The 31-Gene Expression Profile Test Outperforms AJCC in Stratifying Risk of Recurrence in Patients with Stage I Cutaneous Melanoma

BACKGROUND

Patients with stage I cutaneous melanoma (CM) are considered at low risk for metastasis or melanoma specific death; however, because the majority of patients are diagnosed with stage I disease, they represent the largest number of melanoma deaths annually. The 31-gene expression profile (31-GEP) test has been prospectively validated to provide prognostic information independent of staging, classifying patients as low (Class 1A), intermediate (Class 1B/2A), or high (Class 2B) risk of poor outcomes.

METHODS

Patients enrolled in previous studies of the 31-GEP were combined and evaluated for recurrence-free (RFS) and melanoma-specific survival (MSS) (n = 1261, "combined"). A second large, unselected real-world cohort (n = 5651) comprising clinically tested patients diagnosed 2013-2018 who were linked to outcomes data from the NCI Surveillance, Epidemiology, and End Results (SEER) Program registries was evaluated for MSS.

RESULTS

Combined cohort Class 1A patients had significantly higher RFS than Class 1B/2A or Class 2B patients (97.3%, 88.6%, 77.3%, p < 0.001)-better risk stratification than AJCC8 stage IA (97.5%) versus IB (89.3%). The SEER cohort showed better MSS stratification by the 31-GEP (Class 1A = 98.0%, Class 1B/2A = 97.5%, Class 2B = 92.3%; p < 0.001) than by AJCC8 staging (stage IA = 97.6%, stage IB = 97.9%; p < 0.001).

CONCLUSIONS

The 31-GEP test significantly improved patient risk stratification, independent of AJCC8 staging in patients with stage I CM. The 31-GEP provided greater separation between high- (Class 2B) and low-risk (Class 1A) groups than seen between AJCC stage IA and IB. These data support integrating the 31-GEP into clinical decision making for more risk-aligned management plans.

31-Gene Expression Profile Testing in Cutaneous Melanoma and Survival Outcomes in a Population-Based Analysis: A SEER Collaboration

PURPOSE

The DecisionDx-Melanoma 31-gene expression profile (31-GEP) test is validated to classify cutaneous malignant melanoma (CM) patient risk of recurrence, metastasis, or death as low (class 1A), intermediate (class 1B/2A), or high (class 2B). This study aimed to examine the effect of 31-GEP testing on survival outcomes and confirm the prognostic ability of the 31-GEP at the population level.

METHODS

Patients with stage I-III CM with a clinical 31-GEP result between 2016 and 2018 were linked to data from 17 SEER registries (n = 4,687) following registries' operation procedures for linkages. Melanoma-specific survival (MSS) and overall survival (OS) differences by 31-GEP risk category were examined using Kaplan-Meier analysis and the log-rank test. Crude and adjusted hazard ratios (HRs) were calculated using Cox regression model to evaluate variables associated with survival. 31-GEP tested patients were propensity score-matched to a cohort of non-31-GEP tested patients from the SEER database. Robustness of the effect of 31-GEP testing was assessed using resampling.

RESULTS

Patients with a 31-GEP class 1A result had higher 3-year MSS and OS than patients with a class 1B/2A or class 2B result (MSS: 99.7% v 97.1% v 89.6%, P < .001; OS: 96.6% v 90.2% v 79.4%, P < .001). A class 2B result was an independent predictor of MSS (HR, 7.00; 95% CI, 2.70 to 18.00) and OS (HR, 2.39; 95% CI, 1.54 to 3.70). 31-GEP testing was associated with a 29% lower MSS mortality (HR, 0.71; 95% CI, 0.53 to 0.94) and 17% lower overall mortality (HR, 0.83; 95% CI, 0.70 to 0.99) relative to untested patients.

CONCLUSION

In a population-based, clinically tested melanoma cohort, the 31-GEP stratified patients by their risk of dying from melanoma.

Treatment patterns and outcomes in prostate cancer patients tested with Decipher in SEER

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Background: In 2021, national data between the Decipher 22-gene prognostic gene expression classifier (GC) for men with prostate cancer and the Surveillance, Epidemiology, and End Results (SEER) cancer registries were linked. The purpose of the work is to report on the linkage by characterizing national GC usage and its association with treatment decisions for men with prostate cancer. Methods: Patients in the SEER registries with primary prostate cancer diagnosis from 2010 to 2018 were included and linked to data from GC testing conducted between 2014 to 2020 (Veracyte, San Diego, CA). GC scores (range 0-1) and GC risk groups (low, intermediate, and high) were used for continuous and categorical analyses. Multivariable logistic regression was used to quantify the association between GC and active surveillance and watchful waiting (AS/WW) use and adverse pathology at radical prostatectomy (RP). Adverse pathology was defined as pathological grade group ≥3, pathological stage ≥pT3b, or lymph node invasion. Results: A total of 575,363 patients were eligible for analysis, of which 10,528 patients underwent GC testing (5,015 GC biopsy test, and 5,513 GC RP test). The median age was 67 for both tested and untested, but more white patients underwent testing (82% vs 76%, p < 0.001). For GC biopsy tested patients, AS/WW was highest for those with GC low risk results (41%) as compared to those with intermediate (32%) or high (17%) GC risk (p < 0.001). RP rates were lower in the tested compared to untested (25% vs. 36%, p < 0.001), and among the tested patients, RP use increased by GC risk group (19% of low, 25% of intermediate, and 34% of high GC risk, p < 0.001). A similar trend by GC risk group in management for radiation therapy was observed (13% of low, 19% of intermediate, and 29% of high GC risk, p < 0.001). In a multivariable logistic regression adjusted for age, race, NCCN risk group, and year of diagnosis, GC tested patients were more likely to undergo AS/WW compared to untested (OR 2.9 [95% CI, 2.8-3.1], p < 0.001). Within the subset of patients classified as NCCN low/favorable intermediate risk at biopsy and who were subsequently treated with RP (n = 594), GC high risk (> 0.6) was associated with more than 3 times the odds of harboring adverse pathology (OR 3.2 [95% CI 1.6-6.4], p < 0.001). Conclusions: Using the first ever linked SEER-Decipher data, we demonstrate that population-based treatment patterns are independently associated with GC test results. Patients with lower GC scores are independently more likely to undergo AS/WW; those with higher scores are more likely to have adverse pathology at time of RP.

Validation of the 31-gene expression profile test to stratify melanoma-specific survival in an unselected, prospectively tested cohort of patients with stage IIB-III cutaneous melanoma

e21538

Background: Given recent FDA extended approval of Pembrolizumab for stage IIB-IIC cutaneous melanoma (CM) patients, it is critical to risk-stratify patients to balance potential benefits versus toxicities of adjuvant therapy. The 31-gene expression profile (31-GEP) is a validated test for CM for risk of recurrence or metastasis prognosis in patients with stage I-III CM. A low-risk (Class 1A) 31-GEP result is associated with lower recurrence risk and higher melanoma-specific survival than an intermediate (Class 1B/2A) or high-risk (Class 2B) result. To validate the 31-GEP’s ability to stratify patients’ risk in an unselected, prospectively tested cohort of therapy-eligible CM patients, we collaborated with the National Cancer Institute and the Surveillance, Epidemiology, and End Results (SEER) program. Methods: A linkage was conducted between SEER registries’ CM cases diagnosed 2012-2018, and 31-GEP tested patients between 2013-2020. A de-identified dataset was used for the analysis. Kaplan-Meier analysis with log-rank test was used to analyze patient melanoma-specific survival (MSS) in the overall cohort and the subset of patients with potential adjuvant therapy access: stage IIB-III melanoma (n = 615). Results: In the overall cohort of patients (N = 5,225), those with a 31-GEP Class 1A result had higher 3-year MSS than patients with a Class 2B result (99.7% vs. 90.4%, p < 0.001). In multivariable Cox regression analysis, a Class 2B result was an independent significant predictor of MSS (HR = 5.71, p = 0.01), as were age (HR = 1.05, p < 0.001), SLN positivity (HR = 2.42, p = 0.02), and T2b (HR = 8.29, p = 0.025) and T4b (HR = 11.99, p = 0.009) tumors. In the subset of patients with stage IIB-III melanoma, those with a 31-GEP Class 1A result had higher 3-year MSS (98.8% vs. 82.4%, p = 0.02) than patients with a Class 2B result. Patients with a Class 2B result had a five and a half times higher event rate than those with a Class 1A result for MSS (5.5% [21/382] vs. 1.0% [1/105]). Conclusions: In a large, unselected, prospectively tested cohort of patients with stage I-III CM, the 31-GEP stratified patient risk of dying from melanoma, validating previous studies. While the 31-GEP identified a subgroup (Class 1A) of traditionally high-risk patients (stage IIB-III CM) who had a > 98% MSS over three years, it can also facilitate identifying patients who could warrant earlier adjuvant therapy with a higher 31-GEP class designation.

Receipt of guideline-concordant care among young adult women with breast cancer

BACKGROUND

Little is known about the real-world care of young adult (YA) females (aged 20-39 years) with breast cancer. This study describes factors associated with the receipt of guideline-concordant care (GCC) among YAs.

