Oncotype DX Recurrence Score Assay Research Articles

Abstract PO5-01-08: The impact of Human Epidermal growth factor Receptor 2 (HER2) expression by RT-PCR on tumor characteristics and outcome in estrogen receptor (ER) positive, HER2 negative early-stage breast cancer

Abstract Background: The role of HER2 expression in HER2 negative breast cancer is evolving. Whether HER2 expression has an impact on ER positive, HER2 negative early-stage breast cancer in unclear. Oncotype DX assay Recurrence Score comprises of standardized quantitative HER2 mRNA expression levels by RT-PCR. The objective of this study was to investigate the impact of Oncotype HER2 score on tumor characteristics and outcome. Methods: All women assigned to the Clalit Health Services registry between 2006 to 2011 with ER positive, HER2 negative early-stage breast cancer whose tumor were sent for oncotype were identified. Patients in which HER2 score was reported in the oncotype results were included. Differences in age, tumor characteristics and chemotherapy administration between lower HER2 score (H1), i.e. HER2 score ≤ 9.1, to higher HER2 score (H2), i.e. 9.2-10.7, were analyzed. 5-year Kaplan–Meier for distant recurrence free survival (DRFS) and overall survival (OS) were estimated and differences between H1 and H2 were evaluated. Analyses were repeated separately for node negative and for node positive (N mic and 1-3 lymph nodes) disease. Results: A total of 1535 patients were included, 948 patients with node negative disease and 587 with node positive disease. Of these, 814 and 721 patients were categorized to the H1 and H2 groups, respectively. Median follow-up was 5.4 years. The distribution of oncotype RS was different, with significantly lower proportion of patients with RS between 0-10 and higher proportion of RS above 25 in the H1 group compared to the H2 groups. This difference was identified both for patients with node negative and node positive disease (Table). The distributions of age, tumor size and histological subtype were comparable between the H1 and the H2 groups, both for node negative and node positive disease. Within each RS group, administration of chemotherapy was comparable between H1 and H2 groups, regardless of nodal involvement. DRFS and OS were not associated with HER2 score. For RS 0-25, node negative disease, 5-year DRFS was 96.2% in H1 and 96.4% in H2 groups (p=0.92) and 5-year OS was 97.2% in H1 and 98.1% in H2 groups (p=0.39). For RS >25, node negative disease, 5-years DRFS was 89% in H1 and 90.8% in H2 groups (p=0.33) and 5-year OS was 90.6% in H1 and 90.8% in H2 groups (p=0.7). Similarly, for node positive disease, DRFS and OS were comparable between H1 and H2 group in all subgroups. Conclusions: Low HER2 mRNA expression by Oncotype RT-PCR assay was associated with significantly high Oncotype RS. Patients' outcome was not directly affected by HER2 score and was determined by RS. Further study is desired to clarify the role of HER2 expression in early stage, luminal breast cancer. Table. Comparison of age and tumor characteristics between low (H1) and high (H2) HER2 score Citation Format: Hadar Goldvaser, Raz Mutai, Salomon Stemmer, Iryna Kuchuk, Margarita Tokar, Shani Paluch-Shimon, Rinat Yerushalmi, Karen Drumea, Ella Evron, Amir Sonnenblick, Einav Gal-Yam, Gil Bar Sela, Ayelet Shai, Rotem Merose, Avital Bareket-Samish, Lior Soussan-Gutman. The impact of Human Epidermal growth factor Receptor 2 (HER2) expression by RT-PCR on tumor characteristics and outcome in estrogen receptor (ER) positive, HER2 negative early-stage breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-01-08.

Molecular Characterization of HER2-Low Invasive Breast Carcinoma by Quantitative RT-PCR Using Oncotype DX Assay.

