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Peters AL, Hall PS, Jordan LB, Soh FY, Hannington L, Makaranka S, Urquhart G, Vallet M, Cartwright D, Marashi H, Elsberger B. Enhancing clinical decision support with genomic tools in breast cancer: A Scottish perspective. Breast 2024; 75:103728. [PMID: 38657322 PMCID: PMC11061332 DOI: 10.1016/j.breast.2024.103728] [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] [Received: 10/28/2023] [Revised: 03/12/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION The Oncotype DX Breast RS test has been adopted in Scotland and has been the subject of a large population-based study by a Scottish Consensus Group to assess the uptake of the recurrence score (RS), evaluate co-variates associated with the RS and to analyse the effect it may have had on clinical practice. MATERIALS & METHODS Pan-Scotland study between August 2018-August 2021 evaluating 833 patients who had a RS test performed as part of their diagnostic pathway. Data was extracted retrospectively from electronic records and analysis conducted to describe change in chemotherapy administration (by direct comparison with conventional risk assessment tools), and univariate/multivariate analysis to assess relationship between covariates and the RS. RESULTS Chemotherapy treatment was strongly influenced by the RS (p < 0.001). Only 30 % of patients received chemotherapy treatment in the intermediate and high risk PREDICT groups, where chemotherapy is considered. Additionally, 55.5 % of patients with a high risk PREDICT had a low RS and did not receive chemotherapy. There were 17 % of patients with a low risk PREDICT but high RS who received chemotherapy. Multivariate regression analysis showed the progesterone receptor Allred score (PR score) to be a strong independent predictor of the RS, with a negative PR score being associated with high RS (OR 4.49, p < 0.001). Increasing grade was also associated with high RS (OR 3.81, p < 0.001). Classic lobular pathology was associated with a low RS in comparison to other tumour pathology (p < 0.01). Nodal disease was associated with a lower RS (p = 0.012) on univariate analysis, with menopausal status (p = 0.43) not influencing the RS on univariate or multivariate analysis. CONCLUSIONS Genomic assays offer the potential for risk-stratified decision making regarding the use of chemotherapy. They can help reduce unnecessary chemotherapy treatment and identify a subgroup of patients with more adverse genomic tumour biology. A recent publication by Health Improvement Scotland (HIS) has updated guidance on use of the RS test for NHS Scotland. It suggests to limit its use to the intermediate risk PREDICT group. Our study shows the impact of the RS test in the low and high risk PREDICT groups. The implementation across Scotland has resulted in a notable shift in practice, leading to a significant reduction in chemotherapy administration in the setting of high risk PREDICT scores returning low risk RS. There has also been utility for the test in the low risk PREDICT group to detect a small subgroup with a high RS. We have found the PR score to have a strong independent association with high risk RS. This finding was not evaluated by the key RS test papers, and the potential prognostic information provided by the PR score as a surrogate biomarker is an outstanding question that requires more research to validate.
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Affiliation(s)
- A L Peters
- Beatson West of Scotland Cancer Centre, Gartnavel Hospital, NHS Greater Glasgow & Clyde, 1053 Great Western Rd, Glasgow G12 0YN, UK; Cancer Research UK (CRUK) Scotland Institute, Switchback Road, Bearsden, Glasgow G61 1BD, UK.
| | - P S Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XR, UK
| | - L B Jordan
- Ninewells Hospital & Medical School, NHS Tayside, Department of Pathology, Dundee, DD1 9SY, UK
| | - F Y Soh
- Raigmore Hospital, NHS Highland, Department of Oncology, Inverness IV2 3UJ, UK
| | - L Hannington
- Beatson West of Scotland Cancer Centre, Gartnavel Hospital, NHS Greater Glasgow & Clyde, 1053 Great Western Rd, Glasgow G12 0YN, UK
| | - S Makaranka
- Aberdeen Royal Infirmary, NHS Grampian, Department of Breast Surgery, Aberdeen AB25 2ZN, UK
| | - G Urquhart
- Aberdeen Royal Infirmary, NHS Grampian, Department of Oncology, Aberdeen AB25 2ZN, UK
| | - M Vallet
- Edinburgh Cancer Research Centre, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XR, UK
| | - D Cartwright
- Beatson West of Scotland Cancer Centre, Gartnavel Hospital, NHS Greater Glasgow & Clyde, 1053 Great Western Rd, Glasgow G12 0YN, UK; Cancer Research UK (CRUK) Scotland Institute, Switchback Road, Bearsden, Glasgow G61 1BD, UK
| | - H Marashi
- Beatson West of Scotland Cancer Centre, Gartnavel Hospital, NHS Greater Glasgow & Clyde, 1053 Great Western Rd, Glasgow G12 0YN, UK
| | - B Elsberger
- Aberdeen Royal Infirmary, NHS Grampian, Department of Breast Surgery, Aberdeen AB25 2ZN, UK
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Eslami B, Alipour S, Golfam F, Jahabnin B, Omranipour R. Effective Ki-67 Reduction by Pre-Surgery Short-Term Administration of Letrozole in (Hormone-Positive) Breast Cancer. IRANIAN JOURNAL OF PATHOLOGY 2023; 19:103-106. [PMID: 38864079 PMCID: PMC11164301 DOI: 10.30699/ijp.2023.2002772.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/04/2023] [Indexed: 06/13/2024]
Abstract
Background & Objective Antigen Ki-67 (histone-based nuclear protein) is a static marker of tumor cell proliferation and growth and is commonly measured to indicate the effect of treatment in breast cancer patients. This single-arm trial study aimed to evaluate the effect of short-term endocrine therapy (letrozole) on Ki-67 levels in menopausal women with early hormone-positive breast cancer who were referred to two university hospitals. Methods Patients with a pre-treatment Ki67 of 5% or less were excluded from the study. Participants (n=25) received oral letrozole (2.5 mg daily) seven days before surgery. Ki-67% on both biopsies and the surgical specimens were measured and compared. Results and Conclusion The mean age of patients was 62±9.4 (48-83 years). Our result indicated that pre-surgery consumption of letrozole for hormone-positive breast cancer can significantly decrease the of Ki-67 labeling index (23.24±9.74 vs. 16.92±9.55, P=0.001 by paired t-test), with no drug-related adverse events.
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Affiliation(s)
- Bita Eslami
- Breast Diseases Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sadaf Alipour
- Breast Diseases Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Surgery, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Behnaz Jahabnin
- Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramesh Omranipour
- Breast Diseases Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
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Oliveira LJC, Megid TBC, Rosa DD, Magliano CADS, Assad DX, Argolo DF, Sanches SM, Testa L, Bines J, Kaliks R, Caleffi M, de Melo Gagliato D, Sahade M, Barroso-Sousa R, Corrêa TS, Shimada AK, Batista DN, Musse Gomes D, Cesca MG, Gaudêncio D, Moura LMA, de Araújo JAP, Katz A, Mano MS. Cost-effectiveness analysis of Oncotype DX from a Brazilian private medicine perspective: a GBECAM multicenter retrospective study. Ther Adv Med Oncol 2022; 14:17588359221141760. [PMID: 36601632 PMCID: PMC9806428 DOI: 10.1177/17588359221141760] [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: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 12/28/2022] Open
Abstract
Background Oncotype DX (ODX) is a validated assay for the prediction of risk of recurrence and benefit of chemotherapy (CT) in both node negative (N0) and 1-3 positive nodes (N1), hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) early breast cancer (eBC). Due to limited access to genomic assays in Brazil, treatment decisions remain largely driven by traditional clinicopathologic risk factors. ODX has been reported to be cost-effective in different health system, but limited data are available considering the reality of middle-income countries such as Brazil. We aim to evaluate the cost-effectiveness of ODX across strata of clinical risk groups using data from a dataset of patients from Brazilian institutions. Methods Clinicopathologic and ODX information were analyzed for patients with T1-T3, N0-N1, HR+/HER2- eBC who had an ODX performed between 2005 and 2020. Projections of CT indication by clinicopathologic criteria were based on binary clinical risk categorization based on the Adjuvant! Algorithm. The ODX score was correlated with the indication of CT according to TAILORx and RxPONDER data. Two decision-tree models were developed. In the first model, low and high clinical risk patients were included while in the second, only high clinical risk patients were included. The cost for ODX and CT was based on the Brazilian private medicine perspective. Results In all, 645 patients were analyzed; 411 patients (63.7%) had low clinical risk and 234 patients (36.3%) had high clinical risk disease. The ODX indicated low (<11), intermediate (11-25), and high (>25) risk in 119 (18.4%), 415 (64.3%), and 111 (17.2%) patients, respectively. Among 645 patients analyzed in the first model, ODX was effective (5.6% reduction in CT indication) though with an incremental cost of United States Dollar (US$) 2288.87 per patient. Among 234 patients analyzed in the second model (high clinical risk only), ODX led to a 57.7% reduction in CT indication and reduced costs by US$ 4350.66 per patient. Conclusions Our study suggests that ODX is cost-saving for patients with high clinical risk HR+/HER2- eBC and cost-attractive for the overall population in the Brazilian private medicine perspective. Its incorporation into routine practice should be strongly considered by healthcare providers.
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Affiliation(s)
| | | | - Daniela Dornelles Rosa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | | | - Daniele Xavier Assad
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | - Daniel Fontes Argolo
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica CLION – Grupo CAM, Salvador,
Brazil
| | - Solange Moraes Sanches
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil AC,Camargo Cancer Center, São Paulo, Brazil
| | - Laura Testa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - José Bines
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Rafael Kaliks
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Israelita
Albert Einstein, São Paulo, Brazil
| | - Maira Caleffi
- Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | - Debora de Melo Gagliato
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Beneficência
Portuguesa, São Paulo, Brazil
| | - Marina Sahade
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Romualdo Barroso-Sousa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | | | - Andrea Kazumi Shimada
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
| | - Daniel Negrini Batista
- Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Daniel Musse Gomes
- Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | | | | | | | | | - Artur Katz
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Max Senna Mano
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
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Berdunov V, Millen S, Paramore A, Griffin J, Reynia S, Fryer N, Brown R, Longworth L. Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score ® Test in Node-Negative Early Breast Cancer. Clinicoecon Outcomes Res 2022; 14:619-633. [PMID: 36157054 PMCID: PMC9505370 DOI: 10.2147/ceor.s360049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/13/2022] [Indexed: 11/23/2022]
Abstract
Background The 21-gene assay (the Oncotype DX Breast Recurrence Score® test) is a validated multigene assay which produces the Recurrence Score® result (RS) to inform decisions on the use of adjuvant chemotherapy in human epidermal growth factor receptor 2-negative (HER2-), hormone receptor positive (HR+) early invasive breast cancer. A model-based economic evaluation estimated the cost-effectiveness of the 21-gene assay against the use of clinical risk tools alone based on the latest evidence from prospective studies. Methods The proportion of patients assigned to chemotherapy conditional on their RS result was obtained from retrospective data from the Clalit registry. The probability of distant recurrence with endocrine and chemo-endocrine therapy conditional on RS result was obtained from TAILORx and NSABP B-20 trials. The cost-effectiveness of the 21-gene assay compared to using clinical risk tools alone was estimated in terms of cost per quality-adjusted life-year (QALY) over a lifetime horizon. Results The 21-gene assay was more effective (0.17 more quality-adjusted life years) at a lower cost (-£519) over a lifetime compared to clinical risk alone. The model results were sensitive to assumptions around the magnitude of benefit of chemotherapy in the high RS result subgroup. Other assumptions underpinning the model, such as the proportion of patients assigned to chemotherapy in the low and mid-range RS result subgroups and long-term distant recurrence probabilities, had a smaller impact on the results. Conclusion The analysis showed that the cost-effectiveness of the 21-gene assay is sensitive to assumptions for chemotherapy sparing for patients with RS 0–25 whose outcomes with endocrine therapy are no worse compared to chemotherapy-assigned patients, and a chemotherapy benefit in the RS 26–100 group. Future studies need to incorporate a wider set of tumour profiling tests other than the 21-gene assay to allow a direct comparison of their cost-effectiveness.
