Dr. Vibhay PareekGenetic assays in breast cancer

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Prognostic and predictive markers:

Axillary node statusHistological gradeTumor sizePatient ageLVIER/PR statusHer2 Neu StatusMammaprintOncotype DX

Prognostic or recurrence riskThese markers estimate risk of disease recurrence

ER StatusHer2 Neu StatusOncotype DX testPredictive (Treatment benefits)These markers predict treatment benefit

The question is why is it needed

Several tests are available to help improve the prediction of patient survival upon diagnosis of breast cancer. These prognostic tests assist the decision-making process for cancer treatment by allowing physicians to identify patients who are at low risk of recurrence. The currently available tests examine the activity levels of 16 to 70 genes.

Oncotype DXMammaPrintMammostratProsignaGenomic assays available

Estimate a womans risk of recurrence of early-stage, hormone-receptor-positive breast cancer, as well as how likely she is to benefit from chemotherapy after breast cancer surgeryEstimate a womans recurrence risk of DCIS (ductal carcinoma in situ) and/or the risk of a new invasive cancer developing in the same breast, as well as how likely she is to benefit from radiation therapy after DCIS surgeryAnalyzes the activity of 21 genes and then calculates a recurrence score number between 0 and 100; the higher the score, the greater the risk of recurrence.

Oncotype DX

Estimate a womens recurrence risk for early-stage breast cancerThe breast cancer can be hormone-receptor-positive or hormone-receptor-negativeAnalyzes 70 genes to see how active they are and then calculates either a high-risk or a low-risk recurrence scoreMammaPrint results can help a woman and her doctor make a more informed decision about whether to use chemotherapy to reduce recurrence risk

MammaPrint

Estimate a womans risk of recurrence of early-stage, hormone-receptor-positive breast cancerMeasures the levels of five genes in breast cancer cellsCalculate a risk index scoreThe higher the risk index, the more likely the cancer is to come backWomen are assigned to a risk category (high, moderate, or low) based on their risk index score.

Mammostrat

Analyzes the activity of 58 genes and calculates a risk of recurrence score (low, intermediate, or high)Research suggests the Prosigna assay eventually may be used more frequently to make treatment decisions based on the risk of distant recurrence (cancer coming back in a part of the body away from the breast) within 10 years of diagnosis of early-stage hormone-receptor positive disease with up to three positive lymph nodes after 5 years of hormonal therapy treatment in postmenopausal women

Prosigna assay

The Oncotype DX test is a genomic test that analyzes the activity of a group of genes that can affect how a cancer is likely to behave and respond to treatment. The Oncotype DX test is the only one of the four genomic tests for breast cancer (MammaPrint, Mammostrat, and Prosigna are the others) with results that have been validated with much vigorous research

The Oncotype DX is used in two ways:

to help doctors figure out a womans risk of early-stage, ER +ve breast cancer coming back (recurrence), as well as how likely she is to benefit from chemotherapy after breast cancer surgeryto help doctors figure out a womans risk of DCIS (ductal carcinoma in situ) coming back (recurrence) and/or the risk of a new invasive cancer developing in the same breast, as well as how likely she is to benefit from radiation therapy after DCIS surgery

Because strong results are available and the Oncotype DX test is included in the NCCN and ASCO treatment guidelines, it is the only genomic breast cancer test widely used to make treatment decisions.The results of the Oncotype DX test, combined with other features of the cancer, can help you make a more informed decision about whether or not to have chemotherapy to treat early-stage hormone-receptor-positive breast cancer or radiation therapy to treat DCIS.

youve recently been diagnosed with stage I or II invasive breast cancerthe cancer is estrogen-receptor-positivethere is no cancer in your lymph nodes (lymph node-negative breast cancer)you and your doctor are making decisions about chemotherapyyouve recently been diagnosed with DCISyoure having lumpectomy to remove the DCIS

Eligibility for the test:

How does oncotype dx work:

The Oncotype DX genomic test analyzes the activity of 21 genes that can influence how likely a cancer is to grow and respond to treatment.Looking at these 21 genes can provide specific information on:the likelihood that the breast cancer will returnwhether youre likely to benefit from chemotherapy if youre being treated for early-stage invasive breast cancerwhether youre likely to benefit from radiation therapy if youre being treated for DCIS

Oncotype DX test results assign a Recurrence Score a number between 0 and 100 to the early-stage breast cancer or DCIS

Recurrence Score lower than 18:low risk of recurrence. The benefit of chemotherapy for is likely to be small and will not outweigh the risks of side effects.Recurrence Score of 18 up to and including 30: The cancer has an intermediate risk of recurrence. Its unclear whether the benefits of chemotherapy outweigh the risks of side effects.Recurrence Score greater than or equal to 31: The cancer has a high risk of recurrence, and the benefits of chemotherapy are likely to be greater than the risks of side effects.

