Oncotype scoring rant

It is odd how different doctors approach this. My OC urged me to get the oncotype testing done so she would know whether or not to recommend chemo as part of my treatment program. She said she wanted to know as much as possible before making any recommendations-I certainly did not need to agree to have chemo if my numbers were high or anything like that. I definitely didn't have to make any guarantees that I would follow the suggestions of this test to get my insurance company to pay for it.

Generally, I think insurance covers it if the OC orders it because it is more likely to be used to rule out the need for chemo (before the oncotype test almost everyone w BC got chemo-oncotype testing has saved insurance companies money) than to encourage those who might not have gotten chemo to have it. They don't order it for those who will definitely need chemo (large aggressive tumor w several nodes involved). I certainly wanted my OC to have all the info available before she made treatment decisions and I'm not sure why your doctor didn't feel the same way. I'd get a second opinion/see someone else if for no other reason than you don't seem to trust him.

I think you are right. In this day and age, it seems part of the standard of care package for someone with your stats and insurance companies don't seem to have any qualms about paying for it-unlike the MRI I had to fight for/wait for insurance to approve. What he's telling you doesn't seem right to me. I don't think you should have had to ask for it. Doctors at both breast centers I consulted wanted oncotype testing done for me and did not make treatment recommendations until they saw the results.

Hi swedge:

For IDC "Tumor >0.5 cm" that is either pN0 or pN1mi (≤2 mm axillary node metastasis), the NCCN guidelines indicate:

"consider 21-gene RT-PCR assay" (by that they mean OncotypeDX for invasive disease)

Thus, making the decision based on traditional criteria alone is formally within the guidelines, and guidance is provided for when the test is "not done". But I think the best practice would be to have raised it with you as an option (actively "consider" with you).

I noticed you have "Stage IB" in your profile. In another thread, you posted tumor size as 6 mm. Your profile is showing 0/2 nodes.

I was wondering if you are actually Stage IA. Did you have perfectly clear nodes or was there some limited lymph node involvement, such as pN1mi (≤2 mm axillary node metastasis)?

Considering size only, a 6 mm tumor is a "T1" size tumor, more particularly a "T1b" size (Tumor > 5 mm but ≤ 10 mm in greatest dimension). But that is just the "T" or size component of stage, not the actual stage.

Node status is incorporated into the stage determination as shown here:

https://cancerstaging.org/references-tools/quickre...

As you can see in line 2 of the Table entitled ANATOMIC STAGE/PROGNOSTIC GROUPS at page 1, a "T1" (e.g., 6 mm T1b-size) tumor, that is node negative (N0), and M0 would be Stage IA (T1 N0 M0). I am Stage IA (with a T1a size tumor of 1.5 mm).

In contrast, from line 4 of the Table, a "T1" tumor (e.g, T1b-size) with micrometastasis in the node (N1mi), and M0 would be Stage IB (T1 N1mi M0).

I am just another patient, so if you have any question about the above, please seek clarification with your providers.

BarredOwl

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2 hours ago - edited 45 minutes ago by BarredOwl

Hi swedge:

For IDC "Tumor >0.5 cm" that is either pN0 or pN1mi (≤2 mm axillary node metastasis), the NCCN guidelines indicate:

"consider 21-gene RT-PCR assay" (by that they mean OncotypeDX for invasive disease)

Thus, making the decision based on traditional criteria alone is formally within the guidelines, and guidance is provided for when the test is "not done". But I think the best practice would be to have raised it with you as an option (actively "consider" with you).

I noticed you have "Stage IB" in your profile. In another thread, you posted tumor size as 6 mm. Your profile is showing 0/2 nodes.

I was wondering if you are actually Stage IA, since you have perfectly clear nodes. Was there some limited lymph node involvement not in yor profile, such as pN1mi (≤2 mm axillary node metastasis)?

Considering size only, a 6 mm tumor is a "T1" size tumor, more particularly a "T1b" size (Tumor > 5 mm but ≤ 10 mm in greatest dimension). But that is just the "T" or size component of stage, not the actual stage.

Node status is incorporated into the stage determination as shown here:

https://cancerstaging.org/references-tools/quickre...