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Real-world analysis of clinical and economic impact of 21-gene recurrence score (RS) testing in early-stage breast cancer (ESBC) in Ireland. Breast Cancer Res Treat 2021; 188:789-798. [PMID: 33835293 DOI: 10.1007/s10549-021-06211-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Results from TAILOR-X suggest that up to 70% of hormone receptor-positive (HR+) node-negative (N0) ESBC patients (pts) may avoid chemotherapy (CT) with RS ≤ 25. We assess clinical and economic impacts of RS testing on treatment using real-world data. METHODS From October 2011 to February 2019, a retrospective, cross-sectional observational study was conducted of HR+ N0 ESBC pts who had RS testing in Ireland. Pts were classified low risk (RS ≤ 25) and high risk (RS > 25). Clinical risk was calculated. Data were collected via electronic patient records. Cost data were supplied by the National Healthcare Pricing Regulatory Authority. RESULTS 963 pts. Mean age is 56 years. Mean tumour size is 1.7 cm. 114 (11.8%), 635 (66%), 211 (22%), 3 (0.2%) pts had G1, G2, G3 and unknown G, respectively. 796 pts (82.8%) low RS, 159 (16.5%) high RS and 8 pts (0.7%) unknown RS. 263 pts (26%) were aged ≤ 50 at diagnosis; 117 (45%) had RS 0-15, 63 (24.5%) 16-20, 39 (15.3%) 21-25 and 40 (15.2%) RS 26-100. 4 pts (1.5%) had unknown RS. Post-RS testing, 602 pts (62.5%) had a change in CT decision; 593 changed to hormone therapy (HT) alone. In total, 262 pts received CT. Of pts receiving CT; 138 (53%) had RS > 25, 124 (47%) had RS ≤ 25. Of pts aged ≤ 50, 153 (58%) had high clinical risk, of whom 28 had RS 16-20. Assay use achieved a 62.5% change in treatment with 73% of pts avoiding CT. This resulted in savings of €4 million in treatment costs. Deducting assay costs, savings of €1.9 million were achieved. CONCLUSION Over the 8 years of the study, a 62.5% reduction in CT use was achieved with savings of over €1,900,000.
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6
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Bhattacharyya GS, Doval DC, Desai CJ, Chaturvedi H, Sharma S, Somashekhar S. Overview of Breast Cancer and Implications of Overtreatment of Early-Stage Breast Cancer: An Indian Perspective. JCO Glob Oncol 2020; 6:789-798. [PMID: 32511068 PMCID: PMC7328098 DOI: 10.1200/go.20.00033] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/15/2022] Open
Abstract
The prevalence and mortality of breast cancer is increasing in Asian countries, including India. With advances in medical technology leading to better detection and characterization of the disease, it has been possible to classify breast cancer into various subtypes using markers, which helps predict the risk of distant recurrence, response to therapy, and prognosis using a combination of molecular and clinical parameters. Breast cancer and its therapy, mainly surgery, systemic therapy (anticancer chemotherapy, hormonal therapy, targeted therapy, and immunotherapy), and radiation therapy, are associated with significant adverse influences on physical and mental health, quality of life, and the economic status of the patient and her family. The fear of recurrence and its devastating effects often leads to overtreatment, with a toxic cost to the patient financially and physically in cases in which this is not required. This article discusses some aspects of a breast cancer diagnosis and its impact on the various facets of the life of the patient and her family. It further elucidates the role of prognostic factors, the currently available biomarkers and prognostic signatures, and the importance of ethnically validating biomarkers and prognostic signatures.
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Affiliation(s)
| | - Dinesh C. Doval
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Chirag J. Desai
- Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | | | - Sanjay Sharma
- Asian Cancer Institute, Somaiya Ayurvihar, Mumbai, Maharashtra, India
| | - S.P. Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, India
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Ahmed S, Pati S, Le D, Haider K, Iqbal N. The prognostic and predictive role of 21-gene recurrence scores in hormone receptor-positive early-stage breast cancer. J Surg Oncol 2020; 122:144-154. [PMID: 32346902 DOI: 10.1002/jso.25952] [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: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022]
Abstract
Over the past two decades, gene expression profiling of breast cancer has emerged as an important tool in early-stage breast cancer management. The approach provides important information on underlying biological mechanisms, breast cancer classification, future risk potential of developing recurrent metastatic disease, and provides beneficial clues for adjuvant chemotherapy in hormone receptor (HR) positive breast cancer. Of the commercially available genomic tests for breast cancer, the prognostic and predictive value of 21-gene recurrence score tests have been validated using both retrospective data and prospective clinical trials. In this paper, we reviewed the current evidence on 21-gene expression profiles for HR-positive HER2-negative early-stage breast cancer management. We show that current evidence supports endocrine therapy alone as an appropriate adjuvant systemic therapy for approximately 70% of women with HR-positive, HER2-negative, node-negative breast cancer. Evolving evidence also suggests that 21-gene recurrence scores have predictive values for node-positive breast cancer and that chemotherapy can be avoided in more than half of women with nodes 1 to 3 positive HR-positive breast cancer. Furthermore, retrospective data also supports the predictive role of 21-gene recurrence scores for adjuvant radiation therapy. A prospective trial in this area is ongoing.
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Affiliation(s)
- Shahid Ahmed
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Sukanya Pati
- Department of Pharmacology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Duc Le
- Department of Radiation Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kamal Haider
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nayyar Iqbal
- Department of Medical Oncology, Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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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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9
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Masucci L, Torres S, Eisen A, Trudeau M, Tyono I, Saunders H, Chan KW, Isaranuwatchai W. Cost-utility analysis of 21-gene assay for node-positive early breast cancer. ACTA ACUST UNITED AC 2019; 26:307-318. [PMID: 31708649 DOI: 10.3747/co.26.4769] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background For women with lymph node (ln)-positive, estrogen receptor-positive, and her2 (human epidermal growth factor receptor 2)-negative breast cancer (bca), current guidelines recommend treatment with both hormonal therapy and chemotherapy. The 21-gene Recurrence Score (rs) assay might be helpful in selecting patients with bca who can be spared chemotherapy when they have 1-3 positive lns and a lower risk of recurrence. In the present study, we performed a cost-utility analysis comparing use of the 21-gene rs assay with current practice from the perspective of a Canadian health care payer. Methods A Markov model was developed to determine costs and quality-adjusted life-years (qalys) over a patient's lifetime. Patient outcomes in both study groups were examined based on published clinical trials. Costs were derived primarily from published Canadian sources. Costs and outcomes were discounted at 1.5% annually, and costs are reported in 2016 Canadian dollars. A probabilistic analysis was used, and the model parameters were varied in a sensitivity analysis. Results The results indicate that use of the 21-gene rs assay was less costly ($432 less) and more effective (0.22 qalys) than current practice. The probabilistic analysis revealed that 70% of the 10,000 simulated incremental cost-effectiveness ratios were in the southeast quadrant. The results were sensitive to the probability of a low rs and to the probability of receiving chemotherapy in the low-risk rs category and in current practice. Conclusions Use of the 21-gene rs assay could be a cost-effective strategy for Ontario patients with estrogen receptor-positive, her2-negative early bca and 1-3 positive lns.
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Affiliation(s)
- L Masucci
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - S Torres
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - A Eisen
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - M Trudeau
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON
| | - I Tyono
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - H Saunders
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - K W Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.,Cancer Care Ontario, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON
| | - W Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, University of Toronto, Toronto, ON.,Canadian Centre for Applied Research in Cancer Control, University of Toronto, Toronto, ON.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
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10
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Yoo SH, Kim TY, Kim M, Lee KH, Lee E, Lee HB, Moon HG, Han W, Noh DY, Han SW, Kim TY, Im SA. Development of a Nomogram to Predict the Recurrence Score of 21-Gene Prediction Assay in Hormone Receptor-Positive Early Breast Cancer. Clin Breast Cancer 2019; 20:98-107.e1. [PMID: 31522959 DOI: 10.1016/j.clbc.2019.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/15/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION A 21-gene prediction assay (Oncotype DX) is helpful to estimate benefit from adjuvant chemotherapy in patients with hormone receptor-positive, lymph node-negative early breast cancer. This study was conducted to develop a model to estimate high recurrence score (RS) using easily available clinicopathologic parameters in limited-resource countries. PATIENTS AND METHODS Hormone receptor-positive, lymph node-negative early breast cancer patients who underwent Oncotype DX were enrolled onto the training set (n = 192). The risk category range of the RS was the same as in the TAILORx study. The multivariable logistic regression model was used to identify significant variables associated with high RS. The independent validation set (n = 264) was established from patients of a different time period. RESULTS The median age in the training set was 47 years, and 78.0% were premenopausal. The number of patients with low RS (< 11), intermediate RS (11-25), and high RS (> 25) were 42 (22.0%), 122 (63.9%), and 27 (14.1%), respectively. High nuclear grade, no progesterone receptor expression, and high Ki-67 were associated with high RS, and these variables were used to construct the nomogram. It had significant discriminatory power in internal validation (area under the curve = 0.856) and in the validation set (area under the curve = 0.828). The calibration plot showed optimal agreement between predicted and actual probabilities in both sets. CONCLUSION A nomogram was successfully developed with 3 simple parameters. The probability of high RS can be easily and conveniently estimated using our nomogram. It might be useful to determine whether or not Oncotype DX is conducted in the TAILORx era. Future large-scale prospective studies are warranted.
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Affiliation(s)
- Shin Hye Yoo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Miso Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eunshin Lee
- Department of General Surgery, Seoul National University Hospital, Seoul, Korea
| | - Han-Byoel Lee
- Department of General Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyeong-Gon Moon
- Department of General Surgery, Seoul National University Hospital, Seoul, Korea
| | - Wonshik Han
- Department of General Surgery, Seoul National University Hospital, Seoul, Korea
| | - Dong-Young Noh
- Department of General Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sae-Won Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-You Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seock-Ah Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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11
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Prospective, multicenter study on the economic and clinical impact of gene-expression assays in early-stage breast cancer from a single region: the PREGECAM registry experience. Clin Transl Oncol 2019; 22:717-724. [DOI: 10.1007/s12094-019-02176-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
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12
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Allocating healthcare resources to genomic testing in Canada: latest evidence and current challenges. J Community Genet 2019; 13:467-476. [PMID: 31273679 DOI: 10.1007/s12687-019-00428-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/14/2019] [Indexed: 12/30/2022] Open
Abstract
Precision medicine (PM) informed by next-generation sequencing (NGS) poses challenges for health technology assessment (HTA). To date, there has been limited reimbursement of genomic testing with NGS in Canada, particularly for whole-genome and whole-exome sequencing (WGS/WES). Through a structured literature review, we examine Canadian economic evidence and evidentiary challenges for the adoption of genomic testing. We searched Medline (PubMed) for published Canadian studies generating economic evidence for PM informed by NGS. Our search focused on studies examining the costs and/or value of NGS. We reviewed included studies and summarized results according to evaluation type, clinical context, NGS technology, and test strategy. We then grouped HTA challenges encountered by authors when evaluating NGS. Our review included twenty-five studies. To determine the economic impacts of NGS-informed PM in Canada, studies applied cost-effectiveness analysis (52%, n = 13), stated preference analysis (20%, n = 5), cost-consequence analysis (16%, n = 4), and healthcare resource utilization or costing analysis (12%, n = 3). NGS panels were the most common technology evaluated (n = 13), followed by WGS and/or WES (n = 8). The included studies highlighted multiple challenges when generating economic evidence, many of which remain unaddressed. Challenges were broadly related to (1) accounting for all NGS outcomes; (2) addressing uncertainty; and (3) improving consistency of economic approaches. Canadian studies are beginning to produce estimates of the economic impacts of NGS-informed PM, yet challenges for HTA remain. While solutions and real-world evidence are generated, lifecycle health technology management methods can be designed to better support resource allocation decisions for genomic testing in Canada.
