70-gene Prognosis Signature Research Articles

Application of MammaPrint test on Chinese patient with breast cancer.

e13671 Background: A 70-gene prognosis-signature, known as MammaPrint (MP), is validated as a good predictor of recurrence in patients with ER+/HER2- early stage breast cancer in Europe and America. Previous studies on Japanese and Korean breast cancer patients showed that the proportion of MP Low-Risk tumours is significantly lower than the percentage which reported in previous studies. Here we use MammaPrint to determine the gene profiles of breast cancer tumours from Chinese patients and investigate the test’s potential clinical applications. Methods: Formalin-fixed, paraffin-embedded (FFPE) tumour samples or fresh tumour samples from 594 eligible breast cancer patients were collected from 97 hospitals in China. Tumor RNAs were isolated from samples and analyzed using RNA sequencing technology. Clinical risk was categorized based on the Adjuvant! algorithm as used in the MINDACT trial. Concordance between risk predicted by the MammaPrint and clinical characteristics were evaluated. We also analyzed the clinical-pathology features of patients and compared them to previous studies. Results: Overall, 315 patients were categorized as clinical high risk (182 were MP Low-Risk and 133 MP High-Risk), while 279 patients were categorized as clinical low risk (203 were MP Low-Risk and 76 MP High-Risk). The concordance rate between risk predicted by the MammaPrint and clinical characteristics was 56.57%. Among the clinical-pathology features, age, ER/PR/HER2 status, tumour grade and tumour size were significantly related to the genomic risk (p = 0.009, 0.003, < 0.001, 0.001, < 0.001, and 0.007 respectively). Conclusions: The proportion of MP Low-Risk tumours was 64.81%, which is similar to previous validated studies in Europe and America. Of the patients that were clinical high risk, 58% was categorized as MP Low-Risk, and this group of patients may have limited benefit from chemotherapy. Our results indicate that MammaPrint is applicable to Chinese patients and has potential value in clinical practice to avoid over-treatment.

Long Noncoding RNA Signature and Disease Outcome in Estrogen Receptor-Positive Breast Cancer Patients Treated with Tamoxifen.

PurposeRecent data have shown that the expression levels of long noncoding RNAs (lncRNAs) are associated with tamoxifen sensitivity in estrogen receptor (ER)-positive breast cancer. Herein, we constructed an lncRNA-based model to predict disease outcomes of ER-positive breast cancer patients treated with tamoxifen.MethodsLncRNA expression information was acquired from Gene Expression Omnibus by re-mapping pre-existing microarrays of patients with ER-positive breast cancer treated with tamoxifen. The distant metastasis-free survival (DMFS) predictive signature was subsequently built based on a Cox proportional hazard regression model in discover cohort patients, which was further evaluated in another independent validation dataset.ResultsSix lncRNAs were found to be associated with DMFS in the discover cohort, which were used to construct a tamoxifen efficacy-related lncRNA signature (TLS). There were 133 and 362 patients with TLS high- and low-risk signatures in the discover cohort. Both univariate and multivariate analysis demonstrated that TLS was associated with DMFS. TLS high-risk patients had worse outcomes than low-risk patients, with a hazard ratio of 4.04 (95% confidence interval, 2.83–5.77; p<0.001). Both subgroup analysis and receiver operating characteristic analysis indicated that TLS performed better in lymph node-negative, luminal B, 21-gene recurrence score high-risk, and 70-gene prognosis signature high-risk patients. Moreover, in a comparison of the 21-gene recurrence score and 70-gene prognosis signature, TLS showed a similar area under receiver operating characteristic curve in all patients. Gene Set Enrichment Analysis indicated that TLS high-risk patients showed different gene expression patterns related to the cell cycle and nucleotide metabolism from those of low-risk patients.ConclusionThis six-lncRNA signature was associated with disease outcome in ER-positive breast cancer patients treated with tamoxifen, which is comparable to previous messenger RNA signatures and requires further clinical evaluation.

