The EndoPredict Gene-Expression Assay in Clinical Practice - Performance and Impact on Clinical Decisions

Abstract

The validated EndoPredict assay is a novel tool to predict the risk of metastases of patients with estrogen receptor positive, HER2 negative breast cancer treated with endocrine therapy alone. It has been designed to integrate genomic and clinical information and includes clinico-pathological factors such as tumor size and nodal status. The test is feasible in a decentral setting in molecular pathology laboratories. In this project, we investigated the performance of this test in clinical practice, and performed a retrospective evaluation of its impact on treatment decisions in breast cancer. During one year, EndoPredict assays from 167 patients could be successfully performed. For retrospective evaluation of treatment decisions, a questionnaire was sent to the clinical partner. Regarding the molecular EP class, samples from 56 patients (33.5%) had a low-risk, whereas 111 patients (66.5%) showed a high-risk gene profile. After integration of the clinicopathological factors the combined clinical and molecular score (EPclin) resulted in a low-risk group of 77 patients (46.4%), while 89 (53.6%) had a high risk EPclin score. The EPclin-based estimated median 10-year-risk for metastases with endocrine therapy alone was 11% for the whole cohort. The median handling time averaged three days (range: 0 to 11 days), 59.3% of the tests could be performed in three or less than three days. Comparison of pre- and post-test therapy decisions showed a change of therapy in 37.7% of patients. 16 patients (12.3%) had a change to an additional chemotherapy while 25.4% of patients (n = 33) changed to an endocrine therapy alone. In 73 patients (56.2%) no change of therapy resulted. In 6.1% of patients (n = 8), the patients did not agree to the recommendation of the tumor board. Our results show that the EndoPredict assay could be routinely performed in decentral molecular pathology laboratories and the results markedly change treatment decisions.

Figure 1. Distribution of EP class and EP clin class.

Distribution of EP class and EP clin class of all included EndoPredict assays (A). Distribution of EP class and EP clin class of a subgroup of patient for which therapy decision data were available (B).

Figure 2. Test performance of the EndoPredict assay during one year.

167 samples could successfully analysed during one year.

Figure 3. Distribution of the molecular risk score EP related to the histological grade and mitotic index.

Distribution of the molecular risk score EP related to the histological grade (A) as well as to the mitotic index (B). The continuous line revealed the median, the dotted line highlighted the cutoff point of the molecular risk score EP. The cutoff point of ki67 was extracted from the St. Gallen guidelines .

Figure 4. Changes in therapy decisions.

Changes in therapy decisions regarding the decision before and after the EndoPredict assay.

Figure 5. Therapy decision related to the molecular risk score EP and the combined clinical and molecular score (EPclin).

Association between the molecular risk score EP, the combined clinical and molecular score (EPclin) and therapy decision (A). The group of patient’s desire for other therapy was excluded. The dotted vertical line marks the cutoff values of the molecular risk score EP, the broken horizontal line marks the cutoff value of the combined clinical and molecular score (EPclin). Additionally, the therapy decisions related to the combined clinical and molecular score (EPclin) are shown (B). The broken horizontal line marks the cutoff value of the combined clinical and molecular score (EPclin), the continuous line indicates the median.