Change in therapeutic management after the EndoPredict assay in a prospective decision impact study of Mexican premenopausal breast cancer patients

Decision impact studies, evidence of clinical utility for genomic assays in cancer: A scoping review

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.

Concordance between Ki‑67 index in invasive breast cancer and molecular signatures: EndoPredict and MammaPrint

Identifying patients with hormone receptor-positive (HR+) early invasive breast cancer (EIBC) who benefit from adjuvant chemotherapy has improved with molecular signature tests. However, due to high cost and limited availability, alternative tests are used. The present study sought to evaluate the performance of the proliferation marker Ki-67 to identify these patients and explore its association with molecular signatures and risk stratification markers. From the San José TecSalud Hospital in Monterrey México, patients with HR+ EIBC as tested with EndoPredict or MammaPrint and Ki-67 index were identified. They were categorized into two groups: Group 1 (June 2016-August 2018) was evaluated using EndoPredict and Group 2 (June 2016-August 2018) with MammaPrint. A ≥20% Ki67 index cutoff was utilized to identify highly proliferative EIBC and an area under the receiver-operating characteristic curve and κ concordance were utilized to evaluate the performance of Ki-67 index compared to molecular signature tests. In the EndoPredict group, 54/96 patients were considered high-risk based on their EPclin score, while 57/96 patients had Ki-67 index ≥20%. However, there was no significant overall concordance between them (59.37%, κ=0.168, P=0.09), while the given risk of distant recurrence given in percentage by EPclin had a positive association with the Ki67 index (P=0.04). In the MammaPrint group, 21/70 patients were considered high-risk and 36/70 patients presented with a Ki-67 index ≥20% with a significant overall concordance (67.14%, κ=0.35, P<0.001). In addition, high Ki-67 index was associated with the Nottingham histological grade in both groups. In conclusion, there was a concordance between Ki-67 and MammaPrint risk stratification of HR+ EIBC and no concordance with the EndoPredict molecular signature, but a positive association with the given percentage of recurrence and the median Ki-67 index as the cutoff at our center. Cost-effectiveness analyses of these tests in developing countries are required; until then, the use of Ki-67 appears reasonable to aid clinical decisions, together with the other established clinicopathological variables.

[uPA/PAI-1 and EPClin®: Comparison of their impact on the management of intermediate-prognosis breast cancers]

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.