Tamoxifen therapy benefit for patients with 70-gene signature high and low risk

BackgroundBreast cancer molecular prognostic tools that predict recurrence risk have mainly been established on endocrine-treated patients and thus are not optimal for the evaluation of benefit from endocrine therapy. The Stockholm tamoxifen (STO-3) trial which randomized postmenopausal node-negative patients to 2-year tamoxifen (followed by an optional randomization for an additional 3-year tamoxifen vs nil), versus no adjuvant treatment, provides a unique opportunity to evaluate long-term 20-year benefit of endocrine therapy within prognostic risk classes of the 70-gene prognosis signature that was developed on adjuvantly untreated patients.MethodsWe assessed by Kaplan–Meier analysis 20-year breast cancer-specific survival (BCSS) and 10-year distant metastasis-free survival (DMFS) for 538 estrogen receptor (ER)-positive, STO-3 trial patients with retrospectively ascertained 70-gene prognosis classification. Multivariable analysis of long-term (20 years) BCSS by STO-3 trial arm in the 70-gene high-risk and low-risk subgroups was performed using Cox proportional hazard modeling adjusting for classical patient and tumor characteristics.ResultsTamoxifen-treated, 70-gene low- and high-risk patients had 20-year BCSS of 90 and 83%, as compared to 80 and 65% for untreated patients, respectively (log-rank p < 0.0001). Notably, there is equivalent tamoxifen benefit in both high (HR 0.42 (0.21–0.86), p = 0.018) and low (HR 0.46 (0.25–0.85), p = 0.013) 70-gene risk categories even after adjusting for clinico-pathological factors for BCSS. Limited tamoxifen exposure as given in the STO-3 trial provides persistent benefit for 10–15 years after diagnosis in a time-varying analysis. 10-year DMFS was 93 and 85% for low- and high-risk tamoxifen-treated, versus 83 and 70% for low- and high-risk untreated patients, respectively (log-rank p < 0.0001).ConclusionsPatients with ER-positive breast cancer, regardless of high or low 70-gene risk classification, receive significant survival benefit lasting over 10 years from adjuvant tamoxifen therapy, even when given for a relatively short duration.

Long-term impact of the 70-gene signature on breast cancer outcome

Several studies have validated the prognostic value of the 70-gene prognosis signature (MammaPrintR), but long-term outcome prediction of these patients has not been previously reported. The follow-up of the consecutively treated cohort of 295 patients (<53 years) with invasive breast cancer (T1-2N0-1M0; n = 151 N0, n = 144 N1) diagnosed between 1984 and 1995, in which the 70-gene signature was previously validated, was updated. The median follow-up for this series is now extended to 18.5 years. A significant difference is seen in long-term distant metastasis-free survival (DMFS) for the patients with a low- and a high-risk 70-gene signature (DMFS p < 0.0001), as well as separately for node-negative (DMFS p < 0.0001) and node-positive patients (DMFS p = 0.0004). The 25-year hazard ratios (HRs) for all patients for DMFS and OS were 3.1 (95 % CI 2.02–4.86) and 2.9 (95 % CI 1.90–4.28), respectively. The HRs for DMFS and OS were largest in the first 5 years after diagnosis: 9.6 (95 % CI 4.2–22.1) and 11.3 (95 % CI 3.5–36.4), respectively. The 25-year HRs in the subgroup of node-negative patients for DMFS and OS were 4.57 (95 % CI 2.31–9.04) and 4.73 (95 % CI 2.46–9.07), respectively, and for node-positive patients for DMFS and OS were 2.24 (95 % CI 1.25–4.00) and 1.83 (95 % CI 1.07–3.11), respectively. The 70-gene signature remains prognostic at longer follow-up in patients <53 years of age with stage I and II breast cancer. The 70-gene signature’s strongest prognostic power is seen in the first 5 years after diagnosis.Electronic supplementary materialThe online version of this article (doi:10.1007/s10549-013-2831-4) contains supplementary material, which is available to authorized users.

High concordance for MammaPrint 70 genes by RNA next generation sequencing.

3065 Background: The development of new biomarkers often requires fresh frozen (FF) samples. Recently we showed that microarray gene expression data generated from FFPE material are comparable to data extracted from the FF counterpart, including known signatures such as the 70-gene prognosis signature (Mittempergher L et al., 2011). As described by Luo et al (2010) RNA profiling using next generation sequencing (RNA-Seq) is now applicable to archival FFPE specimens. Methods: Technical performance and the comparison between the RNA-Seq 70-gene read-out and the MammaPrint test (Glas et al., 2006) is evaluated in a series of 15 patients (11/15 with matched FFPE/FF material). RNA-Seq was carried out using minor adjustments of the Illumina TruSeq RNA preparation method. RNA sequencing libraries were prepared starting from 100ng of total RNA. Next, the DSN (Duplex-Specific Nuclease) normalization process was used to remove ribosomal RNA and other abundant transcripts (Luo et al, 2010). The libraries were paired-end sequenced on the Illumina HiSeq 2000 instrument with multiplexing of 4 libraries per lane. The resulting sequences were mapped to the human reference genome (build 37) using TopHat 1.3.1(Trapnell et al., 2009). The HTSeq-count tool was used to generate the total number of uniquely mapped reads for each gene. Results: Between 14% and 45% of the total number of reads were assigned to protein-coding genes. The minimum coverage per 1000bp of CDS was 38 reads. The 70 MammaPrint genes were successfully mapped to the RNA-Seq transcripts. We calculated the Pearson correlation coefficient between the centroids of the original good prognosis template (van’t Veer et al., 2002) and the 70-gene read count determined by RNA-Seq of each sample. Predictions based on the 70-gene RNA-Seq data showed a high agreement with the actual MammaPrint test predictions (&gt;90%), irrespective of whether the RNA-seq was performed on FF or FFPE tissue. Conclusions: New generation RNA-sequencing is a feasible technology to assess diagnostic signatures.