METHODS

The authors identified 1259 YA women with invasive breast cancer diagnosed in 2013 in the National Cancer Institute's Patterns of Care study. Hospital records were re-abstracted, and treatment was verified. Using the National Comprehensive Cancer Network's 2013 breast cancer guidelines, the authors assessed the receipt of GCC by cancer subtype among a subset of YAs (n = 952). Associations between sociodemographic and clinical factors and GCC receipt were examined.

RESULTS

Most YAs were 35 to 39 years old (51.2%) and partnered (56.4%); half had hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors. GCC was found for 81.7% of YAs. Relationships between sociodemographic and clinical factors and GCC receipt differed by subtype. Stage was the only significant predictor of GCC receipt for all subtypes (stage II vs III: odds ratio [OR] for HR+/HER2+, 0.20; 95% confidence interval [CI], 0.08-0.50; OR for HR-/HER2+, 0.13; 95% CI, 0.07-0.25; OR for HR-/HER2-, 3.86; 95% CI, 1.55-9.62; OR for HR+/HER2-, 2.81; 95% CI, 1.63-5.80).

CONCLUSIONS

GCC is high among YAs with breast cancer. The effects of sociodemographic factors and treatment facility size on GCC differ by subtype. Consistent with recommendations, tumor biology, not age, is associated with GCC for all subtypes. Future studies should assess the effect of GCC on survival among YAs.

Utilization of the Cancer Medications Enquiry Database (CanMED)-National Drug Codes (NDC): Assessment of Systemic Breast Cancer Treatment Patterns

Cancer Medications Enquiry Database (CanMED) is comprised of two interactive, nomenclature-specific databases within the Observational Research in Oncology Toolbox: CanMED-Healthcare Common Procedure Coding System (HCPCS) and CanMED-National Drug Code (NDC), described through this study. CanMED includes medications with a) a US Food and Drug Administration-approved cancer treatment or treatment-related symptom management indication, b) inclusion in treatment guidelines, or c) an orphan drug designation. To demonstrate the joint utility of CanMED, medication codes associated with female breast cancer treatment were identified and utilization patterns were assessed within Surveillance Epidemiology and End Results-Medicare (SEER) data. CanMED-NDC (11_2018 v.1.2.4) includes 6860 NDC codes: chemotherapy (1870), immunotherapy (164), hormone therapy (3074), and ancillary therapy (1752). Treatment patterns among stage I-IIIA (20 701) and stage IIIB-IV (2381) breast cancer patients were accordant with guideline-recommended treatment by stage and molecular subtype. CanMED facilitates identification of medications from observational data (eg, claims and electronic health records), promoting more standardized and efficient treatment-related cancer research.

Development and Utility of the Observational Research in Oncology Toolbox: Cancer Medications Enquiry Database-Healthcare Common Procedure Coding System (HCPCS)

PURPOSE

Health-care claims are of increasing utility as a rich, real-world data resource for conducting treatment-related cancer research. However, multiple dynamic coding nomenclatures exist, leading to study variability. To promote increased standardization and reproducibility, the National Cancer Institute (NCI) developed the Cancer Medications Enquiry Database (CanMED)-Healthcare Common Procedure Coding System (HCPCS) within the Observational Research in Oncology Toolbox.

METHODS

The CanMED-HCPCS includes codes for oncology medications that a) have a US Food and Drug Administration-approved indication for cancer treatment or treatment-related symptom management; b) are present in National Comprehensive Cancer Network guidelines; or c) carry an orphan drug designation for treatment or management of cancer. Included medications and their HCPCS codes were primarily identified based on Center for Medicare and Medicaid Services annual HCPCS Indices (2012-2018). To demonstrate the utility of the CanMED-HCPCS, use of systemic treatment for stage II-IV colorectal cancer patients included in the Surveillance, Epidemiology, and End Results-Medicare data (2007-2013) was assessed.

RESULTS

The CanMED-HCPCS (v2018) includes 332 HCPCS codes for cancer-related medications: chemotherapy (156), immunotherapy (74), hormonal therapy (54), and ancillary therapy (48). Observed treatment trends within the NCI Surveillance, Epidemiology, and End Results-Medicare data were as expected; utilization of each treatment type increased with stage, and immunotherapy was largely confined to use among stage IV patients.

CONCLUSION

The CanMED-HCPCS provides a comprehensive resource that can be used by the research community to facilitate systematic identification of medications within claims or electronic health data using the HCPCS nomenclature and greater reproducibility of cancer surveillance and health services research.

Association of SARS-CoV-2 Seropositive Antibody Test With Risk of Future Infection

IMPORTANCE

Understanding the effect of serum antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on susceptibility to infection is important for identifying at-risk populations and could have implications for vaccine deployment.

OBJECTIVE

The study purpose was to evaluate evidence of SARS-CoV-2 infection based on diagnostic nucleic acid amplification test (NAAT) among patients with positive vs negative test results for antibodies in an observational descriptive cohort study of clinical laboratory and linked claims data.

DESIGN, SETTING, AND PARTICIPANTS

The study created cohorts from a deidentified data set composed of commercial laboratory tests, medical and pharmacy claims, electronic health records, and hospital chargemaster data. Patients were categorized as antibody-positive or antibody-negative according to their first SARS-CoV-2 antibody test in the database.

MAIN OUTCOMES AND MEASURES

Primary end points were post-index diagnostic NAAT results, with infection defined as a positive diagnostic test post-index, measured in 30-day intervals (0-30, 31-60, 61-90, >90 days). Additional measures included demographic, geographic, and clinical characteristics at the time of the index antibody test, including recorded signs and symptoms or prior evidence of coronavirus 2019 (COVID) diagnoses or positive NAAT results and recorded comorbidities.

RESULTS

The cohort included 3 257 478 unique patients with an index antibody test; 56% were female with a median (SD) age of 48 (20) years. Of these, 2 876 773 (88.3%) had a negative index antibody result, and 378 606 (11.6%) had a positive index antibody result. Patients with a negative antibody test result were older than those with a positive result (mean age 48 vs 44 years). Of index-positive patients, 18.4% converted to seronegative over the follow-up period. During the follow-up periods, the ratio (95% CI) of positive NAAT results among individuals who had a positive antibody test at index vs those with a negative antibody test at index was 2.85 (95% CI, 2.73-2.97) at 0 to 30 days, 0.67 (95% CI, 0.6-0.74) at 31 to 60 days, 0.29 (95% CI, 0.24-0.35) at 61 to 90 days, and 0.10 (95% CI, 0.05-0.19) at more than 90 days.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients with positive antibody test results were initially more likely to have positive NAAT results, consistent with prolonged RNA shedding, but became markedly less likely to have positive NAAT results over time, suggesting that seropositivity is associated with protection from infection. The duration of protection is unknown, and protection may wane over time.

Incidence of Benign Meningiomas in the United States: Current and Future Trends

Background

Benign meningiomas are the most frequently reported central nervous system tumors in the United States, with increasing incidence in past decades. However, the future trajectory of this neoplasm remains unclear.

Methods

We analyzed benign meningioma incidence of cases identified by any means (eg, radiographically with or without microscopic confirmation) in US Surveillance, Epidemiology, and End Results cancer registries among groups aged 35 to 84 years during 2004-2017 by sex and race and ethnicity using age-period-cohort models. We employed age-period-cohort forecasting models to glean insights regarding the etiology, distribution, and anticipated future (2018-2027) public health impact of this neoplasm.

Results

In all groups, meningioma incidence overall increased through 2010, then stabilized. Temporal declines were statistically significant overall and in most groups. JoinPoint analysis of cohort rate-ratios identified substantial acceleration in White men born after 1963 (from 1.1% to 3.2% per birth year); cohort rate-ratios were stable or increasing in all groups and all birth cohorts. We forecast that meningioma incidence through 2027 will remain stable or decrease among groups aged 55-84 years but remain similar to current levels among groups aged 35-54 years. The case count of total meningioma burden in 2027 is expected to be approximately 30 470, similar to the expected case count of 27 830 in 2018.

Conclusions

Between 2004 and 2017, overall incidence of benign meningioma increased and then stabilized or declined. For 2018-2027, our forecast is incidence will remain generally stable in younger age groups but decrease in older age groups. Nonetheless, the total future burden will remain similar to current levels because the population is aging.

Pathology Laboratory Policies and Procedures for Releasing Diagnostic Tissue for Cancer Research

CONTEXT.—

The Surveillance, Epidemiology, and End Results (SEER) cancer registry program is currently evaluating the use of archival, diagnostic, formalin-fixed, paraffin-embedded (FFPE) tissue obtained through SEER cancer registries, functioning as honest brokers for deidentified tissue and associated data. To determine the feasibility of this potential program, laboratory policies for sharing tissue for research needed to be assessed.

OBJECTIVE.—

To understand the willingness of pathology laboratories to share archival diagnostic tissue for cancer research and related policies.

DESIGN.—

Seven SEER registries administered a 27-item questionnaire to pathology laboratories within their respective registry catchment areas. Only laboratories that processed diagnostic FFPE specimens and completed the questionnaire were included in the analysis.