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13
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Hannouf MB, Zaric GS, Blanchette P, Brezden-Masley C, Paulden M, McCabe C, Raphael J, Brackstone M. Cost-effectiveness analysis of multigene expression profiling assays to guide adjuvant therapy decisions in women with invasive early-stage breast cancer. THE PHARMACOGENOMICS JOURNAL 2019; 20:27-46. [PMID: 31130722 DOI: 10.1038/s41397-019-0089-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/07/2018] [Accepted: 03/27/2019] [Indexed: 12/22/2022]
Abstract
Gene expression profiling (GEP) testing using 12-gene recurrence score (RS) assay (EndoPredict®), 58-gene RS assay (Prosigna®), and 21-gene RS assay (Oncotype DX®) is available to aid in chemotherapy decision-making when traditional clinicopathological predictors are insufficient to accurately determine recurrence risk in women with axillary lymph node-negative, hormone receptor-positive, and human epidermal growth factor-receptor 2-negative early-stage breast cancer. We examined the cost-effectiveness of incorporating these assays into standard practice. A decision model was built to project lifetime clinical and economic consequences of different adjuvant treatment-guiding strategies. The model was parameterized using follow-up data from a secondary analysis of the Anastrozole or Tamoxifen Alone or Combined randomized trial, cost data (2017 Canadian dollars) from the London Regional Cancer Program (Canada) and secondary Canadian sources. The 12-gene, 58-gene, and 21-gene RS assays were associated with cost-effectiveness ratios of $36,274, $48,525, and $74,911/quality-adjusted life year (QALY) gained and resulted in total gains of 379, 284.3, and 189.5 QALYs/year and total budgets of $12.9, $14.2, and $16.6 million/year, respectively. The total expected-value of perfect information about GEP assays' utility was $10.4 million/year. GEP testing using any of these assays is likely clinically and economically attractive. The 12-gene and 58-gene RS assays may improve the cost-effectiveness of GEP testing and offer higher value for money, although prospective evidence is still needed. Comparative field evaluations of GEP assays in real-world practice are associated with a large societal benefit and warranted to determine the optimal and most cost-effective assay for routine use.
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Affiliation(s)
- Malek B Hannouf
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Gregory S Zaric
- Ivey School of Business, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Phillip Blanchette
- London Regional Cancer Program, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Christine Brezden-Masley
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Hematology and Oncology, St. Michael's Hospital, Toronto, ON, Canada
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Christopher McCabe
- The Institute of Health Economics, Edmonton, AB, Canada.,Faculty of Medicine, Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jacques Raphael
- London Regional Cancer Program, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Muriel Brackstone
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,London Regional Cancer Program, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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14
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Kim J, Kim A, Kim C. Examination of the Biomark assay as an alternative to Oncotype DX for defining chemotherapy benefit. Oncol Lett 2019; 17:1812-1818. [PMID: 30675242 PMCID: PMC6341800 DOI: 10.3892/ol.2018.9784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 11/09/2018] [Indexed: 12/30/2022] Open
Abstract
Currently the 21-gene recurrence score (RS) assay called Oncotype DX is recommended by the National Comprehensive Cancer Network guideline for defining the benefit of chemotherapy. To overcome the cost disadvantages of the Oncotype DX assay and the turnaround time, a multigene assay was examined to compare the correlation of the RS and the predicted score (PS) of the present study. Paraffin-embedded tissues of 50 cases with early-stage estrogen receptor (ER)-positive breast cancer, who underwent the Oncotype DX test were used. A total of 149 candidate genes with high correlation to the RS were identified, in another project (Lee et al, unpublished data). Reverse transcription-quantitative polymerase chain reaction biomark assays were conducted using the dynamic array integrated fluidic circuit and the correlation analysis was performed with BRB ArrayTools. A predictive model was developed by the coefficient and gene expression, and 41 genes were identified. If the cut-off was ≥18, the predicted model was 18/50 cases, and the RS was 19, indicating that the differential rate of predicted response against RS was 2%. If the cutoff was ≥11, the predicted model was 38/50 cases and the RS was 34, indicating a difference of 8%. Genes common to the Oncotype DX and the Biomark assay include marker of proliferation Ki-67, aurora kinase A, Erb-B2 receptor tyrosine kinase 2, glutathione S-transferase Mu 1, estrogen receptor 1, progesterone receptor, B-cell lymphoma 2, signal peptide CUB domain EGF-like 2 and 5 reference genes. The remaining 28 genes are involved in various pathways and functions. This result indicates that there is a significant correlation between PS and RS scores, although validation of results is required to accurately determine the risk of distant recurrence. The Biomark assay is an easy and inexpensive way to measure mRNA expression. The present study demonstrates the possibility of the Biomark assay as an alternative for defining chemotherapy benefit in individual patients with ER-positive early-stage breast cancer.
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Affiliation(s)
- Jinkyoung Kim
- Department of Pathology, Korea University Guro Hospital, Guro-gu, Seoul 08308, Republic of Korea
| | - Aeree Kim
- Department of Pathology, Korea University Guro Hospital, Guro-gu, Seoul 08308, Republic of Korea
| | - Chungyeul Kim
- Department of Pathology, Korea University Guro Hospital, Guro-gu, Seoul 08308, Republic of Korea
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15
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Martel S, Lambertini M, Simon R, Matte C, Prady C. Adherence to guidelines in requesting Oncotype DX in a publicly funded health care system. ACTA ACUST UNITED AC 2018; 25:e311-e318. [PMID: 30111977 DOI: 10.3747/co.25.3965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Oncotype dx [odx (Genomic Health, Redwood City, CA, U.S.A.)] is an approved prognostic tool for women with node-negative, hormone receptor-positive, her2-negative breast cancer. Because of cost, optimal use of this test is crucial, especially in a publicly funded health care system. We evaluated adherence with our provincial guidelines for odx requests, the management of patients with an intermediate recurrence score (rs), and the cost impact of odx. Methods This retrospective study included 201 consecutive patients with an odx request from two university institutions in Quebec between May 2012 and December 2014. Concordance with provincial guidelines was estimated, with its 95% confidence interval (ci). For patients with an intermediate rs, factors influencing the final treatment decision were assessed. The cost impact of odx was derived from the proportion of patients for whom chemotherapy was not recommended. Results In 93.0% of patients (95% ci: 89.5% to 96.6%), odx was ordered according to guidelines. The concordance was similar in both institutions (92.7%; 95% ci: 88.1% to 97.3%; and 93.6%; 95% ci: 88.2% to 99.0%). In 112 (55.7%), 78 (38.8%), and 9 (4.5%) patients, the rs suggested low, intermediate, and high risk respectively. In the intermediate-risk group, most patients (n = 58, 74.4%) did not receive chemotherapy, mainly because of patient preference and the absence of a clear proven benefit. Savings of CA$100,000 for the study period (2.5 years) were estimated to be associated with odx use. Conclusions In our experience, the use of odx was concordant with published recommendations and had a positive cost impact.
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Affiliation(s)
- S Martel
- Département d'hémato-oncologie, cisss Montérégie centre/Hôpital Charles-Lemoyne, centre affilié de l'Université de Sherbrooke, Greenfield Park, QC
| | - M Lambertini
- Department of Medical Oncology and.,Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - R Simon
- Département de chirurgie and
| | - C Matte
- Département de pathologie, cisss Montérégie centre/Hôpital Charles-Lemoyne, centre affilié de l'Université de Sherbrooke, Greenfield Park, QC
| | - C Prady
- Département d'hémato-oncologie, cisss Montérégie centre/Hôpital Charles-Lemoyne, centre affilié de l'Université de Sherbrooke, Greenfield Park, QC
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16
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Wang SY, Dang W, Richman I, Mougalian SS, Evans SB, Gross CP. Cost-Effectiveness Analyses of the 21-Gene Assay in Breast Cancer: Systematic Review and Critical Appraisal. J Clin Oncol 2018; 36:1619-1627. [PMID: 29659329 DOI: 10.1200/jco.2017.76.5941] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Purpose Prior studies examining cost effectiveness of the 21-gene assay (Oncotype DX [ODX]) for women with hormone receptor-positive, early-stage breast cancer have yielded disparate results. We aimed to explore why these analyses may have yielded different conclusions. Methods We conducted a systematic literature review of cost-effectiveness analyses (CEAs) of ODX. We examined the extent to which the structure of CEA modeling, the assumptions of the models, and the selection of input parameters influenced cost-effectiveness estimates. We also explored the prevalence of industry funding and whether industry funding was associated with study designs favoring ODX. Results We identified 27 analyses, 15 of which received industry funding. In 18 studies, the clinical characteristics (eg, tumor size and grade) commonly used to make chemotherapy decisions were not incorporated into simulation modeling; thus, these studies would favor ODX being cost effective and might not reflect clinical practice. Most studies ignored the heterogeneous effect of ODX on chemotherapy use; only five studies assumed that ODX would increase chemotherapy use for clinically low-risk patients but decrease chemotherapy use for clinically high-risk patients. No study used population-based joint distributions of ODX recurrence score and tumor characteristics, and 12 studies inappropriately assumed that chemotherapy would increase distant recurrence for the low recurrence score group; both approaches overestimated the benefits of ODX. Industry-funded studies tended to favor ODX; all five studies that reported ODX as being cost saving were industry funded. In contrast, two studies that reported an incremental cost-effectiveness ratio > $50,000 per quality-adjusted life-year were not funded by industry. Conclusion Although a majority of published analyses indicated that ODX is cost effective, they incorporated study designs that can increase the risk of bias.
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Affiliation(s)
- Shi-Yi Wang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Weixiong Dang
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Ilana Richman
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Sarah S Mougalian
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Suzanne B Evans
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
| | - Cary P Gross
- Shi-Yi Wang and Weixiong Dang, Yale University School of Public Health; Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale Cancer Center; and Shi-Yi Wang, Ilana Richman, Sarah S. Mougalian, Suzanne B. Evans, and Cary P. Gross, Yale University School of Medicine, New Haven, CT
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17
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Martínez Del Prado P, Alvarez-López I, Domínguez-Fernández S, Plazaola A, Ibarrondo O, Galve-Calvo E, Ancizar-Lizarraga N, Gutierrez-Toribio M, Lahuerta-Martínez A, Mar J. Clinical and economic impact of the 21-gene recurrence score assay in adjuvant therapy decision making in patients with early-stage breast cancer: pooled analysis in 4 Basque Country university hospitals. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:189-199. [PMID: 29593426 PMCID: PMC5863711 DOI: 10.2147/ceor.s146095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose The 21-gene recurrence score (RS) is a genomic test developed as a prognostic and predictive tool to improve the treatment decision making in cases of estrogen receptor-positive and human epidermal growth factor receptor 2-negative early-stage breast cancer. This study examined the clinical and economic impact of its use in 4 Basque Country university hospitals. Methods Taking into consideration the RS result, we recorded the recommended initial systemic adjuvant therapy (endocrine therapy with or without chemotherapy) according to standard clinicopathologic factors and the final decision about chemotherapy. Then, if the RS was high, chemotherapy was recommended; it was not recommended if the RS was low; for those with an intermediate RS, clinicopathologic factors were considered, and the initial recommendation based on those factors was maintained. In addition, the probability of switching treatment was calculated. Then, we developed an economic evaluation by measuring the treatment’s incremental short-term budget impact from both the societal perspective and that of the Basque Health System. Patients’ characteristics and chemotherapy use were analyzed using logistic regressions and receiver operating characteristic curves. Results Without an RS, chemotherapy would have been prescribed to 56% of 401 patients, but, with RS use, that percentage decreased to 25. The overall rate of decision change was 35.4%. Test inclusion led to a reduction in chemotherapy costs of €922 per patient in the total population. Although this reduction did not entirely offset the cost of the test, the productivity loss per patient was reduced by €1,977. Conclusion The 21-gene RS test significantly changed the indication for chemotherapy. As chemotherapy treatments with no benefit were avoided, patients’ quality of life was improved. The short-term economic impact was negative for the Basque Health Service, but savings resulted when sick-leave costs were included.
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Affiliation(s)
| | - Isabel Alvarez-López
- Medical Oncology Service, Donostia University Hospital, Donostia-San Sebastián, Spain.,Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | | | - Arrate Plazaola
- Medical Oncology Service, Onkologikoa, Donostia-San Sebastián, Spain
| | - Oliver Ibarrondo
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain
| | - Elena Galve-Calvo
- Medical Oncology Service, Basurto University Hospital, Bilbao, Spain
| | - Nerea Ancizar-Lizarraga
- Medical Oncology Service, Donostia University Hospital, Donostia-San Sebastián, Spain.,Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | | | | | - Javier Mar
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain.,Health Services Research on Chronic Patients Network, Kronikgune Group, Bilbao, Spain
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18
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Iwamoto T, Katagiri T, Niikura N, Miyoshi Y, Kochi M, Nogami T, Shien T, Motoki T, Taira N, Omori M, Tokuda Y, Fujiwara T, Doihara H, Gyorffy B, Matsuoka J. Immunohistochemical Ki67 after short-term hormone therapy identifies low-risk breast cancers as reliably as genomic markers. Oncotarget 2018; 8:26122-26128. [PMID: 28412725 PMCID: PMC5432244 DOI: 10.18632/oncotarget.15385] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 01/31/2017] [Indexed: 01/10/2023] Open
Abstract
Background The purpose of this study was to test whether immunohistochemical (IHC) Ki67 levels after short-term preoperative hormone therapy (post-Ki67) predict similar numbers of patients with favorable prognoses as genomic markers. Results Thirty paired cases (60 samples) were enrolled in this study. Post-Ki67 levels were significantly lower than pre-treatment Ki67 levels (P < 0.001). Post-Ki67 predicted more low-risk cases (83.3%, 25/30) than pre-genomic surrogate signature(GSS) (66.7%: 20/30), but the difference in predictive power was not significant (P = 0.233). Proliferation (MKI67, STK15, Survivin, CCNB1, and MYBL2) and estrogen (ER, PGR, BCL2, and SCUBE2) related signatures were significantly downregulated after therapy (P < 0.001 and 0.041, respectively). Materials and Methods Core needle biopsy specimens of primary breast cancer were collected at Okayama University Hospital from hormone receptor-positive and human epidermal growth factor 2-negative patients that subsequently received two weeks of neoadjuvant hormone therapy. Paired post-treatment specimens from surgical samples were also collected. IHC Ki67 levels and GSS were compared between pre- and post-hormone treatment samples. Changes of gene expression pattern in short-term hormone therapy were also assessed. Conclusions IHC based post-Ki67 levels may have distinct predictive power compared with the naïve IHC Ki67. Future studies with larger cohorts and longer follow-up periods may be needed to validate our results.