Economic evaluation of the 70-gene prognosis-signature (MammaPrint®) in hormone receptor-positive, lymph node-negative, human epidermal growth factor receptor type 2-negative early stage breast cancer in Japan

The 70-gene prognosis-signature is validated as a good predictor of recurrence for hormone receptor-positive (ER+), lymph node-negative (LN-), human epidermal growth factor receptor type 2-negative (HER2-) early stage breast cancer (ESBC) in Japanese patient population. Its high cost and potential in avoiding unnecessary adjuvant chemotherapy arouse interest in its economic impact. This study evaluates the cost-effectiveness of including the assay into Japan's social health insurance benefit package. An economic decision tree and Markov model under Japan's health system from the societal perspective is constructed with clinical evidence from the pool analysis of validation studies. One-way sensitivity analyses are also performed. Incremental cost-effectiveness ratio is estimated as ¥3,873,922/quality adjusted life year (QALY) (US$43,044/QALY), which is not more than the suggested social willingness-to-pay for one QALY gain from an innovative medical intervention in Japan, ¥5,000,000/QALY (US$55,556/QALY). However, sensitivity analyses show the instability of this estimation. The introduction of the assay into Japanese practice of ER+, LN-, HER2- ESBC treatment by including it to Japan's social health insurance benefit package has a reasonable chance to be judged as cost-effective and may be justified as an efficient deployment of finite health care resources.

P1-06-20: Response to Neo-Adjuvant Chemotherapy and Outcomes for I-SPY 1 Patients Stratified by the 70-Gene Prognosis Signature (MammaPrint) and Molecular Subtyping (BluePrint).

Abstract Background Classification of breast cancers into molecular subtypes may be important for the proper selection of therapy for patients as tumors with seemingly similar biology can have strikingly different clinical outcomes. We analyzed response to neo-adjuvant chemotherapy as a function of molecular sub-types and show patient survival from the multi-center neo adjuvant trial, I-SPY I (CALGB 150007/150012; ACRIN 6657). Previous analyses had shown that breast cancer subtypes as identified by immunohistochemistry or molecular analyses, have distinct clinical outcome (Esserman, ASCO 2009). Here, we analyze how the 70-gene signature (MammaPrint) together with an 80-gene molecular subtyping profile (BluePrint=Basal-type, Luminal-type, ERBB2-type; de Snoo, ASCO, 2010 and manuscript under review) can sub-classify patients. Materials: This study was carried out on genomics data of core needle biopsies from 149 out of 221 patients enrolled in the I-SPY I trial, a multi-center trial designed to identify predictive markers of pathological complete response (pCR) and disease-free survival (DFS) in women with locally advanced breast cancer (3 cm or greater). All women received neoadjuvant Doxorubicin &amp; Cytoxan followed by paclitaxel chemotherapy. The 70-gene and the subtyping signatures, Basal, Luminal and ERBB2-type were determined on 44K Agilent arrays available through the I-SPY 1 data portal (Esserman, ASCO, 2009 and manuscript under review). Results: The 70-gene signature classified 9% of patients (13/149) as Low Risk, of whom one patient was ERBB2-type, and the other 12 were Luminal-type. None of these patients experienced a pCR. The remaining 136 were classified as 70-gene High Risk (91%), of whom 47% were classified as Luminal-type with a pCR rate of 13%, 41% were Basal-type with a pCR rate of 34%, and 12% were ERBB2-type with a pCR rate of 56%. Patients with BluePrint Basal-type tumors had a 5-year DFS of 61%; ERBB2-type had a 5-year DFS of 78%; 70-gene High Risk/Luminal-type had a 5-year DFS of 73% and 70-gene Low Risk/Luminal-type showed 5-year DFS of 100%. The molecular subtype classification shows significant association to clinically assessed receptor status. However, clinically assessed HER2+ patients were distributed across all molecular subtypes, where ER+HER+ are predominantly classified as Luminal-type. Conclusion: This study was performed with the I-SPY I dataset, which provides a platform to compare, contrast &amp; combine marker signatures to tailor therapy. We show how combining BluePrint, with MammaPrint risk-classification can detect specific groups of patients who are at high risk of recurrence and who would have a higher likelihood to benefit from chemotherapy. Furthermore, MammaPrint Low Risk patients do not benefit from neo-adjuvant therapy, though have excellent survival rates, suggesting that the Low Risk Luminal-type patients could be managed conservatively. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-20.