HER2 immunohistochemistry (IHC) reproducibility is suboptimal for HER-low cases (IHC 1+ or 2+). The Yale cohort included 214 stages I-II estrogen receptor positive breast cancers with IHC scores 0, 1+, and 2+ and routine Oncotype DX Recurrence Score (RS) results. The Exact Sciences (ES) cohort included 9 57 624 patients who had an Oncotype DX RS assay that assigns HER2-negative, equivocal, or positive status based on HER2 mRNA levels. HER2 mRNA levels varied across IHC categories but with increasing medians of 9.10 (n = 89), 9.20 (n = 71), and 9.45 (n = 54) in IHC 0, 1+, and 2+, respectively. 22.4% of HER2-low (1+/2+) cancer had RS > 25. Over 98% of HER-low cancers were HER2-negative by Oncotype DX assignment. Cancers with higher mRNA levels exist within IHC 0 and low categories, most of the HER2-low patients by IHC have low RS indicating no benefit from current adjuvant chemotherapies.

ECOG-ACRIN E2197: Comparison of HER2 gene expression by RT-PCR across all HER2 immunohistochemistry groups with recurrence analysis.

515 Background: Accurate assessment of HER2-low [immunohistochemical (IHC) score of 1+ or 2+ and in-situ hybridization negative] breast cancer is clinically relevant following DESTINY-Breast04. In hormone receptor positive breast cancers, Oncotype DX assay Recurrence Score results are widely used to guide adjuvant chemotherapy selection, and standardized quantitative HER2 mRNA reference-normalized expression levels by RT-PCR are included in patient reports. Previously, a high degree of concordance between central IHC and quantitative HER2 by RT-PCR was demonstrated in E2197. Here, we compare quantitative HER2 gene expression using Oncotype DX assay within all IHC subgroups and risk of recurrence in E2197. Methods: Data analyzed were from a case-control sample from E2197 (no adjuvant anti-HER2 therapy) of 755 patients. Central IHC for HER2 used duplicate 1.0 mm microarrays (HercepTest, Dako) and scored per 2007 ASCO/CAP guidelines. Based on quantitative reference-normalized RT-PCR measures of HER2 expression, cases were assigned: positive ≥11.5 units, equivocal ≥10.7 to <11.5 units, and negative <10.7 units (1 unit increase represents ~2-fold increase in RNA). Spearman’s rank correlation was used to measure strength of association between the 2 methods. Cox proportional hazards regression was used to evaluate the association between quantitative HER2 expression and recurrence (defined as invasive breast cancer in local, regional, or distant sites). Analyses were weighted to account for study design. Results: 48% were IHC 0, 11% were IHC 1+, 23% were IHC 2+, and 18% were IHC 3+. 85% were HER2 negative, 3% equivocal, and 11% positive by RT-PCR. While there was moderately strong correlation between HER2 IHC and HER2 gene expression by RT-PCR [Spearman’s rho: 0.63 (95% CI: 0.59, 0.67); p<0.001], there were wide and overlapping ranges of HER2 gene expression across all IHC categories with almost identical medians and inter-quartile ranges for HER2 IHC 1+ and 2+ (n=248; see table). An exploratory analysis showed 86% of IHC 0, 97% of IHC 1+, and 99% of IHC 2+ had HER2 >8 units. After controlling for baseline clinicopathologic features (age, hormone receptor status, grade, size, and nodal status), continuous quantitative HER2 expression was associated with time to recurrence in HER2 IHC 0 to 2+ [HR 1.17 per 1-unit increase in HER2 (95% CI 1.01, 1.35; p=0.036)]. Conclusions: There was a wide range of quantitative HER2 gene expression using Oncotype DX assay across all IHC categories; continuous HER2 expression is independently associated with recurrence. Quantitative HER2 expression may be useful for identification of HER2-low breast cancer. Further studies are needed. [Table: see text]

Adjuvant Chemotherapy for Patients with Breast Cancer Based on Clinical and Evolving Oncotype DX Criteria

