Science, Medicine and Society

Course Essay: Oncotype DX

What is the Oncotype DX test? The traditional diagnosis of breast cancer relies greatly on histopathology and immunohistochemistry of neoplastic cells. Treatment of breast cancer is usually based on these tests1. Almost half of female breast cancer sufferers in Ireland receive either chemotherapy or hormonal therapy or both5 based on these costumary forms of diagnoses. The National Surgical Adjuvant Breast and Bowel Project (NASBP) performed a clinical trial which showed that tamoxifen and chemotherapy are beneficial to node-negative (tumour not present in lymph nodes), oestrogen-receptor (ER) positive breast cancer patients1. However, if they were to be given to everyone, eighty-five per cent of the patients will be over-treated. This is because women who receive adjuvant tamoxifen h recurrence rate of fifteen per cent within ten years of initial diagnosis1. Therefore, a more accurate means of predicting the likelihood of the breast cancer returning after treatment and the level of success of chemotherapy in individual patients is needed the Oncotype DX test. The Oncotype DX test is a diagnostic tool which utilizes reversetranscriptasepolymerase-chain reaction (RT-PCR) assay based on the expression of 21 genes consisting of 5 reference genes (ACTB, GAPDH, GUS, RPLPO, and TFRC) and 16 cancer genes (GRB7, HER2 , Ki67, STK15, Survivin, CCNB1, MYBL2, MMP11, CTSL2, ER, PGR, BCL2, SCUBE2, GSTM1, CD68 and BAG1) collected from paraffin embedded tumour tissues2. These genes are known to have a role in the proliferation of tumour cells and hormonal response which are the usual traits seen in response to chemotherapy3. It is a commercially available multigene expression test to help predict the benefit of chemotherapy for early stage breast cancer patients with lymph nodenegative, HER2 negative, ER positive breast cancer4. The test is performed on a tumour tissue obtained from a previous surgery. RNA is extracted from a formalinfixed, paraffin-embedded tumour tissue followed by DNAse I treatment. Then, the amount of RNA is measured and verification test is performed for the absence of DNA contamination. Using Prism 7900HT instruments (Applied Biosystems), quantitative TaqMan RT-PCR reactions is perfomed in 384-well plates after the reverse transcription is carried out. Each of the genes expression is measured and produced in triplicate followed by normalization relative to the 5 reference genes. Measurement of the values of the referenced-normalized genes is in the range 0 to 15 where an increase of 1 unit means RNA is approximately doubled. The score of each gene group is then used to calculate the recurrence score (RS) which indicates the likelihood of distant recurrence 1, 3. The test gives a recurrence score which provides an accurate measurement of the cancers aggressiveness and the therapys efficacy2 derived from the values obtained from the 16 referenced-normalised genes. The recurrence score ranges from 0 to 100 which predicts the benefit of chemotherapy and determines the likelihood of the breast cancer recurring within ten years of initial diagnosis. Higher recurrence score means a greater possibility that the cancer will return which also

Student Number: 11314561

Science, Medicine and Society

Course Essay: Oncotype DX Student Number: 11314561
aids in identifying the risk group of the patient (patient can be classified as low, intermediate or high risk depending on RS) 1. What is the test used for and why? Diagnostic and analytical techniques which divide the cancer patient population into very large groups are not advantageous in producing or applying treatment for individual patients2. Studies have shown that women with breast cancer do not receive the same amount of benefit from chemotherapy3. A more personalized diagnosis like the Oncotype DX test improves the quality of examination and treatment of early stage breast cancer. Women with early stage breast cancer that are node-negative, HER2 negative, ER positive have the option to undergo through this test4, 9. The American Society of Clinical Oncology (ASCO), St. Gallen and the National Comprehensive Cancer Network (NCCN) have included the Oncotype DX test into their clinical practice guidelines4 in order to diminish the possibility of unnecessary chemotherapy treatment for patients who do not need them. The recurrence score obtained from the test assists in determining if chemotherapy will be beneficial to the patient and predict the likelihood of distant recurrence1. It has been shown that there is a correlation between the level of risk and benefit from chemotherapy. Higher risk patients (recurrence score greater than 31) were found to have a larger benefit from chemotherapy compared to those who are in the low risk (RS less than 18) category who only received minimal benefit from the treatment3. Patients with intermediate risk (RS within the range 18-31) tumours were found to have no apparent huge benefit from chemotherapy but its clinical significance is still not to be dismissed3.High risk patients who underwent RS guided adjuvant treatment were also estimated to have a 20-30% reduced risk of distant recurrence and its associated mortality8. These findings suggest that identifying the RS value of patients is of great importance in providing the patient with a more individualized mode of treatment and most especially in improving their health and life expectancy. By having reproducible and quantitative information allows clinicians to determine the most successful treatment that can possibly eradicate the disease. Because of the predictive and prognostic characteristics of the Oncotype DX test, therapists can be more precise and thorough in treating early stage breast cancer patients. As a result, patients are less likely to be exposed to unnecessary cytotoxic drugs that are commonly found in chemotherapy. What is the science underlying the development of this test? To establish an efficient and accurate diagnostic tool, researches must first find and collect suitable candidates or in this case sufficient tumour samples to obtain a consistent result and also for validation of its accuracy. The development of