RESULTS.—

Of the 153 responding laboratories, 127 (83%) responded that they process FFPE specimens. Most (n = 88; 69%) were willing to share tissue specimens for research, which was not associated with the number of blocks processed per year by the laboratories. Most laboratories retained the specimens for at least 10 years. Institutional regulatory policies on sharing deidentified tissue varied considerably, ranging from requiring a full Institutional Review Board review to considering such use exempt from Institutional Review Board review, and 43% (55 of 127) of the laboratories did not know their terms for sharing tissue for research.

CONCLUSIONS.—

This project indicated a general willingness of pathology laboratories to participate in research by sharing FFPE tissue. Given the variability of research policies across laboratories, it is critical for each SEER registry to work with laboratories in their catchment area to understand such policies and state legislation regulating tissue retention and guardianship.

Real-world data suggest antibody positivity to SARS-CoV-2 is associated with a decreased risk of future infection

Importance There is limited evidence regarding whether the presence of serum antibodies to SARS-CoV-2 is associated with a decreased risk of future infection. Understanding susceptibility to infection and the role of immune memory is important for identifying at-risk populations and could have implications for vaccine deployment. Objective The purpose of this study was to evaluate subsequent evidence of SARS-CoV-2 infection based on diagnostic nucleic acid amplification test (NAAT) among individuals who are antibody-positive compared with those who are antibody-negative, using real-world data. Design This was an observational descriptive cohort study. Participants The study utilized a national sample to create cohorts from a de-identified dataset composed of commercial laboratory test results, open and closed medical and pharmacy claims, electronic health records, hospital billing (chargemaster) data, and payer enrollment files from the United States. Patients were indexed as antibody-positive or antibody-negative according to their first SARS-CoV-2 antibody test recorded in the database. Patients with more than 1 antibody test on the index date where results were discordant were excluded. Main Outcomes/Measures Primary endpoints were index antibody test results and post-index diagnostic NAAT results, with infection defined as a positive diagnostic test post-index, as measured in 30-day intervals (0-30, 31-60, 61-90, >90 days). Additional measures included demographic, geographic, and clinical characteristics at the time of the index antibody test, such as recorded signs and symptoms or prior evidence of COVID-19 (diagnoses or NAAT+) and recorded comorbidities. Results We included 3,257,478 unique patients with an index antibody test. Of these, 2,876,773 (88.3%) had a negative index antibody result, 378,606 (11.6%) had a positive index antibody result, and 2,099 (0.1%) had an inconclusive index antibody result. Patients with a negative antibody test were somewhat older at index than those with a positive result (mean of 48 versus 44 years). A fraction (18.4%) of individuals who were initially seropositive converted to seronegative over the follow up period. During the follow-up periods, the ratio (CI) of positive NAAT results among individuals who had a positive antibody test at index versus those with a negative antibody test at index was 2.85 (2.73 - 2.97) at 0-30 days, 0.67 (0.6 - 0.74) at 31-60 days, 0.29 (0.24 - 0.35) at 61-90 days), and 0.10 (0.05 - 0.19) at >90 days. Conclusions Patients who display positive antibody tests are initially more likely to have a positive NAAT, consistent with prolonged RNA shedding, but over time become markedly less likely to have a positive NAAT. This result suggests seropositivity using commercially available assays is associated with protection from infection. The duration of protection is unknown and may wane over time; this parameter will need to be addressed in a study with extended duration of follow up.

Abstract P3-07-01: Breast cancer-specific mortality (BCSM) in patients age 50 years or younger with node-positive (N+) breast cancer (BC) treated based on the 21-gene assay in clinical practice

Introduction: The 21-gene Breast Recurrence Score® assay was shown in SWOG 8814 to predict chemotherapy (CT) benefit for patients (pts) with N+ BC and Recurrence Score® (RS) result≥31 but not RS &lt;18. In TAILORx, endocrine therapy was non-inferior to chemoendocrine therapy in 6,711 randomized pts with RS results 11-25 and N0 disease, although subgroup analyses suggested that pts age 50 years and younger with RS results 16-25 may derive some CT benefit. As we await the randomized RxPONDER results for RS 0-25 in N+ pts, we characterize BCSM in N+ pts diagnosed at age 50 years or younger by RS groups in the population-based SEER study of pts treated according to Recurrence Score results. Methods: Recurrence Score results were provided electronically to SEER registries per their linkage methods (Petkov npj Breast Cancer 2016). Eligible pts were diagnosed (Jan 2004 - Dec 2014) with N+ (micrometastases, 1-3 positive nodes), HR+, HER2-negative BC, and had no prior malignancy or multiple tumors. BCSM estimates by reported CT use were computed using TAILORx/RxPONDER cut-points of 11, 15, 20, and 25, and should be interpreted cautiously given known under-reporting of CT use to SEER, lack of randomization, and limited follow-up. Results: Among 2,588 eligible pts with Recurrence Score results, 417 (16%) had RS 0-10, 756 (29%) had RS 11-15, 715 (27%) had RS 16-20, 350 (14%) had RS 21-25, and 350 (14%) had RS 26-100. Median follow-up time was 41 months (interquartile range 24-65.) There was a significant association between Recurrence Score result and BCSM (p&lt;0.0001) without and with adjustment for tumor size, grade, and reported CT use. Reported CT use and 5-year BCSM increased with increasing Recurrence Score result (Table.)Conclusions: Reported CT and 5-year BCSM in young pts with N+ BC increased with increasing Recurrence Score results in real-world clinical practice. 5-year BCSM was less than 2% in young pts with Recurrence Score result 0-25 and CT use reported as no or unknown. Pts with Recurrence Score result 26-100 have increased risk of BCSM despite high reported CT use.

5-year BCSM, by RS Group and Reported CT UseCT reported as 'No/Unknown'CT reported as 'Yes' RS GroupN (%)5-y BCSM ±SEN (%)5-y BCSM ±SE0-10295 (71%)0.0% ±0.0122 (29%)0.0% ±0.011-15471 (62%)0.5% ±0.3285 (38%)2.3% ±1.416-20368 (51%)1.3% ±0.9347 (49%)1.6% ±0.921-25119 (34%)1.6% ±1.6231 (66%)1.2% ±1.226-10049 (14%)4.4% ±4.3301 (86%)6.1% ±2.0

Citation Format: Valentina I Petkov, Allison W Kurian, Debbie M Jakubowski, Steven Shak. Breast cancer-specific mortality (BCSM) in patients age 50 years or younger with node-positive (N+) breast cancer (BC) treated based on the 21-gene assay in clinical practice [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-07-01.

Uptake of the 21-Gene Assay Among Women With Node-Positive, Hormone Receptor−Positive Breast Cancer

Background: This study assessed uptake of the Oncotype DX 21-gene assay over time and characterized which sociodemographic and clinical factors are associated with test uptake among women with lymph node−positive (LN+), hormone receptor−positive, HER2-negative breast cancer. Methods: Invasive breast cancer cases diagnosed in 2010 through 2013 were included from a SEER database linked to 21-gene assay results performed at Genomic Health’s Clinical Laboratory. Factors associated with 21-gene assay uptake were identified using a multivariable logistic regression model. Results: Uptake of the 21-gene assay increased over time and differed by race, socioeconomic status (SES), and age. In the multivariable model, when clinical and SES variables were controlled for, racial differences in test uptake were no longer observed. Private insurance status was associated with higher odds of 21-gene assay uptake (Medicaid vs private insurance: adjusted odds ratio, 0.86; P=.02), and high area-level SES was associated with an increased odds of uptake (quintile 5 vs 1: adjusted odds ratio, 1.6; P<.001). Demographic factors such as age and marital status influenced test uptake, and use varied greatly by geographic region. Uptake of the 21-gene assay increased over time and preceded the assay’s inclusion in the NCCN Guidelines for LN+ breast cancer. Differences in uptake by race, SES, and age have persisted over time. However, when clinical and SES variables were controlled for, racial differences in assay uptake were no longer observed. Socioeconomic variables, such as health insurance type and area-level SES, were associated with assay uptake. Conclusions: Future research should continue to document practice patterns related to the 21-gene assay. Given variation in testing associated with area-level SES, insurance coverage, and geographic region, interventions to understand and reduce differential uptake are needed to ensure equitable access to this genomic test.