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Affiliation(s)
- Takayuki Iwamoto
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan.,Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan
| | - Toyomasa Katagiri
- Division of Genome Medicine, Institute for Genome Research, Tokushima University, Tokushima, Japan
| | - Naoki Niikura
- Department of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuichiro Miyoshi
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Mariko Kochi
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan.,Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan
| | - Tomohiro Nogami
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Takayuki Motoki
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan.,Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan
| | - Naruto Taira
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Masako Omori
- Department of Pathology, Okayama University Hospital, Okayama, Japan
| | - Yutaka Tokuda
- Department of Breast and Endocrine Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan
| | - Hiroyoshi Doihara
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Balazs Gyorffy
- MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary.,nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Junji Matsuoka
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan.,Department of Gastroenterological Surgery, Okayama University Hospital, Okayama, Japan.,Department of Palliative and Supportive Medicine, Okayama University Hospital, Okayama, Japan
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19
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Siow ZR, De Boer RH, Lindeman GJ, Mann GB. Spotlight on the utility of the Oncotype DX ® breast cancer assay. Int J Womens Health 2018; 10:89-100. [PMID: 29503586 PMCID: PMC5827461 DOI: 10.2147/ijwh.s124520] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Oncotype DX® assay was developed to address the need for optimizing the selection of adjuvant systemic therapy for patients with estrogen receptor (ER)-positive, lymph node-negative breast cancer. It has ushered in the era of genomic-based personalized cancer care for ER-positive primary breast cancer and is now widely utilized in various parts of the world. Together with several other genomic assays, Oncotype DX has been incorporated into clinical practice guidelines on biomarker use to guide treatment decisions. The Oncotype DX result is presented as the recurrence score which is a continuous score that predicts the risk of distant disease recurrence. The assay, which provides information on clinicopathological factors, has been validated for use in the prognostication and prediction of degree of adjuvant chemotherapy benefit in both lymph node-positive and lymph node-negative early breast cancers. Clinical studies have consistently shown that the Oncotype DX has a significant impact on decision making in adjuvant therapy recommendations and appears to be cost-effective in diverse health care settings. In this article, we provide an overview of the validation and clinical impact studies for the Oncotype DX assay. We also discuss its potential use in the neoadjuvant setting, as well as the more recent prospective validation trials, and the economic and utility implications of studies that use a lower cutoff score to define low-risk disease.
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Affiliation(s)
- Zhen Rong Siow
- ACRF Stem Cells and Cancer Division, Walter and Eliza Hall Institute of Medical Research.,Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital
| | - Richard H De Boer
- Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital
| | - Geoffrey J Lindeman
- ACRF Stem Cells and Cancer Division, Walter and Eliza Hall Institute of Medical Research.,Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - G Bruce Mann
- Department of Medical Oncology, Peter MacCallum Cancer Centre.,Familial Cancer Centre, The Royal Melbourne Hospital.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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Chandler Y, Schechter CB, Jayasekera J, Near A, O’Neill SC, Isaacs C, Phelps CE, Ray GT, Lieu TA, Ramsey S, Mandelblatt JS. Cost Effectiveness of Gene Expression Profile Testing in Community Practice. J Clin Oncol 2018; 36:554-562. [PMID: 29309250 PMCID: PMC5815401 DOI: 10.1200/jco.2017.74.5034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Gene expression profile (GEP) testing can support chemotherapy decision making for patients with early-stage, estrogen receptor-positive, human epidermal growth factor 2-negative breast cancers. This study evaluated the cost effectiveness of one GEP test, Onco type DX (Genomic Health, Redwood City, CA), in community practice with test-eligible patients age 40 to 79 years. Methods A simulation model compared 25-year societal incremental costs and quality-adjusted life-years (QALYs) of community Onco type DX use from 2005 to 2012 versus usual care in the pretesting era (2000 to 2004). Inputs included Onco type DX and chemotherapy data from an integrated health care system and national and published data on Onco type DX accuracy, chemotherapy effectiveness, utilities, survival and recurrence, and Medicare and patient costs. Sensitivity analyses varied individual parameters; results were also estimated for ideal conditions (ie, 100% testing and adherence to test-suggested treatment, perfect test accuracy, considering test effects on reassurance or worry, and lowest costs). Results Twenty-four percent of test-eligible patients had Onco type DX testing. Testing was higher in younger patients and patients with stage I disease ( v stage IIA), and 75.3% and 10.2% of patients with high and low recurrence risk scores received chemotherapy, respectively. The cost-effectiveness ratio for testing ( v usual care) was $188,125 per QALY. Considering test effects on worry versus reassurance decreased the cost-effectiveness ratio to $58,431 per QALY. With perfect test accuracy, the cost-effectiveness ratio was $28,947 per QALY, and under ideal conditions, it was $39,496 per QALY. Conclusion GEP testing is likely to have a high cost-effectiveness ratio on the basis of community practice patterns. However, realistic variations in assumptions about key variables could result in GEP testing having cost-effectiveness ratios in the range of other accepted interventions. The differences in cost-effectiveness ratios on the basis of community versus ideal conditions underscore the importance of considering real-world implementation when assessing the new technology.
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Affiliation(s)
- Young Chandler
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Clyde B. Schechter
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jinani Jayasekera
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aimee Near
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suzanne C. O’Neill
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudine Isaacs
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles E. Phelps
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - G. Thomas Ray
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tracy A. Lieu
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott Ramsey
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeanne S. Mandelblatt
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
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Choi Y, Kim A, Kim J, Lee J, Lee SY, Kim C. Optimization of RNA Extraction from Formalin-Fixed Paraffin-Embedded Blocks for Targeted Next-Generation Sequencing. J Breast Cancer 2017; 20:393-399. [PMID: 29285045 PMCID: PMC5744000 DOI: 10.4048/jbc.2017.20.4.393] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/21/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose Breast cancer has a high prevalence in Korea. To achieve personalized therapy for breast cancer, long-term follow-up specimens are needed for next-generation sequencing (NGS) and multigene analysis. Formalin-fixed paraffin-embedded (FFPE) samples are easier to store than fresh frozen (FF) samples. The objective of this study was to optimize RNA extraction from FFPE blocks for NGS. Methods RNA quality from FF and FFPE tissues (n=5), expected RNA amount per unit area, the relationship between archiving time and quantity/quality of FFPE-extracted RNA (n=14), differences in quantitative real-time polymerase chain reaction (qRT-PCR) and NGS results, and comparisons of both techniques with tissue processing at different institutions (n=96) were determined in this study. Results The quality of RNA did not show any statistically significant difference between paired FF and FFPE specimens (p=0.49). Analysis of tumor cellularity gave an expected RNA amount of 33.25 ng/mm2. Archiving time affected RNA quality, showing a negative correlation with RNA integrity number and a positive correlation with threshold cycle. However, RNA from samples as old as 10 years showed a 100% success rate in qRT-PCR using short primers, showing that the effect of archiving time can be overcome by proper experiment design. NGS showed a higher success rate than qRT-PCR. Specimens from institution B (n=46), which were often stored in a refrigerator for more than 6 hours and fixed without slicing, showed lower success rates and worse results than specimens from the other institutes. Conclusion Archived FFPE tissues can be used to extract RNA for NGS if they are properly processed before fixation. The expected amount of RNA per unit size calculated in this study will be useful for other researchers.
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Affiliation(s)
- Yoojin Choi
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Aeree Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Jinkyoung Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Jinhwan Lee
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Soo Yeon Lee
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Chungyeul Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
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22
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Mittmann N, Earle CC, Cheng SY, Julian JA, Rahman F, Seung SJ, Levine MN. Population-Based Study to Determine the Health System Costs of Using the 21-Gene Assay. J Clin Oncol 2017; 36:238-243. [PMID: 29193984 DOI: 10.1200/jco.2017.74.2577] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose The 21-gene assay Oncotype Dx (Genomic Health, Redwood City, CA) test is used to aid the decision about chemotherapy in patients with hormone receptor-positive breast cancer who received endocrine therapy. Economic studies to support test adoption used decision-analytic models with assumptions and data derived from disparate sources. The objective was to evaluate whether the 21-gene assay test resulted in an overall cost expense or saving to the health system. Patients and Methods One thousand participants enrolled in a field evaluation study, were linked to population-level health system administrative databases, and were observed for 20 months. The cost for the cohort, which included the cost of the test, subsequent treatments received, and health care encounters, was determined. The cost in the absence of the test was compared with the pretest recommendation about chemotherapy from the field study for a base case and under scenarios that reflected different adjuvant chemotherapy use. Overall health system costs and incremental costs were calculated. Results The 21-gene assay resulted in a net decrease in chemotherapy use of 23%. For the base case incremental analysis, the actual overall health system cost of this cohort, including the cost of 21-gene assay, was $29.2 million compared with $26.2 million in the absence of the test-an increase of $3.1 million. For three of the four scenario analyses, the actual overall cost to the health system exceeded the estimated cost in the absence of the test. Results showed that, when at least half of the population received adjuvant chemotherapy, the cost increased to $30.2 million. Conclusion The use of real-world administrative data showed that, despite lower rates of chemotherapy use, the 21-gene assay test results in an overall incremental cost to the health care system in the short-term under most assumptions.
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Affiliation(s)
- Nicole Mittmann
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Craig C Earle
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Stephanie Y Cheng
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Jim A Julian
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Farah Rahman
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Soo Jin Seung
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Mark N Levine
- Nicole Mittmann, Sunnybrook Research Institute, Cancer Care Ontario, and University of Toronto; Craig C. Earle, Ontario Institute for Cancer Research; Craig C. Earle, Stephanie Y. Cheng, and Farah Rahman, Institute for Clinical Evaluative Sciences; Soo Jin Seung, Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto; and Jim A. Julian and Mark N. Levine, Juravinski Cancer Centre, McMaster University, and Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
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23
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Blok EJ, Bastiaannet E, van den Hout WB, Liefers GJ, Smit VTHBM, Kroep JR, van de Velde CJH. Systematic review of the clinical and economic value of gene expression profiles for invasive early breast cancer available in Europe. Cancer Treat Rev 2017; 62:74-90. [PMID: 29175678 DOI: 10.1016/j.ctrv.2017.10.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/29/2017] [Indexed: 01/12/2023]
Abstract
Gene expression profiles with prognostic capacities have shown good performance in multiple clinical trials. However, with multiple assays available and numerous types of validation studies performed, the added value for daily clinical practice is still unclear. In Europe, the MammaPrint, OncotypeDX, PAM50/Prosigna and Endopredict assays are commercially available. In this systematic review, we aim to assess these assays on four important criteria: Assay development and methodology, clinical validation, clinical utility and economic value. We performed a literature search covering PubMed, Embase, Web of Science and Cochrane, for studies related to one or more of the four selected assays. We identified 147 papers for inclusion in this review. MammaPrint and OncotypeDX both have evidence available, including level IA clinical trial results for both assays. Both assays provide prognostic information. Predictive value has only been shown for OncotypeDX. In the clinical utility studies, a higher reduction in chemotherapy was achieved by OncotypeDX, although the number of available studies differ considerably between tests. On average, economic evaluations estimate that genomic testing results in a moderate increase in total costs, but that these costs are acceptable in relation to the expected improved patient outcome. PAM50/prosigna and EndoPredict showed comparable prognostic capacities, but with less economical and clinical utility studies. Furthermore, for these assays no level IA trial data are available yet. In summary, all assays have shown excellent prognostic capacities. The differences in the quantity and quality of evidence are discussed. Future studies shall focus on the selection of appropriate subgroups for testing and long-term outcome of validation trials, in order to determine the place of these assays in daily clinical practice.
