"High Risk" Mammaprint Luminal Bs- what was your 'score'?

BarredOwl

Hello barcelonagirl:

Thanks for your additional remarks and clinical information, which is quite interesting. I think you are citing some results of the RASTER trial, found here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC373462...

"The 5-year DRFI probabilities for 70-gene signature low-risk (n = 219) and high-risk (n = 208) patients were 97.0% and 91.7% (p = 0.03), respectively (Supporting Information Fig. 1). Importantly, this difference in outcome was observed despite the fact that in the 70-gene signature low-risk group 15% (33/219) of the patients received adjuvant chemotherapy, versus 81% (169/208) in the high-risk group."

If so, I would just note that the 91.7% number is actually a five-year distant-recurrence-free interval (DRFI):

"For this analysis, we estimated five-year distant-recurrence-free interval (DRFI), comprising distant recurrence and death from breast cancer".

This would not count local recurrences by my reading (DRFI is different from disease-free survival).

The trial results and assay results appear to focus on distant-recurrence. So for high risk patients, the probability of distant recurrence at 10-years was 29% without treatment (see sample report link from Tshire, top, "Distant Recurrence Probability Without Treatment"). Similarly, the Physician's Brochure linked above says: "Patients classified as "High Risk" had a 29% chance to develop distant metastases at 10 years without adjuvant treatment."

Do you agree?

BarredOwl

Lisey

Barred, I know I"m waking this thread up... forgive me. I wanted to add my stats as I'm more borderline than tshire is.. but on the low end. My paper doesn't say I'm borderline, yet I'm so close to zero it freaks me out a little. Anyway, here is mine to add to the food for thought. I have a call in to Agendia, and apparently a pathologist will be calling me back tomorrow with answers. I'll post them here just so others like Tshires will know what they told me. I plan on asking Tshire's question as well.

BarredOwl

Hi Lisey:

There was a good deal of confusion at the start of the thread.

"Borderline" has a specific meaning, and according to information provided by Agendia, if a result is considered "borderline" the report will clearly indicate it.

Please see the small print on your personal MammaPrint FFPE report (dated 27 July 2016), in the section entitled "Assay Description". On my screen I had to enlarge it and its a bit fuzzy, but it appears to state:

"If a FFPE sample's MammaPrint Index (MPI) falls within a pre-defined area around the classification cut-off between - 0.050 and + 0.050, the classification accuracy is less than 90%. See MammaPrint Physician's Brochure found on www.agendia.com for more information."

I assume your report does not indicate your result was a "borderline" result, and your MammaPrint Index ("MPI") of + 0.059 is outside of the specified range (if I am seeing it correctly on my screen).

I note that the original FDA 510(k) document linked above in the thread gave a slightly different borderline range (-0.0575 to +0.0575) for MammaPrint FFPE. It is possible that the borderline range was updated by Agendia, and I would think the content of your more current report controls in this regard.

Note that the "borderline" ranges are DIFFERENT for MammaPrint versus MammaPrint FFPE. Again, one should look to the content of their personal report.

As explained above, the MPI value is a number between - 1.0 and +1.0 and is calculated by a computer algorithm:

"Data analysis is performed according to a specific MammaPrint ® FFPE algorithm (MammaPrint® Index, or MPI). The algorithm calculates the correlation of the sample expression profile to a template (the mean expression profile of 44 tumors with a known good clinical outcome) and determines the molecular profile of the sample. This algorithm is designed and programmed by Agendia and compiled into a standalone software program, "X- Print Analysis Software". The "X-Print Analysis Software" loads a data file (CSV) which is created by the laboratory technician by extracting specific information from the laboratory database. The "X-Print Analysis Software" reads the CSV file, opens the Feature Extraction Software data files (TXT), performs quality control checks, determines the sample expression profile, calculates the correlation of sample profile to the "Low Risk" template profile on a scale of -1.000 to +1.000 (MammaPrint® FFPE reportable range), compares the calculated correlation to a pre-defined cut-off value and determines the samples prognostic profile (i.e., Low Risk, High Risk, Low Risk Borderline, or High Risk Borderline)."

There is a single comparator or template profile, and it is a "low risk" template:

'. . .calculates the correlation of sample profile to the "Low Risk" template profile on a scale of -1.000 to +1.000 (MammaPrint® FFPE ..."