Introduction: Oncotype DX assay recurrence score (ODX-RS) cut-off values have recently changed after the publication of the TAILOR-X trial results. We aim to explore decisions for adjuvant chemotherapy (ACT) based on physicians’ clinical assessment and the evolving ODX-RS. Methodology: Patients who underwent ODX testing after curative surgical resection of estrogen receptor positive (ER+), Her2 non-overexpressed (Her2–) and lymph node-negative (LN–) breast cancer (BC) were eligible. Management of these patients was guided by the results of the old ODX-RS-1 (<18, 18–30, and ≥31) risk grouping. For the purpose of this study, treatment decisions were also assumed according to TAILOR-X results (ODX-RS-2). Decisions of 3 medical oncologists on ACT were solicited by blinding them to the RS to investigate concordance with ODXA RS-1 and 2 recommendations. Results: Sixty-six consecutive patients were included. Median age was 50.5 (range: 21–73) years. There was 1 male patient, and 37/65 females (56.9%) were premenopausal. Among the 3 oncologists, recommendations for ACT based on clinical assessment were discrepant in 29 (43.9%) patients. Based on majority consensus (≥2 oncologists), ACT would have been recommended to 22/41 (53.7%) and 22/46 (47.82%) patients with low-risk tumors according to ODX-RS-1 and ODX-RS-2, respectively. Compared to ODX-RS-1, ODX-RS-2 identifies 12% (46 vs. 41) more low-risk patients and 66% (20 vs. 12 patients) more high-risk patients. Conclusion: Overtreatment and discrepancies in the management of patients with ER+/Her2–/LN– early BC can be minimized by the implementation of ODX genomic assay. Some differences in ACT recommendations exist between ODX-RS-1 and ODX-RS-2.

Decisions on adjuvant chemotherapy for patients with breast cancer based on clinical and evolving Oncotype DX criteria.

e12009 Background: Oncotype-DX assay recurrence score (ODX-RS) cut-off values have recently changed in response to the results of the TAILOR-X trial. We aim to explore decisions for ACT based on physicians’ clinical assessment and on evolving ODX-RS. Methods: Patients who underwent ODX testing after curative surgical resection of estrogen receptor positive (ER+), Her2 non-over-expressed (Her2-) and lymph node negative (LN-) BC were included. Patients with micro-metastases to LNs were excluded. Data was collected retrospectively from the electronic records. Management of these patients was guided by the results of the old ODX-RS-1 (&lt;18, 18-30 &amp; ≥31) risk grouping. For the purpose of this study, treatment decisions were also assumed according to TAILOR-X results (ODX-RS-2). Decisions of 3 medical oncologists on ACT were solicited by blinding them to the RS values to investigate inter-physicians discrepancy and concordance with ODXA RS-1&amp;2. Results: Sixty six consecutive patients fulfilled the inclusion criteria. Median age was 50.5 (range: 21-73) years. There was one male patient and 37 out of 65 females (56.9%) were pre-menopausal. Median tumor size was 21.5 (range: 10-55) mm and the grade were I, II and III in 6 (9.1%), 46 (69.7%) and 41 (21.2%) patients respectively. The 3 oncologists’ had discrepancies about ACT recommendations in 29 (44%) patients. Based on majority opinion (≥2 oncologists), ACT would have been recommended to 22/41 (53.7%) and 24/46 (52.2%) patients with low risk tumors according to ODXA RS-1 and ODXA RS-2 respectively. Similar number of patients (n=12) would have received ACT regardless of ODXA RS cut-off value (table). Conclusions: Decisions on ACT for patients with ER+/Her2-/LN- early BC should be guided by ODX-RS to prevent overtreatment and discrepancies in management. Broadly, ODXA RS-1 and ODXA RS-2 seem to guide ACT decisions in similar proportions of patients. Nevertheless minor differences exist and need to be studied in larger cohorts. [Table: see text]

P004 - Decision impact of the 21-Gene Oncotype DX Recurrence Score Assay® in the Czech Republic on recommendations for adjuvant chemotherapy in estrogen receptor positive early stage breast cancer (ESBC) patients

P004 - Decision impact of the 21-Gene Oncotype DX Recurrence Score Assay® in the Czech Republic on recommendations for adjuvant chemotherapy in estrogen receptor positive early stage breast cancer (ESBC) patients

Prospective Evaluation of the Impact of the 21-Gene Recurrence Score Assay on Adjuvant Treatment Decisions for Women with Node-Positive Breast Cancer in Ontario, Canada.