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Affiliation(s)
- E J Blok
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - W B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - G J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - J R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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24
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Dzimitrowicz H, Mougalian S, Storms S, Hurd S, Chagpar AB, Killelea BK, Horowitz NR, Lannin DR, Harigopal M, Hofstatter E, DiGiovanna MP, Adelson KB, Silber A, Abu-Khalaf M, Chung G, Zaheer W, Abdelghany O, Hatzis C, Pusztai L, Sanft TB. Impacts of Early Guideline-Directed 21-Gene Recurrence Score Testing on Adjuvant Therapy Decision Making. J Oncol Pract 2017; 13:e1012-e1020. [PMID: 29048991 DOI: 10.1200/jop.2017.022731] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE The 21-gene recurrence score (RS) assay is used to help formulate adjuvant chemotherapy recommendations for patients with estrogen receptor-positive, early-stage breast cancer. Most frequently, medical oncologists order RS after surgery. Results take an additional 2 weeks to return, which can delay decision making. We conducted a prospective quality-improvement project to assess the impact of early guideline-directed RS ordering by surgeons before the first visit with a medical oncologist on adjuvant therapy decision making. MATERIALS AND METHODS Surgical oncologists ordered RS testing following National Comprehensive Cancer Network guidelines at time of diagnosis or at time of surgery between July 1, 2015 and December 31, 2015. We measured the testing rate of patients eligible for RS, time to chemotherapy decisions, rates of chemotherapy use, accrual to RS-based clinical trials, cost, and physician acceptance of the policy and compared the results to patients who met eligibility criteria for early guideline-directed testing during the 6 months before the project. RESULTS Ninety patients met eligibility criteria during the testing period. RS was ordered for 91% of patients in the early testing group compared with 76% of historical controls ( P < .001). Median time to chemotherapy decision was significantly shorter in the early testing group (20 days; 95% CI, 17 to 23 days) compared with historical controls (32 days; 95% CI, 29 to 35 days; P < .001). There were no significant differences in time to chemotherapy initiation, chemotherapy use, RS-based trial enrollment, or calculated costs between the groups. CONCLUSION Early guideline-directed RS testing in selected patients is an effective way to shorten time to treatment decisions.
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Affiliation(s)
- Hannah Dzimitrowicz
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sarah Mougalian
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sherri Storms
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Sandra Hurd
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Anees B Chagpar
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Brigid K Killelea
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Nina R Horowitz
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Donald R Lannin
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Malini Harigopal
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Erin Hofstatter
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Michael P DiGiovanna
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Kerin B Adelson
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Andrea Silber
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Maysa Abu-Khalaf
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Gina Chung
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Wajih Zaheer
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Osama Abdelghany
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Christos Hatzis
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Lajos Pusztai
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
| | - Tara B Sanft
- Yale University School of Medicine; Yale New Haven Hospital-Smilow Cancer Hospital, New Haven, CT
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25
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Jahn B, Arvandi M, Rochau U, Fiegl H, Goebel G, Marth C, Siebert U. Development of a novel prognostic score for breast cancer patients using mRNA expression of CHAC1. J Comp Eff Res 2017; 6:563-574. [PMID: 29091014 DOI: 10.2217/cer-2017-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM To develop a prognostic score for primary breast cancer patients integrating conventional predictors and the novel biomarker CHAC1 to aid adjuvant chemotherapy decisions. PATIENTS & METHODS A prognostic score for overall survival was developed using: conventional predictors from a dataset of 1777 patients and the weight of CHAC1 mRNA expression from an independent dataset of 106 patients using multivariate Cox regression. RESULTS The new score includes: CHAC1 mRNA expression, age, tumor size, HER2 neu status, lymph node status and degree of malignancy. Using a cut-off value of 11 score points, 10-year survival was 82% in low-risk (n = 34) and 43% in high-risk patients (n = 72). The addition of CHAC1 resulted in 16% reclassification. CONCLUSION Including CHAC1 in prognostic prediction may aid (and change) personalized treatment selection.
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Affiliation(s)
- Beate Jahn
- Institute of Public Health, Medical Decision Making & Health Technology Assessment, Department of Public Health, Health Services Research & Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics & Technology, Hall in Tirol, Austria
| | - Marjan Arvandi
- Institute of Public Health, Medical Decision Making & Health Technology Assessment, Department of Public Health, Health Services Research & Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics & Technology, Hall in Tirol, Austria
| | - Ursula Rochau
- Institute of Public Health, Medical Decision Making & Health Technology Assessment, Department of Public Health, Health Services Research & Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics & Technology, Hall in Tirol, Austria.,ONCOTYROL, Division of Health Technology Assessment & Bioinformatics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Heidi Fiegl
- Department of Obstetrics & Gynaecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Goebel
- Department of Medical Statistics, Informatics & Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Marth
- Department of Obstetrics & Gynaecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making & Health Technology Assessment, Department of Public Health, Health Services Research & Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics & Technology, Hall in Tirol, Austria.,ONCOTYROL, Division of Health Technology Assessment & Bioinformatics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria.,Center for Health Decision Science, Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Institute for Technology Assessment & Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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26
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Tumour-infiltrating lymphocytes (TILs)-related genomic signature predicts chemotherapy response in breast cancer. Breast Cancer Res Treat 2017; 167:39-47. [PMID: 28905250 DOI: 10.1007/s10549-017-4502-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/07/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE The present study evaluated whether morphological-measured stromal and intra-tumour tumour-infiltrating lymphocytes (TILs) levels were associated with gene expression profiles, and whether TILs-associated genomic signature (GS) could be used to predict clinical outcomes and response to therapies in several breast cancer subtypes. METHODS We retrospectively evaluated haematoxylin eosin (HE)-TILs levels and gene expression profiling data from 40 patients with primary breast cancer and extracted the 22 overexpressed genes in cases with high TILs scores as the TILs-GS. The TILs-GS were compared with breast cancer subtype and were evaluated predictive values for prognosis and response to therapies. RESULTS Higher TILs-GS expressions were observed for triple-negative and human epidermal growth factor receptor 2 (HER2) positive (+) breast cancers, compared to the luminal types (P < 0.001). With the exception of HER2+, the TILs-GS had no prognostic value in subtypes of breast cancers. The Wilcoxon test revealed significantly different TILs-GS levels between the cases with pathological complete response (pCR) and residual disease after anthracycline and taxane-based neoadjuvant chemotherapy, with the exception of the luminal-low proliferation subtype. In the multivariate analysis, pCR was independently associated with smaller tumour size, higher histological grade, ER negativity, HER2 positivity and higher TILs-GS scores (OR 2.02, 95% CI 1.30-3.14, P = 0.025). CONCLUSIONS TILs-GS was associated with stromal and intra-tumour TILs levels, as evaluated using HE, which predicted prognosis and chemotherapy response in several breast cancer subtypes. Further studies are needed to perform stratification according to TILs-GS levels and the conventional breast cancer subtypes.
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27
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Trifiletti DM, Sturz VN, Showalter TN, Lobo JM. Towards decision-making using individualized risk estimates for personalized medicine: A systematic review of genomic classifiers of solid tumors. PLoS One 2017; 12:e0176388. [PMID: 28486497 PMCID: PMC5423583 DOI: 10.1371/journal.pone.0176388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/10/2017] [Indexed: 12/16/2022] Open
Abstract
Recent advances in the understanding of the genetic underpinnings of cancer offer the promise to customize cancer treatments to the individual through the use of genomic classifiers (GCs). At present, routine clinical utilization of GCs is uncommon and their current scope and status, in a broad sense, are unknown. As part of a registered review (PROSPERO 2014:CRD42014013371), we systematically reviewed the literature evaluating the utility of commercially available GCs by searching Ovid Medline (PubMed), EMBASE, the Cochrane Database of Systematic Reviews, and CINAHL on September 2, 2014. We excluded articles involving pediatric malignancies, non-solid or non-invasive cancers, hereditary risk of cancer, non-validated GCs, and GCs involving fewer than 3 biomarkers. A total of 3,625 studies were screened, but only 37 met the pre-specified inclusion criteria. Of these, 15 studies evaluated outcomes and clinical utility of GCs through clinical trials, and the remainder through the use of mathematical models. Most studies (29 of 37) were specific to hormone-receptor positive breast cancer, whereas only 4 studies evaluated GCs in non-breast cancer (prostate, colon, and lung cancers). GCs have spurred excitement across disciplines in recent decades. While there are several GCs that have been validated, the general quality of the data are weak. Further research, including prospective validation is needed, particularly in the non-breast cancer GCs.
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Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Vanessa N. Sturz
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Jennifer M. Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Felts JL, Zhu J, Han B, Smith SJ, Truica CI. An Analysis of Oncotype DX Recurrence Scores and Clinicopathologic Characteristics in Invasive Lobular Breast Cancer. Breast J 2017; 23:677-686. [DOI: 10.1111/tbj.12751] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Junjia Zhu
- Department of Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania
| | - Bing Han
- Department of Pathology; Penn State Hershey Medical Center; Hershey Pennsylvania
| | - Stanley J. Smith
- Department of Surgery; Penn State Hershey Medical Center; Hershey Pennsylvania
| | - Cristina I. Truica
- Department of Hematology Oncology; Penn State Cancer Institute; Hershey Pennsylvania
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Song JL, Chen C, Yuan JP, Sun SR. Progress in the clinical detection of heterogeneity in breast cancer. Cancer Med 2016; 5:3475-3488. [PMID: 27774765 PMCID: PMC5224851 DOI: 10.1002/cam4.943] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/22/2016] [Accepted: 09/23/2016] [Indexed: 12/18/2022] Open
Abstract
Breast cancer is currently the most common form of cancer and the second‐leading cause of death from cancer in women. Though considerable progress has been made in the treatment of breast cancer, the heterogeneity of tumors (both inter‐ and intratumor) remains a considerable diagnostic and prognostic challenge. From clinical observation to genetic mutations, the history of understanding the heterogeneity of breast cancer is lengthy and detailed. Effectively detecting heterogeneity in breast cancer is important during treatment. Various methods of depicting this heterogeneity are now available and include genetic, pathologic, and imaging analysis. These methods allow characterization of the heterogeneity of breast cancer on a genetic level, providing greater insight during the process of establishing an effective therapeutic plan. This study reviews how the understanding of tumor heterogeneity in breast cancer evolved, and further summarizes recent advances in the detection and monitoring of this heterogeneity in patients with breast cancer.
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Affiliation(s)
- Jun-Long Song
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Jing-Ping Yuan
- Department of Pathology, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Sheng-Rong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
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Markopoulos C, van de Velde C, Zarca D, Ozmen V, Masetti R. Clinical evidence supporting genomic tests in early breast cancer: Do all genomic tests provide the same information? Eur J Surg Oncol 2016; 43:909-920. [PMID: 27639633 DOI: 10.1016/j.ejso.2016.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 08/17/2016] [Indexed: 01/17/2023] Open
Abstract
Breast cancer (BC) has historically been treated as a single disease entity; however, in the last decade, insights into its molecular heterogeneity have underpinned the development/commercialisation of several genomic tools whose goal is to guide patient management in early BC. These include the Oncotype DX® Breast Recurrence Score™ assay, MammaPrint®, Prosigna®, and EndoPredict®. Although these assays are similar in that they are all multigene assays reflecting risk of recurrence, they differ substantially in the technological platform used to measure gene expression; the number and identity of genes assessed; the patient populations used for development and validation; and the level of evidence supporting clinical utility. They also differ in the amount of evidence demonstrating their impact on treatment decisions and cost effectiveness in different countries. This review discusses these 4 assays, highlighting the clinical evidence that supports each of them, while focussing on the Recurrence Score assay. This assay has the greatest body of evidence supporting its clinical utility and decision impact/effectiveness, and currently is the only one validated as a predictor of response to adjuvant chemotherapy in hormone-receptor positive early BC patients treated with endocrine therapy and to be included as such in international/national BC treatment guidelines. The review also discusses ongoing prospective trials investigating the 4 assays, recent outcome studies, as well as analyses comparing different assays on the same tumour blocks.
