***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Purpose To compare the cost-effectiveness of the tumor subtyping assays Mammostrat ® and Oncotype DX ® for assessing risk of recurrence in early-stage breast cancer and the potential benefit of adjuvant chemotherapy . Methods Cost-effectiveness analysis from a US third-party payer perspective . A 10 year Markov model was developed to estimate costs and effects of using each method of risk assessment . The percentages of patients assessed as high , moderate , or low risk were obtained from multicenter , prospect i ve , r and omized controlled trials . The analysis simulated the experience of women progressing through various model states representing clinical treatments and subsequent disease . Published recurrence data for Mammostrat ® were adjusted appropriately to account for differences between definitions and sample s of Oncotype DX ® and Mammostrat ® in the original clinical trials . Cost and utility data were obtained from previously published studies . Sensitivity analyses examined how base-case results might differ when input values and assumptions varied . Results Base-case costs for women assessed using Mammostrat ® were $ 15,782 , compared with $ 18,051 for women assessed with Oncotype DX ® . Thus , cost savings of $ 2,268 result ed from using Mammostrat ® . Both Mammostrat ® and Oncotype DX ® result ed in similar life years ( 9.880 and 9.882 ) and quality -adjusted life years ( 7.935 and 7.940 ) , respectively . Sensitivity analyses demonstrated that the assumptions made about recurrence are the key drivers of model results . Discussion Cost savings associated with the use of Mammostrat ® instead of Oncotype DX ® are largely due to the difference in cost between the two tests . Since survival and quality -adjusted life years were similar using either assay , Mammostrat ® has economic advantages for women with early-stage breast cancer BACKGROUND Prior studies with the use of a prospect ive-retrospective design including archival tumor sample s have shown that gene-expression assays provide clinical ly useful prognostic information . However , a prospect ively conducted study in a uniformly treated population provides the highest level of evidence supporting the clinical validity and usefulness of a biomarker . METHODS We performed a prospect i ve trial involving women with hormone-receptor-positive , human epidermal growth factor receptor type 2 (HER2)-negative , axillary node-negative breast cancer with tumors of 1.1 to 5.0 cm in the greatest dimension ( or 0.6 to 1.0 cm in the greatest dimension and intermediate or high tumor grade ) who met established guidelines for the consideration of adjuvant chemotherapy on the basis of clinicopathologic features . A reverse-transcriptase-polymerase-chain-reaction assay of 21 genes was performed on the paraffin-embedded tumor tissue , and the results were used to calculate a score indicating the risk of breast-cancer recurrence ; patients were assigned to receive endocrine therapy without chemotherapy if they had a recurrence score of 0 to 10 , indicating a very low risk of recurrence ( on a scale of 0 to 100 , with higher scores indicating a greater risk of recurrence ) . RESULTS Of the 10,253 eligible women enrolled , 1626 women ( 15.9 % ) who had a recurrence score of 0 to 10 were assigned to receive endocrine therapy alone without chemotherapy . At 5 years , in this patient population , the rate of invasive disease-free survival was 93.8 % ( 95 % confidence interval [ CI ] , 92.4 to 94.9 ) , the rate of freedom from recurrence of breast cancer at a distant site was 99.3 % ( 95 % CI , 98.7 to 99.6 ) , the rate of freedom from recurrence of breast cancer at a distant or local-regional site was 98.7 % ( 95 % CI , 97.9 to 99.2 ) , and the rate of overall survival was 98.0 % ( 95 % CI , 97.1 to 98.6 ) . CONCLUSIONS Among patients with hormone-receptor-positive , HER2-negative , axillary node-negative breast cancer who met established guidelines for the recommendation of adjuvant chemotherapy on the basis of clinicopathologic features , those with tumors that had a favorable gene-expression profile had very low rates of recurrence at 5 years with endocrine therapy alone . ( Funded by the National Cancer Institute and others ; Clinical Trials.gov number , NCT00310180 . ) BACKGROUND The likelihood of distant recurrence in patients with breast cancer who have no involved lymph nodes and estrogen-receptor-positive tumors is poorly defined by clinical and histopathological measures . METHODS We tested whether the results of a reverse-transcriptase-polymerase-chain-reaction ( RT-PCR ) assay of 21 prospect ively selected genes in paraffin-embedded tumor tissue would correlate