The 21-gene Recurrence Score (RS) assay is only reimbursed in Ontario for node-negative and micrometastatic node-positive (N+) early-stage breast cancer (EBC). We carried out a prospective study to evaluate the impact of the assay on treatment decisions for women with N+ EBC. Women with estrogen receptor-positive, human epidermal growth receptor 2-negative EBC and one to three positive axillary lymph nodes, who were candidates for adjuvant chemotherapy in addition to hormonal treatment, but in whom the benefit of chemotherapy was uncertain, were eligible. The primary objective was to characterize how the results of the RS assay affected physicians' recommendations for adjuvant chemotherapy. Secondary objectives were to characterize changes in the physicians' and patients' level of confidence in treatment recommendations, to determine whether the results of the RS assay affected patients' treatment preferences, and to determine the final treatment administered. Seventy-two patients were recruited; the mean age was 61. RS was <18 in 55%, between 18 and 30 in 36%, and ≥31 in 9% of patients. Treatment recommendations changed in 36% of all evaluable patients. The most significant change was in the group with a low RS. Physicians' and patients' confidence in treatment recommendations increased in 49% and 54% of cases, respectively. Upfront chemotherapy was recommended to 79% of patients before the assay; 42% ultimately received chemotherapy. The RS assay resulted in a substantial decrease in the number of patients who received chemotherapy and in an increase in physicians' and patients' confidence in the adjuvant treatment recommendations. This is the first decision impact study to include exclusively women with ER-positive, HER2-negative, early-stage breast cancer with 1-3 positive lymph nodes, a population typically treated with adjuvant chemotherapy. This study provides evidence that, in these patients, the Oncotype Dx Recurrence Score assay influences systemic treatment decisions. Most of the changes in treatment recommendation resulted in withdrawal of chemotherapy or change in recommendation from a chemotherapy regimen with anthracyclines to a taxane-only regimen. If prospective studies confirm that these decisions result in good outcomes, a reduction in the use of chemotherapy might result in pharmacoeconomic savings.

Does the oncotype DX assay recurrence score correlate with other predictive tools when planning adjuvant chemotherapy in early breast cancer?

Does the oncotype DX assay recurrence score correlate with other predictive tools when planning adjuvant chemotherapy in early breast cancer?

Prospective Clinical Utility Study of the Use of the 21-Gene Assay in Adjuvant Clinical Decision Making in Women With Estrogen Receptor-Positive Early Invasive Breast Cancer: Results From the SWITCH Study.

The 21-gene Oncotype DX Recurrence Score assay is a validated assay to help decide the appropriate treatment for estrogen receptor-positive (ER+), early-stage breast cancer (EBC) in the adjuvant setting. The choice of adjuvant treatments might vary considerably in different countries according to various treatment guidelines. This prospective multicenter study is the first to assess the impact of the Oncotype DX assay in the French clinical setting. A total of 100 patients with ER+, human epidermal growth factor receptor 2-negative EBC, and node-negative (pN0) disease or micrometastases in up to 3 lymph nodes (pN1mi) were enrolled. Treatment recommendations, physicians' confidence before and after knowing the Recurrence Score value, and physicians' perception of the assay were recorded. Of the 100 patients, 95 were evaluable (83 pN0, 12 pN1mi). Treatment recommendations changed in 37% of patients, predominantly from chemoendocrine to endocrine treatment alone. The proportion of patients recommended chemotherapy decreased from 52% pretest to 25% post-test. Of patients originally recommended chemotherapy, 61% were recommended endocrine treatment alone after receiving the Recurrence Score result. For both pN0 and pN1mi patients, post-test recommendations appeared to follow the Recurrence Score result for low and high values. Physicians' confidence improved significantly. These are the first prospective data on the impact of the Oncotype DX assay on adjuvant treatment decisions in France. Using the assay was associated with a significant change in treatment decisions and an overall reduction in chemotherapy use. These data are consistent with those presented from European and non-European studies.