Impact of mammographic screening on the detection of good and poor prognosis breast cancers

We sought to compare the molecular signature of node negative cancers from two cohorts 15 years apart, to determine if there is molecular evidence of increase in low and ultralow risk cancers over time. We studied the impact of age, time period of diagnosis, and mammographic screening on biology of tumors where The Netherlands Cancer Institute 70-gene prognosis signature was generated as part of 2 validation series, one retrospective (1984-1992), Cohort 1, and one prospective (2004-2006), Cohort 2. A total of 866 patients were analyzed. Regardless of time period of diagnosis, the proportion of T1, grade 1, hormone receptor positive (HR) tumors, and good prognosis by 70-gene signature significantly increases as age increases (P < 0.01). In women aged 49-60, the time period of diagnosis significantly affects the proportion of cancers that were NKI 70-gene low risk: 40.6% (67/165) compared with 58% (119/205) for Cohorts 1 and 2, respectively. This is in contrast to the absence of a significant change for women under age 40, where 25% (17/68) and 30% (17/56) were low risk in Cohorts 1 and 2, respectively. In women aged 49-60, using an ultralow risk threshold of the 70-gene signature, 10% of tumors in Cohort 1 were ultralow risk compared with 30% for women with screen-detected cancers in Cohort 2. Older age and method of detection (screening) are associated with a higher likelihood of a biologically low risk tumor. In women over age 50, biologically low risk tumors are frequent and tools that classify risk may minimize overtreatment.

Additional value and potential use of the 70-gene prognosis signature in node-negative breast cancer in daily clinical practice

BackgroundThe 70-gene prognosis signature has strong prognostic value in node-negative breast cancer, independent of established prognostic factors. It is unclear whether all node-negative patients should receive a signature result. We therefore evaluated its additional prognostic information to a combination of established prognostic guidelines. MethodsWe evaluated 701 patients from three previously described series in whom a signature result was available. Clinical risk was on the basis of Adjuvant! Online (AO), St Gallen guidelines (St G) and Nottingham Prognostic Index (NPI). Overall survival (OS) analyses were carried out in patients treated at the Netherlands Cancer Institute (Amsterdam) who did not receive adjuvant systemic treatment (AST). ResultsOnly 6% (10 of 156) of estrogen receptor (ER)-negative tumours had a good prognosis signature. The signature was not useful for ER-positive tumours and concordant high AO, high St G and/or high NPI clinical risks (N = 139). The 10-year OS estimate for good signature tumours with these characteristics was <80% and AST would therefore be appropriate irrespective of the signature result. In contrast, for patients with a concordant low AO, low St G and/or low NPI risk and in discordant clinical risk patients, the signature identified low-risk patients in whom AST could be safely withheld (10-year OS > 90%). ConclusionThe 70-gene prognosis signature provides additional prognostic information especially in ER-positive lymph node-negative breast cancer patients with a predominant low or discordant clinical risk on the basis of AO, St G and/or NPI.

Identification of a low-risk subgroup of HER-2-positive breast cancer by the 70-gene prognosis signature

Identification of a low-risk subgroup of HER-2-positive breast cancer by the 70-gene prognosis signature

The 70-Gene Prognostic Signature for Korean Breast Cancer Patients

PurposeA 70-gene prognostic signature has prognostic value in patients with node-negative breast cancer in Europe. This diagnostic test known as "MammaPrint™ (70-gene prognostic signature)" was recently validated and implementation was feasible. Therefore, we assessed the 70-gene prognostic signature in Korean patients with breast cancer. We compared the risk predicted by the 70-gene prognostic signature with commonly used clinicopathological guidelines among Korean patients with breast cancer. We also analyzed the 70-gene prognostic signature and clinicopathological feature of the patients in comparison with a previous validation study.MethodsForty-eight eligible patients with breast cancer (clinical T1-2N0M0) were selected from four hospitals in Korea. Fresh tumor samples were analyzed with a customized microarray for the 70-gene prognostic signature. Concordance between the risk predicted by the 70-gene prognostic signature and risk predicted by commonly used clinicopathological guidelines (St. Gallen guidelines, National Institutes of Health [NIH] guideline, and Adjuvant! Online) was evaluated.ResultsPrognosis signatures were assessed in 36 patients. No significant differences were observed in the clinicopathological features of patients compared with previous studies. The 70-gene prognosis signature identified five (13.9%) patients with a low-risk prognosis signature and 31 (86.1%) patients with a high-risk prognosis signature. Clinical risk was concordant with the prognosis signature for 29 patients (80.6%) according to the St. Gallen guidelines; 30 patients (83.4%) according to the NIH guidelines; and 23 patients (63.8%) according to the Adjuvant! Online. Our results were different from previous validation studies in Europe with about a 40% low-risk prognosis and about a 60% high-risk prognosis. The high incidence in the high-risk group was consistent with data in Japan.ConclusionThe results of 70-gene prognostic signature of Korean patients with breast cancer were somewhat different from those identified in Europe. This difference should be studied as whether there is a gene disparity between Asians and Europeans. Further large-scale studies with a follow-up evaluation are required to assess whether the use of the 70-gene prognostic signature can predict the prognosis of Korean patients with breast cancer.