Recurrence Score lower than 39:The DCIS has a low risk of recurrence. The benefit of radiation therapy is likely to be small and will not outweigh the risks of side effects.Recurrence Score between 39 and 54:The DCIS has an intermediate risk of recurrence. Its unclear whether the benefits of radiation therapy outweigh the risks of side effects.Recurrence Score greater than 54:The DCIS has a high risk of recurrence, and the benefits of radiation therapy are likely to be greater than the risks of side effects.

We will consider the Recurrence Score in combination with other factors, such as the size and grade of the cancer, the number of hormone receptors the cancer cells have (many versus few), and your age. Together, the decision about whether or not you should have chemotherapy or radiation therapy can be made.

Levels of Gene Expression Determine Recurrence Score

21-gene assay = 16 outcome-related genes + 5 reference genesHigher expression levels offavorable genes = RSHigher expression levels ofunfavorable genes = RS

A risk score is calculated from 0 -100

Cutoff points chosen based onResults of NSABP trial B-20

Results: Population distribution by Oncotype DX risk groupA Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative Breast Cancer

Intermed. risk27.0%

Low risk51.0%Paik .S. et al. N Engl J Med 2004;351:2817-26

High risk22.0%

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All patients

Low Risk (RS < 18)

Years1000

204060DRFS (%)

80

02610481216

14Intermediate Risk (RS 18 - 30)

High Risk (RS 31)

P < 0.00001Distant Recurrence-Free Survival (%)Paik .S. et al. N Engl J Med 2004;351:2817-2693%69%

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Recurrence Score

403530252015105005101520253035404550Recurrence ScoreRate of Distant Recurrence at 10 years

95% C.I.

Recurrence Rate

LowRS < 18Rec. Rate = 6.8%C.I. = 4.0% - 9.6%IntermediateRS 18 - 31Rec. Rate = 14.3%C.I. = 8.3% - 20.3%HighRS 31Rec. Rate = 30.5%C.I. = 23.6% - 37.4%

Paik .S. et al. N Engl J Med 2004;351:2817-26

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Prospective Validation of Oncotype DX:TAILORX Trial

Low RS:HormonalTherapy

High RS:Chemo +HormonalTherapy

Hormonal TherapyChemo + Hormonal11,248 ER+/LN- patients

Low RS associated with minimal chemotherapy benefitHigh RS associated with large chemotherapy benefit

The Oncotype DX Recurrence Score provides precise, quantitative information for individual patients on prognosis across and statistically independent of information on patient age, tumor size, and tumor grade.

Conclusion:

High grade

Low grade

High riskLow riskMammaPrint

Old versus new diagnostics of cancer:from microscope to microarray

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The MammaPrint test, made by Agendia, is a genomic test that analyzes the activity of certain genes in early-stage breast cancer.Used to help make treatment decisions based on the cancer's risk of coming back (recurrence) within 10 years after diagnosis.Knowing if a woman has a high or low risk of early-stage breast cancer coming back might help women and their doctors decide if chemotherapy or other treatments to reduce risk after surgery are needed.

stage I or stage IIinvasivesmaller than 5 centimetersestrogen-receptor-positive or -negativein three or fewer lymph nodes

Eligibility:

The MammaPrint test can be performed on fresh or freshly frozen breast cancer tissue or tissue that has been treated or "fixed" with a special solution to preserve the genetic material. The MammaPrint test also can be done on a sample of preserved tissue that was removed during the original biopsy or surgery.