Abstract P4-11-32: Routine histopathological variables predict oncotype DX risk categories

Abstract Background: Oncotype DX(ODX) is a clinically validated, commercially available multi-gene assay that provides prognostic and predictive information in estrogen receptor(ER)-positive, Her2-negative breast cancer. Because health care system does not cover this expensive assay in many countries, physicians and researchers try to use routine histopathological variables predict ODX Recurrence Score (RS). Hyunseok Kim et.al presented at ASCO that Estimated Recurrence Score (ERS) model could identify those patients most likely to benefit from including ODX RS results in therapeutic decision-making (J Clin Oncol 32:5s, 2014 suppl; abstr 559). Methods: We retrospectively reviewed histopathological slides between July 2007 and April 2014 from Toranomon Hospital patients (n=149) with early stage ER-positive, Her2-negative breast cancer, for whom ODX was ordered. We developed an original linear regression model using routine histopathological markers (Allred Score for progesterone receptor (PR), nuclear grade(NG), and Ki67) to calculate an Estimated Recurrence Score (ERS), and correlated it with the observed ODX RS assay result. ERS=20.46+0.298xKi67–1.48xPR+1.41xNG predicts the ODX RS with an R2 of 0.48. In order to internally validate this model in the Toranomon Hospital cohort in Japan, we adapted Hyunseok’s algorithm. Results: 132 patients had an observed RS ≤ 25 (89%) and 17 patients had an observed RS above 25 (11%). When the ERS was &amp;lt; 21 (n=124), we accurately classified 97% of them (120) who were found to have a low risk (observed RS ≤ 25). Similarly, 83% of those (5/6) with an ERS &amp;gt; 30 fell into a high risk category with observed RS &amp;gt; 25. Table1 (TAILORx risk categories)Toranomon cohortODX ≤25ODX RS&amp;gt;25TotalERS &amp;lt; 211204124ERS(21-30)11819ERS(&amp;gt; 30)156Total13217149 We also presented the comparison of ERS and observed RS based on original risk categories. Table2 (Original risk categories )Toranomon cohortODX RS&amp;lt;18ODX RS 18-30ODX RS&amp;gt;30TotalERS(&amp;lt;18)6633099ERS(18-30)1725244ERS(&amp;gt;30)0156Total83597149 Conclusions: We developed an ERS model to find those patients most likely to benefit from ODX RS results in clinical practice setting. Although further external and prospective validation is mandatory, preliminary result supports the usefulness of this ERS model. Citation Format: Hidetaka Kawabata, Keiichi Kinowaki, Nobuko Tamura, Yoko Kobayashi, Masami Kadowaki, Daishu Miura, Toshimi Takano, Akihiko Shimomura, Tsuguo Iwatani, Yuko Kitawaki, Takeshi Fujii. Routine histopathological variables predict oncotype DX risk categories [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-11-32.

Use of the 21-gene recurrence score assay (RS) and chemotherapy (CT) across health care (HC) systems.

6580 Background: The Oncotype DX (Genomic Health, Redwood City, CA; GHI) RS estimates 10-yr risk of distant recurrence and CT benefit in patients (pts) with ER+, early-stage breast cancer (EBC). Af...