Identification of a low-risk subgroup of HER-2-positive breast cancer by the 70-gene prognosis signature

Background:Overexpression of HER-2 is observed in 15–25% of breast cancers, and is associated with increased risk of recurrence. Current guidelines recommend trastuzumab and chemotherapy for most HER-2-positive patients. However, the majority of patients does not recur and might thus be overtreated with adjuvant systemic therapy. We investigated whether the 70-gene MammaPrint signature identifies HER-2-positive patients with favourable outcome.Methods:In all, 168 T1–3, N0–1, HER-2-positive patients were identified from a pooled database, classified by the 70-gene signature as good or poor prognosis, and correlated with long-term outcome. A total of 89 of these patients did not receive adjuvant chemotherapy.Results:In the group of 89 chemotherapy-naive patients, after a median follow-up of 7.4 years, 35 (39%) distant recurrences and 29 (33%) breast cancer-specific deaths occurred. The 70-gene signature classified 20 (22%) patients as good prognosis, with 10-year distant disease-free survival (DDFS) of 84%, compared with 69 (78%) poor prognosis patients with 10-year DDFS of 55%. The estimated hazard ratios (HRs) were 4.5 (95% confidence interval (CI) 1.1–18.7, P=0.04) and 3.8 (95% CI 0.9–15.8, P=0.07) for DDFS and breast cancer-specific survival (BCSS), respectively. In multivariate analysis adjusted for known prognostic factors and hormonal therapy, HRs were 5.8 (95% CI 1.3–26.7, P=0.03) and 4.7 (95% CI 1.0–21.7, P=0.05) for DDFS and BCSS, respectively.Interpretation:The 70-gene prognosis signature is an independent prognostic indicator that identifies a subgroup of HER-2-positive early breast cancer with a favourable long-term outcome.

Evaluation of the 70-gene prognosis MammaPrint signature for the prediction of prognosis of breast cancer independently from histologic grade.

561 Background: Histologic grade is one of the strongest prognostic factors for breast cancer patients. In this study we assessed the prognostic value of the 70-gene prognosis signature (MammaPrint), validated for node-negative and -positive patients, for grade (G) 1-3 breast cancer. Methods: 1630 tumor samples of pT1-3 N0-1 breast cancer patients from 7 previously reported studies were analyzed and classified by MammaPrint as low or high risk. 10-year breast cancer-specific survival (BCSS) and distant disease-free survival (DDFS) was analyzed using Kaplan-Meier survival curves and multivariate Cox regression analyses. Results: Of 1,630 patients 392 (24%) were classified as G1 (21% 70-gene high risk), 646 (40%) as G2 (42% high risk) and 592 (36%) as G3 (86% high risk), respectively. At 10 years of follow-up, the 70-gene signature accurately distinguished low-risk from high-risk tumors for all histologic grades: within G1 tumors, absolute BCSS was 91% for 70-gene low risk and 82% for 70-gene high risk patients, HR 2.6 (95%CI 1.1-5.7), p = 0.02. Within G2 survival was 88% (low risk) and 68% (high risk), HR 3.3 (2.1-5.3), p < 0.01 and within G3 survival was 86% (low risk) and 64% (high risk), HR 3.4 (1.6- 7.2), p < 0.01. For DDFS: G1 HR 2.8 (1.5-5.4), p < 0.01), G2 HR 2.2 (1.5-3.2), p < 0.01 and G3 HR 2.4 (1.3-4.5), p < 0.01. Multivariate analysis with known prognostic factors and adjuvant therapy including histologic grade and the signature confirmed MammaPrint as strongest independent prognostic factor for 10-year survival (HR BCSS 2.8 [1.8-4.3], p < 0.01) and DDFS HR 2.2 [1.5-3.2], p < 0.01). Limited to chemotherapy-untreated patients only, results were similar (multivariate HR BCSS 2.3 [1.5-3.8], p < 0.01 and DDFS HR 1.9 [1.3-2.8], p < 0.01). Conclusions: The 70-gene MammaPrint signature provides independent prognostic information for all histological grades. Of note, “G1/70-gene high-risk” patients had a relatively poor 10-year BCSS of 82%, and therefore may be treated aggressively. In contrast, “G3/70-gene low-risk” patients achieved a 10-year BCSS of 86%, where adjuvant chemotherapy might be of limited benefit. This study confirms the clinical value of the 70-gene signature for all histological grades. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Agendia Agendia