Oncotype DX DCIS use and clinical utility: A SEER population-based study

e12046

Background: OncotypeDX DCIS is a 12-gene assay designed to predict the 10-year risk of local recurrence and to guide treatment decisions, specifically the benefit of radiation therapy in breast ductal carcinoma in situ (DCIS). The test became available in December 2011 and is not currently recommended by guidelines. The Surveillance, Epidemiology and End Results (SEER) program captures cancer data at the population-level and has been conducting annual linkages with Genomic Health Clinical Laboratory, the only lab performing the test, to identify patients receiving the test. Methods: SEER cases diagnosed with in situ breast cancer (DCIS or papillary in situ) between 2011-2015 were included in the analysis. SEER data on patient demographics, tumor characteristics, and treatments were combined with linkage variables for OncotypeDX DCIS tests reported by Genomic Health. Logistic regression was used to identify which patient related factors were associated with having received the test and to evaluate the relationship between test generated risk categories and treatments. Results: Of the 68,826 in situ breast cancer cases, 2,155 were linked to DCIS test data. Test utilization increased from < 1% to 5.3% for patients diagnosed in 2011 vs. 2015. Patients were less likely to receive the test if they had larger and higher-grade tumors, were divorced, had Medicaid insurance, and were in the lowest socioeconomic status tertile. The majority of patients (68%) were at low risk, 17% intermediate, and 15% in the high risk group. Patients at intermediate or high risk were more likely to receive radiation (OR = 2.4, 95% CI: 1.8-3.2 and OR = 3, 95% CI: 2.3,4.1, respectively) than the low risk group. High risk patients were more likely than low risk patients to receive chemotherapy (OR = 4.3, 95% CI: 1.2, 14.4) and to undergo mastectomy than lumpectomy (OR = 1.47, 95% CI: 1.12-1.93). Conclusions: Clinical adoption of the OncotypeDX DCIS test has been slow. The association between multiple demographic factors and receiving the test indicated disparities in the US population. Clinical factors also influenced whether patients received the test. OncotypeDX DCIS results appeared to guide clinical decisions.

Abstract P1-08-14: Trend of utilization of Oncotype DX testing among female hormone receptor positive breast cancer patients in 17 SEER registries, 2004-2015

Background: Oncotype DX, a 21-gene Recurrence Score (RS) assay, has been validated as assay that effectively predicts recurrence and chemotherapy (chemo) benefits for hormone receptor positive (HR+) human epidermal growth factor receptor 2 negative (HER2-) breast cancer (BC). Although guidelines recommend the test to lymph node (LN) negative (PN0) BC patients, it has also been used in patients with 1-3 positive LN (PN1) in clinical practice. The study aimed to 1) examine the trend of utilization of Oncotype DX testing for HR+ and PN0 or PN1 BC patients from 2004 to 2015, as well as the trend in patients with different clinical risk; 2) investigate the trend of having reported chemo in patients with low, intermediate, and high RS; and 3) compare cause-specific survival (CSS) and overall survival (OS) between patients who had test and those who did not.

Methods: Data from Genomic Health Inc., the sole Oncotype DX testing provider in the U.S., was linked with routinely collected data from 17 SEER registries. Women who received surgery for stage I-III, HR+ and PN0 or PN1 BC diagnosed in 2004-2015 were included. The Cochrane-Armitage trend test was conducted for trend analysis. Using the overall sample as standard population (frequency of each age-racial group in overall sample as weight), age-race standardized percentage of test use was calculated. Since HER2 data was available only after 2010, survival analysis was restricted to HR+/HER2- patients diagnosed in 2010-2014 whose BC was the only primary tumor. Patients who used and those who did not use the test were matched on propensity score, which was calculated based on age, race, marital status, insurance, grade, tumor size, surgery type, radiation, and chemo within each diagnosis year. Stratified Cox proportional hazards model was used to compare survival between two matched groups. Proportional hazard assumption was met for each model.

Results: Out of 346,380 PN0 and 103,317 PN1 patients, the percentage of using Oncotype DX test increased from 2.0% to 38.2%, and from 0.5% to 28.0% from 2004 to 2015, respectively (P-for-trend &lt; 0.0001 for each). Age-race standardized percentage of test use was the highest and increased most rapidly for tumors with intermediate clinical risk (moderately differentiated or tumor size 2.1-5.0cm) among PN0 patients, but for tumors with low clinical risk (well differentiated or tumor size ≤2.0cm) among PN1 patients. From 2004 to 2015, the percentage of having reported chemo decreased in patients with low (PN0: 14.7% to 1.8%; PN1: 27.3% to 16.2%) and intermediate RS (PN0: 36.1% to 28.6%; PN1: 60.0% to 44.7%), but increased among patients with high RS (PN0: 59.0% to 75.4%; PN1: 66.7% to 74.2%). Test use was associated with better CSS (PN0: hazard ratio [HR] 2.15, 95% CI 1.73-2.67; PN1: HR 2.83, 95% CI 2.02-3.95) and OS (PN0: HR 2.05, 95% CI 1.81-2.33; PN1: HR 2.65, 95% CI 2.10-3.35).

Conclusions: The use of Oncotype DX test has increased steadily among female HR+ BC patients since 2004. It reduced unnecessary chemo among patients with low or intermediates RS, and increased chemo use in patients with high RS. Among HR+/HER2- patients, those who used test had better CSS and OS than those who did not.

Citation Format: Zhang L, Hsieh M-C, Petkov VI, Yu Q, Wu X-C. Trend of utilization of Oncotype DX testing among female hormone receptor positive breast cancer patients in 17 SEER registries, 2004-2015 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-14.

Abstract P3-12-23: Utilization and survival benefit of radiation therapy among hormone receptor positive breast cancer patients with recurrence score from Oncotype DX testing

Background: Radiation therapy (RT) improves survival of breast cancer (BC) patients receiving the lumpectomy. Oncotype DX, a 21-gene Recurrence Score (RS) assay, has been validated to predict the risk of recurrence and chemotherapy benefit for hormone receptor positive (HR+) BC without metastatic lymph nodes (PN0). With increasing use of Oncotype DX, it is unclear if the utilization and survival benefit of RT vary by RS in clinical practice. This study aimed to 1) examine if the RS from Oncotype DX testing influences RT utilization among HR+ BC patients with PN0 who received lumpectomy; and 2) investigate if RT is associated with better cause-specific survival (CSS) and overall survival (OS) among patients stratified by the low, intermediate, and high RS.

Methods: Data from Genomic Health Inc., the sole Oncotype DX testing provider in the U.S., was linked with routinely collected data from 17 SEER registries. Women who were diagnosed with PN0 and HR+ BC in 2004-2015, received the lumpectomy, and had RS from Oncotype DX testing were included. Patients who had multiple tumors, received RT before or within surgery, or had less than 2 months follow-up were excluded. Patients diagnosed in 2004-2014 and followed through the end of 2015 were included in the survival analysis. RS was categorized into low (&lt;18), intermediate (18-30), and high (&gt;30). RT was categorized into yes, no or unknown. Multivariable logistic regression was applied to examine the association between RS and RT utilization. To compare survival differences, patients receiving RT and patients having no or unknown RT were matched on propensity score, which was calculated based on diagnosis year, age, race, marital status, tumor size, grade, number of lymph nodes examined, chemotherapy, and participating state. Stratified Cox proportional hazards models were used to compare CSS and OS between two matched groups. Proportional hazard assumption was evaluated.

Results: Out of 48,615 patients, 56.8% had low, 36.1% had intermediate, and 7.1% had high RS; 84.5% received RT (86.6%, 82.8%, and 76.4% in low, intermediate, and high RS patients, respectively; P &lt; 0.0001). After adjusting for covariates, patients with intermediate (odds ratio [OR] 0.75; 95% CI 0.71-0.79; P &lt; 0.0001) and high RS (OR 0.53; 95% CI 0.47-0.59; P &lt; 0.0001) were less likely to receive RT than patients with low RS. Among patients with low or intermediate RS, having no or unknown RT was associated with worse CSS (low RS: hazard ratio [HR] 6.00, 95% CI 1.77-20.37, P = 0.004; intermediate RS: HR 2.12, 95% CI 1.19-3.77, P = 0.01) and OS (low RS: HR 2.29, 95% CI 1.56-3.35, P &lt; 0.0001; intermediate RS: HR 2.22, 95% CI: 1.54-3.21, P &lt; 0.0001). RT utilization was not significantly associated with CSS or OS among patients with high RS.

Conclusions: Among HR+, PN0 BC patients receiving the lumpectomy, lower RS was associated with higher RT utilization. RT was associated with better CSS and OS among patients with low or intermediate RS. Among patients with high RS, no association between RT and survival was observed.

Citation Format: Zhang L, Hsieh M-C, Petkov VI, Wu X-C, Yu Q. Utilization and survival benefit of radiation therapy among hormone receptor positive breast cancer patients with recurrence score from Oncotype DX testing [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-23.

Annual Report to the Nation on the Status of Cancer, part II: Recent changes in prostate cancer trends and disease characteristics

BACKGROUND

Temporal trends in prostate cancer incidence and death rates have been attributed to changing patterns of screening and improved treatment (mortality only), among other factors. This study evaluated contemporary national-level trends and their relations with prostate-specific antigen (PSA) testing prevalence and explored trends in incidence according to disease characteristics with stage-specific, delay-adjusted rates.

METHODS

Joinpoint regression was used to examine changes in delay-adjusted prostate cancer incidence rates from population-based US cancer registries from 2000 to 2014 by age categories, race, and disease characteristics, including stage, PSA, Gleason score, and clinical extension. In addition, the analysis included trends for prostate cancer mortality between 1975 and 2015 by race and the estimation of PSA testing prevalence between 1987 and 2005. The annual percent change was calculated for periods defined by significant trend change points.

RESULTS

For all age groups, overall prostate cancer incidence rates declined approximately 6.5% per year from 2007. However, the incidence of distant-stage disease increased from 2010 to 2014. The incidence of disease according to higher PSA levels or Gleason scores at diagnosis did not increase. After years of significant decline (from 1993 to 2013), the overall prostate cancer mortality trend stabilized from 2013 to 2015.