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Affiliation(s)
- C Markopoulos
- Athens University Medical School, 8 Iassiou Street, 11521, Athens, Greece.
| | - C van de Velde
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - D Zarca
- Institut Français du Sein, 15 rue Jean Nicot, 75007, Paris, France
| | - V Ozmen
- Istanbul Faculty of Medicine, Istanbul University, Bahçelievler Mahallesi, E-5 Yanyol, Kültür Sokak, No: 14, Metroport Busidence, Bahçelievler, İstanbul, 34180, Istanbul, Turkey
| | - R Masetti
- Surgical Breast Unit, Catholic University of Rome, Largo Agostino Gemelli, 8, 00168, Rome, Italy
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Cost-utility analyses of drug therapies in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:407-24. [PMID: 27572551 DOI: 10.1007/s10549-016-3924-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/20/2016] [Indexed: 01/08/2023]
Abstract
The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.
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Marguet S, Mazouni C, Ramaekers BL, Dunant A, Kates R, Jacobs VR, Joore MA, Harbeck N, Bonastre J. European cost-effectiveness study of uPA/PAI-1 biomarkers to guide adjuvant chemotherapy decisions in breast cancer. Eur J Cancer 2016; 63:168-79. [DOI: 10.1016/j.ejca.2016.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/15/2016] [Accepted: 05/14/2016] [Indexed: 12/25/2022]
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Basu A, Carlson JJ, Veenstra DL. A Framework for Prioritizing Research Investments in Precision Medicine. Med Decis Making 2016; 36:567-80. [PMID: 26502985 PMCID: PMC5845804 DOI: 10.1177/0272989x15610780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 09/02/2015] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The adoption of precision medicine (PM) has been limited in practice to date, and yet its promise has attracted research investments. Developing foundational economic approaches for directing proper use of PM and stimulating growth in this area from multiple perspectives is thus quite timely. METHODS Building on our previously developed expected value of individualized care (EVIC) framework, we conceptualize new decision-relevant metrics to better understand and forecast the expected value of PM. Several aspects of behavior at the patient, physician, and payer levels are considered that can inform the rate and manner in which PM innovations diffuse throughout the relevant population. We illustrate this framework and the methods using a retrospective evaluation of the use of OncotypeDx genomic test among breast cancer patients. RESULTS The enriched metrics can help inform many facets of PM decision making, such as evaluating alternative reimbursement levels for PM tests, implementation and education programs for physicians and patients, and decisions around research investments by manufacturers and public entities. We replicated prior published results on evaluation of OncotypeDx among breast cancer patients but also illustrated that those results are based on assumptions that are often not met in practice. Instead, we show how incorporating more practical aspects of behavior around PM could lead to drastically different estimates of value. CONCLUSION We believe that the framework and the methods presented can provide decision makers with more decision-relevant tools to explore the value of PM. There is a growing recognition that data on adoption is important to decision makers. More research is needed to develop prediction models for potential diffusion of PM technologies.
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Affiliation(s)
- Anirban Basu
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle
- Departments of Health Services and Economics, University of Washington, Seattle
| | - Josh J. Carlson
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle
| | - David L. Veenstra
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle
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Chae EY, Moon WK, Kim HH, Kim WH, Cha JH, Shin HJ, Choi WJ, Han W, Noh DY, Lee SB, Ahn SH. Association between Ultrasound Features and the 21-Gene Recurrence Score Assays in Patients with Oestrogen Receptor-Positive, HER2-Negative, Invasive Breast Cancer. PLoS One 2016; 11:e0158461. [PMID: 27362843 PMCID: PMC4928814 DOI: 10.1371/journal.pone.0158461] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 06/16/2016] [Indexed: 11/26/2022] Open
Abstract
A multigene expression assay corresponds to the likelihood of breast cancer recurrence after the initial diagnosis and can be used to guide the decision for additional chemotherapy. However, only few studies have investigated the associations between the imaging features of breast cancer and the results of multigene expression assays. Our study was to identify the relationship between imaging features on ultrasound (US) and the recurrence score (RS) on a 21-gene expression assay in patients with oestrogen receptor (ER)-positive, HER2-negative breast cancer. 267 patients with ER-positive, HER-negative invasive breast cancer who underwent examinations using US and Oncotype DX assay were included. US images were independently reviewed by dedicated breast radiologists who were blind to the RS. Tumour roundness was measured using a laboratory-developed software program. The pathological data were reviewed, including immunohistochemistry results. Univariate analysis was performed to assess the associations between the RS and each variable. Multiple logistic regression analysis was used to identify independent predictors of high RS. Of 267 patients, 147 (55%) had low, 96 (36%) intermediate, and 24 (9%) had high RS. According to the univariate analysis, parallel orientation, presence of calcification in the mass, and tumour roundness were positively associated with high RS. Multiple logistic regression analysis showed that parallel orientation (OR = 5.53) and tumour roundness (OR = 1.70 per 10 increase) were associated with high RS. Parallel orientation and tumour roundness are independent variables that may predict high RS in patients with ER-positive, HER2-negative breast cancer.
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Affiliation(s)
- Eun Young Chae
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Woo Kyung Moon
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail: (HHK); (WKM)
| | - Hak Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
- * E-mail: (HHK); (WKM)
| | - Won Hwa Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joo Hee Cha
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Hee Jung Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Woo Jung Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong-Young Noh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Sei Hyun Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
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Cromwell I, Gaudet M, Peacock SJ, Aquino-Parsons C. Cost-effectiveness analysis of anal cancer screening in women with cervical neoplasia in British Columbia, Canada. BMC Health Serv Res 2016; 16:206. [PMID: 27349646 PMCID: PMC4924299 DOI: 10.1186/s12913-016-1442-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 05/28/2016] [Indexed: 12/02/2022] Open
Abstract
Background Precursors to anal squamous cell carcinoma may be detectable through screening; however, the literature suggests that population-level testing is not cost-effective. Given that high-grade cervical neoplasia (CIN) is associated with an increased risk of developing anal cancer, and in light of changing guidelines for the follow-up and management of cervical neoplasia, it is worthwhile to examine the costs and effectiveness of an anal cancer screening program delivered to women with previously-detected CIN. Methods A model of anal cancer screening and treatment was constructed, to estimate the cost-effectiveness of a population of CIN II/III+ women who were screened using anal cytology vs. one that received no anal cancer screening. Costs were based on Canadian estimates, and survival was based on estimates taken from the scientific literature. Effectiveness was measured in terms of life years gained (LYG) and quality-adjusted life years (QALYs). The model was run for 50 cycles, with each cycle representing one year. Results Incremental cost (screened vs. unscreened) was $82.17 per woman in the model. Incremental effectiveness was 0.004 LYG, and was equivalent to zero in terms of QALY. An ICER of $20,561/LYG was calculated, while no meaningful incremental cost-effectiveness ratio (ICER) could be calculated for quality-adjusted survival. Conclusion Our analysis suggests that anal cancer screening is cost-effective in terms of overall survival in women with a previous diagnosis of CIN II or CIN III as part of regular follow-up, but may not contribute meaningfully-different quality-adjusted survival due to the adverse effects of screening-related interventions. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1442-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- I Cromwell
- Canadian Centre for Applied Research in Cancer Control, Vancouver, Canada. .,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada.
| | - M Gaudet
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, Canada.,Division of Radiation Oncology, The Ottawa Hospital, Ottawa, Canada
| | - S J Peacock
- Canadian Centre for Applied Research in Cancer Control, Vancouver, Canada.,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - C Aquino-Parsons
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, Canada
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Cost-effectiveness of using a gene expression profiling test to aid in identifying the primary tumour in patients with cancer of unknown primary. THE PHARMACOGENOMICS JOURNAL 2016; 17:286-300. [PMID: 27019982 DOI: 10.1038/tpj.2015.94] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 10/30/2015] [Accepted: 11/13/2015] [Indexed: 12/18/2022]
Abstract
We aimed to investigate the cost-effectiveness of a 2000-gene-expression profiling (GEP) test to help identify the primary tumor site when clinicopathological diagnostic evaluation was inconclusive in patients with cancer of unknown primary (CUP). We built a decision-analytic-model to project the lifetime clinical and economic consequences of different clinical management strategies for CUP. The model was parameterized using follow-up data from the Manitoba Cancer Registry, cost data from Manitoba Health administrative databases and secondary sources. The 2000-GEP-based strategy compared to current clinical practice resulted in an incremental cost-effectiveness ratio (ICER) of $44,151 per quality-adjusted life years (QALY) gained. The total annual-budget impact was $36.2 million per year. A value-of-information analysis revealed that the expected value of perfect information about the test's clinical impact was $4.2 million per year. The 2000-GEP test should be considered for adoption in CUP. Field evaluations of the test are associated with a large societal benefit.
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Safonov A, Wang S, Gross CP, Agarwal D, Bianchini G, Pusztai L, Hatzis C. Assessing cost-utility of predictive biomarkers in oncology: a streamlined approach. Breast Cancer Res Treat 2016; 155:223-34. [PMID: 26749360 DOI: 10.1007/s10549-016-3677-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/02/2016] [Indexed: 10/22/2022]
Abstract
Evaluation of cost-utility is critical in assessing the medical utility of predictive or prognostic biomarkers. Current methods involve complex state-transition models, requiring comprehensive data inputs. We propose a simplified decision-analytic tool to explore the relative effect of factors contributing to the cost-utility of a biomarker. We derived a cost-utility metric, the "test incremental cost-effectiveness ratio" (TICER) for biomarker-guided treatment compared to no biomarker use. This method uses data inputs readily accessible through clinical literature. We compared our results with traditional cost-effectiveness analysis of predictive biomarkers for established (HER2-guided trastuzumab, ALK-guided crizotinib, OncotypeDX-guided adjuvant chemotherapy) and emerging (ROS1-guided crizotinib) targeted treatments. We conducted sensitivity analysis to determine which factors had the greatest impact on TICER estimates. Base case TICER for HER2 was $149,600/quality-adjusted life year (QALY), for ALK was $22,200/QALY, and for OncotypeDX was $11,600/QALY, consistent with literature-reported estimates ($180,000/QALY, $202,800/QALY, $8900/QALY, respectively). Base case TICER for ROS1-guided crizotinib was $205,900/QALY. Generally, when treatment cost is considerably greater than biomarker testing costs, TICER is driven by clinical outcomes and health-related quality of life, while biomarker prevalence and treatment cost have a lesser effect. Our simplified decision-analytic approach produces values consistent with existing cost-effectiveness analyses. Our results suggest that biomarker value is mostly driven by the clinical efficacy of the targeted agent. A user-friendly web tool for complete TICER analysis has been made available for open use at http://medicine.yale.edu/lab/pusztai/ticer/ .
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Affiliation(s)
| | - Shiyi Wang
- Yale School of Public Health, New Haven, USA.,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, New Haven, USA
| | - Cary P Gross
- Yale School of Medicine, New Haven, USA.,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, New Haven, USA.,Yale Cancer Center, Yale University, New Haven, USA
| | | | | | - Lajos Pusztai
- Yale School of Medicine, New Haven, USA.,Yale Cancer Center, Yale University, New Haven, USA
| | - Christos Hatzis
- Yale School of Medicine, New Haven, USA. .,Yale Cancer Center, Yale University, New Haven, USA.
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Jahn B, Rochau U, Kurzthaler C, Hubalek M, Miksad R, Sroczynski G, Paulden M, Kluibenschädl M, Krahn M, Siebert U. Cost effectiveness of personalized treatment in women with early breast cancer: the application of OncotypeDX and Adjuvant! Online to guide adjuvant chemotherapy in Austria. SPRINGERPLUS 2015; 4:752. [PMID: 26693110 PMCID: PMC4666888 DOI: 10.1186/s40064-015-1440-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022]
Abstract
A Breast Cancer Outcomes model was developed at the ONCOTYROL research center to evaluate personalized test-treatment strategies in Austria. The goal was to evaluate the cost-effectiveness of a new 21-gene assay (ODX) when used in conjunction with the Adjuvant! Online (AO) decision aid to support personalized decisions about use of adjuvant chemotherapy in early-stage breast cancer patients in Austria. We applied a validated discrete-event-simulation model to a hypothetical cohort of 50 years old women over a lifetime horizon. The test-treatment strategies of interest were defined using three-letter acronyms. The first (second, third) letter indicates whether patients with a low (intermediate, high) risk according to AO were tested using ODX (Y yes, N no). The main outcomes were life-years gained, quality-adjusted life-years (QALYs), costs and cost effectiveness. Robustness of the results was tested in sensitivity analyses. Results were compared to a Canadian analysis conducted by the Toronto Health Economics and Technology Assessment Collaborative (THETA). Five of eight strategies were dominated (i.e., more costly and less effective: NNY, NYN, YNN, YNY, YYN). The base-case analysis shows that YYY (ODX provided to all patients) is the most effective strategy and is cost effective with an incremental cost-effectiveness ratio of 15,700 EUR per QALY gained. These results are sensitive to changes in the probabilities of distant recurrence, age and costs of chemotherapy. The results of the base-case analysis were comparable to the THETA results. Based on our analyses, using ODX in addition to AO is effective and cost effective in all women in Austria. The development of future genetic tests may require alternative or additional test-treatment strategies to be evaluated.