The 70-gene prognosis signature predicts early metastasis in breast cancer patients between 55 and 70 years of age

BackgroundThe majority of breast cancer patients are postmenopausal women who are increasingly being offered adjuvant chemotherapy. Since the beneficial effect of chemotherapy in postmenopausal patients predominantly occurs in the first 5 years after diagnosis, a prognostic marker for early events can be of use for adjuvant treatment decision making. The aim of this study was to evaluate the prognostic value of the 70-gene prognosis signature for early events in postmenopausal patients. MethodsFrozen tumor samples from 148 patients aged 55–70 years were selected (T1–2, N0) and classified by the 70-gene prognosis signature (MammaPrint™) into good or poor prognosis. Eighteen percent received hormonal therapy. ResultsBreast cancer-specific survival (BCSS) at 5 years was 99% for the good-prognosis signature versus 80% for the poor-prognosis signature group (P=0.036). The 70-gene prognosis signature was a significant and independent predictor of BCCS during the first 5 years of follow-up with an adjusted hazard ratio of 14.4 (95% confidence interval 1.7–122.2; P=0.01) at 5 years. ConclusionThe 70-gene prognosis signature can accurately select postmenopausal patients at low risk of breast cancer-related death within 5 years of diagnosis and can be of clinical use in selecting postmenopausal women for adjuvant chemotherapy.

Early determination of metastatic potential in breast cancer: The 70-gene signature in small tumors

518 Background: Small breast cancers are often considered as low risk tumors in clinico-pathologic risk assessment and treatment guidelines. However, since the ability to metastasize is an early and inherent genetic property of breast cancer and consequently even small tumors can metastasize, identification of prognostic subgroups for patients with small tumors would help to optimize treatment strategies. In the present study the 70-gene prognosis signature (MammaPrint), validated as independent prognostic indicator for node-negative and positive patients, was used to assess prognosis for pT1 breast cancer. Methods: 965 tumor samples of women with pT1 breast cancer from 7 previously reported studies were analyzed and classified by MammaPrint as good or poor prognosis. 10-year distant disease-free survival (DDFS) and breast cancer-specific survival (BCSS) was analyzed according to the 70-gene prognosis signature separately for pT1a/b (1–10mm) and pT1c (11–20mm) tumors. Results: Median follow-up was 7.1 years (range 0.2–25.2). 526 of 965 patients (55%) were classified as good prognosis and 439 (45%) as poor prognosis by the 70-gene signature. 562 patients (59%) received no adjuvant treatment, 19% received hormonal treatment only, 10% chemotherapy only and 12% both respectively. The 70-gene signature accurately predicted differences in 10-year DDFS (HR 2.7 [1.9–3.9], p&lt;0.01) and BCSS (HR 4.0 [2.6–6.3], p&lt;0.01) for all T1 tumors. Similar results were obtained by multivariate analysis for all patients, adjusted for known prognostic factors and adjuvant therapy, as well as for adjuvant untreated patients. At 10 years, for small pT1a/b tumors (n=140), DDFS was 93% vs. 78% for the good and poor prognosis groups (HR 3.9 [1.0–15.2], p=0.048), while in the T1c group (n=825) DDFS was 86% vs. 72% (HR 2.6 [1.8–4.0], p&lt;0.01). BCSS was 87% vs. 73% for the good and poor prognosis groups in the T1a/b group (HR 2.4 [0.8–7.7], p=0.128) and 92% vs. 72% (HR 4.4 [2.7–7.1], p&lt;0.01) in T1c tumors, respectively. Conclusions: The 70-gene signature is a strong and independent prognostic indicator also in small breast tumors. Patients with T1a/b or T1c tumors and a genomic high risk gene signature for developing distant metastases may be selected for additional adjuvant hormonal and chemotherapy. [Table: see text]

Daily clinical practice of fresh tumour tissue freezing and gene expression profiling; logistics pilot study preceding the MINDACT trial

PurposeThe 70-gene prognosis-signature is a prognostic tool for early breast cancer analysis. In addition to scientific evidence, implementation of the signature in clinical trials and daily practice requires logistical feasibility. The aim of our study was to test logistics for gene expression profiling on fresh frozen tumour tissue in the preparation for the prospective, multinational Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) trial. MethodsSixty-four patients were included in six European hospitals. Fresh frozen tumour samples were shipped on dry ice to Agendia B.V., where RNA was isolated and subsequently hybridised on the 70-gene prognosis-signature (MammaPrint™). ResultsTumour samples were obtained in 60 of 64 patients. Among the 60 samples, 11 contained insufficient tumour cells (<50%) and three contained insufficient RNA quality. All 46 samples eligible for genomic profiling were successfully hybridised, and the results were reported on average within 4–5d. ConclusionGene expression profiling on fresh frozen tissue is feasible in daily clinical practice.