The MammaPrint test looks at the activity of 70 genes and then calculates a recurrence score that is either low risk or high risk

Factors include:agesize of the cancercancer gradewhether cancer cells were found in nearby lymph nodesgeneral health

Prognosis Classifier for Breast Cancer based on Genomic Profiling

Good signature

Poor signature

threshold

Rows: 70 significant prognosis genes

Columns: tumor samplesThreshold set with 10% false negatives91% sensitivity; 73% specificityMetastases: white = +

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Good signature

Poor signature

Years1000

204060% patients metastasis free

80

024681012Years1000

204060Overall survival (%)

80

024681012Metastasis Free SurvivalOverall survival85.2%50.6%94.5%54.6%H.R. = 5.195% CI = 2.9 - 9.0P < 0.001H.R. = 8.695% CI = 4 - 19P < 0.001van de Vijver M.J. et al. N Eng J Med 2002;347(25):1999-2009.A Gene-Expression Signature as a Predictor of Survival in Breast CancerResults: all patients

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Raster trial: an implementation study

The Mammostrat test, made by Clarient Diagnostic Services, is a genomic test that measures the levels of five certain genes in early-stage, hormone-receptor-positive breast cancer cells

Research suggests the Mammostrat test eventually may be widely used to help make treatment decisions based on whether the cancer has a lower or high risk of coming back (recurrence).

Mammostrat can be used to analyze early-stage, hormone-receptor-positive breast cancers. Stage I and stage II cancers are early-stage cancers.

The Mammostrat test is performed on preserved tissue that was removed during the original biopsy or surgery.

Eligibility:

The Prosigna Breast Cancer Prognostic Gene Signature Assay (formerly called the PAM50 test), made by NanoString, is a genomic test that analyzes the activity of certain genes in early-stage hormone-receptor-positive breast cancer.

Research suggests the test may eventually be widely used to help make treatments decisions based on the risk of distant recurrence for postmenopausal women within 10 years of diagnosis of early-stage hormone-receptor positive disease with up to three positive lymph nodes after 5 years of hormonal therapy treatment.

Knowing if a woman has a high or low risk of distant recurrence more than 5 years after diagnosis may be able to help doctors figure out whether 5 years or 10 years of hormonal therapy is better for her situation. Research has shown that taking tamoxifen for 10 years instead of 5 years can better lower the risk of recurrence and improve overall survival for many women. But if doctors knew that a woman had a low risk of distant recurrence, they might be able spare her the extra 5 years of hormonal therapy treatment.

stage I or stage II and lymph node-negativestage II with one to three positive nodeshormone-receptor-positiveinvasivehave been treated with surgery and hormonal therapy

Eligibility:

The Prosigna assay looks at the activity of 58 genes (called the PAM50 gene signature) to estimate the risk of distant recurrence of hormone-receptor-positive breast cancer from 5 to 10 years after diagnosis after 5 years of hormonal therapy treatment in postmenopausal women.

Based on these activity levels, Prosigna assay results are reported as a risk of recurrence (ROR) score from 0 to 100 in two ways:node-negative cancers are classified as low (0-40), intermediate (41-60), or high (61-100) risknode-positive cancers are classified as low (0-40) or high (41-100) risk

summary

ConclusionsGene signatures augment current clinicopathological variables in assessing risk of recurrenceGene expression profiles may be both prognostic and predictive for patients with early breast cancerNCCN guidelines suggest that Oncotype DX is an option for risk evaluation in 0.6-1 cm tumors with unfavorable characteristics or in >1 cm LN-, ER+/HER2 negative tumors

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NCCN guidelines include Oncotype DX testing in the treatment-decision pathway for node-negative and micrometastatic disease

Tumor 0.6-1.0 cm, moderately or poorly differentiated, intermediate or high grade, or vascular invasionTumor > 1 cm with favorable or unfavorable pathologic featuresConsider Oncotype DXHormone receptor-positive, HER2-negative diseasepT1, pT2, or pT3 and pN1miNo test

RS < 18RS 18-30RS 31Adjuvant endocrine therapy adjuvant chemotherapyAdjuvant endocrine therapyendocrine therapy adjuvant chemotherapyAdjuvant endocrine therapy + adjuvant chemotherapy

59Main point: The National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology for breast cancer suggests the use of Oncotype DX in patients with hormone receptor-positive, HER2-negative, node-negative or micrometastasis-involved disease.

The option of using a gene-based assay of tumor tissue, namely the Oncotype DX assay, to help guide chemotherapy treatment decisions is now included within the systemic adjuvant treatment decision pathway for patients with node-negative or pN1mi (micrometastasis: 0.2-2.0 mm), hormone receptor-positive, HER2-negative tumors that are 0.6-1.0 cm and moderately/poorly differentiated or with unfavorable features or tumors that are > 1 cm.Category 2B: The recommendation is based on lower level evidence, and there is nonuniform NCCN consensus (but no major disagreement). http://www.nccn.org/professionals/physician_gls/categories_of_consensus.asp

National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed [Apr 27, 2009].