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Affiliation(s)
- B Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - U Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - C Kurzthaler
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Hubalek
- Department of Obstetrics and Gynaecology, Medical University Innsbruck, Innsbruck, Austria
| | - R Miksad
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - G Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Paulden
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON Canada ; Department of Emergency Medicine, University of Alberta, Edmonton, AB Canada
| | - M Kluibenschädl
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON Canada
| | - U Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center 1, A-6060 Hall i.T, Austria ; Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria ; Center for Health Decision Science, Department of Health Policy and Management, T.H.Chan Harvard School of Public Health, Boston, MA USA ; Institute for Technology Assessment and Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA USA
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Epstein AJ, Wong YN, Mitra N, Vachani A, Hin S, Yang L, Smith-McLallen A, Armstrong K, Groeneveld PW. Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer. J Clin Oncol 2015; 33:4259-67. [PMID: 26598749 DOI: 10.1200/jco.2015.61.9023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We assessed the associations between the 21-gene recurrence score assay (RS) receipt, subsequent chemotherapy use, and medical expenditures among patients with early-stage breast cancer. PATIENTS AND METHODS Data from the Pennsylvania Cancer Registry were used to assemble a retrospective cohort of women with early-stage breast cancer from 2007 to 2010 who underwent initial surgical treatment. These data were merged with administrative claims from the 12-month periods before and after diagnosis to identify comorbidities, treatments, and expenditures (n = 7,287). Propensity score-weighted regression models were estimated to identify the effects of RS receipt on chemotherapy use and medical spending in the year after diagnosis. RESULTS The associations between RS receipt and outcomes varied markedly by patient age. RS use was associated with lower chemotherapy use among women younger than 55 (19.2% lower; 95% CI, 10.6 to 27.9). RS use was associated with higher chemotherapy use among women 75 to 84 years old (5.7% higher; 95% CI, 0.4 to 11.0). RS receipt was associated with lower adjusted 1-year medical spending among women younger than 55 ($15,333 lower; 95% CI, $2,841 to $27,824) and with higher spending among women who were 75 to 84 years old ($3,489 higher; 95% CI, $857 to $6,122). CONCLUSION RS receipt was associated with reduced use of adjuvant chemotherapy and lower health care spending among women with breast cancer who were younger than 55. Conversely, among women 75 and older, RS testing was associated with a modest increase in chemotherapy use and slightly higher spending. From a population perspective, the impact of RS testing on breast cancer treatment and health care costs is much greater in younger women.
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Affiliation(s)
- Andrew J Epstein
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Yu-Ning Wong
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Nandita Mitra
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Anil Vachani
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Sakhena Hin
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Lin Yang
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Aaron Smith-McLallen
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Katrina Armstrong
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Peter W Groeneveld
- Andrew J. Epstein and Peter W. Groeneveld, Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center; Andrew J. Epstein, Yu-Ning Wong, Nandita Mitra, Anil Vachani, Sakhena Hin, Lin Yang, and Peter W. Groeneveld, University of Pennsylvania; Yu-Ning Wong, Temple University Health System; Aaron Smith-McLallen, Independence Blue Cross, Philadelphia, PA; Katrina Armstrong, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
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Levine MN, Julian JA, Bedard PL, Eisen A, Trudeau ME, Higgins B, Bordeleau L, Pritchard KI. Prospective Evaluation of the 21-Gene Recurrence Score Assay for Breast Cancer Decision-Making in Ontario. J Clin Oncol 2015; 34:1065-71. [PMID: 26598746 DOI: 10.1200/jco.2015.62.8503] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To evaluate the 21-gene recurrence score (RS) on decision-making in a population-based cohort. PATIENTS AND METHODS Patients with axillary node-negative or nodal micrometastases, estrogen receptor-positive, and human epidermal growth factor receptor 2-negative breast cancer being considered for chemotherapy were eligible. All cancer treatment centers in Ontario, Canada, participated. Oncologists made a preliminary recommendation for endocrine therapy with or without chemotherapy on the basis of Adjuvant! Online (AOL) risk estimation. Patients were asked for their preference regarding chemotherapy. After RSs were available, patients returned for final decision-making. Patient satisfaction was measured by using the decisional conflict scale. RESULTS Between January 2012 and July 2013, 1,000 patients were recruited. RSs were available for 979 patients. In 58% of patients, risk was categorized as low (RS, 0 to 18); in 33%, intermediate (RS, 19 to 30); and in 9%, high (RS, ≥ 31). Oncologists' recommendations pretest and post-test remained the same in 464 patients (48%), changed from unsure or chemotherapy to no chemotherapy in 365 (38%), and changed from unsure or no chemotherapy to chemotherapy in 143 (15%). After the test, oncologists recommended chemotherapy for 236 patients, 81% of whom received chemotherapy. Of 151 patients in whom risk was classified as intermediate by means of AOL, 41% were a low risk and 44% intermediate risk with RS. Of 298 patients at high risk with AOL, 16% had a high risk RS. None of 236 patients with grade I tumors had a high-risk RS. Mean total decisional conflict scale score significantly improved from pretest to post-test from 34 to 19 (P < .001). CONCLUSION The RS substantially influenced both oncologists' recommendations and patients' preferences for chemotherapy. The major effect was avoidance of chemotherapy when AOL indicated high or intermediate risk.
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Affiliation(s)
- Mark N Levine
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada.
| | - Jim A Julian
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Philippe L Bedard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Andrea Eisen
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Maureen E Trudeau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Brian Higgins
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Louise Bordeleau
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
| | - Kathleen I Pritchard
- Mark N. Levine, Jim A. Julian, and Louise Bordeleau, McMaster University, Hamilton; Mark N. Levine and Louise Bordeleau, Hamilton Health Sciences Juravinski Cancer Centre, Hamilton; Mark N. Levine and Jim A. Julian, Ontario Clinical Oncology Group and Escarpment Cancer Research Institute, Hamilton; Philippe L. Bedard, Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, University of Toronto, Toronto; Phillipe L. Bedard, Princess Margaret Hospital, Toronto; Andrea Eisen, Maureen E. Trudeau, and Kathleen I. Pritchard, Odette Sunnybrook Regional Cancer Centre; Toronto; and Brian Higgins, Peel Regional Cancer Centre, Mississauga, Ontario, Canada
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Dreyfus C, Ballester M, Gligorov J, Agranat P, Antoine M, Tengher I, Bricou A. [Impact of the 21-gene assay in decision-making during multidisciplinary breast meeting: A French experience]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2015; 43:780-5. [PMID: 26584893 DOI: 10.1016/j.gyobfe.2015.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/29/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The 21-gene assay (Oncotype DX(®)) test is used to estimate the risk of recurrence and to predict the benefit of adjuvant chemotherapy at an early stage of endocrine responsive breast cancers, without HER2 overexpression or amplification. This test corresponds to a recurrence score (RS), classifying patients into three groups (low, intermediate or high risk). The objective of this two-center prospective study is to define the impact of Oncotype DX(®) in clinical practice. METHODS Between August 2013 and May 2015, an Oncotype DX(®) test was decided in multidisciplinary meeting, to certain patients with an indication of adjuvant chemotherapy for HR+ and HER2 negative cancers. The therapeutic changes after knowledge of RS were collected. An estimate of the economic impact was performed and a correlation between the RS and usual breast cancer prognostic markers was investigated. RESULTS Thirty-nine patients had a test, twenty-six (66.7%) of them have finally been no indication retaining chemotherapy. The economy obtained through the use of the test was estimated around 173,000euros. It has not been demonstrated correlation between the RS, the usual decisional and prognostic factors for breast cancer or with adjuvant! Online. CONCLUSIONS The RS has an additional decision value compared to other common decision criteria. Use of Oncotype DX(®) reduced in our experience the indications of adjuvant chemotherapy. The medical and economic impact could be significant.
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Affiliation(s)
- C Dreyfus
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France
| | - M Ballester
- Service de gynécologie-obstétrique, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - J Gligorov
- Service d'oncologie médicale, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - P Agranat
- Service d'oncologie médicale, université Paris XIII-Bobigny, AP-HP, Avicenne, 125, rue de Stalingrad, 93000 Bobigny, France
| | - M Antoine
- Laboratoire d'anatomopathologie, Sorbonne université, AP-HP, Tenon, IUC-UPMC, Paris, France
| | - I Tengher
- Laboratoire d'anatomopathologie, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France
| | - A Bricou
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, AP-HP, Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France.
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42
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Bombard Y. Translating personalized genomic medicine into clinical practice: evidence, values, and health policy. Genome 2015; 58:491-7. [PMID: 26577841 DOI: 10.1139/gen-2015-0145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yvonne Bombard
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy, Management & Evaluation, University of Toronto.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy, Management & Evaluation, University of Toronto
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43
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Iwamoto T, Kelly C, Mizoo T, Nogami T, Motoki T, Shien T, Taira N, Hayashi N, Niikura N, Fujiwara T, Doihara H, Matsuoka J. Relative Prognostic and Predictive Value of Gene Signature and Histologic Grade in Estrogen Receptor-Positive, HER2-Negative Breast Cancer. Clin Breast Cancer 2015; 16:95-100.e1. [PMID: 26631838 DOI: 10.1016/j.clbc.2015.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/28/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND In estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer, first-generation genomic signatures serve predominately as prognostic biomarkers and secondarily as predictors of response to chemotherapy. We compared both the prognostic and predictive value of histologic grades and genomic markers. METHODS We retrieved publicly available cDNA microarray data from 1373 primary ER(+)/HER2(-) breast cancers and developed a genomic signature simulated from Recurrence Online (http://www.recurrenceonline.com/) to calculate the recurrence score and risk using predefined sets of genes in the cDNA microarray. We then compared the prognostic and predictive information provided by histologic grade and genomic signature. RESULTS Based on genomic signatures, 55%, 28%, and 17% of breast cancers were classified as low, intermediate, and high risk, respectively, whereas the histologic grades were I, II, and III in 22%, 59%, and 19% of breast cancers, respectively. Univariate analysis in the untreated cohort revealed that both histologic grade (overall P = .007) and genomic signature (P < .001) could predict prognosis. Results were similar using the genomic signature, with pathologic complete response rates of 4.6%, 5.7%, and 16.5% for low-, intermediate-, and high-risk cancers, respectively. Neither biomarker was statistically significant in multivariate analysis for predictive response to neoadjuvant chemotherapy (NAC). CONCLUSION Genomic signature was better at identifying low-risk cases compared to histologic grade alone, but both markers had similar predictive values for NAC response. Better predictive biomarkers for NAC response are still needed.
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Affiliation(s)
| | | | | | | | | | | | | | - Naoki Hayashi
- Department of Breast Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Naoki Niikura
- Department of Breast and Endocrine Surgery, Tokai University Hospital, Kanagawa, Japan
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Jahn B, Rochau U, Kurzthaler C, Paulden M, Kluibenschädl M, Arvandi M, Kühne F, Goehler A, Krahn MD, Siebert U. Lessons Learned from a Cross-Model Validation between a Discrete Event Simulation Model and a Cohort State-Transition Model for Personalized Breast Cancer Treatment. Med Decis Making 2015; 36:375-90. [PMID: 26476865 DOI: 10.1177/0272989x15604158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 07/13/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Breast cancer is the most common malignancy among women in developed countries. We developed a model (the Oncotyrol breast cancer outcomes model) to evaluate the cost-effectiveness of a 21-gene assay when used in combination with Adjuvant! Online to support personalized decisions about the use of adjuvant chemotherapy. The goal of this study was to perform a cross-model validation. METHODS The Oncotyrol model evaluates the 21-gene assay by simulating a hypothetical cohort of 50-year-old women over a lifetime horizon using discrete event simulation. Primary model outcomes were life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). We followed the International Society for Pharmacoeconomics and Outcomes Research-Society for Medical Decision Making (ISPOR-SMDM) best practice recommendations for validation and compared modeling results of the Oncotyrol model with the state-transition model developed by the Toronto Health Economics and Technology Assessment (THETA) Collaborative. Both models were populated with Canadian THETA model parameters, and outputs were compared. RESULTS The differences between the models varied among the different validation end points. The smallest relative differences were in costs, and the greatest were in QALYs. All relative differences were less than 1.2%. The cost-effectiveness plane showed that small differences in the model structure can lead to different sets of nondominated test-treatment strategies with different efficiency frontiers. We faced several challenges: distinguishing between differences in outcomes due to different modeling techniques and initial coding errors, defining meaningful differences, and selecting measures and statistics for comparison (means, distributions, multivariate outcomes). CONCLUSIONS Cross-model validation was crucial to identify and correct coding errors and to explain differences in model outcomes. In our comparison, small differences in either QALYs or costs led to changes in ICERs because of changes in the set of dominated and nondominated strategies.