The "template" is "the mean expression profile of 44 tumors with a known good clinical outcome."

In your case, the mRNA expression levels of 70 genes from part of the tumor sample were determined, and the combined information was used to generate a sample mRNA expression profile. Your sample mRNA expression profile was compared by computer program to the "low risk" template profile, which calculated an MPI value (reflecting a certain degree of correlation with the template profile). Your positive MPI value (+ 0.059) is above the clinical classification threshold of zero for MammaPrint® FFPE and reflects a particular computer-based measure of the level of correlation with or similarity to the low risk template profile. The value generated places you in the "low risk" category, with certain average risks of recurrence determined by various clinical studies for the low risk cohort.

To my layperson's knowledge, no published study has correlated specific numerical values of MammaPrint Index ("MPI") with differing degrees of risk of recurrence.

As always, be sure to confirm all information above with your MO and with Agendia.

BarredOwl

Lisey

Barred, I appreciate your great insight on all this. I'm only .009 away from the borderline, so that of course makes me really nervous... but not enough to change my mind on no chemo. I just got word back I'm an Ultra Rapid CYP2D6 metabolizer, so at least I have happy news there. (no symptoms yet on the Tamoxifen)... In any case, I found this thread looking for the borderline numbers and low and behold, you found it on my own papers!

I have a phone appointment with the lead pathologist at Agendia tomorrow. I do plan on discussing with her some of these questions. I'll return and report!

BarredOwl

For completeness, I add the following comments.

(A) If a report clearly states that a result is "borderline", it is necessary to discuss this with one's medical oncologist. Inquiries should also be made with Agendia regarding what the result means and the level of accuracy of any classification.

(B) It is also possible that the MammaPrint Index ("MPI") number may fall within the borderline range defined on your report (see e.g., Assay Description section), yet would not be indicated as a "borderline" result. It is necessary to discuss this situation with one's medical oncologist, and to make inquiries with Agendia. Some information from Agendia indicates that a sample with a first MammaPrint Index falling within the applicable borderline range near zero is re-tested prior to final risk classification:

"Samples that lie within the borderline region and that are close to the threshold are more likely to switch classes with repeated analyses. In a diagnostic setting these samples will be performed in duplicate in order to obtain better outcome accuracy. A borderline sample will be re-tested from RNA onwards going through the following steps a second time: synthesis, amplification, labeling, hybridization, and scanning and XPrint analysis. After two QC-passed results are generated for a borderline sample, the MammaPrint® Index of both results will be averaged, and the final risk classification will be made according to the mean value."

Possible questions for the MO and Agendia would include: Was my sample re-tested by Agendia? If it was re-tested, please provide an explanation of what the final result means. Does this mean that the final risk classification of either "high risk" or "low risk" (resulting from re-testing and averaging of scores) has >90% chance of being correctly classified?

These two scenarios are quite uncommon. Most people's MPI will fall outside of the borderline range noted in their personal report.

BarredOwl

Lisey

Hi Everyone. I called and spoke to the chief Pathologist at Agendia. She told me they test all samples TWICE to confirm the status. (including mine which was only 0.009 outside of the borderline) If there is a discrepancy, they test it 2 more times after that. She confirmed to me I'm in the low zone (twice) and while she agreed that logically, my numbers are 'more risky' than someone not so close to the zero, but she said the numbers they give are AVERAGES for the entire spectrum of Low Risk with the variances given. She also mentioned the numbers are for no chemo or hormonal therapy, so there's that.

So in a way, our assumption that those of us closer to zero are right to think we have more risk (in the Low Risk group) than someone farther from zero. It would be inverse for the High Risk group, is accurate.. but they don't have a way of quantifying that difference so they just use averages. I think it said 1.3% (0-3.1%) for the first 5 years for Low Risk. FFPE samples are only for 5 years at this point, since the technology is more recent. She also said that Agendia has phased out their Targetprint as well because they are doing the 'mammoprint/blueprint' suite for everyone instead.

I am glad I was tested more than once and both times was in low risk. But my risk is probably more in the 3.1% rather than 1.3%.. but I"m good with no chemo.

BarredOwl

Hi Lisey:

Thank you very much for the update.

The advice you received is consistent with the comments above "that the binary MammaPrint test does not provide individualized risks, but only provides the average risk associated with the high risk cohort or the average risk associated with the low risk cohort." In other words, the recurrence risk estimates are based on risks determined for a group and are expressed as averages with confidence intervals ("CI").