Reply to E.J. Moylan et al

The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-38 study was designed to determine whether gemcitabine (G) added to dose-dense paclitaxel (P) following dose-dense doxorubicin and cyclophosphamide (dose-dense AC followed by PG) would improve outcomes in women with node-positive breast cancer relative to both dose-dense AC followed by P and docetaxel (T) AC (TAC).1 Dose-dense AC followed by P had been defined as an optimal adjuvant chemotherapy regimen with a toxicity profile that allowed for the addition of G and represented the conventional control arm for B-38. However, it was recognized that if dose-dense AC followed by PG improved outcomes over dose-dense AC followed by P, questions about the activity of the regimen relative to an optimal T-based regimen would persist, so B-38 included TAC as a second control arm. Inclusion of what were perceived as two optimal adjuvant chemotherapy regimens as controls also provided the opportunity for direct comparison of the two regimens in a large phase III trial. Results showed no benefit with the addition of G and no statistical differences in efficacy between the control regimens. However, toxicity profiles differed; thus, physicians and patients can now choose an anthracycline and taxane regimen based on considerations of schedule and toxicity, not relative efficacy. As Moylan et al2 point out, there was no statistically significant difference between dose-dense therapy and TAC in the estrogen receptor (ER) –positive cohort, which supports our statement regarding these findings. The results from B-38 were analyzed and submitted for publication before results from the referenced Southwest Oncology Group (SWOG) study were reported. Clearly, the use of weekly paclitaxel is an acceptable alternative to the dose-dense schedule of four cycles of paclitaxel, but it may be associated with more neurotoxicity. The meta-analysis by Bonilla et al is not based on data from trials but from a literature review. In fact, the authors stated in the conclusion, “However, additional data from randomized controlled trials are needed before dose-dense therapy can be considered as the standard of care.”3 NSABP B-38 is one such trial, with almost 5,000 patients randomly assigned. Moylan et al express “grave concerns” about the characterization in our study of the control regimens with equivalent efficacy as optimal, inferring that we were advocating for indiscriminant use of these regimens in all patients with node-positive, ER-positive breast cancer. This was clearly not the theme of our discussion. B-38 was designed in 2002, was activated in 2004, and completed accrual in 2007. Perou et al4 first described their intrinsic breast cancer types by unsupervised hierarchical clustering analysis in 2000. The apparent utility of the Oncotype DX recurrence score assay to identify subgroups of patients with ER-positive breast cancer who did not derive benefit from chemotherapy was reported in 2006 by the NSABP in node-negative patients5,6 and by SWOG in 2009 in node-positive patients.7 As a result of these and other studies, it has been increasingly recognized that the degree of benefit a patient receives from chemotherapy depends on the molecular subtype of the tumor. As stated in our discussion, biology must be the most important consideration for the development of future trials. The era of large adjuvant trials that do not consider molecular subtypes has run its course. We agree that many patients with node-positive, ER-positive breast cancer may not require a third-generation adjuvant regimen or need chemotherapy at all. Trials such as RxSPONDER ({type:clinical-trial,attrs:{text:NCT01272037,term_id:NCT01272037}}NCT01272037), which is evaluating the role of chemotherapy in node-positive patients with low Oncotype DX recurrence scores, are needed to determine whether promising predictive markers will be able to define groups of ER-positive patients who will not benefit from chemotherapy. Conversely, we should be recruiting patients with high-risk ER-positive tumors to trials such as SWOG 1207/NSABP B-53 ({type:clinical-trial,attrs:{text:NCT01674140,term_id:NCT01674140}}NCT01674140), which is evaluating the addition of a mammalian target of rapamycin inhibitor to endocrine therapy, rather than continuing to address nuances of chemotherapy.

A signature of immune function genes associated with recurrence-free survival in breast cancer patients

The clinical significance of tumor-infiltrating immune cells has been reported in a variety of human carcinomas including breast cancer. However, molecular signature of tumor-infiltrating immune cells and their prognostic value in breast cancer patients remain elusive. We hypothesized that a distinct network of immune function genes at the tumor site can predict a low risk versus high risk of distant relapse in breast cancer patients regardless of the status of ER, PR, or HER-2/neu in their tumors. We conducted retrospective studies in a diverse cohort of breast cancer patients with a 1-5year tumor relapse versus those with up to 7years relapse-free survival. The RNAs were extracted from the frozen tumor specimens at the time of diagnosis and subjected to microarray analysis and real-time RT-PCR. Paraffin-embedded tissues were also subjected to immunohistochemistry staining. We determined that a network of immune function genes involved in B cell development, interferon signaling associated with allograft rejection and autoimmune reaction, antigen presentation pathway, and cross talk between adaptive and innate immune responses were exclusively upregulated in patients with relapse-free survival. Among the 299 genes, five genes which included B cell response genes were found to predict with >85% accuracy relapse-free survival. Real-time RT-PCR confirmed the 5-gene prognostic signature that was distinct from an FDA-cleared 70-gene signature of MammaPrint panel and from the Oncotype DX recurrence score assay panel. These data suggest that neoadjuvant immunotherapy in patients with high risk of relapse may reduce tumor recurrence by inducing the immune function genes.