CONCLUSIONS

After a decline in PSA test usage, there has been an increased burden of late-stage disease, and the decline in prostate cancer mortality has leveled off. Cancer 2018;124:2801-2814. © 2018 American Cancer Society.

Molecular Characterization and Mortality From Breast Cancer in Men

Purpose Limited data exist on the molecular biology, treatment, and outcomes of breast cancer in men, and much of our understanding in this area remains largely an extrapolation from data in women with breast cancer. Materials and Methods We studied men and women with hormone receptor-positive breast cancer and the 21-gene Breast Recurrence Score (RS) results. Differences in clinical characteristics and gene expression were determined, and distribution of RS results was correlated with 5-year breast cancer-specific survival (BCSS) and overall survival. Results There were 3,806 men and 571,115 women. Men were older than women (mean age, 64.2 v 59.1 years; P < .001). RS < 18 predominated in both genders, but RS ≥ 31 was more frequent in men (12.4% v 7.4%; P < .001), as were very low scores (RS < 11; 33.8% v 22.1%; P < .001). Mean gene expression was higher in men for the estrogen receptor (ER), proliferation, and invasion groups. ER was lowest and progesterone receptor was highest in women younger than 50 years of age, with a progressive increase in ER with age. Men younger than 50 years of age had slightly lower ER and progesterone receptor compared with older men. Survival data were available from SEER for 322 men and 55,842 women. Five-year BCSS was 99.0% (95% CI, 99.3% to 99.9%) and 95.9% (95% CI, 87.6% to 98.7%) for men with RS < 18 and RS 18-30, respectively, and for women, it was 99.5% (95% CI, 99.4% to 99.6%) and 98.6% (95% CI, 98.4% to 98.8%), respectively. RS ≥ 31 was associated with an 81.0% 5-year BCSS in men (95% CI, 53.3% to 93.2%) and 94.9% 5-year BCSS (95% CI, 93.9% to 95.7%) in women. Five-year BCSS and overall survival were lower in men than in women. Conclusion This study reveals some distinctive biologic features of breast cancer in men and an important prognostic role for RS testing in both men and women.

Abstract P6-13-03: Breast cancer-specific mortality (BCSM) in patients with node-positive (N+) breast cancer (BC) treated based on the 21-gene assay in clinical practice

Introduction: The Recurrence Score® (RS) assay was shown in SWOG 8814 to predict chemotherapy (CT) benefit for patients (pts) with N+ BC and RS ≥31 but not RS &lt;18. As we await the randomized RxPONDER results for RS 0-25, we characterized BCSM for RS groups (cutoffs of 11, 18, 25, and 31) in the large population-based SEER study of pts treated based on RS results.

Methods: RS results were provided electronically to SEER registries per their linkage methods (Petkov npj Breast Cancer 2016). Eligible pts were diagnosed (Jan 2004 - Dec 2012) with N+ (micrometastases, 1-3 positive nodes), HR+, HER2-negative BC, and had no prior malignancy or multiple tumors. BCSM estimates by reported CT use were computed using standard cutpoints of 18 and 31 and TAILORx/RxPONDER cutpoints of 11 and 25, and should be interpreted cautiously given known under-reporting of CT use to SEER and lack of randomization.

Results: Among 6,483 pts with RS results, 1,312 (20%) had RS &lt;11, 2,478 (38%) had RS 11-17, 1,831 (28%) had RS 18-25, 432 (7%) had RS 26-30, and 430 (7%) had RS ≥31. There was a significant association between RS results and BCSM (p&lt;0.001) without and with adjustment for age, tumor size, and grade. Reported CT use and 5-y BCSM increased with increasing RS result (Table). For pts with RS &lt;11 and RS 11-17, CT use was reported in approximately a quarter of pts, and 5-y BCSM was low regardless of CT use. For pts with RS 18-25, CT use was more common and the 5-y BCSM was about 2%. For pts with RS of 26-30 or ≥31, CT was common, and higher 5-y BCSM was observed.

5-y BCSM, by RS Group and Reported CT Use CT reported as ‘No/Unknown’CT reported as ‘Yes’RS groupN (%)5-y BCSM (95% CI)N (%)5-y BCSM (95% CI)&lt;111066 (81%)1.8% (0.7%, 4.6%)246 (19%)1.3% (0.3%, 5.3%)11-171869 (75%)0.5% (0.2%, 1.1%)609 (25%)2.3% (0.9%, 5.8%)18-251034 (56%)2.0% (1.0%, 3.9%)797 (44%)1.9% (0.8%, 4.5%)26-30144 (33%)7.7% (2.8%, 20.3%)288 (67%)4.0% (1.6%, 10.1%)≥3199 (23%)11.9% (5.3%, 25.6%)331 (77%)11.1% (6.9%, 17.6%)

Conclusion: Reported CT use and 5-y BCSM in N+ BC increased with increasing RS results in “real-world” clinical practice. 5-y BCSM with RS &lt;18 was less than 2% in pts with no or unknown CT use. 5-y BCSM in pts treated based on RS results appears to increase considerably with RS &gt;25.

Citation Format: Shak S, McCullough D, Petkov VI. Breast cancer-specific mortality (BCSM) in patients with node-positive (N+) breast cancer (BC) treated based on the 21-gene assay in clinical practice [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-13-03.

Abstract P1-06-03: Breast cancer-specific survival (BCSS) in SEER patients with 21-gene Recurrence Score® (RS) results &lt;11 classified as prognostic stage IA by new 8th edition AJCC staging manual

Introduction: The 8th edition of the AJCC Staging Manual added molecular features for the first time and now includes ER, PR, HER2, and the 21-gene assay for prognostic staging. We obtained real-world evidence of BCSS by age, tumor size, and grade in a population-based SEER analysis of N0, HR+, HER2-negative breast cancer and RS &lt;11 (tumor size up to 5 cm) to obtain more detailed information on clinically “unfavorable” subgroups.

Methods: RS results were provided to SEER registries as mandated by their methods for linkage (Petkov npj Breast Cancer 2016). Patients (pts) with RS &lt;11 and size up to 5 cm were eligible if N0, HR+, HER2-negative, had no prior malignancy, and were diagnosed between Jan 2004 and Dec 2012 (SEER survival updated through 2013). 5-year BCSS was estimated using actuarial methods.

Results: 9,304 pts had RS &lt;11 (19% of those meeting all other eligibility), with median follow-up of 40 months. Median age was 59 y, with 22% &lt;50 y and 16% ≥70 y. Tumor size was &gt;2 cm in 21% of pts. Tumor grade was moderate in 54% and poor in 8% of pts. Overall, 5-year BCSS for pts with RS &lt;11 was 99.6% (95% CI 99.4%, 99.7%), with reported chemotherapy (CT) use in 3.3% of pts. In contrast, BCSS for pts with RS &gt;25 and RS ≥31 was 3.5% and 4.7%, respectively, with frequent CT use. 5-year BCSS for important clinicopathologic subgroups show high 5-year BCSS despite “unfavorable” age, tumor size, and grade (Table).

5-y BCSS for RS &lt;11, by Clinicopathologic FactorsRS &lt;11 and Age &lt;50 yRS &lt;11 and Tumor Size 2.1-5.0 cmRS &lt;11 and Poor Tumor GradeN (% of N with CT ‘Yes’)5-y BCSS (95% CI)N (% of N with CT ‘Yes’)5-y BCSS (95% CI)N (% of N with CT ‘Yes’)5-y BCSS (95% CI)2009 (6.2%)100% (100%, 100%)1976 (5.5%)99.3% (98.5%, 99.7%)686 (5.8%)99.5% (97.9%, 99.9%)

Conclusions: In this SEER population-based study, pts with RS &lt;11 had a wide range of clinicopathologic features. 5-year BCSS was high (&gt;99%), regardless of age, tumor size, or grade. These results support the new AJCC staging criteria that classify N0, HR+, HER2-negative pts with RS &lt;11 and tumor size up to 5 cm as having Prognostic Stage IA disease.

Citation Format: Baehner FL, Petkov VI, McCullough D, Shak S. Breast cancer-specific survival (BCSS) in SEER patients with 21-gene Recurrence Score® (RS) results &lt;11 classified as prognostic stage IA by new 8th edition AJCC staging manual [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-03.

Quality Assessment of Tumor Size Data Collection for Pancreatic and Breast Cancer in SEER

BACKGROUND AND OBJECTIVES

In 2017, the Surveillance, Epidemiology, and End Results (SEER) program piloted a reactive quality audit plan (r-QAP) to analyze Collaborative Stage (CS) tumor size in breast and pancreatic cancer. Preevaluation objectives were to establish procedures and analytic scope for SEER quality audits, cutoffs for data completeness/accuracy, and key decision checkpoints.

METHODS

Tumor size data between 2004-2014 were selected from SEER registries for pancreatic and breast cancers, and initially assessed by site and registry for completeness. Further exploration was undertaken via cross tabulation in SEER with the American Joint Committee on Cancer (AJCC) 6th edition derived T data item to evaluate discrepancies between these closely related variables.