The MammaPrint Index ("MPI") number appears to be generated from the patient's microarray data by a software program which uses an algorithm or "classifier". The program takes the mRNA expression data from 70 genes, determines the "sample expression profile", and assesses its degree of similarity to a standard low risk expression profile (the standard or low risk "template" profile is a "mean expression profile of 44 tumors with a known good clinical outcome"). The degree of similarity to the standard low risk profile is expressed as the MPI value between -1.0 and +1.0, with +1.0 being the highest degree of correlation. After this correlation step, the calculated MPI value is used to classify one as either "high risk" or "low risk" (relative to the "clinical classification threshold" of zero), within the accuracy of the test.

The MPI value reflects the degree of "correlation" between the sample profile and the low risk standard or template profile. The output of the test is the final risk classification of high risk or low risk. Various clinical validation studies were performed to assess the "prognostic" ability of the test. They determined various types of average recurrence risk among a group of patients classified as "high risk" and among a groups of patients classified as "low risk". Thus, the average recurrence risks provided are based on risks determined for the high risk or low risk group as a whole.

It is my understanding that the clinical validation studies did not look at how recurrence risk might vary within the low risk group according to MPI value. They did not determine how risk might vary within the high risk group according to MPI value. Thus, whether positive "low risk" MPI values closer to the clinical classification threshold of 0 are or are not associated with greater risk compared with those closer to +1.0, or whether negative "high risk" MPI values closer to 0 are or are not associated with lower risk compared to those closer to -1.0, is not known. One should be cautious about drawing conclusions in the absence of data. As the Agendia pathologist stated, "they don't have a way of quantifying that difference so they just use averages." Again, they don't have a way of quantifying the difference, because it has never been determined in a clinical study. It may not behave intuitively, or as a continuous variable.

They designed a binary test (high or low). They have not looked at the recurrence risks associated with individual MPI values, and therefore, they have not established differences in recurrence risk (or the size of such differences, if any, or the statistical significance of such differences, if any) between specific MPI values within the same risk category (e.g., Low risk, MPI +0.3 versus Low risk MPI +0.9). In my layperson's understanding, hypothesizing statistically significant differences in recurrence risk between different MPI values within the same risk category where none has been measured in a clinical study would be speculative.

BarredOwl

BarredOwl

For more information about the MammaPrint test, see these selected references:

van't Veer (2002): http://www.nature.com/nature/journal/v415/n6871/pdf/415530a.pdf

van de Vijver (2002): http://www.nejm.org/doi/pdf/10.1056/NEJMoa021967

Buyse (2006), TRANSBIG: http://jnci.oxfordjournals.org/content/98/17/1183.full.pdf

Knauer (2010): http://dev.agendia.com.previewdns.com/wp-content/uploads/2013/05/Knauer_2010_Breast_Cancer_Res_Treat.pdf

Drukker (2013), RASTER: http://onlinelibrary.wiley.com/doi/10.1002/ijc.28082/epdf

Piccart (2016), MINDACT: This EORTC news feature includes the text of the AACR 2016 abstract re the primary analysis from the MINDACT trial of MammaPrint:

http://www.eortc.org/news/mindact-mammaprint-genetic-test-can-reduce-use-of-post-surgery-chemotherapy-among-early-stage-breast-cancer-patients/

BarredOwl

cajunqueen15

Well, yikes, I hope a strongly negative high risk score does not indicate that the cancer is much more likely than the average "high risk" cancer to recur!

I'm weighing in here at -.839 High Risk, Luminal B. I knew from the outset that I had a very aggressive cancer with my ki-67 at 75 (DCIS) and 78% (IDC) and because it had already totally infiltrated two lymph nodes but was still tiny and could not be felt. In fact, my breast tumor was smaller than the next in one of my lymph nodes!

I am almost 15 months out from my initial diagnosis of high-grade DCIS with comedonecrosis (apprently they missed the IDC tumor on the biopsy, which could not be seen by mammogram). No evidence of disease so far. Tick, tick, tick.