with the likelihood of distant recurrence in patients with node-negative , tamoxifen-treated breast cancer who were enrolled in the National Surgical Adjuvant Breast and Bowel Project clinical trial B-14 . The levels of expression of 16 cancer-related genes and 5 reference genes were used in a prospect ively defined algorithm to calculate a recurrence score and to determine a risk group ( low , intermediate , or high ) for each patient . RESULTS Adequate RT-PCR profiles were obtained in 668 of 675 tumor blocks . The proportions of patients categorized as having a low , intermediate , or high risk by the RT-PCR assay were 51 , 22 , and 27 percent , respectively . The Kaplan-Meier estimates of the rates of distant recurrence at 10 years in the low-risk , intermediate-risk , and high-risk groups were 6.8 percent ( 95 percent confidence interval , 4.0 to 9.6 ) , 14.3 percent ( 95 percent confidence interval , 8.3 to 20.3 ) , and 30.5 percent ( 95 percent confidence interval , 23.6 to 37.4 ) . The rate in the low-risk group was significantly lower than that in the high-risk group ( P<0.001 ) . In a multivariate Cox model , the recurrence score provided significant predictive power that was independent of age and tumor size ( P<0.001 ) . The recurrence score was also predictive of overall survival ( P<0.001 ) and could be used as a continuous function to predict distant recurrence in individual patients . CONCLUSIONS The recurrence score has been vali date d as quantifying the likelihood of distant recurrence in tamoxifen-treated patients with node-negative , estrogen-receptor-positive breast cancer BACKGROUND PAM50 is a 50-gene test that is design ed to identify intrinsic breast cancer subtypes and generate a Risk of Recurrence ( ROR ) score . It has been developed to be carried out in qualified routine hospital pathology laboratories . PATIENTS AND METHODS One thous and four hundred seventy-eight postmenopausal women with estrogen receptor (ER)+ early breast cancer ( EBC ) treated with tamoxifen or tamoxifen followed by anastrozole from the prospect i ve r and omized ABCSG-8 trial were entered into this study . Patients did not receive adjuvant chemotherapy . RNA was extracted from paraffin blocks and analyzed using the PAM50 test . Both intrinsic subtype ( luminal A/B , HER2-enriched , basal-like ) and ROR score were calculated . The primary analysis was design ed to test whether the continuous ROR score adds prognostic value in predicting distant recurrence ( DR ) over and above st and ard clinical variables . RESULTS In all tested subgroups , ROR score significantly adds prognostic information to the clinical predictor ( P<0.0001 ) . PAM50 assigns an intrinsic subtype to all cases , and the luminal A cohort had a significantly lower ROR at 10 years compared with Luminal B ( P<0.0001 ) . Significant and clinical ly relevant discrimination between low- and high-risk groups occurred also within all tested subgroups . CONCLUSION ( S ) The results of the primary analysis , in combination with recently published results from the ATAC trial , constitute Level 1 evidence for clinical validity of the PAM50 test for predicting the risk of DR in postmenopausal women with ER+ EBC . A 10-year metastasis risk of < 3.5 % in the ROR low category makes it unlikely that additional chemotherapy would improve this outcome -this finding could help to avoid unwarranted overtreatment . CLINICAL TRIAL NUMBER ABCSG 8 : NCT00291759 BACKGROUND This study examined the impact of the Recurrence Score ( RS ) in Spanish breast cancer patients and explored the associations between clinicopathological markers and likelihood of change in treatment recommendations . PATIENTS AND METHODS Enrollment was offered consecutively to eligible women with estrogen receptor-positive ; human epidermal growth factor receptor 2-negative , node-negative breast cancer . Oncologists recorded treatment recommendation and confidence in it before and after knowing the patient 's RS . RESULTS Treatment recommendation changed in 32 % of 107 patients enrolled : in 21 % from chemohormonal ( CHT ) to hormonal therapy ( HT ) and in 11 % from HT to CHT . RS was associated with the likelihood of change from HT to CHT ( P < 0.001 ) and from CHT to HT ( P < 0.001 ) . Confidence of oncologists in treatment recommendations increased for 60 % of cases . Higher tumor grade ( P = 0.007 ) and a high proliferative index ( Ki-67 ) ( P = 0.023 ) were significantly associated with a greater chance of changing from HT to CHT , while positive progesterone receptor status ( P = 0.002 ) with a greater probability of changing from CHT to HT . CONCLUSIONS Results from the first prospect i ve European study are consistent with published experience and use of the