RESULTS

For both cancer sites, completeness improved between 2004 and 2014, with the proportion of known tumor size values increasing from 60.6% to 79.2% in pancreatic cancer and from 94.0% to 95.9% in breast cancer. Tumor size plausibility categories were established wherein any tumor over 100 mm for pancreatic cancer or over 200 mm for breast cancer were considered highly unlikely. Only 2% of pancreas tumors and 0.1% of breast tumors were implausibly large per site-specific cutoffs. Less than 2% of all tumor size values were potentially discrepant in cross-tabulation with AJCC 6th edition derived T for each site.

CONCLUSIONS

Most tumor size values appear to fall within acceptable ranges based on r-QAP activities, and implausibly large tumor size values are rare. Different natural histories and clinical presentation for pancreatic and breast cancer illustrate the need for site-specific cutoffs. Our results indicate that there are no major quality issues in the SEER research database for the CS tumor size data item in either pancreatic or breast cancer.

The performance of the 21-gene assay standard cutpoints of 18 and 31 in HR+, HER2- invasive breast cancer (BC), while waiting for TAILORx mid-range recurrence score results

537

Background: The Recurrence Score (RS) was shown in NSABP B-20 to predict chemotherapy (CT) benefit for RS ≥31 and no CT benefit for RS <18. The TAILORx results for RS <11 (NEJM 2015) reported excellent outcomes with no opportunity for CT to add additional benefit. As we await TAILORx results for RS 11-25, we characterized BC specific mortality (BCSM) for RS groups (cutoffs of 11, 18, 25, and 31) in the population-based SEER study of pts treated based on RS. Methods: RS results were provided to SEER registries per their methods (npj Breast Cancer 2016). Pts diagnosed (Jan 2004 - Dec 2012) with N0 HR+ HER2- negative BC, and no prior malignancy were eligible. BCSM estimates by CT use were computed using standard cutpoints of 18 and 31 and TAILORx cutpoints of 11 and 25. Results: Among 49,681 with a RS, 9,486 (19%) had RS <11, 17,988 (36%) had RS 11-17, 14,541 (29%) had RS 18-25, 3,805 (8%) had RS 26-30, and 3,861 (8%) had RS ≥31. Reported CT use and 5-y BCSM increased with increasing RS. For pts with both RS <11 and RS 11-17, CT use was uncommon and 5-y BCSM was low regardless of CT use. For pts with RS 18-25, CT use was more common and the 5-y BCSM was about 1% regardless of CT use. For pts with RS of 26-30 or ≥31, CT was common, and lower 5-y BCSM was observed with CT reported yes than with CT reported no or unknown. Conclusions: Pts in real-world clinical practice with RS <11, consistent with TAILORx, and pts with RS 11-17 have low 5-y BCSM with limited CT use, supporting hormonal therapy alone for pts with RS <18. The high end of the TAILORx mid-range (18-25) also showed good 5-y BCSM both with and without CT, highlighting the importance of the randomized results of TAILORx. [Table: see text]

Factors associated with 21-gene assay receipt among women with lymph node positive breast cancer

6554

Background: The 21-gene Breast Recurrence Score (RS) assay predicts breast cancer (BC) recurrence and adjuvant chemotherapy benefit in select patients with lymph node-positive (LN+), hormone receptor-positive (HR+), HER2 negative BC. This study examines factors associated with assay uptake among women with LN+ BC in SEER databases. Methods: In this population-based study, incident BC cases in SEER registries (2010-2013) were linked to RS results from assays performed by Genomic Health. Our study sample included women with non-metastatic, LN+ (≥1 positive LN), HER2-, HR+, BC. We use logistic regression to identify demographic, SES, and tumor characteristics associated with having the 21-gene assay ordered. Results: A total of 4428 (14.0%) of 31520 women with LN+, HR+, HER2-, BC had the assay ordered. Uni- and multi-variate analyses identified key factors that were significantly associated with the proportion of women tested. In the multivariable analysis, age (aOR: 2.23, p<0.001, 65-74 v <45 years) and BC diagnosis year (aOR:1.75, P<0.001 2013 vs 2010) were positively associated with assay receipt; whereas number of positive LN (aOR: 0.14, p<0.001, 4+ positive LN vs 1 positive LN), tumor grade and size, low SES, being black, and being widowed were negatively associated with assay uptake (p<0.001). Having Medicaid was associated with lower odds of test receipt (p=0.01). Finally, we identified geographic variation in assay ordering. See univariate results (Table). Conclusions: Important demographic and SES variables were associated with test receipt in LN+ disease, and differed from those previously reported in node negative disease. Moving forward, increased awareness of these disparities, particularly among low SES, Medicaid, Black and widowed patients, along with targeted interventions may help to improve quality of care and equity in test receipt. [Table: see text]

SEER study of breast cancer specific mortality (BCSM) in patients with lobular tumors treated based on recurrence score results

11568

Background: Linking the 21-gene assay RS result to the SEER Registries demonstrated very low 5-y BCSM with low RS and high 5-y BCSM with high RS across subgroups, such as nodal status, age, tumor size and grade (npj Breast Cancer 2016). Given the large sample size and interest in outcomes as a function of tumor characteristics, we characterized the relationship between RS results and BCSM in patients reported by SEER with lobular morphology. Methods: Patients with RS and lobular morphology based on the registry ICD-O-3 code 8520 were eligible if node negative (N0) or node positive up to 3 positive nodes (N+mic,1-3), HR+, HER2- negative, no prior malignancy, and diagnosed between Jan 2004 and Dec 2012. No information in SEER is available regarding lobulars, ie., trabecular, alveolar, solid and pleomorphic. 5-y BCSM was estimated using actuarial methods. Results: There were 6,075 eligible patients reported with lobular morphology (11% of cases). Median age was 59 years; 88%/12% were N0/N+; 31%/62%/7% grade 1/2/3; 61%/39% ≤2 cm/>2 cm. Median follow-up was 44 months. A minority (8%) had RS >25. Chemotherapy (CT) use and BCSM increased with increasing RS. In multivariable analysis in N0 disease, continuous RS result and tumor size predicted BCSM (p=0.003 and p=0.04, respectively), whereas age and tumor grade were non-significant. In multivariable analysis in N+ disease, continuous RS result alone predicted BCSM (p=0.002). Conclusions: In these analyses the prognosis of patients with lobular breast cancer treated based on RS results depends on both nodal status and the RS result. The 5-y BCSM for lobular breast cancer is excellent with RS of 25 or less, and increases for RS >25. [Table: see text]

Breast cancer-specific survival in patients with lymph node-positive hormone receptor-positive invasive breast cancer and Oncotype DX Recurrence Score results in the SEER database

PURPOSE

The Oncotype DX^® Breast Recurrence Score™ (RS) assay is validated to predict breast cancer (BC) recurrence and adjuvant chemotherapy benefit in select patients with lymph node-positive (LN+), hormone receptor-positive (HR+), HER2-negative BC. We assessed 5-year BC-specific survival (BCSS) in LN+ patients with RS results in SEER databases.

METHODS

In this population-based study, BC cases in SEER registries (diagnosed 2004-2013) were linked to RS results from assays performed by Genomic Health (2004-2014). The primary analysis included only patients (diagnosed 2004-2012) with LN+ (including micrometastases), HR+ (per SEER), and HER2-negative (per RT-PCR) primary invasive BC (N = 6768). BCSS, assessed by RS category and number of positive lymph nodes, was calculated using the actuarial method.

RESULTS

The proportion of patients with RS results and LN+ disease (N = 8782) increased over time between 2004 and 2013, and decreased with increasing lymph node involvement from micrometastases to ≥4 lymph nodes. Five-year BCSS outcomes for those with RS < 18 ranged from 98.9% (95% CI 97.4-99.6) for those with micrometastases to 92.8% (95% CI 73.4-98.2) for those with ≥4 lymph nodes. Similar patterns were found for patients with RS 18-30 and RS ≥ 31. RS group was strongly predictive of BCSS among patients with micrometastases or up to three positive lymph nodes (p < 0.001).

CONCLUSIONS

Overall, 5-year BCSS is excellent for patients with RS < 18 and micrometastases, one or two positive lymph nodes, and worsens with additionally involved lymph nodes. Further analyses should account for treatment variables, and longitudinal updates will be important to better characterize utilization of Oncotype DX testing and long-term survival outcomes.

Abstract PD7-06: SEER study of breast cancer-specific mortality in patients with poorly differentiated tumors treated based on recurrence score results

Introduction: The SEER Program of the NCI is an authoritative source of cancer incidence and survival statistics. Linking the 21-gene assay Recurrence Score® (RS) results to the SEER Registries (N=44,825) demonstrated very low 5-year breast cancer-specific mortality (BCSM) with RS &lt;18 across many key clinical-pathological subgroups, such as age, nodal status, tumor grade, and size (npj Breast Cancer. 2016;2:16017). Given the large sample size and specific interest in outcomes as a function of tumor grade, further stratification of patients with poorly differentiated tumors was performed to determine BCSM when examined by both tumor grade and tumor size.