BarredOwl

Hi cajunqueen15:

As I noted up above, the test is designed to provide a binary output (high or low). While the particular MammaPrint Index or "MPI" value (e.g., - 0.839) reflects the degree of correlation with a low risk template profile and is used to classify the sample profile as high or low risk (see discussion above, where negative values reflect a lower degree of correlation), to my layperson's knowledge, no study has evaluated or reported on the recurrence risks associated with individual MPI values (e.g., - 0.839) in the same risk category, and therefore, they have not established differences in recurrence risk (or the size of such differences, if any, or the statistical significance of such differences, if any) between specific MPI values within the same risk category (e.g., High risk, MPI - 0.3 versus High risk MPI - 0.9). ***

I note the initial MINDACT trial results were recently published in the New England Journal of Medicine (NEJM), and may be of interest to you:

Cardoso (2016): http://www.nejm.org/doi/full/10.1056/NEJMoa1602253

(The complete article is available for purchase)

Hudis editorial (2016): http://www.nejm.org/doi/pdf/10.1056/NEJMe1607947

(The complete article is available for purchase)

Hunter perspective (2016) (starts part way down the page): http://www.nejm.org/doi/pdf/10.1056/NEJMp1608282

You can purchase a one-day pass to the NEJM and download the complete pdf copies of the Cardoso paper and the Hudis editorial (plus anything else you want). Be sure to access and save down copies of the Supplementary Appendix to Cardoso and a copy of the MINDACT Protocol. The Supplementary Appendix contains a large amount of additional data and information and is a must-have.

BarredOwl

---

*** In contrast, the MammaPrint risk category (high versus low) is used to stratify the BluePrint Luminal-type into BluePrint Luminal-type A and BluePrint Luminal-type B subcategories. BluePrint is an 80-gene test from the same test provider (Agendia), and assigns a BluePrint ("BP") molecular subtype of: Luminal-type; HER2-type; or Basal-type. If the BluePrint result is "Luminal-type", then the MammaPrint result (High or Low) is used for further sub-classification:

(a) MammaPrint Low-Risk / BluePrint "Luminal-type": Luminal-type (A)

(b) MammaPrint High-Risk / BluePrint "Luminal-type": Luminal-type (B)

---

UPDATE: Cardoso (2016) and all Supplementary Materials, including the Supplementary Appendix, are now available for FREE at the link above.

cajunqueen15

Thanks for the articles! Sounds like they are worth a read on a rainy day while the kids nap.

In truth, I did not need Mammaprint to tell me what I already knew. That my cancer was vicious, spreading like wildfire, and far more aggressive than the average "high risk" cancer. Although I understand that it is speculative to surmise that a high negative number means the cancer deserves a special category of "extremely high risk," lol, I knew my cancer was already in that group.

I did not have Mammaprint/Blueprint to decide about chemo or to tell me whether I was high risk or not. In fact, I had it after chemo was completed and halfway through radiation. I had genomic testing done so I would know where the cancer was likely to spread first. I figured based on the aggressive factor that it was either Luminal B or the rare form of ER/PR+ Basal-like tumors. So now I'm keeping an eye on my bones and liver since Luminal tends to go there first. Que sera, sera. If I make it 5 years from diagnosis NED, I will truly believe it's gone and can plan accordingly. It's either all gone or it's everywhere. Tick, tick, tick.

BarredOwl

Just an update on questions above regarding differing MammaPrint Index values, which appear to be the subject of some on-going research in the I-SPY 2 Trial, as recently reported at AACR 2016. In these reports, the MammaPrint "High" risk group was subdivided into two groups.

Wolf (2016), AACR Abstract 858: http://cancerres.aacrjournals.org/content/76/14_Supplement/858

"Combining sensitivity markers to identify triple-negative breast cancer patients most responsive to veliparib/carboplatin: results from the I-SPY 2 TRIAL"

Wolf (2016), AACR Abstract 859: http://cancerres.aacrjournals.org/content/76/14_Supplement/859

"Gene and pathway differences between MammaPrint High1/High2 risk classes: results from the I-SPY 2 TRIAL in breast cancer"

Please keep in mind that meeting abstracts are preliminary in nature. There may be important caveats and limitations to the findings reported. For example, observations may be limited to the particular context (e.g., subset, drug regimens) investigated and/or may not be confirmed in further analysis or subsequent studies.

