Impact of Oncotype DX breast Recurrence Score testing on adjuvant chemotherapy use in early breast cancer: Real world experience in Greater Manchester, UK.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) recommended the Oncotype DX® Breast Recurrence Score® (RS) assay as an option for informing adjuvant chemotherapy decisions in node-negative, oestrogen receptor (ER)+, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer assessed to be at intermediate risk of recurrence based on clinicopathological factors. We evaluated the impact of RS testing on adjuvant chemotherapy decision-making in routine clinical practice in a UK Cancer Network. METHODS: RS testing was performed in 201 females with newly diagnosed, ER+, HER2-negative, invasive breast cancer who underwent breast surgery with curative intent, were calculated to have a >3% overall survival benefit at 10 years from adjuvant chemotherapy based on PREDICT, and were considered for adjuvant chemotherapy. The impact of RS testing on adjuvant treatment decisions/associated cost was assessed. RESULTS: In all patients, the multi-disciplinary team recommended chemotherapy but the RS result allowed 127/201 patients (63.2%) to avoid unnecessary adjuvant chemotherapy. Amongst ER+, HER2-negative, node-negative patients (eligible for Oncotype DX testing in UK guidelines), 60.3% were spared chemotherapy. In node-positive patients, the assay reduced the use of chemotherapy by 69.2%. The use of RS testing to guide treatment in these 201 patients was associated with significant cost saving (when considering the cost of RS testing for all patients plus chemotherapy and its associated cost for 74 patients). CONCLUSIONS: Incorporating RS testing into routine clinical practice for selected node-negative and node-positive breast cancer patients significantly reduces the use of chemotherapy (p < 0.001) with its associated morbidity and costs.

Preoperative radiotherapy for operable rectal cancer--is a lower dose to a reduced volume acceptable?

AIMS: A retrospective audit was carried out to determine the rate of local recurrence (recurrent tumour within the lesser pelvis or the perineal wound) in 88 rectal cancer patients treated with 20 Gy/four fractions of adjuvant preoperative radiotherapy and curative surgery. MATERIALS AND METHODS: All patients were followed-up by clinical examination with rigid sigmoidoscopy at 6 monthly intervals if the rectum was intact, and computed tomography of the pelvis at 1, 2 and 5 years after surgery. In total, 171 patients with rectal cancer were identified under the care of one surgeon over a period of 11 years from May 1992 to April 2003. We excluded patients with rectal cancer from preoperative adjuvant radiotherapy if they had evidence at presentation of distant metastases, if they had fixed rectal tumours, were treated by local excision and had previous radiotherapy to the pelvis. On this basis, only 88 were considered for preoperative radiotherapy and curative resection with a median follow-up of 5.16 years. RESULTS: The 5-year survival by stage was Dukes A 96%, Dukes B 65% and Dukes C 36%. Overall, four patients (of 88) developed a recurrence within the lesser pelvis or the perineal wound, giving a local recurrence of 4.2% at 3 years (from a Kaplan-Meier graph). CONCLUSIONS: This single-centre audit suggests that a lower dose of radiotherapy to a smaller volume provides an acceptable local recurrence rate that compares very favourably with the well-publicised Swedish and Dutch trials of 25 Gy/five fractions. It was not the intention of this audit to suggest that this dose should be widely adopted. However, given the long-term gastrointestinal morbidity and risk of second malignancies, we advise caution when formulating even more intensive radiotherapy and chemoradiotherapy regimens for rectal cancer.