Methods: Patients were eligible if node negative (N0), HR+, HER2-negative (by RT-PCR), had no prior malignancy, had poorly differentiated (G3) tumors, and were diagnosed between Jan 2004 (test available in Jan 2004) and Dec 2011 (SEER survival updated through 2012). BCSM was defined according to pre-existing robust methodology (J Natl Cancer Inst. 2010;102:1584). RS was categorized according to the cutpoints of 18 and 31 established in the NSABP B-14 study. Five-year BCSM was estimated using actuarial methods.

Results: Among 6,666 eligible patients with G3 tumors, 4,683 had tumors ≤2 cm and 1,983 had tumors &gt;2 cm. Median age was 57 years; 99.1% were female. Median follow-up was 39 months. The proportion of patients with RS &lt;18 was 29% among those with tumors ≤2 cm and 25% among those with tumors &gt;2 cm, somewhat lower than the overall population. For RS &lt;18, 5-year BCSM was 0.3% (G3; ≤2 cm) and 1.4% (G3; &gt;2 cm); reported chemotherapy use was 10% and 16%, respectively. 5-year BCSM for all groups are provided in Table. An additional year of BCSM follow-up in N0 G3 disease, as well as results for patients with node positive (micrometastases or 1-3 positive nodes) G3 disease, will be available for presentation.

N0, G3 tumor, RS &lt;18N0, G3 tumor, RS 18-30N0, G3 tumor, RS ≥31Tumor sizeN5-y BCSM (95% CI)N5-y BCSM (95% CI)N5-y BCSM (95% CI)≤2 cm13620.3% (0.1%, 1.2%)21482.1% (1.3%, 3.3%)11732.9% (1.8%, 4.7%)&gt;2 cm4861.4% (0.4%, 4.6%)8514.6% (2.7%, 7.8%)6469.0% (6.0%, 13.4%)

Conclusions: Although patients with poorly differentiated tumors have worse prognosis in general, the RS identifies a sizable proportion of patients who can expect good outcomes without chemotherapy and its associated toxicity.

Citation Format: Petkov VI, Miller DP, Howlader N, Baehner FL, Penberthy L, Shak S. SEER study of breast cancer-specific mortality in patients with poorly differentiated tumors treated based on recurrence score results [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD7-06.

Cancer Incidence and Survival Trends by Subtype Using Data from the Surveillance Epidemiology and End Results Program, 1992-2013

Background: Cancers are heterogeneous, comprising distinct tumor subtypes. Therefore, presenting the burden of cancer in the population and trends over time by these tumor subtypes is important to identify patterns and differences in the occurrence of these subtypes, especially to generalize findings to the U.S. general population.Methods: Using SEER Cancer Registry Data, we present incidence rates according to subtypes for diagnosis years (1992-2013) among men and women for five major cancer sites: breast (female only), esophagus, kidney and renal pelvis, lung and bronchus, and thyroid. We also describe estimates of 5-year relative survival according to subtypes and diagnosis year (1992-2008). We used Joinpoint models to identify years when incidence rate trends changed slope. Finally, recent 5-year age-adjusted incidence rates (2009-2013) are presented for each subtype by race and age.Results: Hormone receptor-positive and HER2-negative was the most common subtype (about 74%) of breast cancers. Adenocarcinoma made up about 69% of esophagus cases among men. Adenocarcinoma also is the most common lung subtype (43% in men and 52% in women). Ninety percent of thyroid subtypes were papillary. Distinct incidence and survival patterns emerged by these subtypes over time among men and women.Conclusions: Histologic or molecular subtype revealed different incidence and/or survival trends that are masked when cancer is considered as a single disease on the basis of anatomic site.Impact: Presenting incidence and survival trends by subtype, whenever possible, is critical to provide more detailed and meaningful data to patients, providers, and the public. Cancer Epidemiol Biomarkers Prev; 26(4); 632-41. ©2016 AACR.

Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study

The 21-gene Recurrence Score assay is validated to predict recurrence risk and chemotherapy benefit in hormone-receptor-positive (HR+) invasive breast cancer. To determine prospective breast-cancer-specific mortality (BCSM) outcomes by baseline Recurrence Score results and clinical covariates, the National Cancer Institute collaborated with Genomic Health and 14 population-based registries in the the Surveillance, Epidemiology, and End Results (SEER) Program to electronically supplement cancer surveillance data with Recurrence Score results. The prespecified primary analysis cohort was 40-84 years of age, and had node-negative, HR+, HER2-negative, nonmetastatic disease diagnosed between January 2004 and December 2011 in the entire SEER population, and Recurrence Score results (N=38,568). Unadjusted 5-year BCSM were 0.4% (n=21,023; 95% confidence interval (CI), 0.3-0.6%), 1.4% (n=14,494; 95% CI, 1.1-1.7%), and 4.4% (n=3,051; 95% CI, 3.4-5.6%) for Recurrence Score <18, 18-30, and ⩾31 groups, respectively (P<0.001). In multivariable analysis adjusted for age, tumor size, grade, and race, the Recurrence Score result predicted BCSM (P<0.001). Among patients with node-positive disease (micrometastases and up to three positive nodes; N=4,691), 5-year BCSM (unadjusted) was 1.0% (n=2,694; 95% CI, 0.5-2.0%), 2.3% (n=1,669; 95% CI, 1.3-4.1%), and 14.3% (n=328; 95% CI, 8.4-23.8%) for Recurrence Score <18, 18-30, ⩾31 groups, respectively (P<0.001). Five-year BCSM by Recurrence Score group are reported for important patient subgroups, including age, race, tumor size, grade, and socioeconomic status. This SEER study represents the largest report of prospective BCSM outcomes based on Recurrence Score results for patients with HR+, HER2-negative, node-negative, or node-positive breast cancer, including subgroups often under-represented in clinical trials.

Automated determination of metastases in unstructured radiology reports for eligibility screening in oncology clinical trials

Enrolling adequate numbers of patients that meet protocol eligibility criteria in a timely manner is critical, yet clinical trial accrual continues to be problematic. One approach to meet these accrual challenges is to utilize technology to automatically screen patients for clinical trial eligibility. This manuscript reports on the evaluation of different automated approaches to determine the metastatic status from unstructured radiology reports using the Clinical Trials Eligibility Database Integrated System (CTED). The study sample included all patients (N = 5,523) with radiologic diagnostic studies (N = 10,492) completed in a two-week period. Eight search algorithms (queries) within CTED were developed and applied to radiology reports. The performance of each algorithm was compared to a reference standard which consisted of a physician's review of the radiology reports. Sensitivity, specificity, positive, and negative predicted values were calculated for each algorithm. The number of patients identified by each algorithm varied from 187 to 330 and the number of true positive cases confirmed by physician review ranged from 171 to 199 across the algorithms. The best performing algorithm had sensitivity 94%, specificity 100%, positive predictive value 90%, negative predictive value 100%, and accuracy of 99%. Our evaluation process identified the optimal method for rapid identification of patients with metastatic disease through automated screening of unstructured radiology reports. The methods developed using the CTED system could be readily implemented at other institutions to enhance the efficiency of research staff in the clinical trials eligibility screening process.

Effort required in eligibility screening for clinical trials

PURPOSE

Determining eligibility for a clinical trial (CT) typically requires a lengthy manual review of data for a single evaluation. The cost associated with eligibility screening is typically not compensated through contracts supporting CTs.

METHODS

We used a real-time tracking system that captures CT evaluations and provides information on evaluation outcomes and time spent on each eligibility screening by research staff. Using these data, we describe the effort and costs of eligibility screening overall and per enrolled patient for cancer CTs. The study sample included all completed eligibility assessment (evaluation) records for the 18-month study period. We used generalized multinomial modeling to predict evaluation outcomes and then used the resulting parameter coefficients to estimate the effort associated with each participant, adjusted for probability of being enrolled. From these data, we calculated cost associated with eligibility screening.

RESULTS

We found substantial variation in attributed cost by study type and phase. The cost of eligibility screening ranged by study phase from $129.15 to $336.48 per enrolled patient. The estimated annual cost of screening was more than $90,000.

CONCLUSION

This study provides results based on prospectively captured effort to estimate the largely nonreimbursed costs of eligibility screening and suggests that screening can be a significant financial burden to an institution. Centers performing CTs may need to acknowledge the differences in screening costs for different study types when negotiating contracts with funding organizations. Information such as that captured here could support such negotiations to reduce the gap between reimbursed and nonreimbursed costs.

Osteoporosis in men: the value of laboratory testing

Evaluation of 234 men referred for osteoporosis found many with undiagnosed secondary causes and multiple unrecognized risk factors.

INTRODUCTION

Studies in women with postmenopausal osteoporosis suggest that many have unrecognized disorders affecting bone. Men are considered more likely to have underlying, possibly correctable causes. We studied the prevalence of risk factors, secondary causes, and laboratory abnormalities in men with and without previously known causes for osteoporosis.

METHODS

We reviewed the charts of 234 men with osteoporosis diagnosed by bone mineral density testing. In addition to screening chemistries, 25-hydroxyvitamin D, testosterone, luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, and spot urinary calcium-to-creatinine ratio were measured.

