Oncotype Dx Test Anyone?

Hi - I actually have some confusion about the LCIS which was reported on the biopsy from late January but not on the early March post-lumpectomy path report. I asked the surgeon about this on Friday and he stated that perhaps there was just a smidge of LCIS and the biopsy itself removed it. I wonder if the Oncotype report will address the type of cancer?

Yes, I am on board for radiation but don't know what the impact of the presence of LCIS has with regard to rads. If I even have/had it . . . 

Kam170 - thanks for sharing your scores. Bet that made taking on the chemo "easier." (you know what I mean . . . ) Looks like lots of you end up with slightly higher than the spreadsheet scores. If I count my Nottingham as a 5, I get 19. If I count my Nottingham as 3, I get 14+. I have already decided that if it's 18 or above, I will take chemo. Will report back the actual score when it comes in later this week.

You all are the best - thank you!

blueberry...don't lament and feel lonely with a higher score.  The good news is that there are better treatments today than a mere decade ago and mortalities have greatly improved.  Furthermore, it is more frequent to see sisters here with intermediate scores debating what they should do.  Higher score sisters would be less likely to post, because chemo would be a given.  Good luck!  I wish you well with active treatment and beyond!

Thank you for your responses. I am feeling much better about it all. Is anyone else starting chemo in April?  Nancy, how many cycles of chemo did you have?

I was blessed my score was low but I can see those of you with higher scores feel a sense of relief because your treatment plan is pretty much a slam dunk. Having to make that decision to me just adds more stress and anxiety that none of us need. The Oncotype test is a great tool for Oncologists. It saved me from chemo. I remember when I got THE call from my BS' office with the results of my test I asked her what the highest score they had from the test and she said 59. Good luck with your treatment plans. I did 33 RADS treatments and did fine with them. Diane

Voracious - I would say it is just as important to do the Oncotype score on a grade 3 as a grade 1 and there was never any question from my MOs that I would get the Oncotype test as a grade 3.  Important because even a grade 3 could get a low score and avoid the "presumed" chemo (though that conflict between grade and score presents another dilemna for the patient).  That is actually the marketing  line for Oncotype scoring - to give chemo only when needed and the acknowledgement that the Nottingham grade isn't a perfect predictor.

Additionally, my MO is giving it to all of her patients that are node positive too just to give her a better understanding of the aggressiveness of the tumor.   And since even a grade 1 can get a high score, she probably gives it to all her node negative ER+ patients too - but that kind of goes without saying.

Kam...here's an interesting study regarding the use of the OncotypeDX test and how it affected decisions.  It seems that, overall, quite a number of low and intermediate grade patients had high OncotypeDX scores and 1/3 of patients with Grade 3 tumors that were smaller than 1 cm had high recurrence scores... yet only 68% of those with high scores chose chemo.  Likewise, analysis found that in younger patients, despite low recurrence scores, 33% chose chemotherapy or ovarian suppression.

http://ecancer.org/journal/7/pdf/380-the-impact-of-the-oncotype-dx-recurrence-score-on-treatment-decisions-and-clinical-outcomes-in-patients-with-early-breast-cancer-the-maccabi-healthcare-services-experience-with-a-unified-testing-policy.php

"Next, we evaluated the treatment approach in 293 patients aged ≤ 50 years, and assessed physicians’ choice of chemotherapy and/or
LHRH agonists in addition to hormonal therapy with tamoxifen (LHRH agonists are considered as a potential substitute for chemotherapy
in ER+ premenopausal women [12–17]) versus none. In this age group, overall, a more aggressive treatment approach was noted, and
even in the low Recurrence Score group, close to one-third of patients received chemotherapy and/or LHRH agonists. Still, the proportion
of patients receiving LHRH agonists and/or chemotherapy varied significantly across Recurrence...."

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According to this study... 20% of patients with Grade 3 tumors had LOW recurrence scores...and according to the researchers, they hope that once the TailorX trial is completed they will be better able to assess the outliers...However, it appears until that is known, more younger patients will continue to get more aggressive treatment.....