RS as proposed in European clinical practice guidelines and provide evidence on how Oncotype DX and clinicopathological factors are complementary and patient selection may be improved Abstract Purpose : Improved underst and ing of risk of recurrence ( ROR ) is needed to reduce cases of recurrence and more effectively treat breast cancer patients . The purpose of this study was to examine how a gene-expression profile ( GEP ) , identified by Prosigna , influences physician adjuvant treatment selection for early breast cancer ( EBC ) and the effects of this influence on optimizing adjuvant treatment recommendations in clinical practice . Methods : A prospect i ve , observational , multicenter study was carried out in 15 hospitals across Spain . Participating medical oncologists completed pre- assessment , post- assessment , and follow-up question naires recording their treatment recommendations and confidence in these recommendations , before and after knowing the patient ’s ROR . Patients completed question naires on decision-making , anxiety , and health status . Results : Between June 2013 and January 2014 , 217 patients enrolled and a final 200 were included in the study . Patients were postmenopausal , estrogen receptor positive , human epidermal growth hormone factor negative , and node negative with either stage 1 or stage 2 tumors . After receiving the GEP results , treatment recommendations were changed for 40 patients ( 20 % ) . The confidence of medical oncologists in their treatment recommendations increased in 41.6 % and decreased in 6.5 % of total cases . Patients reported lower anxiety after physicians made treatment recommendations based on the GEP results ( p < 0.05 ) . Conclusions : Though this study does not include evaluation of the impact of GEP on long-term outcomes , it was found that GEP results influenced the treatment decisions of medical oncologists and their confidence in adjuvant therapy selection . Patients ’ anxiety about the selected adjuvant therapy decreased with use of the GEP Oncotype DX testing is reimbursed in Israel for node-negative and node-positive ( N1 + ; up to 3 positive nodes including micrometastases ) , estrogen receptor positive ( ER+ ) , breast cancer patients . This retrospective study evaluated the impact of Oncotype DX testing on treatment decisions in N1+/ER+ breast cancer patients . To this end , we compared treatments for all N+ patients for whom testing had been ordered with treatments for patients with similar characteristics where the test had not been available . The retrospective analysis included 951 patients ( 282 Oncotype DX , 669 controls ) , all of whom received endocrine therapy with or without chemotherapy .  In Oncotype DX patients , 7.1 , 37.0 , and 100 % of those with low , intermediate , and high Recurrence Score results ( Oncotype DX summary score ) received chemotherapy , respectively ( P < 0.0001 , all comparisons ) .  Chemotherapy use was lower in Oncotype DX patients versus controls ( 24.5 vs. 70.1 % ) . In a multivariate logistic regression analysis in which the probability of receiving chemotherapy  was modeled as a function of Oncotype DX testing , age , tumor size , tumor grade , nodal status , and the interactions between Oncotype DX testing and the other covariates , Oncotype DX testing was associated with significantly lower odds of receiving chemotherapy  ( odds ratio 0.16 ; 95 % CI 0.11–0.24 ; P < 0.0001 ) . In summary , our findings suggest that Oncotype DX testing has a significant impact on reducing  chemotherapy use in N1+/ER+ breast cancer patients in Israel Background : The aim of this study was to examine whether EndoPredict ( EP ) , a novel genomic expression test , is effective in predicting local recurrence (LR)-free survival ( LRFS ) following surgery for breast cancer in postmenopausal women . In addition , we exam 
    Output:
    
MammaPrint and OncotypeDX both have evidence available , including level IA clinical trial results for both assays .
Both assays provide prognostic information .
Predictive value has only been shown for OncotypeDX .
In the clinical utility studies , a higher reduction in chemotherapy was achieved by OncotypeDX , although the number of available studies differ considerably between tests .
On average , economic evaluations estimate that genomic testing results in a moderate increase in total costs , but that these costs are acceptable in relation to the expected improved patient outcome .
PAM50/prosigna and EndoPredict showed comparable prognostic capacities , but with less economical and clinical utility studies .
Furthermore , for these assays no level IA trial data are available yet .
In summary , all assays have shown excellent prognostic capacities .