Science, Medicine and Society

Course Essay: Oncotype DX Student Number: 11314561
the Oncotype DX test involved patients who were enrolled in the National Surgical Adjuvant Breast and Bowel Project (NSABP) trial B-141. Fixed, paraffin-embedded tumour samples obtained from patients who received tamoxifen between the trial periods were utilised in developing the test. However, samples that only have 5% (or less) tumour tissue and those with low RT-PCR signal were excluded from the test1. There are two objectives associated with the development of the 21 gene RTPCR assay: to determine if a higher fraction of patients who did not have a distant recurrence for more than 10 years after surgery are in the low risk category and to determine if there is an important relationship between the risk of distant recurrence and the RS of a patient1. RNA is extracted from the blocks of paraffin embedded tumour tissue. The removal of paraffin was done using xylene extraction and then washed by ethanol. This is followed by the isolation of RNA with MasterPure Purification Kit along with DNAse I treatment. Quantification of the RNA is then performed by RiboGreen fluorescence method2. Traces of DNA residues are assessed by TaqMan quantitative PCR assay through the presence of -actin DNA2. DNA contaminated RNA extracts are purified by subjecting it again to DNAse I treatment2. RT-PCR is then used to measure the expression of the genes found in the block samples of tumour tissue1. Genes that most closely represent the disease were then selected. Fourhundred-forty-seven patients were involved in the preliminary studies and in the whole human genome, 250 candidate genes were found to have an association with the character of breast cancer tumour. From these 250 candidate genes, 16 cancerrelated genes and 5 reference genes were chosen1. The cancer related genes were subdivided into five groups according to their role or correlated expression or both. Genes responsible for cell proliferation include Ki67, STK15, Survivin, CCNB1 (cyclin b1) and MYBL2 while the oestrogen group is comprised of ER, PGR, BCL2 and SCUBE2. The HER2 group is composed of HER2 and GRB7. MMP11 (stromolysin 3) and CTSL2 (cathepsin L2) are regarded as invasion genes. GSTM1, CD68 and BAG1 have no relations with the rest of the genes and so are considered as others. The 16 cancer genes were selected because of their strong performance in the three preliminary studies and reliable performance of the primer or probe in the assay. The recurrence score was established by calculating the expression of the cancer-related genes relative to the five reference genes 1. Each group of genes are given a score according to the measurement of the expression of the individual genes. The unscaled recurrence score (RSu) is calculated as follows: RSu= +0.47xHER2 group score 0.34xER group score + 1.04xproliferation group score + 0.10xinvasion group score + 0.05xCD68 0.08xGSTM1 0.07xBAG1. Genes with increased expression that are associated with an increased risk of recurrence are assigned with a plus sign whereas genes with increased expression but result to a decreased risk of recurrence are given a minus sign. RSu is then rescaled to give the final recurrence score. If the value of RSu is less than zero then

