BC-Specific Mortality in Patients 50 Years Old or Younger



Michael D. Alvarado, MD: The Oncotype DX Breast Recurrence Score was originally developed for ER [estrogen receptor]-positive patients who were lymph node—negative. After those data came out and showed that it was extremely robust and other studies showed the same type of information, oncologists and researchers started thinking, “Well, maybe we can utilize this test in node-positive patients.” We’re getting a lot of great information for node-negative patients, but can we actually use it in node-positive patients? Could there be a group of women who are estrogen receptor–positive and node-positive who would not benefit from the addition of chemotherapy?

Originally, there was a great trial called SWOG-8814, which looked at node-positive patients. In this retrospective-prospective analysis, it did show for postmenopausal women that there was no benefit of the addition of chemotherapy for women that had a recurrence score of less than 18. This gave us information such that we could potentially use this in postmenopausal patients, maybe with small tumor burden in the lymph nodes or a micrometastasis or 1 positive node. But these were really limited data.

There were also some data from the TransATAC trial looking at node-positive patients showing that women who had 1 to 3 positive nodes and got hormone therapy alone and were postmenopausal, actually had very good outcomes. Again, this added to the information that maybe there are women, specifically in the postmenopausal setting, who would not benefit from the addition of chemotherapy. I think oncologists across the country started incorporating these data into their postmenopausal patients.

Now, recently at the San Antonio Breast Cancer Symposium in 2019, there was a poster presentation looking at premenopausal women, or women under the age of 50, with node-positive breast cancer who were ER-positive and also had received the Oncotype recurrence score test. This was in a poster presentation and it was from the SEER [Surveillance, Epidemiology, and End Results] data, which include a very large number of women. We’re talking about large data sets here, thousands of women. What these data showed is that even women who are under the age of 50 who have either micrometastases or 1 positive lymph node, if they didn’t get chemotherapy, they actually did very well.

This adds to the body of evidence that the recurrence score can be used for node-positive patients. Specifically now, we can start looking at premenopausal women or women under the age of 50 for these patients who have 1 positive node or micrometastases. We can potentially now take away that overtreatment they were receiving with chemotherapy, but really we should use it on the basis of an individualized discussion and multidisciplinary tumor board discussion to look at these patients.

Now, is this changing practice? I think it is. In our own clinic, we are definitely identifying women who are under the age of 50 where if they have a micrometastasis or a single positive node, our oncologists feel more comfortable ordering the recurrence score, looking at the number, and helping identify potential patients who can forego chemotherapy and get endocrine therapy alone. It really is great for these women as well.

Transcript Edited for Clarity

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