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1.  Societal cost-effectiveness analysis of the 21-gene assay in estrogen-receptor–positive, lymph-node–negative early-stage breast cancer in Japan 
Background
Breast-cancer incidence and mortality have been increasing in Japan. Japanese-specific clinical validity and utility data for the 21-gene assay (Oncotype DX® Breast Cancer Assay; Genomic Health, Inc., Redwood City, USA) are now available. The objective of this study was to evaluate the cost-effectiveness of the 21-gene assay for the guidance of adjuvant chemotherapy decisions in estrogen-receptor–positive, lymph-node–negative, early-stage breast cancer patients, from the Japanese societal perspective.
Methods
The recurrence risk group distribution by the 21-gene assay result and the assay’s influence on adjuvant chemotherapy recommendations were obtained from a study of 104 patients. A state-transition cohort (Markov) model tracked time from surgery until distant recurrence and from distant recurrence to death. Adjuvant chemotherapy benefit by 21-gene assay risk group was based on published clinical validation studies. Direct and indirect medical costs were obtained from the referral centers. Utilities associated with progression and chemotherapy-related adverse events were extracted from literature. Sensitivity analyses assessed the key drivers and robustness of the primary outcomes.
Results
The 21-gene assay identified 48% of patients as low-risk, 36% as intermediate-risk, and 16% as high-risk. Total acute chemotherapy-related costs decreased by ¥154,066 due to less adjuvant chemotherapy usage. In the high-risk group, adjuvant chemotherapy use increased 18%, leading to survival benefits. Chemotherapy use overall decreased by 19%. Monitoring costs increased by ¥3,744 but recurrence costs declined by ¥46,113 per patient. Use of the 21-gene assay increased quality-adjusted–life-years (QALYs) by 0.241 per patient on average; the net cost per QALY gained was ¥636,752 ($6,368).
Conclusions
The 21-gene assay for women with estrogen-receptor–positive, lymph-node–negative, early-stage breast cancer is projected to be cost-effective in Japan.
doi:10.1186/1472-6963-14-372
PMCID: PMC4165904  PMID: 25190451
Breast cancer; Cost-effectiveness; Cost-benefit; Molecular diagnostic testing; Genetic testing
2.  Biomarker Modulation Following Short Term Vorinostat in Women with Newly-Diagnosed Primary Breast Cancer 
Purpose
Agents that target the epigenome demonstrate activity in breast cancer models. In preclinical studies, the histone deacetylase inhibitor vorinostat induces cell cycle arrest, apoptosis and differentiation. We evaluated biomarker modulation in breast cancer tissues obtained from women with newly-diagnosed invasive disease who received vorinostat and those who did not.
Experimental Design
Tumor specimens were collected from 25 women who received up to 6 doses of oral vorinostat 300 mg twice daily and from 25 untreated controls in a non-randomized study. Candidate gene expression was analyzed by RT-PCR using the Oncotype DX® 21-gene assay, and by immunohistochemistry for Ki-67 and cleaved caspase-3. Matched samples from treated women were analyzed for gene methylation by QM-MSP. Wilcoxon non-parametric tests were used to compare changes in quantitative gene expression levels pre- and post-vorinostat with changes in expression in untreated controls, and changes in gene methylation between pre- and post-vorinostat samples.
Results
Vorinostat was well-tolerated and there were no study-related delays in treatment. Compared to untreated controls, there were statistically significant decreases in the expression of proliferation-associated genes Ki-67 (p=0.003), STK15 (p=0.005), and Cyclin B1 (p=0.03) following vorinostat, but not in other genes by the Oncotype DX® assay, or in expression of Ki-67 or cleaved caspase-3 by immunohistochemistry. Changes in methylation were not observed.
Conclusions
Short term vorinostat administration is associated with a significant decrease in expression of proliferation-associated genes in untreated breast cancers. This demonstration of biological activity supports investigation of vorinostat in combination with other agents for the management of breast cancer.
doi:10.1158/1078-0432.CCR-13-0033
PMCID: PMC3718062  PMID: 23719261
Breast cancer; epigenetics; histone deacetylase inhibitors; vorinostat; predictive biomarkers
3.  Physician Survey of the Effect of the 21-Gene Recurrence Score Assay Results on Treatment Recommendations for Patients With Lymph Node–Positive, Estrogen Receptor–Positive Breast Cancer 
Journal of Oncology Practice  2011;7(2):94-99.
This physician survey looks at the effect of the 21-gene recurrence score assay results on adjuvant treatment recommendations for patients with lymph node–positive, estrogen receptor–positive breast cancer.
Purpose:
To survey the effect of the 21-gene recurrence score (RS) assay results on adjuvant treatment recommendations for patients with lymph node–positive (N+), estrogen receptor–positive (ER+) breast cancer.
Methods:
Medical oncologists who ordered the 21-gene RS assay were invited to complete a survey regarding their most recent patient with N+/ER+ breast cancer. We obtained responses from 160 (16%) of the 1,017 medical oncologists.
Results:
Most of the respondents were in community (71%) versus academic (25%) settings and had practiced for a median of 11 years. T1, T2, or T3 disease was reported in 62%, 35%, and 3% of patients, respectively. One, two, three, or ≥ 4 nodes were reported in 69%, 18%, 6%, and 3% of patients, respectively. Eighty-six percent of the oncologists made treatment recommendations before obtaining the RS; 51% changed their recommendations after receiving the RS. In 33%, treatment intensity decreased from chemotherapy plus hormonal therapy to hormonal therapy alone. In 9%, treatment intensity increased from hormonal therapy alone to chemotherapy plus hormonal therapy. In 8%, treatment recommendations changed in a way that did not fit the definition of either increased or decreased intensity.
Conclusion:
In this survey of physician practice, the RS result was used to guide adjuvant treatment decision making in N+/ER+ breast cancer more often in patients with tumors less than 5 cm in size and one to three positive lymph nodes than in patients with larger tumors and four or more positive nodes and yielded an overall reduction in recommendations for chemotherapy.
doi:10.1200/JOP.2010.000046
PMCID: PMC3051869  PMID: 21731516

Results 1-3 (3)