A recently published article in the Journal of Global Oncology questioning the routine utility of Oncotype DX in early hormone-positive breast cancer is noteworthy to read.[1] Although the test itself is useful, there is considerable debate regarding its routine use in all patients with hormone-positive early breast cancer, especially in resource-limited settings. It is uncertain whether clinical judgment and inexpensive tools such as PREDICT online, which is based on clinical and tumor characteristics can replace testing in most such women.

The authors conducted an online survey of 100 medical oncologists in India to assess the utility of gene expression testing in breast cancer. Of the available tests, 71% preferred Oncotype DX and 94 % felt these tests were very expensive. More than 50% of oncologists reported using PREDICT online for adjuvant decision-making, and most of them felt that it could be used as an alternative in a resource-constrained setting.

The authors described various limitations of using Oncotype DX in India. First, the median age at the diagnosis of patients with breast cancer is approximately a decade younger than in the West and the utility of Oncotype DX is limited in patients younger than 35 years.[2] This also means that the age-based score cutoffs recommended in the TAILORX study may not be valid in Indian women. Second, breast cancer screening is not widely implemented in the country, and hence, most diagnoses are based on symptomatic presentation and not screen-detected. Furthermore, the stage distribution is different from more common higher stage diagnosis in India. Finally, the cost is a major factor, and such a test being funded by the government is not justifiable, given the different health priorities in a populous nation with miniscule gross domestic product spending on health.

Easily accessible and validated tools such as PREDICT online[3] estimate the 5-year and 10-year survival rates for individual patients based on routinely performed tumor characteristics along with the absolute benefit of chemotherapy and hormonal therapy. This is extensively used in clinics to discuss the benefit of chemotherapy with patients and making an informed decision regarding adjuvant treatment. Such tools are likely to remain the alternative standard until the cost of gene expression testing limits its routine use.

In conclusion, Oncotype DX is unlikely to be accessible to all the patients diagnosed with early hormone-positive breast cancer in India. The utility for routine testing is debatable as well due to different demographic patterns of breast cancer in India. In such a situation, clinical judgment, along with tools such as PREDICT online, is of paramount importance in arriving at a well-informed decision regarding adjuvant chemotherapy.

• References

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1.  Batra A, Patel A, Gupta VG, Mehta P, Tvsvgk T, Biswas B. et al. Oncotype DX: Where does it stand in India?. J Glob Oncol 2019; 5: 1-2
2.  Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol 2017; 13: 289-95
3.  https://breast.predict.nhs.uk/predict_v2.0.html Available from [Last accessed on 2019 Oct 20]

1.  Batra A, Patel A, Gupta VG, Mehta P, Tvsvgk T, Biswas B. et al. Oncotype DX: Where does it stand in India?. J Glob Oncol 2019; 5: 1-2
2.  Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol 2017; 13: 289-95
3.  https://breast.predict.nhs.uk/predict_v2.0.html Available from [Last accessed on 2019 Oct 20]