SD = 2.5 [max. 80], mean distress 3±1 [max. 10]). CONCLUSIONS EndoPredict ® (EpClin) is clinically useful in deciding whether or not to administer adjuvant chemotherapy in patients with intermediate risk. A single-step decision is preferable since adding chemotherapy at a later stage increases anxiety and distress.
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Affiliation(s)
- Frédérique Penault-Llorca
- Université Clermont Auvergne, Centre Jean Perrin, Department of Biology and Pathology, INSERM, U1240 Imagerie Moléculaire et Stratégies Théranostiques, Clermont Ferrand, France
| | - Fabrice Kwiatkowski
- Université Clermont Auvergne, Centre Jean Perrin, Department of Biostatistics, INSERM, U1240 Imagerie Moléculaire et Stratégies Théranostiques, Clermont Ferrand, France
| | - Antoine Arnaud
- Department of Medical Oncology, Institut Sainte Catherine, Avignon, France
| | - Christelle Levy
- Department of Medical Oncology, Centre François Baclesse, Caen, France
| | | | - Lionel Uwer
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre Les Nancy, France
| | - Olfa Derbel
- Department of Medical Oncology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Annick Le Rol
- Department of Medical Oncology, Centre Hospitalier Intercommunal, Quimper, France
| | - Jean-Philippe Jacquin
- Department of Medical Oncology, Institut de Cancérologie Lucien Newirth, Saint Priest en Jarez, France
| | | | | | - Véronique Girre
- Department of Medical Oncology, Centre Hospitalier Départemental de Vendée, La Roche sur Yon, France
| | - Cyril Foa
- Department of Medical Oncology, Hôpital Saint Joseph, Marseille, France
| | - Emmanuel Guardiola
- Department of Medical Oncology, Centre Hospitalier de La Dracénie, Draguignan, France
| | - Alain Lortholary
- Department of Medical Oncology, Centre Catherine de Sienne, Nantes, France
| | - Stéphanie Catala
- Department of Medical Oncology, Centre Catalan D'oncologie, Perpignan, France
| | - Séverine Guiu
- Department of Medical Oncology, Institut Régional Du Cancer Montpellier (ICM), Val D'Aurelle, Montpellier, France
| | | | - Diane Boinon
- Department of Supportive Care, Psycho-oncology Unit, Gustave Roussy, Villejuif, France
| | | | - Suzette Delaloge
- Department of Medical Oncology, Gustave Roussy, Villejuif, France.
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11
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Alexandre M, Maran-Gonzalez A, Viala M, Firmin N, D'Hondt V, Gutowski M, Bourgier C, Jacot W, Guiu S. Decision of Adjuvant Systemic Treatment in HR+ HER2- Early Invasive Breast Cancer: Which Biomarkers Could Help? Cancer Manag Res 2019; 11:10353-10373. [PMID: 31849525 PMCID: PMC6912012 DOI: 10.2147/cmar.s221676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/21/2019] [Indexed: 11/23/2022] Open
Abstract
The decision to administer adjuvant chemotherapy in treatment of early invasive breast cancer (EBC) is often complex, particularly for hormone receptor-positive (HR+) diseases, and current guidelines often classify these patients in an intermediate-risk group. Several biomarkers are currently available in this indication, in order to obtain additional and more accurate prognostic information compared to classic clinicopathological characteristics and guide the indication of adjuvant chemotherapy, optimizing the efficacy/toxicity ratio. We conducted a systematic review to evaluate the clinical validity and clinical utility of five biomarkers (uPA/PAI-1, OncotypeDX®, MammaPrint®, PAM50, and EndoPredict®) in HR+/HER2- EBC, whatever the nodal status. A total of 89 studies met the inclusion criteria. Even though data currently available confirm the clinical validity of these biomarkers, there is a lack of data regarding clinical utility for most of them. Prospective studies in well-defined populations are needed to integrate these biomarkers in a decision strategy.
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Affiliation(s)
- Marie Alexandre
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - Aurélie Maran-Gonzalez
- Department of Pathology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - Marie Viala
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - Nelly Firmin
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - Véronique D'Hondt
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France.,INSERM U1194 - Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France.,University of Montpellier, Montpellier,France
| | - Marian Gutowski
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - Céline Bourgier
- INSERM U1194 - Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France.,Department of Radiation Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France
| | - William Jacot
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France.,INSERM U1194 - Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France.,University of Montpellier, Montpellier,France
| | - Séverine Guiu
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier, Montpellier Cedex 5 34298, France.,INSERM U1194 - Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France.,University of Montpellier, Montpellier,France
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12
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Märkl B, Kazik M, Harbeck N, Jakubowicz E, Hoffmann R, Jung T, Steinfeld D, Schenkirsch G, Schlimok G, Oruzio D. Impact of uPA/PAI-1 and disseminated cytokeratin-positive cells in breast cancer. BMC Cancer 2019; 19:692. [PMID: 31307406 PMCID: PMC6632216 DOI: 10.1186/s12885-019-5857-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 06/20/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The protease uPA and its inhibitor PAI-1 play major roles in hemostasis and are also involved in cancer progression. This is mainly caused by their ability to degrade extracellular matrix-facilitating tumor cell migration. This study aimed to investigate the impact of uPA/PAI-1 and disseminated cytokeratin-positive cells (dCK+) on the outcome and the existence of synergistic effects. METHODS We retrospectively analyzed a cohort of 480 breast cancer cases with known uPA/PAI-1 and dCK+ status. uPA/PAI-1 was tested on fresh tumor samples using a commercial ELISA test. Bone marrow aspirates were investigated immunocytochemically for CK18. RESULTS DCK+ cells were identified in 23% of cases. uPA positivity was significantly associated with the occurrence of dCK+ cells (P = 0.028). uPA and PAI-1 were significantly associated with outcome in the subgroup of early-stage cases without chemotherapy. DCK+ cells alone were not prognostic. However, we found synergistic effects. In the subgroup of node-negative cases with and without chemotherapy, the prognostic impact of uPA and PAI-1 was enhanced in cases with additional dCK-positivity (triple +). In cases without chemotherapy, triple-positive status was independently prognostic (HR: 9.3 CI: 1.1-75) next to T stage. CONCLUSIONS uPA and PAI-1 seem to influence the metastatic potential of dCK+ cells, which underlines its important role in tumor progression.
