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Suzanne C. O'Neill, Claudine Isaacs, Calvin Chao, Huei-Ting Tsai, Chunfu Liu, Bola F. Ekezue, Nandini Selvam, Larry G. Kessler, Marc D. Schwartz, Tania Lobo and Arnold L. Potosky

Background A number a practice guidelines incorporate consideration of gene expression profiling (GEP) of early-stage, hormone receptor–positive, HER2-negative breast tumors with existing pathologic features to refine recurrence estimates and

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Jill R. Tichy, Elgene Lim and Carey K. Anders

worse prognosis and more-aggressive phenotype, higher proportions of high-grade and later-stage tumors, lower estrogen receptor (ER) positivity, and, in some studies, higher expression of HER2. 3 - 5 Furthermore, a young woman with invasive breast

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Kristin K. Deeb, Jakub P. Sram, Hanlin Gao and Marwan G. Fakih

genetic alterations have been associated with chemotherapy or targeted therapy resistance, such as PIK3CA mutations, HER2 amplification, PTEN mutations, BRAF mutations, and NRAS and HRAS mutations, as the authors previously reviewed. 46

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Mara A. Piltin, Kathryn Eckert, Margaret Wight, Alan J. Shienbaum, Jeanine Chiffarano, Trina A. Poretta, Tamara A. LaCouture, Monica N. Khattak, Michele E. Gaguski, Alyssa Imperatore, Sruti Golthi and Kahyun Yoon-Flannery

treatment. Methods: Our Multidisciplinary Breast Leadership Committee instituted a policy for reflex Oncotype DX testing on patients under the age of 70 with estrogen receptor positive, HER2-neu protein–negative, and node-negative invasive breast cancers

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Elizabeth Reed, Robin M. Lally and Roksana Zak

unavailable (n=66). Eight clinical pathways based on ER, PR, and HER2 status were developed to guide treatment, considerations, evidence-based neoadjuvant and adjuvant therapy, and survivorship care. Pathways, with associated educational webinars and links to

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Efrat Dotan, Elizabeth Handorf, Caitlin R. Meeker, Bianca Lewis, Kelly Filchner, Jennifer S. Winn and Lori J. Goldstein

training phase of the study to date, with average age 74 (range, 65–90) and 84% Caucasian. The majority of patients had subtype ER/PR+, HER2- (75%) and 46% were on first-line therapy. 277 recommended interventions were identified: 174 immediate

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Zachary Veitch, Omar F. Khan, Derek Tilley, Patricia A. Tang, Domen Ribnikar, Douglas A. Stewart, Xanthoula Kostaras, Karen King and Sasha Lupichuk

of <85% or ≥85% on breast cancer outcomes in women diagnosed with stage I–III, hormone receptor–positive/negative, HER2-negative breast cancer treated with adjuvant FEC for 3 cycles followed by docetaxel (D) for 3 cycles (FEC-D) chemotherapy from 2007

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Tiffany H. Svahn, Joyce C. Niland, Robert W. Carlson, Melissa E. Hughes, Rebecca A. Ottesen, Richard L. Theriault, Stephen B. Edge, Anne F. Schott, Michael A. Bookman and Jane C. Weeks

After the first report of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial, adjuvant aromatase inhibitor use increased rapidly among National Comprehensive Cancer Network member institutions. Increased aromatase inhibitor use was associated with older age, vascular disease, overexpression of human epidermal growth factor receptor 2 (HER2), or more advanced stage, and substantial variation was seen among institutions. This article examines adjuvant endocrine therapy in postmenopausal women after the first report of the trial, identifies temporal relationships in aromatase inhibitor use, and examines characteristics associated with choice of endocrine therapy among 4044 postmenopausal patients with hormone receptor–positive nonmetastatic breast cancer presenting from July 1997 to December 2004. Multivariable logistic regression analysis examined temporal associations and characteristics associated with aromatase inhibitor use. Time-trend analysis showed increased aromatase inhibitor and decreased tamoxifen use after release of ATAC results (P < .0001). In multivariable regression analysis, institution (P <. 0001), vascular disease (P <. 0001), age (P = .0002), stage (P = .0002), and HER2 status (P = .0009) independently predicted aromatase inhibitor use. Institutional rates of use ranged from 15% to 66%. Adjuvant aromatase inhibitor use increased after the first report of ATAC, with this increase associated with older age, vascular disease, overexpression of HER2, or more advanced stage. Substantial variation was seen among institutions.

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Jill A. Foster, Maziar Abdolrasulnia, Hamidreza Doroodchi, Joan McClure and Linda Casebeer

Background

Studies of adherence to breast cancer guidelines have often focused on primary therapies, but concordance with other guideline recommendations has not been examined as extensively. This study assesses the knowledge and practice patterns of medical oncologists in the United States to inform education and quality improvement initiatives that can improve breast cancer care.

Methods

A survey containing case vignettes and related questions was developed to examine oncologists' clinical decision-making in evaluating and treating women with early breast cancer. The instrument was distributed to a random sample of 742 oncologists in the United States and yielded 205 responses (27.6% response rate). Responses from 184 practicing medical oncologists were analyzed relative to the 2007 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer.

Results

Most oncologists made guideline-consistent choices in clarifying indeterminate human epidermal growth factor 2 (HER2) status (85%), initial treatment for early breast cancer (95%), and postsurgical management of locally advanced breast cancer (82%). Guideline-discordant choices were seen in the lack of clip placement before neoadjuvant chemotherapy (36%), unnecessary use of PET scanning for initial assessment (34%), inappropriate assessment of menopausal status (33%), inappropriate use of tumor markers (22%), and use of chest imaging (16%) during posttherapeutic surveillance.

Conclusions

Oncologists often make guideline-consistent choices, but discordant clinical decisions may occur in important aspects of care for early breast cancer. Broadening the diffusion and adoption of guideline recommendations is an important mechanism for addressing these gaps and may substantially improve the quality of breast cancer care.

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Steven Sorscher

definition of HER2-positive breast cancer to include patients who would now be identified as having “HER2-positive” disease based only on metrics such as identifying HER2 gene amplification using “alternative probes” or using polysomy as a surrogate marker