As you can see in line 2 of the Table entitled ANATOMIC STAGE/PROGNOSTIC GROUPS at page 1, a "T1" (e.g., 6 mm T1b-size) tumor, that is node negative (N0), and M0 would be Stage IA (T1 N0 M0).

In contrast, from line 4 of the Table, a "T1" tumor (e.g, T1b-size) with micrometastasis in the node (N1mi), and M0 would be Stage IB (T1 N1mi M0).

I am just another patient, so if you have any question about the above, please seek clarification with your providers.

BarredOwl

That is odd that he didn't mention the Oncotype test. My surgeon mentioned it to me before he referred me to the MO. It seems like a standard practice here to run the test, with ER+ and no or minimal node involvement. Hope you have a low score, and it's clear what to do next. My MO did first ask me how I felt about chemo before we discussed the test, I do think some MOs like to feel you out a bit. The test cost about $4600 but what with all the surgery I luckily (?) already met my deductible so I paid 10% of that.

My ER+/PR+/HER-2-tumor was t1c (1.3 cm), N0, M0, grade 2, mitotic score of 1. I opted for lumpectomy + radiation. The way my oncologist explained it when I walked in and led off with all the reasons why I didn’t want chemo, was that she was 90% sure I didn’t need chemo. But because my tumor was too big to be a t1a or b, she would order the Oncotype DX test to be sure, and depending on the result lay out the pros & cons of my options. She did not insist I agree to chemo should the score indicate it. As expected, I scored low enough to reinforce her decision (and my desire) to avoid chemo. At my cancer center, for hormone+/HER2- M0 N0 tumors <1cm and Grade 1 or 2, they generally don’t need to order Oncotyping because chemo isn’t indicated. For such tumors >2cm, &/or more than 1+ node or grade 3, they usually don’t order Oncotyping because they’d recommend chemo. They save the test for “gray areas” such as mine. In my case, the test--while pricey--was far cheaper than chemo would have been, and was covered 100% by insurance.

Of course this was four years ago and he may have changed his approach since, but It took an entire hour before my MO mentioned the Oncotype DX. And this was after speaking about chemo. He seemed very relieved that I agreed to the test before a decision was made on chemo.

I thought it odd to leave this to the end. It had nothing to do with pressure from insurance, so I'm thinking it may be about style or that the MO has given the "talk" so often and for so long that mention of the Oncotype gets put at the end since is is "new" to an older MO.

None of my many docs mentioned it.

Onco type dx is now the standard of care, Insurance will pay for the test and I'd personally have your Onco run it for you. You do need to know the score and benefit of chemo for you in order to make a proper and informed decision. good luck and keep us posted.

TailoRx came out just after my surgery but before my first MO consult. I first mentioned OncotypeDX to my BS’ nurse before that, during my pre-op “patient education session.” She explained that at N.Shore Kellogg, for stage IA t1a-size tumors with all my other hallmarks (and certainly, those of Grade 1), they don’t bother to order the test unless the patient insists, because chemo would not be recommended and insurance would be unlikely to pay. For tumors over 2cm (IIA) with all my other hallmarks, they’re likely to recommend chemo, so they’d expect the DX score to reflect a higher likelihood of recurrence and chemo efficacy but would order it if the patient wanted, and insurance would probably pay. For tumors such as mine, a tumor size between 1-1.5 cm (t1c but still Stage IA, or for those 1.5-2cm, a Stage IB) is considered a “gray area” despite other indications of non-aggressiveness--so the OncotypeDX is usually recommended by the MO to confirm or refute her decision to recommend or discourage chemo. My MO told me she was 90% certain she wouldn’t recommend chemo but because my tumor size was 1.3 cm (t1c) it was prudent to order the test--and my insurance covered it 100%. Even though TailoRx’ preliminary data (the study has not yet concluded) addressed postmenopausal women with scores<10, Genomic Health’s own website lists “Low Risk” as “0-17” and 18-30 as “Intermediate.” They’re still gathering data on women with scores between 11-17, since we would still be less likely to elect chemo than those in the intermediate range.