Identification of a low risk subgroup in Her2-positive breast cancer by the 70-gene prognosis signature.

Abstract Abstract #4171 Introduction:&amp;#x2028; Her2/neu-overexpression is observed in 15-20% of invasive breast cancers and considered a negative prognostic factor. Most Her2-positive patients are classified as high risk by current treatment guidelines and thus allocated to adjuvant trastuzumab and chemotherapy. However, 74% of patients remained distant recurrence-free at 3 years without trastuzumab in the HERA-trial (HERceptin Adjuvant). In the present study the 70-gene prognosis signature (MammaPrint™), validated as an independent prognostic indicator for patients with up to three positive lymph nodes, was used to identify a subgroup of patients with low risk and favorable outcome.&amp;#x2028; Methods:&amp;#x2028; One-hundred-sixty-nine patients with Her2-positive breast cancer were selected from a pooled dataset of 1280 patients with known Her2-status. Patients had a unilateral T1-3, N0-1 tumor and were treated with either breast-conserving therapy or mastectomy. Samples were analyzed and classified by the 70-gene signature as good or poor prognosis by Agendia Laboratories.&amp;#x2028; Results:&amp;#x2028; After a median follow-up of 65 months (range 4-303) 49 (29%) distant recurrences and 41 (24%) breast cancer-specific deaths occurred. The 70-gene signature classified 27 (16%) patients as good prognosis, with a 10-year distant disease-free survival (DDFS) of 89% (25/27), compared to 142 (84%) patients classified as poor prognosis, who had a DDFS of 64%. The estimated hazard ratios (HR) for genomic risk were 4.9 (95%CI 1.2-20.1,p=0.029) and 4.4 (95%CI 1.1-18.4,p=0.040) for DDFS and breast cancer-specific survival at 10 years, respectively. In multivariate analysis, adjusted for known prognostic factors and adjuvant therapy, only the 70-gene signature and tumor size were independent predictors for 10-year-DDFS with HRs of 5.4 (95%CI 1.3-23.4,p=0.024) and 1.05 (95%CI 1.02-1.08,p=0.001), respectively. The good prognosis group had positive hormone-receptors in 85%, and fewer patients received adjuvant therapy: 16 patients (59%) received no adjuvant treatment, 6 (22%) received adjuvant chemotherapy, 8 (30%) hormonal therapy and 1 (4%) received trastuzumab. For the subgroup of 90 patients who were not treated with adjuvant chemotherapy or trastuzumab, the HR for low versus high 70-gene signature for 10-year DDFS was 4.75 (1.13-19.92,p=0.033).&amp;#x2028; Discussion:&amp;#x2028; The 70-gene signature is a strong independent prognostic indicator that can identify a subgroup with good clinical outcome in Her2-positive early breast cancer even in the absence of adjuvant chemotherapy and trastuzumab. This subgroup will be further studied in the ongoing MINDACT-trial (MIcroarray for Node-negative and 1-3 positive node Disease may Avoid ChemoTherapy) and beyond. The MINDACT-trial will prospectively evaluate if it is acceptable to withhold chemotherapy and/or trastuzumab in Her2-positive, genomic low risk patients. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4171.

Constructive Technology Assessment (CTA) as a tool in Coverage with Evidence Development: The case of the 70-gene prognosis signature for breast cancer diagnostics

