There are several genomic tests that can help predict the risk of recurrence of early-stage breast cancer and determine the benefits of chemotherapy, including Oncotype DX, MammaPrint, Mammostrat, and Prosigna. Oncotype DX analyzes the activity of 21 genes and assigns a Recurrence Score between 0-100, with scores below 18 indicating a low risk cancer unlikely to benefit from chemotherapy. MammaPrint analyzes 70 genes to determine a low or high risk classification. Mammostrat measures levels of 5 genes to calculate a risk index score. Prosigna analyzes 58 genes to estimate the risk of distant recurrence within 10 years as low, intermediate, or high risk. Of the tests, Oncotype

1. Dr. Vibhay Pareek
GENETIC ASSAYS IN BREAST CANCER

5. PROGNOSTIC AND PREDICTIVE MARKERS:

6. • Axillary node status
• Histological grade
• Tumor size
• Patient age
• LVI
• ER/PR status
• Her2 Neu Status
• Mammaprint
• Oncotype DX
PROGNOSTIC OR RECURRENCE RISK
These markers estimate risk of
disease recurrence

7. • ER Status
• Her2 Neu Status
• Oncotype DX test
PREDICTIVE (TREATMENT BENEFITS)

8. THE QUESTION IS WHY IS IT NEEDED ……

9. • 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.

11. • Oncotype DX
• MammaPrint
• Mammostrat
• Prosigna
GENOMIC ASSAYS AVAILABLE

12. • Estimate a woman’s 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 surgery
• Estimate a woman’s 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 surgery
• Analyzes 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

13. • Estimate a women’s recurrence risk for early-stage breast
cancer
• The breast cancer can be hormone-receptor-positive or
hormone-receptor-negative
• Analyzes 70 genes to see how active they are and then
calculates either a high-risk or a low-risk recurrence score
• MammaPrint results can help a woman and her doctor make a
more informed decision about whether to use chemotherapy
to reduce recurrence risk
MAMMAPRINT

14. • Estimate a woman’s risk of recurrence of early-stage,
hormone-receptor-positive breast cancer
• Measures the levels of five genes in breast cancer cells
• Calculate a risk index score
• The higher the risk index, the more likely the cancer is to come
back
• Women are assigned to a risk category (high, moderate, or
low) based on their risk index score.
MAMMOSTRAT

15. • 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

17. • 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

18. • The Oncotype DX is used in two ways:
– to help doctors figure out a woman’s 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 surgery
– to help doctors figure out a woman’s 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

19. • 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.

20. • you’ve recently been diagnosed with stage I or II invasive breast
cancer
• the cancer is estrogen-receptor-positive
• there is no cancer in your lymph nodes (lymph node-negative
breast cancer)
• you and your doctor are making decisions about chemotherapy
• you’ve recently been diagnosed with DCIS
• you’re having lumpectomy to remove the DCIS
ELIGIBILITY FOR THE TEST:

21. HOW DOES ONCOTYPE DX WORK:

22. • 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 return
– whether you’re likely to benefit from chemotherapy if you’re being
treated for early-stage invasive breast cancer
– whether you’re likely to benefit from radiation therapy if you’re being
treated for DCIS

23. • 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. It’s 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.

24. • 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. It’s 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.

25. 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.

27. LEVELS OF GENE EXPRESSION DETERMINE RECURRENCE SCORE
21-gene assay = 16 outcome-related genes + 5 reference genes
Higher expression levels of
“favorable” genes = ↓ RS
Higher expression levels of
“unfavorable” genes = ↑ RS
A risk score is calculated from 0 -100
Cutoff points chosen based on
Results of NSABP trial B-20

28. Results: Population distribution by Oncotype DX risk group
A Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative Breast Cancer
Intermed. risk
27.0%
Low risk
51.0%
Paik .S. et al. N Engl J Med 2004;351:2817-26
High risk
22.0%

29. All patients
Low Risk (RS < 18)
Years
100
0
20
40
60
DRFS(%)
80
0 2 6 104 8 12 1614
Intermediate Risk (RS 18 - 30)
High Risk (RS  31)
P < 0.00001
DISTANT RECURRENCE-FREE SURVIVAL (%)
Paik .S. et al. N Engl J Med 2004;351:2817-26
93%
69%

30. Recurrence Score
40
35
30
25
20
15
10
5
0
0 5 10 15 20 25 30 35 40 45 50
Recurrence Score
RateofDistantRecurrenceat10years
95% C.I.
Recurrence Rate
Low
RS < 18
Rec. Rate = 6.8%
C.I. = 4.0% - 9.6%
Intermediate
RS 18 - 31
Rec. Rate = 14.3%
C.I. = 8.3% - 20.3%
High
RS  31
Rec. Rate = 30.5%
C.I. = 23.6% - 37.4%
Paik .S. et al. N Engl J Med 2004;351:2817-26

31. PROSPECTIVE VALIDATION OF ONCOTYPE DX:TAILORX TRIAL
Low RS:
Hormonal
Therapy
High RS:
Chemo +
Hormonal
Therapy
Hormonal Therapy Chemo + Hormonal
11,248 ER+/LN- patients

32. Low RS associated with minimal chemotherapy benefit
High 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:

34. High gradeLow grade
High riskLow riskMammaPrint
OLD VERSUS NEW DIAGNOSTICS OF CANCER:
FROM MICROSCOPE TO MICROARRAY

35. • 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.

36. • stage I or stage II
• invasive
• smaller than 5 centimeters
• estrogen-receptor-positive or -negative
• in three or fewer lymph nodes
ELIGIBILITY:

37. • 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.

39. • 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:
– age
– size of the cancer
– cancer grade
– whether cancer cells were found in nearby lymph nodes
– general health

41. PROGNOSIS CLASSIFIER FOR BREAST CANCER BASED
ON GENOMIC PROFILING
Good signature
Poor signature
threshold
Rows:70
significant
prognosisgenes
Columns: tumor samples
Threshold set with 10% false negatives
91% sensitivity; 73% specificity
Metastases:
white = +

44. RASTER TRIAL: AN IMPLEMENTATION STUDY

46. • 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).

47. • 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:

49. • 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.

50. • 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.

51. • 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.

52. • stage I or stage II and lymph node-negative
• stage II with one to three positive nodes
• hormone-receptor-positive
• invasive
• have been treated with surgery and hormonal therapy
ELIGIBILITY:

53. • 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.

54. • 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) risk
– node-positive cancers are classified as low (0-40) or high (41-100) risk

56. SUMMARY

57. CONCLUSIONS
• Gene signatures augment current clinicopathological variables in
assessing risk of recurrence
• Gene expression profiles may be both prognostic and predictive for
patients with early breast cancer
• NCCN 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

58. 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 invasion
• Tumor > 1 cm with
favorable or
unfavorable
pathologic
features
Consider
Oncotype
DX
Hormone receptor-positive, HER2-negative disease
pT1, pT2, or pT3 and pN1mi
No test
RS < 18
RS 18-
30
RS ≥ 31
Adjuvant endocrine therapy
± adjuvant chemotherapy
Adjuvant endocrine therapy
endocrine therapy
± adjuvant chemotherapy
Adjuvant endocrine therapy
+ adjuvant chemotherapy