"The rationale for the MHS policy is to identify patients whose lives may be saved by early chemotherapy use and who may not otherwise be

considered for chemotherapy by the treating physicians. Indeed, follow-up data on this cohort, despite being limited (median of 26 months),

with the various treatment approaches as detailed, showed only four locoregional recurrences, one in a patient borderline for eligibility and

another in a noneligible patient. The MHS policy excludes patients with large Grade 3 tumours based on findings from the original Paik

et al [1] report that assessed 668 tamoxifen-treated patients in the NSABP B-14 study and showed that high grade still had significant

prognostic value in multivariable analysis, including the Recurrence Score. While in that report, concordance for histology grade was only

59–65% between two pathologists, it was highest for poorly differentiated tumours (kappa, 0.61) [1]. It should be noted, however, that low

Recurrence Score may occur in about 20% of patients with Grade 3 tumours [1, 5], and that a Recurrence Score–pathology-clinical (RSPC)

assessment was found to be more prognostic for distant recurrence than Recurrence Score alone [23]; nonetheless, the NSABP B20 data

analysis suggests that Recurrence Score is still the best predictor of chemotherapy benefit (RSPC was not predictive of chemotherapy

benefit [23]). We expect the data from a prospective trial that incorporates both Recurrence Score results and grade (the ongoing TAILORx

trial), to best define their relative significance. Another molecular classification method using genomic grading index also supports the use

of molecular classification mostly in Grade 2 tumours [24, 25]. To overcome potential inaccuracies in Grade 3 tumour readings, the MHS

policy allows pathological reviews of all large Grade 3 tumours and approves Oncotype DX testing if one of the reviewers considers the

tumour to be of lower grade...."

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So, what this study is saying is that it appears that with older patients, the Recurrence Score is more helpful in deciding whether chemo is necessary.  However, it also shows that MORE people should have chemo based on high recurrence scores, but are not choosing it.   However, with younger women, despite low recurrence scores, patients are more likely to still receive chemo or ovarian suppression.  The good news, in the few years of the study, very few patients died and they usually died of other causes.

I think until the results of TailorX are known, for those patients in the gray area, or outliers, those with Grade 3 tumors with low scores or Grade 1 with high scores, it might be a good idea to have the additional Mammaprint as the tie breaker.  I think all of these situations should be explained to a patient before they agree to have the Oncotype DX test, because there is a distinct possibility that the results will be ambiguous.  In fact, I sometimes regret having had the test and knowing that my score is 15.  For sure there was relief in knowing that the risks of chemo outweighed the benefit.  And it is also nice to know that for mucinous breast cancer the "average" score is 15, so I fit  "nicely" into the statistics and confirmed that my Grade 1 tumor was at low risk of recurrence.  However,  due to my age, I was informed that although the Recurrence Score was affirmative of my pathology report, I was still encouraged to be a little more aggressive with my treatment.  So, at the end of the day, I'm not sure that the Oncotype DX test brought much to the table except proving I wasn't an outlier.    I was told in advance of the test to do ovarian suppression and 10 years of endocrine therapy and this was BEFORE the Atlas preliminary results were known.

Bottom line, regarding the above study,  there's still more people who should be getting chemo based on the Oncotype DX test who aren't, and there are young women, who despite low scores are getting it.......

Good morning – 

Interesting discussion about Oncotype scores and tumor grades. This is all brand-new to me and I learn a lot from all of you.

To circle back to my anxiety-ridden post from a few days ago, I got the result from the Oncotype Dx
yesterday: 14. That’s puts the “average rate of distant recurrence” at 9%, with
a margin of error of 3%. I should feel elated but, somehow, a 1 out of 10
change for recurrence, WITH the AI’s, is still troubling – like, isn’t there
something else I can do to lower these odds even further?