Constructive Technology Assessment (CTA) is a means to guide early implementation of new developments in society, and can be used as an evaluation tool for Coverage with Evidence Development (CED). We used CTA for the introduction of a new diagnostic test in the Netherlands, the 70-gene prognosis signature (MammaPrint) for node-negative breast cancer patients. Studied aspects were (organizational) efficiency, patient-centeredness and diffusion scenarios. Pre-post structured surveys were conducted in fifteen community hospitals concerning changes in logistics and teamwork as a consequence of the introduction of the 70-gene signature. Patient-centeredness was measured by questionnaires and interviews regarding knowledge and psychological impact of the test. Diffusion scenarios, which are commonly applied in industry to anticipate on future development and diffusion of their products, have been applied in this study. Median implementation-time of the 70-gene signature was 1.2 months. Most changes were seen in pathology processes and adjuvant treatment decisions. Physicians valued the addition of the 70-gene signature information as beneficial for patient management. Patient-centeredness (n = 77, response 78 percent): patients receiving a concordant high-risk and discordant clinical low/high risk-signature showed significantly more negative emotions with respect to receiving both test-results compared with concordant low-risk and discordant clinical high/low risk-signature patients. The first scenario was written in 2004 before the introduction of the 70-gene signature and identified hypothetical developments that could influence diffusion; especially the "what-if" deviation describing a discussion on validity among physicians proved to be realistic. Differences in speed of implementation and influenced treatment decisions were seen. Impact on patients seems especially related to discordance and its successive communication. In the future, scenario drafting will lead to input for model-based cost-effectiveness analysis. Finally, CTA can be useful as a tool to guide CED by adding monitoring and anticipation on possible developments during early implementation, to the assessment of promising new technologies.

Validation of 70-gene prognosis signature in node-negative breast cancer

The 70-gene prognosis signature (van't Veer et al., Nature 415(6871):530-536, 2002) may improve the selection of lymph node-negative breast cancer patients for adjuvant systemic therapy. Optimal validation of prognostic classifiers is of great importance and we therefore wished to evaluate the prognostic value of the 70-gene prognosis signature in a series of relatively recently diagnosed lymph node negative breast cancer patients. We evaluated the 70-gene prognosis signature in an independent representative series of patients with invasive breast cancer (N = 123; <55 years; pT1-2N0; diagnosed between 1996 and 1999; median follow-up 5.8 years) by classifying these patients as having a good or poor prognosis signature. In addition, we updated the follow-up of the node-negative patients of the previously published validation-series (Van de Vijver et al., N Engl J Med 347(25):1999-2009, 2002; N = 151; median follow-up 10.2 years). The prognostic value of the 70-gene prognosis signature was compared with that of four commonly used clinicopathological risk indexes. The endpoints were distant metastasis (as first event) free percentage (DMFP) and overall survival (OS). The 5-year OS was 82 +/- 5% in poor (48%) and 97 +/- 2% in good prognosis signature (52%) patients (HR 3.4; 95% CI 1.2-9.6; P = 0.021). The 5-years DMFP was 78 +/- 6% in poor and 98 +/- 2% in good prognosis signature patients (HR 5.7; 95% CI 1.6-20; P = 0.007). In the updated series (N = 151; 60% poor vs. 40% good), the 10-year OS was 51 +/- 5% and 94 +/- 3% (HR 10.7; 95% CI 3.9-30; P < 0.01), respectively. The DMFP was 50 +/- 6% in poor and 86 +/- 5% in good prognosis signature patients (HR 5.5; 95% CI 2.5-12; P < 0.01). In multivariate analysis, the prognosis signature was a strong independent prognostic factor in both series, outperforming the clinicopathological risk indexes. The 70-gene prognosis signature is also an independent prognostic factor in node-negative breast cancer patients for women diagnosed in recent years.

The 70-gene prognosis-signature predicts disease outcome in breast cancer patients with 1–3 positive lymph nodes in an independent validation study

The 70-gene prognosis-signature has shown to be a valid prognostic tool in node-negative breast cancer. Although axillary lymph node status is considered to be one of the most important prognostic factors, still 25-30% of node-positive breast cancer patients will remain free of distant metastases, even without adjuvant systemic therapy. We therefore investigated whether the 70-gene prognosis-signature can accurately identify patients with 1-3 positive lymph nodes who have an excellent disease outcome. Frozen tumour samples from 241 patients with operable T1-3 breast cancer, and 1-3 positive axillary lymph nodes, with a median follow-up of 7.8 years, were selected from 2 institutes. Using a customized microarray, tumour samples were analysed for the 70-gene tumour expression signature. In addition, we reanalysed part of a previously described cohort (n = 106) with extended follow-up. The 10-year distant metastasis-free (DMFS) and breast cancer specific survival (BCSS) probabilities were 91% (SE 4%) and 96% (SE 2%), respectively for the good prognosis-signature group (99 patients), and 76% (SE 4%) and 76% (SE 4%), respectively for the poor prognosis-signature group (142 patients). The 70-gene signature was significantly superior to the traditional prognostic factors in predicting BCSS with a multivariate hazard ratio (HR) of 7.17 (95% CI 1.81 to 28.43; P = 0.005). The 70-gene prognosis-signature outperforms traditional prognostic factors in predicting disease outcome in patients with 1-3 positive nodes. Moreover, the signature can accurately identify patients with an excellent disease outcome in node-positive breast cancer, who may be safely spared adjuvant chemotherapy.