RESULTS

The mean age was 70.6 years and mean weight was 76.4 kg. The mean T-score for spine, femoral neck, and forearm was -2.2, -2.4, and -2.3, respectively. Evaluation revealed secondary osteoporosis in 75% overall including hypogonadism, vitamin D deficiency, hypercalciuria, subclinical hyperthyroidism, and hyperparathyroidism. In those men with known secondary osteoporosis at the time of dual energy X-ray absorptiometry testing, additional diagnoses were found in just over half. Vitamin D deficiency and insufficiency were very common, and other common risk factors for osteoporosis included age >65, current smoking, and prior fracture. Half of the subjects had ≥ 4 risk factors.

CONCLUSION

Evaluation revealed a specific cause in about half of men thought to have primary osteoporosis. Among men with known secondary osteoporosis, additional risk factors and secondary causes were frequently identified. In conclusion, a relatively modest evaluation of men with osteoporosis will often provide useful information.

Treatment thresholds for osteoporosis in men on androgen deprivation therapy: T-score versus FRAX

Men treated by androgen deprivation therapy (ADT) for localized prostate cancer are at risk for fracture, but it is not known which men require pharmacologic treatment. We found that 33% of men on ADT had osteoporosis of spine, hip, or forearm by dual-energy X-ray absorptiometry (DXA), thus requiring treatment. Using the new fracture prediction algorithm (FRAX) tool with corrected femoral neck T-score identified only 17% requiring treatment, and, if calculated without femoral neck, 54% were identified to need treatment.

INTRODUCTION

Men treated with androgen deprivation therapy (ADT) for prostate carcinoma live long enough to fracture. A new fracture prediction method, FRAX, is based on femoral neck DXA plus risk factors. Thus, DXA or FRAX could determine which men should receive osteoporosis therapy.

METHODS

Of 115 men undergoing ADT referred for DXA testing, those with bone mineral density (BMD) in spine, hip, or forearm of >or=2.5 standard deviations below a normal male ethnicity-adjusted mean were considered treatment candidates. Using FRAX with and without femoral neck BMD, men were treatment candidates if the 10-year hip fracture risk was >or=3% or the major osteoporotic fracture risk was >or=20%.

RESULTS

The men averaged 77 years old; 58% were African-American, and 14.8% were current smokers. Mean femoral neck T-score was -1.4. Using DXA, 38 (33%) men would need treatment. When FRAX was calculated including the femoral neck T-score, only 20 men met criteria for treatment. However, when FRAX was calculated without the T-score, 62 men met criteria for treatment. Overlap among the groups was surprisingly modest.

CONCLUSIONS

DXA and FRAX identify different ADT men for treatment.

Improving osteoporosis management in patients with fractures

A history of fracture is an independent risk factor for future fractures, but patients who have sustained a fracture are rarely evaluated for osteoporosis (OP). The objective of this study was to determine if a simple intervention in a general orthopedic clinic would lead to more fracture patients receiving evaluation and treatment for OP. Patients with a history of fracture visiting a weekly orthopedic clinic during a 6-month intervention period were educated about OP, and a bone mineral density (BMD) test was offered. The number of BMD tests performed and other OP-specific actions taken as a result of the intervention were compared with a 6-month pre-intervention period. The prevalence of OP in those who underwent BMD testing was examined. In the pre-intervention period, only 12.7% (16 of 126) had a BMD test as compared with 62.5% of the 136 intervention-period subjects (odds ratio [OR] 11.5, 95% confidence interval [CI] 6.1, 21.4). Based on BMD test results, 11.9% of the pre-intervention patients, and 41.9% of the intervention patients received OP-specific recommendations (OR 5.3, 95% CI 2.8, 10.1). The intervention led to more patients being treated for low bone mass (9.5% vs 23.5%); OR 2.9, 95% CI 1.4, 5.9. Low bone mass was common among all types of fracture patients: 20% had osteoporosis and 41%, osteopenia. BMD testing in patients with fractures should identify those at risk for future fractures, leading to appropriate treatment.

Performance of the Osteoporosis Self-assessment Screening Tool for osteoporosis in American men

OBJECTIVE

To determine whether the Osteoporosis Self-assessment Tool (OST) can predict central bone mineral density in men, as defined by dual energy x-ray absorptiometry (DXA).

PATIENTS AND METHODS

We applied the OST index to men in pulmonary (evaluated January-May 2001) and rheumatology (evaluated November 2001-March 2002) clinics at a veterans hospital. The calculated OST risk index is based on weight and age.

RESULTS

In 181 men, we arbitrarily defined osteoporosis as a DXA T score of -25 or less in the spine, total hip, or femoral neck. The mean age and weight of the men were 64.3 years and 91.2 kg; 15.6% had osteoporosis by DXA. The OST index ranged from -5 to 19, from which we categorized risk as follows: low, 4 or greater; moderate,-1 to 3; and high, -2 or less. Only 2.0% of men with a low-risk OST index had osteoporosis, whereas 27.0% with a moderate risk and 72.7% with a high risk had osteoporosis. Using an OST cutoff score of 3, we predicted osteoporosis with a sensitivity of 93% and a specificity of 66%. When patients were studied by age in decades, race, or current glucocorticoid use, the predictive value of the OST was maintained.

CONCLUSION

The OST is an easy method to predict osteoporosis by DXA.

Osteoporosis in pulmonary clinic patients: does point-of-care screening predict central dual-energy X-ray absorptiometry?

STUDY OBJECTIVES

Patients in a pulmonary clinic have disorders that predispose them to osteoporosis and may use glucocorticoid therapy, which has been associated with low bone mineral density (BMD) and increased fracture risk. Ideally, all patients at risk for osteoporosis would be screened using the best test available, which is central BMD by dual-energy x-ray absorptiometry (DXA). We proposed to stratify the risk for osteoporosis by the use of a simple questionnaire and point-of-care heel ultrasound BMD measurements.

DESIGN

Cross-sectional screening study.

SETTING

Pulmonary clinic in a single Veterans Affairs Medical Center.

PATIENTS

Approximately 200 male and female patients who had not had previous BMD testing were eligible for the study, and 107 gave consent.

INTERVENTIONS

One hundred seven men (white, 71 men; black, 35 men; and Asian, 1 man) underwent heel BMD testing and filled out a questionnaire. Ninety-eight men underwent a central DXA.

RESULTS

Of 98 subjects, 24.5% had a spine, total hip, or femoral neck (FN) T-score of <or= -2.5, which is the generally accepted definition of osteoporosis diagnosed using DXA, and 44.9% had a T-score of <or= -2.0. The best-fit models for predicting FN or total hip BMD included body weight, heel BMD, corticosteroid use for >or= 7 days, and race, which accounted for 52 to 57% of the variance. When a heel ultrasound T-score of -1.0 was tested to predict a central DXA T-score of -2.0, the sensitivity was 61% and the specificity 64%. Adding the questionnaire score and body mass index (BMI) to the heel T-score improved sensitivity but not specificity. Moreover, BMI and age predicted central BMD with similar sensitivity and specificity. Importantly, of 24 patients with a central DXA T-score of <or= -2.5, only 14 were identified by a heel T-score of <or= -1.0.

CONCLUSIONS

Although the findings from a heel ultrasound plus the answers to a questionnaire were reasonably good indicators for predicting the presence of low BMD, little predictability was gained over the use of BMI and age. In a group of pulmonary clinic patients, the prevalence of osteoporosis was clinically significant, and central DXA testing was the preferable technique for identifying patients who were at risk for fracture.

Glucocorticoid-induced osteoporosis in patients with sarcoidosis

BACKGROUND

Patients with sarcoidosis are at risk for osteoporosis caused by glucocorticoid therapy. However, because of potential hypercalciuria and hypercalcemia, the usual conservative treatment for low bone mass, calcium and vitamin D supplements, may not be well tolerated.

METHODS

Patients with sarcoidosis referred to a metabolic bone clinic were compared with other sarcoidosis patients studied prospectively and patients with chronic obstructive pulmonary disease (COPD) or asthma. The subjects underwent bone mineral density (BMD) testing, and the sarcoidosis patients underwent mobility testing and measurements of serum and urine chemistries, vitamin D levels, bone turnover markers, and sex hormone levels.

RESULTS

The subjects were mostly male African Americans in the 6th decade of life. Many took chronic oral glucocorticoid therapy and often used home oxygen therapy. Low hip BMD was common among the referred group, comparable with patients with COPD. Surprisingly, hypercalciuria and hypercalcemia were uncommon, and serum testosterone levels were frequently low. The use of calcium supplements, multivitamins containing vitamin D, and glucocorticoids had no impact on serum or urine calcium levels. From univariate analysis, potential risk factors for low hip BMD were low weight, low body mass index (BMI), advanced age, and current use of glucocorticoids. However, in stepwise multiple regression analysis, only low BMI predicted about 40% of hip BMD.

CONCLUSIONS

Despite calcium and vitamin D supplements, this group of patients with sarcoidosis had low BMD but relatively infrequent hypercalciuria and hypercalcemia. No prediction model of BMD was adequate. Therefore, we conclude that each patient needs to be assessed individually, including measurement of BMD, serum and urine calcium, and sex steroid status.