I will meet with the MO tomorrow to discuss this more fully.
Part of me wants to throw everything I can at this BC and part wants to go
straight to rads so I can get on with my life.
I need to more fully understand the risks involved with chemo, besides
hair loss and serious discomfort during the process, to appreciate why lowering
one’s odds by 2 or 3% does not seem like a good bet.

Regarding the spreadsheet: since I did not know my ki67
score, filling in the numbers took some guesswork. My results ranged from 14 on
up to 19 depending on how I characterized (guessed at!) various factors – so 14
was smack within that range. 

In the B-14 analysis, there was pathologist agreement in 59-65% of the cases.  The researchers also mention based again, not on this study, but based on the B-14 analysis that there was the most agreement when it came to Grade 3 tumors.  Again in this study 20% of the Grade 3 were found to have LOW recurrence scores.  Also noted, and this speaks to what I mentioned to Kam, the authors of this study hark back to Genomics original study and mention, those with LARGER Grade 3 tumors might be opting OUT from having the Oncotype DX test ("self selection bias"), so that might be the reason behind so many small Grade 3 tumors having low recurrence scores in this study.

The conclusion that I draw from THIS study is that there are still a large number of patients forgoing the test because they have larger Grade 3 tumors and are choosing chemo and make the results of the Oncotype DX test moot.  I can also conclude that pathologists opinions vary more so with Grade 1 and 2 tumors.  And, that based on this study, the Oncotype DX test is identifying more patients who SHOULD be getting chemo.

Lidzy, I'm sure you will arrive at an active treatment plan that you are comfortable with!  Since you are post menopausal, you might wish to discuss adding Zometa to your treatment plan.  Although it is still being studied and is not recommended in the NCCN guidelines, there is growing evidence that it helps reduce mortality in ER positive, postmenopausal patients.

The OncotypeDX test only bases it's recurrence score on the use of Tamoxifen.  The reason being, is that this test was designed years ago, using data collected from before as well as after Tamoxifen was determined to be the Standard of Care since it was the ONLY drug available BEFORE AI's were used.  Any statistics that are mentioned with respect the Oncotype DX test and  AI's, has NOT been quantified.  If you look at the Atlas study, all of the data was based on taking Tamoxifen.  We still don't have any LONG TERM studies quantifying the long term benefit of an AI over taking Tamoxifen.  Short term studies DO confirm a small superiority of an AI over Tamoxifen, HOWEVER....this is a big HOWEVER, this is all still being studied.  If you are interested in the most up-to-date information regarding Tamoxifen and AI's, it can be found in the footnotes of the NCCN guidelines...somewhere around page 98 in the professionals' version.

Lidzy, hello.  I hope you are moving forward with your treatment decisions now that you have your Oncotype DX score.  I know exactly what you are feeling.  I did not get a low score but I can tell you I would not have been comforted to have one...especially when the science says that chemotherapy risks outweigh the benefits in those cases.  What we have to accept is that there is no CURE for breast cancer.  Chemotherapy just isn't proven to be effective with every person and every cancer.   But, if chemotherapy was 100% effective....no one would balk at losing their hair and spending more time in bed and the bathroom.   I guess I am glad that they aren't giving chemo and radiation to everyone....but we need more and better treatments.  That is what we should all be working on with our time and money.

My onc says that despite lowering my recurrence risk from 16% to 13% by doing chemo, my recurrence risk is either 0% or 100%.  I am working to further reduce my risk by 1) limiting alcohol 2) good diet 3) exercise 4) weight control 5) take my AI every day 6) get good sleep 6) be kind to myself and others 7) spend time making me feel good...facials, pedicures, make up, new shoes, etc vacations,  as I can afford it. 

You don't need chemo but there is a lot you can do hon, to improve your situation.

MsP

Voracious - thanks for all of the info.  I will have to find some time to read as I brought home a new furrbaby and he is consuming my time!  

edwards750 you are right.

It's funny I can go quite a while un-worried, but then worry again.

It has been a process.

Like anything else over time we adjust to living with the risk.