Chemotherapy decisions and patient experience with the recurrence score assay for early‐stage breast cancer

Abstract

Background The 21-gene recurrence score assay (RS) stratifies early-stage, estrogen receptor-positive breast cancer by recurrence risk. Few studies have examined how physicians use RS to recommend adjuvant systemic chemotherapy or patient experiences with testing and decision-making. Methods We surveyed 3,880 women treated for breast cancer in 2013-2014, identified by the Los Angeles County and Georgia SEER registries (response rate: 71%). Women reported chemotherapy recommendations, chemotherapy receipt, testing experiences, and decision satisfaction. Registries linked tumor data, RS, and surveys. Regression models examined factors associated with chemotherapy recommendations and receipt by RS and subgroups. Results Of 1,527 patients with Stage I-II, ER/PR(+), HER2-negative disease: 778 received RS (62.6% for node-negative favorable, 24.3% in node-negative, unfavorable, and 13.0% in node-positive disease, p<.001). Overall, 47.2% of patients received a recommendation against chemotherapy and 40.6% received a recommendation for it. RS results correlated with recommendations: nearly all patients with high scores (31-100) received a chemotherapy recommendation (86.9%-96.5% across clinical subgroups), while the majority of patients with low-risk results (0-18) received a recommendation against it (49.2%-78.2% across subgroups). Most patients with high RS received chemotherapy (87.0%, 91.1%, 100% across subgroups), while few patients with low scores received it (2.9%, 9.5%, 26.6% across subgroups). There were no substantial racial/ethnic differences in testing and treatment. Women were largely satisfied with RS and chemotherapy decisions. Conclusions Oncologists use RS to personalize treatment, even in node-positive disease. High satisfaction and absence of disparities in testing and treatment suggests that precision medicine advances have improved systemic breast cancer treatment.

Impact of Genomic Assay Testing and Clinical Factors on Chemotherapy Use After Implementation of Standardized Testing Criteria

“…Of note, the chemotherapy rate observed in patients with Oncotype DX testing was lower in our study versus previously published reports . This likely represents an evolving practice away from chemotherapy use for most patients with HR+/HER2− disease, as comfort with Oncotype DX testing improves and the benefits of chemotherapy are increasingly felt to be limited to a small proportion of these patients.…”

Oncologists’ influence on receipt of adjuvant chemotherapy: does it matter whom you see for treatment of curable breast cancer?

“…[4] A number of studies suggest that oncologists’ adherence to guidelines is high and disparities in treatment for patients with early-stage disease have dissipated. [3,9] Furthermore, there have been advances in standardizing the processing and reporting of tumor biology testing (e.g., ER and HER2), and RS testing (which itself provides standardized information on ER and HER2 expression) is from a sole-source laboratory. [10–14] Finally, the approach to pathology evaluation based on sentinel nodes has become much more uniform, including the collection and processing of specimens.…”

“…The survey was completed by 5,080 eligible patients (70%) and linked to SEER data and RS results. [3] The study protocol was approved by the University of Michigan, the University of Southern California, Emory University, and State Health Departments.…”

“…[1] Over 90% of patients with early-stage disease are treated by the first oncologist they see[2] and 90% of them report that their oncologists advised them to omit or commit to systemic chemotherapy. [3] Treatment recommendations are informed by clinical guidelines, oncologist experience, and patient preferences. Clinical guidelines for adjuvant chemotherapy of patients with curable breast cancer have become increasingly dominant as algorithms have become more precise and evidence-based.…”

Influence of provider factors and race on uptake of breast cancer gene expression profiling

“…In particular, lower adjusted rates of testing have been noted among eligible black patients in a variety of settings, including the National Comprehensive Cancer Network; hospitals in the Atlanta, Georgia metropolitan area; the National Cancer Database; and the California Cancer Registry . However, at least 1 recent population‐based study from Surveillance, Epidemiology, and End Results (SEER) registries failed to find a racial disparity . Institutional characteristics are known drivers of variation in testing rates, and it is possible that observed racial disparities may be explained by the concentration of black patients within hospitals with lower overall rates of testing …”