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Course Essay: Oncotype DX Student Number: 11314561
RS=0. If the RSu value is in between 0 to 100 then the formula RS= 20x (RSu6.7) is used and if RSu exceeds 100 then RS=1001. The acquired recurrence score of a patient determines whether she is in the low, intermediate or high risk category. Low risk breast cancer patients have a recurrence score of less than 18, while intermediate and high risks have scores of 18 to 31 and greater than 31 respectively1, 3. In your opinion is the test likely to benefit breast cancer patients in Ireland? Breast cancer is found to be the most commonly diagnosed cancers in Ireland excluding non-melanoma skin cancer. Statistics from the National Cancer Registry, Ireland have revealed that the total annual average of incidence of invasive breast cancer during the years 2007-2009 is 2692 including 20 cases of male breast cancer. Female invasive breast cancer accounts for 15.8% of the overall female cancer deaths. Ireland also has the fourth highest mortality rate among other European countries when it comes to breast cancer5. Bringing the multigene assay to Ireland will definitely benefit early stage breast cancer patients in the country by providing personalised medical care. This high incidence and mortality rate indicates that the Oncotype DX test is of great importance in diagnosing the type of breast cancer these patients have in order to attain proper treatment. The recurrence score of patients have played a major role in improving the treatments efficacy compared to those who are treated with tamoxifen alone6. Administering treatment without the guidance of the recurrence score may result to significant side-effects from the toxins found in chemotherapy. It may cause a permanent failure of the ovaries and myelosuppression7. The test can prevent these adverse side-effects and may also increase the life expectancy of Irish women with early stage, node negative, ER positive, HER2 negative breast cancer as seen in the USA6. It has been found that therapies based on the recurrence score of patients have an association with increased life expectancy. In the study carried out by Lymanet al. an extra 2.2 years were added to patients who had the Oncotype DX test compared to those receiving tamoxifen treatment alone6. This means that the test is an effective mode of diagnosis with prognostic and predictive significance. Recurrence rates for breast cancer patients are higher in patients below the age of 501 and roughly one-quarter of breast cancer patients in Ireland are under 50 years of age with a continuous increase in mortality rate in the age group 30-345.The use of Oncotype DX in Irish hospitals indicates a promising positive impact on the lives of these young women. The test will not only make medication more personalised but it will also improve the quality of life of these young Irish women. It is clear that some patients are treated with incorrect treatment or dosage of the cytotoxic drug from chemotherapy. The introduction of the Oncotype DX test will revolutionise the diagnosis and treatment of breast cancer in Ireland. With the

Science, Medicine and Society

Course Essay: Oncotype DX Student Number: 11314561
application of this complex, high-throughput, genomic test, many early stage breast cancer patients will be correctly evaluated and tested for the aggressiveness of the cancer. The recurrence score given by the test will aid clinicians in assessing the risk of the cancer returning within ten years of primary diagnosis and their level of benefit from chemotherapy1. Due to its accuracy patients are correctly diagnosed by the test and appropriate adjuvant chemotherapy and/or (solely) hormonal therapy may be given depending on their recurrence score3. This will have a direct impact on the mortality rate of breast cancer patients. It is very likely that the recognition of the test in the country will lower the previous number of breast cancer deaths and improve breast cancer treatment in Ireland. In your opinion might this test be cost effective in the economic management of breast cancer patients in Ireland? A major challenge commonly faced by clinicians is to decide whether to subject the patient on adjuvant chemotherapy or not 7. The traditional diagnosis and treatment plan for node negative, HER2 negative and ER positive early stage breast cancer do not assess the patient as efficiently as demonstrated by the Oncotype DX test. A study conducted in 2010 showed that the 21 gene RT-PCR test has a direct impact on deciding the treatment plan for patients who had the test. It was shown that the overall chemotherapy use has been reduced by 27%8.Consequently, patients save extra money from avoiding unnecessary treatment. With the guidance of RS, patients receive accurate advice on their treatment plan and it helps them in saving money8. Hornberget al. performed an analysis of the tests cost effectiveness and revealed that low risk patients who avoided the toxicity of chemotherapy gained an average of 0.134 quality-adjusted life-year (QALY) a measure of the patients quality and length of life lived where 0 equates death and 1 means perfect health 8. High risks patients who had the test and had no cancer recurrence gained 0.027 QALY. The study also indicated an immediate savings of $1885 on reduced chemotherapy treatment, $427 on management of unfavourable events and $2578 on supportive care cost8. A value of approximately $200 per woman is also estimated to be saved on prevention of cancer recurrence. The model also demonstrated a net total saving of $23 932 to $337 883 depending on the treatment plan. Women who avoided adjuvant chemotherapy and risk of developing second primary cancer from the treatment had an increase of 0.076 QALYs8. A study in 2007 also demonstrated the cost-effectiveness of the diagnostic test. It was found that a net amount of $2256 is saved by using the recurrence score in deciding the treatment plan for an early stage breast cancer patient compared to chemotherapy and tamoxifen treatment. The result also included an incremental cost-effectiveness ratio of $1944 for every life year saved in comparison to tamoxifen alone6.