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Affiliation(s)
- Bruno Märkl
- Institute of Pathology, Universitätsklinikum, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Martin Kazik
- Institute of Pathology, Universitätsklinikum, Stenglinstraße 2, 86156, Augsburg, Germany.,Clinic for Anesthesiology and Intensive Care, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, Universität München (LMU), Munich, Germany
| | - Elzbieta Jakubowicz
- Institute of Pathology, Universitätsklinikum, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Reinhard Hoffmann
- Institute of Laboratory Medicine and Microbiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Thomas Jung
- Clinic for Gynecology and Obstetrics, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Dieter Steinfeld
- Gynecology, Gemeinschaftspraxis Gynäkologische Onkologie, Augsburg, Germany
| | - Gerhard Schenkirsch
- Clinical and Population-based Cancer Registry of Augsburg, Augsburg, Germany
| | - Günter Schlimok
- Hematology and Oncology, Diakonissenkrankenhaus, Augsburg, Germany
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13
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Jakubowicz E, Martin B, Hoffmann R, Kröncke T, Jung T, Steierl R, Steinfeld D, Schenkirsch G, Kriegsmann J, Märkl B. EndoPredict versus uPA/PAI-1 in breast cancer: Comparison of markers and association with clinicopathological parameters. Breast J 2019; 25:450-454. [PMID: 31001905 DOI: 10.1111/tbj.13258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 11/30/2022]
Abstract
We retrospectively investigated concordance of EndoPredict (EPclin) with urokinase plasminogen activator and plasminogen activator inhibitor-1 (uPA/PAI-1) in 72 breast cancer patients and compared the results with grading, molecular subtype and chemotherapy recommendation. Compared to uPA/PAI-1, EPclin proved to be more conservative concerning correlation with clinicopathological parameters and was significantly associated with the recommendation of adjuvant chemotherapy.
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Affiliation(s)
| | - Benedikt Martin
- Institute of Pathology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Reinhard Hoffmann
- Institute of Laboratory Medicine and Microbiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Thomas Kröncke
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Thomas Jung
- Clinic for Gynecology and Obstetrics, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Roman Steierl
- Frauenklinik im Josefinum Augsburg, Katholische Jugendfürsorge Fachklinik, Augsburg, Germany
| | | | - Gerhard Schenkirsch
- Tumor Data Management, Interdisciplinary Cancer Center Augsburg, Augsburg, Germany
| | - Jörg Kriegsmann
- Histology, Cytology and Molecular Diagnostics Center Trier, Trier, Germany
| | - Bruno Märkl
- Institute of Pathology, Universitätsklinikum Augsburg, Augsburg, Germany
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14
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Thangarajah F, Eichler C, Fromme J, Malter W, Caroline Radosa J, Ludwig S, Puppe J, Paepke S, Warm M. The impact of EndoPredict
®
on decision making with increasing oncological work experience: can overtreatment be avoided? Arch Gynecol Obstet 2019; 299:1437-1442. [DOI: 10.1007/s00404-019-05097-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/07/2019] [Indexed: 12/21/2022]
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15
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Sestak I. Risk stratification in early breast cancer in premenopausal and postmenopausal women: integrating genomic assays with clinicopathological features. Curr Opin Oncol 2019; 31:29-34. [PMID: 30299292 DOI: 10.1097/cco.0000000000000490] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW There is growing consensus that genomic assays provide useful complementary information to clinicopathological features in oestrogen receptor-positive breast cancers. Here, ongoing research with multigene tests used for postmenopausal breast cancer and new emerging prognostic and predictive markers for pre and postmenopausal women are summarised. RECENT FINDINGS Results of the TAILORx trial have shown that women with an intermediate risk score do not benefit from adjuvant chemotherapy. Prosgina has been further investigated in a contemporary patient population in postmenopausal women and its use has been extended for premenopausal women. The EndoPredict was extensively used in decision-impact studies showing that its use can potentially reduce the need for adjuvant chemotherapy. Several new genomic assays have been developed, with some of them showing promising use for women with early oestrogen receptor-positive breast cancer. SUMMARY New areas of research for prediction of recurrence and risk stratification involve the development of immune gene signatures that carry modest but significant prognostic value. The recent expansion of high-throughput technology platforms including circulating tumour DNA/RNA and microRNA offer new opportunities to improve prediction models, particularly in women with oestrogen receptor-negative disease and premenopausal women. Genomic assays have clearly improved prognostication of early oestrogen receptor-positive breast cancer but it is clear that standard clinicopathological parameters are still very important when identifying patient for adjuvant chemotherapy.
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Affiliation(s)
- Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University London, London, UK
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