BarredOwl

cajunqueen15

Did I read this correctly that ultra high risk may be more likely to benefit from veliparib/carboplatin? I'm certain I would fall into the ultra high risk, despite the fact that I am not triple negative, but nobody has ever mentioned either of these options to me. I am also crazy tired and may be extrapolating more out of that than was there.

BarredOwl

I believe that veliparib (a PARP inhibitor) is an investigational drug (not yet approved by FDA). The combination regimen of veliparib plus carboplatin (plus standard therapy) appears be an experimental regimen being tested in the I-SPY 2 trial in the neoadjuvant setting:

http://www.nejm.org/doi/full/10.1056/NEJMoa1513749

"We designed I-SPY 2, a phase 2, multicenter, adaptively randomized trial to screen multiple experimental regimens in combination with standard neoadjuvant chemotherapy for breast cancer. The goal is to match experimental regimens with responding cancer subtypes. We report results for veliparib, a poly(ADP-ribose) polymerase (PARP) inhibitor, combined with carboplatin."

I think the conclusion of the AACR abstract linked above applies to triple-negative patients who have two biomarkers: MP2 and PARPi7-high. Probably, more extensive validation is needed before this combination of markers can be used to select patients to receive a particular drug regimen.

BarredOwl

cajunqueen15

I have heard of using PARP inhibitors for BRCA2 carriers...it must have been a trial, though.II know it is not SOC.

Butterfly1234

I hope one of our community members sees this post and responds. I just received via phone from my breast surgeon my Mammaprint results. I don't have a copy yet and will be discussing results with my MO on Monday. I was told I was Luminal B with a score of -0.13. I'm lymph node free, IDC, stage 1, grade 2/3, ER+ PR+ Her-. I'm confused about the high risk because my proliferation rate is low. I'm wondering if I'm going to need chemotherapy. Prior to this test I was told by two radiologists and MO they were 90% sure I would need radiation and hormone therapy. I'm really depressed and trying to cope. At 65 I've never been more frightened

Luckynumber47

Hi butterfly. I too am puzzled by your score. Base on ER positive and low Mitotic rate I would have guessed that you were luminal A, although being high grade is concerning. Did you have an Oncotype done?

I suspect that your MO will leave the chemo choice up to you. Great, right? I'm 63 and decided against chemo unless it was absolutely essential. Luckily my scores were low enough I felt safe skipping it

JuniperCat

Hi, Butterfly. I'm sorry that you are going through this and are so stressed. Can you seek out another opinion? Did you have the Oncotype test done? I am also Luminal B/high risk mammaprint and decided to get a second opinion re: chemo. One MO told me she thought that I should have it while the second one told me that the risks for me in particular outweighed the benefits. I'm hoping some other folks here will see this post and offer you some suggestions. Hang in there.

Luckynumber47

Also, keep in mind that endocrine therapy is a very powerful drug to keep cancer from returning

Butterfly1234

Hi and thanks so much for your reply. I feel so much support from our members.I'm guessing the higher grade bumped me up to high risk for lack of a better term. I did read that a higher grade responds better to radiation. Who knows? Right now I'm on information overload. Will update as I know more. When I spoke with the medical director from agendia she explained the subtypes to me. Seems like 100 years ago so I'm going to request another consult, onward and forward,

Butterfly1234

My breast surgeon prefers Mammaprint because there's no intermediate score. So I didn't get Oncotype. I am going to ask my MO if there are any tests he can run to help make this decision. I read about Ki67 for post menopausal women.

JuniperCat

Butterfly, I don't know how others feel but my doctors didn't put much credence in the Ki67 due to it being considered by some professionals to be unreliable. I'm surprised that they didn't run the Oncotype test.

Butterfly1234

I have a lot more questions than answers right now. I'm hoping for more clarity once my MO has a chance to review my tests results. This along with my clinicals, etc. should provide a treatment plan. I know there are no guarantees. I'm scheduled for my radiation simulation March 30. But, if chemo is recommended we would have to start that very soon and wait on radiation.I'm really anxious and afraid of the chemo and all that goes with it. I'm a strong person but all I seem to do is cry. My poor husband has never seen me like this. I signed up toattend a support group in April. I'm hoping this helps. Thank you all for your support. I know things can be worse and my prayers go out to everyone dealing with this disease.

