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New Insights in Breast Cancer: Independent Conference Coverage of SABCS 2020

Sara Hurvitz, MD, FACP
Joyce O'Shaughnessy, MD
Released: February 19, 2021

Tools to Assess Risk in EBC

Development and Validation of Tool for Prognosis of Distant Recurrence and Prediction of Chemotherapy Benefit

Sara Hurvitz, MD, FACP:
RSClin is a tool that integrates clinical pathologic features with the 21‑gene recurrence score to generate a patient‑specific estimator of distant recurrence and chemotherapy benefit for patients with EBC.[14] It was developed and validated for node‑negative disease, and it is available now here. You enter the patient’s age, tumor size, tumor grade, and recurrence score, and a distant recurrence rate as well as chemotherapy benefit percentage is generated.

Joyce O’Shaughnessy, MD:
Sparano and colleagues developed this tool in patients with node‑negative disease by using data from the TAILORx and NSABP B14 and B20 trials. The tool was then validated using the Clalit database of long‑term outcomes in patients with node‑negative breast cancer and known recurrence scores. At SABCS, they showed that the clinical pathologic integrated score was more powerful than recurrence score alone or than clinical pathologic features alone at predicting the probability of remaining distant recurrence free at 10 years. The tool also provides individual predictions of the absolute benefit from chemotherapy; they showed that as the recurrence scores increased from 0-50, the absolute benefit from the addition of chemotherapy went from 0% to 15%.

So, this tool is very useful and I have already used it in my practice where I wanted to know, at the 10‑year mark, if a patient could stop ET, based on her prognosis at 10 years.

Sara Hurvitz, MD, FACP:
RSClin does not work for node‑positive disease and the validation aspect for chemotherapy benefit was not externally validated in a very large cohort. That said, I think it is useful for clinicians and patients because it gives them a feeling that a patient‑specific value is being generated.

MINDACT: Updated Outcome and Treatment Benefit in Low-Risk EBC

Sara Hurvitz, MD, FACP:
The MINDACT trial evaluated more than 6500 patients who were stratified based on clinical pathologic risk of recurrence using Adjuvant! Online as well as genomic risk based on the 70‑gene MammaPrint signature.[15] This report at SABCS focused on those patients with either low clinical risk or low genomic risk using this platform, and the primary endpoint was distant metastasis–free survival at 5 years.

With 8.7 years of median follow-up, the main conclusion is that low risk is good, be it low clinical pathologic risk or low genomic risk. If a patient is either clinically low risk or genomically low risk, they have an excellent 8‑year distant metastasis–free survival of > 90% without adjuvant chemotherapy. That said, chemotherapy may benefit patients with discordant risk assessments. If they are either high clinical risk or high genomic risk, there may be a small absolute benefit of chemotherapy, but this does appear to be restricted to younger women, which agrees with data we saw in the RxPONDER study.[9] Of course, this begs the question of whether or not we could simply use ovarian suppression in these women who are younger with higher risk.

Joyce O’Shaughnessy, MD:
The number of patients who were clinically low risk and genomically high risk was small, just over 600 patients. One half received chemotherapy, which led to a modest 1.5% improvement in distant metastasis–free survival at 5 years that was not statistically significant vs no chemotherapy. Hence, having a genomically high-risk score was not predictive for chemotherapy benefit. It certainly was prognostic.

The patients who are clinically low risk and genomically low risk have an exceptionally good clinical outcome which is good to know. Those who are clinically low risk who are genomically high risk do not have such a good outcome, and I think it is important to have that information and be able to talk to those patients about the potential benefit from optimized ET, chemotherapy, and so on.

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