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Course Essay: Oncotype DX Student Number: 11314561
The National Centre for Pharmoeconomics (NCP) also carried out an assessment on the cost effectiveness of the 21 gene RT-PCR assay. The NCP concluded that the test resulted to an overall reduced cost in cancer treatment and that the test is cost effective9. With these independent studies carried out to assess the economic management of breast cancer in the country, it is clear that the 21 gene RT-PCR assay is a cost-effective diagnostic tool in helping breast cancer treatment8. With the test only in its early years, it will undoubtedly improve the quality of treatment given to node negative, ER positive and HER2 negative early stage breast cancer patients in Ireland. Word count: 2487 References: 1. Paik S., Shak S., Tang G., Kim C., Baker J., CroninM., Baehner F., Walker M., Watson D., Park T., Hiller W., Fisher E., Wickerham L., Bryant J., and Wolmark N. A Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative Breast Cancer. N Eng J Med [Internet]. 2004 Dec 30 [cited2012 Mar 14]; 351 (27): 2817-26. Available from: http://www.nejm.org.eproxy.ucd.ie/doi/pdf/10.1056/NEJMoa041588 2. Cronin M., Sangli C., Liu M., Pho M., Dutta D., Nguyen A., Jeong J., Wu J., Langone K.C., and Watson D. Analytical Validation of the OncotypeDX Genomic Diagnostic Test for Recurrence Prognosis and Therapeutic Response Prediction in NodeNegative, Estrogen ReceptorPositive Breast Cancer. Clin Chem [Internet]. 2007 Jun [cited 2012 Mar 13]; 53 (6): 1084-91 Available from: http://www.clinchem.org/content/53/6/1084.full.pdf+html 3. Paik, S., Tang, G., Shak, S., Kim, C., Baker, J., Kim, W., Cronin, M., Baehner, F., Watson, D., Bryant, J., Costantino, J., Geyer Jr, C. Gene Expression and Benefit of Chemotherapy in Women with Node-Negative, Estrogen ReceptorPositive Breast Cancer. J ClinOncol [Internet]. 2006 Aug 10 [cited 2012 Mar 14]; 24 (23): 3726-34 Available from: http://171.66.121.246/content/24/23/3726.full 4. Genomic Health Inc. St. Gallen International Breast Cancer Expert Panel Guidelines Include Oncotype DX(R) as Predictor of Chemotherapy Benefit [Internet]. Geneva, Switzerland and Redwood City, CA: Genomic Health Inc; 2011 [2011 Jul 25; 2012 Mar 14]. Available from: http://investor.genomichealth.com/releasedetail.cfm?ReleaseID=593678 5. National Cancer Registry Ireland. Cancer in Ireland 2011: Annual report of the National Cancer Registry. Cork, Ireland. National Cancer Registry, 2011 Available from: http://www.ncri.ie/pubs/pubfiles/AnnualReport2011.pdf

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Course Essay: Oncotype DX Student Number: 11314561
6. Lyman G., Cosler L., Kuderer N., Hornberger J. Impact of a 21-Gene RT-PCR Assay on Treatment Decisions in Early-Stage Breast Cancer: An Economic Analysis Based on Prognostic and Predictive Validation Studies. Cancer [Internet]. 2007 Feb 20 [cited 2012 Mar 16]; 109 (6): 1011-18 Available from: http://onlinelibrary.wiley.com.eproxy.ucd.ie/doi/10.1002/cncr.22506/pdf 7. Yang M, Rajan S, and Issa A. Cost Effectiveness of Gene Expression Profiling for Early Stage Breast Cancer: A Decision-Analytic Model. Cancer [Internet]. 2012 Feb 22 [cited 2012 Mar 17]; Available from: http://onlinelibrary.wiley.com.eproxy.ucd.ie/doi/10.1002/cncr.27443/pdf 8. Hornberger J, Chien, R, Krebs K, and Hochheiser L. US Insurance Programs Experience with a Multigene Assay for Early-Stage Breast Cancer. J Oncol Prac [Internet]. 2011 May [cited 2012 Mar 17]; 17(5): e194-202 Available from: http://www.ajmc.com/articles/AJMC_11JOPmayHornberger_e194/ 9. Health Services Executive. Oncotype DX to be made Available in all Designated Cancer Centres [Internet]. Naas, Co. Kildare: Health Services Executive; Undated [2011 Oct 05; 2012 Mar 18] Available from: http://www.hse.ie/eng/services/Find_a_Service/National_Cancer_Control_Progr amme/Oncotype%20DX%20to%20be%20made%20available%20in%20all%20desi gnated%20cancer%20centres.html