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Affiliation(s)
- Beate Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US)
| | - Ursula Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US)
| | - Christina Kurzthaler
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US)
| | - Mike Paulden
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, ON, Canada (MP, MK),Department of Emergency Medicine; University of Alberta, Edmonton, AB, Canada (MP)
| | - Martina Kluibenschädl
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US),Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, ON, Canada (MP, MK)
| | - Marjan Arvandi
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US)
| | - Felicitas Kühne
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US)
| | - Alexander Goehler
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Department of Radiology, Yale University, New Haven, CT, USA (AG),Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA (AG),Alfried Krupp von Bohlen und Halbach Foundation-Institute for Health Systems Management, University of Duisburg-Essen, Essen, Germany (AG)
| | - Murray D Krahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US)
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria (BJ, UR, CK, MK, MA, MS, FK, AG, US),Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria (BJ, UR, CK, MK, MS, FK, US),Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA (US),Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA (US)
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Economic impact of 21-gene recurrence score testing on early-stage breast cancer in Ireland. Breast Cancer Res Treat 2015; 153:573-82. [PMID: 26364296 DOI: 10.1007/s10549-015-3555-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/21/2015] [Indexed: 12/21/2022]
Abstract
The 21-gene test is a validated multi-gene diagnostic test that predicts chemotherapy (CT) benefit in oestrogen receptor positive (ER+), lymph node-negative (N0) breast cancer (BC) patients (pts). Ireland was the first public health care system to reimburse this test in Europe. Study objectives were to assess the impact of this test on decision-making and to analyse the economic impact of testing. Between October 2011 and February 2013, a national, retrospective, cross-sectional observational study of ER+, N0 BC pts tested with the 21-gene test was conducted. Surveyed breast medical oncologists, provided the assumption for the decision impact analysis that grade (G) 1 pts would not have received CT before testing and G2/3 pts would have received CT before testing. Descriptive statistical analyses were performed. 592 pts were identified; Low, intermediate and high recurrence score were identified in 53, 36 and 10 % pts, respectively. 384 (70 %) pts had G2, 129 (22 %) G3 and 76 (13 %) G1 tumours. Post testing, 345 pts (59 %) experienced a change in CT decision; 339 changed to hormone therapy alone and 6 advised to receive CT. 172 (30 %) pts received CT, 12 (3.9 %) of pts with low scores, 108 (50.9 %) of intermediate risk and 50 (90.9 %) of pts with high risk scores. Net reduction in CT use was 58 % and net savings achieved were €793,565. Since public reimbursement, the introduction of the 21-gene test has resulted in a significant reduction in chemotherapy administration and cost savings for the Irish public healthcare system.
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Luporsi E, Bellocq JP, Barrière J, Bonastre J, Chetritt J, Le Corroller AG, de Cremoux P, Fina F, Gauchez AS, Lamy PJ, Martin PM, Mazouni C, Peyrat JP, Romieu G, Verdoni L, Mazeau-Woynar V, Kassab-Chahmi D. [uPA/PAI-1, Oncotype DX™, MammaPrint(®). Prognosis and predictive values for clinical utility in breast cancer management]. Bull Cancer 2015; 102:719-29. [PMID: 26235416 DOI: 10.1016/j.bulcan.2015.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Elisabeth Luporsi
- Institut de cancérologie de Lorraine, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy cedex, France
| | | | - Jérôme Barrière
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice, France
| | - Julia Bonastre
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - Jérôme Chetritt
- Institut d'histopathologie, 55, rue Amiral-du-Chaffault, 44100 Nantes, France
| | - Anne-Gaëlle Le Corroller
- UMR 912 Inserm, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | | | - Frédéric Fina
- AP-HM, faculté de médecine-secteur Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | | | - Pierre-Jean Lamy
- Institut régional du cancer, 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Pierre-Marie Martin
- AP-HM, faculté de médecine-secteur Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - Chafika Mazouni
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | | | - Gilles Romieu
- Institut régional du cancer, 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Laetitia Verdoni
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France
| | - Valérie Mazeau-Woynar
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France
| | - Diana Kassab-Chahmi
- Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt cedex, France.
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Gligorov J, Pivot XB, Jacot W, Naman HL, Spaeth D, Misset JL, Largillier R, Sautiere JL, de Roquancourt A, Pomel C, Rouanet P, Rouzier R, Penault-Llorca FM. Prospective Clinical Utility Study of the Use of the 21-Gene Assay in Adjuvant Clinical Decision Making in Women With Estrogen Receptor-Positive Early Invasive Breast Cancer: Results From the SWITCH Study. Oncologist 2015; 20:873-9. [PMID: 26112003 DOI: 10.1634/theoncologist.2014-0467] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The 21-gene Oncotype DX Recurrence Score assay is a validated assay to help decide the appropriate treatment for estrogen receptor-positive (ER+), early-stage breast cancer (EBC) in the adjuvant setting. The choice of adjuvant treatments might vary considerably in different countries according to various treatment guidelines. This prospective multicenter study is the first to assess the impact of the Oncotype DX assay in the French clinical setting. METHODS A total of 100 patients with ER+, human epidermal growth factor receptor 2-negative EBC, and node-negative (pN0) disease or micrometastases in up to 3 lymph nodes (pN1mi) were enrolled. Treatment recommendations, physicians' confidence before and after knowing the Recurrence Score value, and physicians' perception of the assay were recorded. RESULTS Of the 100 patients, 95 were evaluable (83 pN0, 12 pN1mi). Treatment recommendations changed in 37% of patients, predominantly from chemoendocrine to endocrine treatment alone. The proportion of patients recommended chemotherapy decreased from 52% pretest to 25% post-test. Of patients originally recommended chemotherapy, 61% were recommended endocrine treatment alone after receiving the Recurrence Score result. For both pN0 and pN1mi patients, post-test recommendations appeared to follow the Recurrence Score result for low and high values. Physicians' confidence improved significantly. CONCLUSION These are the first prospective data on the impact of the Oncotype DX assay on adjuvant treatment decisions in France. Using the assay was associated with a significant change in treatment decisions and an overall reduction in chemotherapy use. These data are consistent with those presented from European and non-European studies.
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Affiliation(s)
- Joseph Gligorov
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Xavier B Pivot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - William Jacot
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Hervé L Naman
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Dominique Spaeth
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Louis Misset
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Rémy Largillier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Jean-Loup Sautiere
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Anne de Roquancourt
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Christophe Pomel
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Philippe Rouanet
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Roman Rouzier
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
| | - Frederique M Penault-Llorca
- APHP Tenon, IUC-UPMC, Sorbonne Université, Alliance Pour la Recherche en Cancérologie, Paris, France; University Hospital Jean Minjoz, UMR1098, SFR IBCT, Besançon, France; Institut du Cancer Montpellier, Université Montpellier 1, Montpellier, France; Centre Azuréen de Cancérologie, Mougins, France; Centre d'Oncologie de Gentilly, Nancy, France; APHP-St. Louis, Université Paris Diderot, Paris, France; Centre Jean-Perrin, Université d'Auvergne, Clermont-Ferrand, France; Research Unit EA 7285, University of Versailles St-Quentin, Montigny-le-Bretonneux, France; Department of Surgery, Institut Curie, Saint-Cloud, France
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Lester-Coll NH, Lee JM, Gogineni K, Hwang WT, Schwartz JS, Prosnitz RG. Benefits and risks of contralateral prophylactic mastectomy in women undergoing treatment for sporadic unilateral breast cancer: a decision analysis. Breast Cancer Res Treat 2015; 152:217-226. [DOI: 10.1007/s10549-015-3462-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/05/2015] [Indexed: 11/28/2022]
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Blank PR, Filipits M, Dubsky P, Gutzwiller F, Lux MP, Brase JC, Weber KE, Rudas M, Greil R, Loibl S, Szucs TD, Kronenwett R, Schwenkglenks M, Gnant M. Cost-effectiveness analysis of prognostic gene expression signature-based stratification of early breast cancer patients. PHARMACOECONOMICS 2015; 33:179-190. [PMID: 25404424 PMCID: PMC4305105 DOI: 10.1007/s40273-014-0227-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The individual risk of recurrence in hormone receptor-positive primary breast cancer patients determines whether adjuvant endocrine therapy should be combined with chemotherapy. Clinicopathological parameters and molecular tests such as EndoPredict(®) (EPclin) can support decision making in patients with estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative cancer. OBJECTIVE Using a life-long Markov state transition model, we determined the health economic impact and incremental cost effectiveness of EPclin-based risk stratification in combination with clinical guidelines [German-S3, National Comprehensive Cancer Center Network (NCCN), and St. Gallen] to decide on chemotherapy use. METHODS Information on overall and metastasis-free survival came from Austrian Breast & Colorectal Cancer Study Group clinical trials 6/8 (n = 1,619) and published literature. Effectiveness was assessed as quality-adjusted life-years (QALYs). Costs (2010) were assessed from a German third-party payer perspective. RESULTS Lifetime costs per patient ranged from <euro>28,268 (St.Gallen and EPclin) to <euro>33,756 (NCCN). Due to an imperfect prognostic value and differences in chemotherapy use, strategies achieved between 13.165 QALYs (NCCN) and 13.173 QALYs (EPclin alone) per patient. Using German-S3 as reference, three strategies showed dominant results (St. Gallen and EPclin, German-S3 and EPclin, EPclin alone). Compared to German-S3, the addition of EPclin saved <euro>3,388 and gained 0.002 QALYs per patient. Combining guidelines with EPclin remained preferable in sensitivity analysis. CONCLUSION Our study suggests that molecular markers can be sensibly combined with clinical guidelines to determine the risk profile of adjuvant breast cancer patients. Compared with the current German best practice (German-S3), combinations of EPclin with the St. Gallen, German-S3 or NCCN guideline and EPclin alone were dominant from the perspective of the German healthcare system.
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Affiliation(s)
- Patricia R Blank
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland,
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50
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Marrone M, Stewart A, Dotson WD. Clinical utility of gene-expression profiling in women with early breast cancer: an overview of systematic reviews. Genet Med 2014; 17:519-32. [PMID: 25474343 DOI: 10.1038/gim.2014.140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 09/02/2014] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This overview systematically evaluates the clinical utility of using Oncotype DX and MammaPrint gene-expression profiling tests to direct treatment decisions in women with breast cancer. The findings are intended to inform an updated recommendation from the Evaluation of Genomic Applications in Practice and Prevention Working Group. METHODS Evidence reported in systematic reviews evaluating the clinical utility of Oncotype DX and MammaPrint, as well as the ability to predict treatment outcomes, change in treatment decisions, and cost-effectiveness, was qualitatively synthesized. RESULTS Five systematic reviews found no direct evidence of clinical utility for either test. Indirect evidence showed Oncotype DX was able to predict treatment effects of adjuvant chemotherapy, whereas no evidence of predictive value was found for MammaPrint. Both tests influenced a change in treatment recommendations in 21 to 74% of participants. The cost-effectiveness of Oncotype DX varied with the alternative compared. For MammaPrint, lack of evidence of the predictive value led to uncertainty in the cost-effectiveness. CONCLUSION No studies were identified that provided direct evidence that using gene-expression profiling tests to direct treatment decisions improved outcomes in women with breast cancer. Three ongoing studies may provide direct evidence for determining the clinical utility of gene-expression profiling testing.
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Affiliation(s)
- Michael Marrone
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alison Stewart
- 1] McKing Consulting Corporation, Atlanta, Georgia, USA [2] Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W David Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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