Clinical relevance of the 21-gene Recurrence Score® assay in treatment decisions for patients with node-positive breast cancer in the genomic era

In contemporary management of early-stage breast cancer, clinical decisions regarding adjuvant systemic therapy are increasingly made after considering both genomic assay results and clinico-pathologic features. Genomic information augments the prognostic information gleaned from clinico-pathologic features by providing risk estimates for distant recurrence and/or breast cancer-specific survival based on individual tumor biology. The 21-gene Oncotype DX Breast Recurrence Score® (RS) assay is validated to be prognostic and predictive of chemotherapy benefit in patients with hormone receptor-positive (HR+), HER2-negative early-stage breast cancer, regardless of nodal status. Because patients frequently are recommended to receive adjuvant chemotherapy based on the perceived poor prognosis related to a positive nodal status, inconsistent use of any prognostic genomic assay in the node-positive (N+) setting likely results in overtreatment of some patients, particularly those with a low genomic risk as defined by the RS test. This comprehensive review of the evidence for the RS assay in patients with N+, HR+, HER2-negative early-stage breast cancer focuses on outcomes of patients with low RS results treated with hormonal therapy alone. Aggregate findings show that the RS assay consistently identifies patients with low genomic risk N+ breast cancer, in whom adjuvant chemotherapy can be avoided without adversely affecting outcomes. This evidence suggests that HR+ patients with limited nodal involvement and low RS results should discuss with their physicians the pros and cons of adjuvant chemotherapy at the time their treatment plans are being decided.