Lisey

My Oncologist likewise puts low value in ki levels for GRADE 2 women only. Studies have shown that KI is helpful for both Grade 1 and Grade 3, but with Grade 2 tumors - there is too much variability proven in different pathologists valueing the ki score. They do the mammaprint results twice to confirm, I've had both the oncotype and mammaprint done. My oncotype was intermediate and my mammaprint low risk (which was surprising to me given the ki value - which the doc told me to disregard as I was a grade 2)... In any case, I would trust the mammaprint.

Juniper, as a grade 3 / high risk mammaprint, I'd seriously consider chemo unless you have other medical conditions which would change your risk. Mammaprint has been proven to be accurate in helping some avoid chemo and others to have it.

JuniperCat

Hi, Lisey! I opted out of chemo due to other health issues. They didn't test my ki levels. That's interesting re: the levels and grade 2. I don't know much at all about ki, but I have noticed that quite a number of people here have had this test done.

BarredOwl

UPDATE: The complete PDF version and Supplemental Materials of the 2016 MINDACT publication are now available for free:

Results from the MINDACT trial with 5 years of follow-up were recently published (Cardoso (2016)). The documents can be accessed here:

Cardoso (2016):

Main Page: http://www.nejm.org/doi/full/10.1056/NEJMoa1602253

PDF version (Free): http://www.nejm.org/doi/pdf/10.1056/NEJMoa1602253

Supplementary Appendix (Free): http://www.nejm.org/doi/suppl/10.1056/NEJMoa1602253/suppl_file/nejmoa1602253_appendix.pdf

Hunter perspective (2016) (Free): http://www.nejm.org/doi/pdf/10.1056/NEJMp1608282

Hudis editorial (2016): http://www.nejm.org/doi/pdf/10.1056/NEJMe1607947

(Available for purchase)

BarredOwl

JuniperCat

Thank you, BarredOwl!!

Eleanora23

I know this thread was a while back, but if someone knows specifically who to ask for to get answers on a mamma print, I would like to know. Been to tired to pursue this and none of my health care team would look twice at this report a year+ ago when I was diagnosed (except my intial breast surgeon, who ran the report, cost my insurance a bundle of $$, then handed me the report stating in big red l RISK" during an early visit before surgery, then refused to discuss the test with me at all. Needless to say she didn't remain my surgeon. Had the bedside manner of Darth Vadar. Once in a while the thought of this report rears its ugly head and I want to get to the bottom of it. ALso want Agendia to be fully informed about what this surgeon does...runs their test without actually using it or responding to questions about it. Peace.

BarredOwl

Hi Eleanora23:

Agendia has no supervisory authority or control over ordering physicians.

Occasionally, surgeons order the MammaPrint test, but often they are not familiar with how to advise patients based on the results, because this is not their area of expertise. Your surgeon may have had good intentions, ordering the test early so that the results would be available for your Medical Oncologist, or he may have ordered it before HER2 status was available (jumping the gun a bit, per the below).

I note you had triple-positive disease (ER+ PR+ HER2+). Typically, the MammaPrint test is ordered by Medical Oncologists, because due to their training and experience, they are familiar with what clinical consensus guidelines for breast cancer provide about use of the test in various patient subgroups and current clinical practice. While HER2+ patients are formally "eligible" for the MammaPrint test, at the time of your treatment and as of this date, clinical consensus guidelines from ASCO and NCCN do not include the MammaPrint test for HER2-positive disease. (The current NCCN guidelines for breast cancer were issued in 2017, after publication of the MINDACT results.) Instead, under current ASCO and NCCN guidelines applicable to HER2-positive disease, recommendations about adjuvant systemic therapy, including chemotherapy, HER2-targeted therapy, endocrine therapy, are based on clincal and pathologic criteria.

In light of the above, probably the reason your medical oncologist was not very interested in the MammaPrint test result is because (in accordance with clinical guidelines) the test result was not driving medical advice in your case. It looks like you received a recommendation for paclitaxel plus trastuzumab (Herceptin), which would be within treatment guidelines applicable your case.

BarredOwl

Butterfly1234

---

It is extremely important that anyone who is Luminal B low clinical risk/high Mammaprint genomic risk read every line of the Cardosa Report (see link above) as well as the supplementary report posted by BarredOwl. I am in this discordant group and after a very lengthy consultation with Agendia's medical consultant I can make a highly informed decision about my treatment options. We also went over every detail of my test results which significantly contributed to a greater understanding of interpreting my test results.