Impact of the 21-Gene Assay in Patients with High-Clinical Risk ER-Positive and HER2-Negative Early Breast Cancer: Results of the KARMA Dx Study

SIMPLE SUMMARY: The 21-gene Oncotype DX Breast Recurrence Score(®) assay is prognostic and predictive of chemotherapy benefit for patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative (HER2−) in Early Breast Cancer (EBC). The KARMA Dx study evaluated the impact of the Recurrence Score(®) results (RS) on the treatment decision for patients with EBC and high-risk clinicopathological characteristics for whom chemotherapy (CT) was considered. A total of 219 consecutive patients were included. After 21-gene testing, treatment decisions changed from CT + endocrine therapy (ET) to ET alone for 67% of the whole group. Physicians’ confidence in their final recommendations increased in 34% of cases. Our findings indicate the substantial potential of the 21-gene test to guide CT recommendations in patients with EBC considered to be at high risk of recurrence based on clinicopathological parameters, regardless of nodal status or treatment setting. ABSTRACT: Background: The 21-gene Oncotype DX Breast Recurrence Score(®) assay is prognostic and predictive of chemotherapy benefit for patients with estrogen receptor-positive, HER2− early breast cancer (EBC). The KARMA Dx study evaluated the impact of the Recurrence Score(®) results (RS) on the treatment decision for patients with EBC and high-risk clinicopathological characteristics for whom chemotherapy (CT) was considered. Methods: Eligible patients with EBC were candidates for the study if CT was considered standard recommendation by local guidelines. Three high-risk EBC cohorts were predefined: (A) pT1-2, pN0/N1mi, and grade 3; (B) pT1-2, pN1, and grades 1–2; and (C) neoadjuvant cT2-3, cN0, and Ki67 ≤ 30%. Treatment recommendations before and after 21-gene testing were registered, as well as treatment received and physicians’ confidence levels in their final recommendations. Results: A total of 219 consecutive patients were included from eight Spanish centers: 30 in cohort A, 158 in cohort B, and 31 in cohort C. Ten patients were excluded from the final analysis as CT was not initially recommended. After 21-gene testing, treatment decisions changed from CT + endocrine therapy (ET) to ET alone for 67% of the whole group. In total, 30% (95% confidence interval [CI] 15% to 49%), 73% (95% CI 65% to 80%), and 76% (95% CI 56% to 90%) of patients ultimately received ET alone in cohorts A, B, and C, respectively. Physicians’ confidence in their final recommendations increased in 34% of cases. Conclusions: Use of the 21-gene test resulted in an overall 67% reduction in CT recommendation in patients considered candidates for CT. Our findings indicate the substantial potential of the 21-gene test to guide CT recommendations in patients with EBC considered to be at high risk of recurrence based on clinicopathological parameters, regardless of nodal status or treatment setting.