The Utility of Breast Cancer Index (BCI) Over Clinical Prognostic Tools for Predicting the Need for Extended Endocrine Therapy: A Safety Net Hospital Experience

Published:August 11, 2022DOI:



      Extended endocrine therapy (EET) benefits select patients with early-stage hormone-receptor positive (HR+) breast cancer (BC) but also incurs side effects and cost. The Clinical Treatment Score at Five Years (CTS5) is a free tool that estimates risks of late relapse in estrogen-receptor positive (ER+) BC using clinicopathologic factors. The Breast Cancer Index (BCI) incorporates 2 genomic assays to estimate late relapse risk and likelihood of benefit from EET. This retrospective study assesses the utility of BCI in selecting EET candidates in a safety net hospital.

      Materials and Methods

      We performed a retrospective chart review on 69 women with early-stage HR+, HER2- BC diagnosed at our institution from December 2009 to February 2016 on whom BCI was submitted. The CTS5 score was also calculated to assess clinical risk of late relapse.


      Median age was 53 years. All patients included in our analysis had early ER+ HER2-negative BC. Roughly half of the patients (55%) were postmenopausal and 61% were of Hispanic origin. A total of 34 patients (49%) were deemed high-risk (>5%) for late relapse by CTS5, compared to 42 (61%) by BCI. BCI identified 31 (45%) patients that would benefit from EET and of those, 74%% were advised EET. 16 (47%) clinical high-risk patients were advised against EET due to low benefit predicted by BCI. In the clinical low risk group, 9 (26%) were recommended EET based on high benefit predicted by BCI.


      BCI is reasonable to consider in early-stage HR+ BC and offered clinically relevant information over clinical pathologic information alone.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Breast cancer.
        World Cancer Research Fund/American Institute for Cancer Research, 2018
      2. Hormone Therapy for Breast Cancer.
        American Cancer Society, 2019
        • Early Breast Cancer Trialist Collaborative Group (EBCTCG)
        Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials.
        Lancet. 2005; 365: 1687-1717
        • Davies C.
        • Godwin J.
        • Gray R.
        • et al.
        Early Breast Cancer Trialist Collaborative Group (EBCTCG). Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials.
        Lancet. 2011; 378: 771-784
        • Fisher B.
        • Dignam J.
        • Bryant J.
        • et al.
        Five versus more than five years of tamoxifen therapy for breast cancer patients with negative lymph nodes and estrogen receptor-positive tumors.
        J Natl Cancer Inst. 1996; 88: 1529-1542
        • Pagani O.
        • Price K.
        • Gelber R.
        • et al.
        international Breast Cancer Study Group (IBCSG).. Patterns of recurrence of early breast cancer according to estrogen receptor status: a therapeutic target for a quarter of a century.
        Breast cancer research and treatment. 2009; 117: 319-324
        • Zhang X.H.
        • Giuliano M.
        • Trivedi M.V.
        • Schiff R.
        • Osborne C.K.
        Metastasis dormancy in estrogen receptor-positive breast cancer.
        Clin Cancer Res. 2013; 19: 6389-6397
        • Brewster A.M.
        • Hortobagyi G.N.
        • Broglio K.R.
        • et al.
        Residual risk of breast cancer recurrence 5 years after adjuvant therapy.
        J Natl Cancer Inst. 2008; 100: 1179-1183
        • Pan H.
        • Gray R.
        • Braybrooke J.
        • et al.
        20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years.
        N Engl J Med. 2017; 377: 1836-1846
        • Davies C.
        • Pan H.
        • Godwin J.
        • et al.
        Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial.
        Lancet. 2013; 381: 805-816
        • Gray R.G.
        • Rea D.
        • Handley K.
        • et al.
        aTTom: Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years in 6,953 women with early breast cancer.
        Journal of Clinical Oncology. 2013; 31: 5
        • Zhao F.
        • Ren D.
        • Shen G.
        • et al.
        Toxicity of extended adjuvant endocrine with aromatase inhibitors in patients with postmenopausal breast cancer: A Systemtic review and Meta-analysis.
        Crit Rev Oncol Hematol. 2020; 156103114
        • Goldvaser H.
        • Barnes T.A.
        • Seruga B.
        • et al.
        Toxicity of Extended Adjuvant Therapy With Aromatase Inhibitors in Early Breast Cancer: A Systematic Review and Meta-analysis.
        J Natl Cancer Inst. 2018; 110
        • Ravdin P.M.
        • Siminoff L.A.
        • Davis G.J.
        • et al.
        Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer.
        J Clin Oncol. 2001; 19: 980-991
        • Dowsett M.
        • Sestak I.
        • Regan M.M.
        Integration of Clinical Variables for the Prediction of Late Distant Recurrence in Patients With Estrogen Receptor-Positive Breast Cancer Treated With 5 Years of Endocrine Therapy: CTS5.
        J Clin Oncol. 2018; 36: 1941-1948
        • Tajiri W.
        • Ijichi H.
        • Takizawa K.
        • et al.
        The clinical usefulness of the CTS5 in the prediction of late distant recurrence in postmenopausal women with estrogen receptor-positive early breast cancer.
        Breast Cancer. 2021; 28: 67-74
        • Zhang Y.
        • Schnabel C.A.
        • Schroeder B.E.
        • et al.
        Breast cancer index identifies early-stage estrogen receptor-positive breast cancer patients at risk for early- and late-distant recurrence.
        Clin Cancer Res. 2013; 19: 4196-4205
        • Bartlett J.M.S.
        • Sgroi D.C.
        • Treuner K.
        • et al.
        Breast Cancer Index and prediction of benefit from extended endocrine therapy in breast cancer patients treated in the Adjuvant Tamoxifen-To Offer More? (aTTom) trial.
        Ann Oncol. 2019; 30: 1776-1783
        • Zhang Y.
        • Sestak I.
        • Cuuzick J.M.
        • et al.
        Correlation of Breast Cancer Index HOXB13/IL17BR (H/I), ER, PR and HER2 and prediction of relative endocrine benefit from tamoxifen and anastrozole in HR+ breast cancer: A TransATAC study.
        Journal of Clinical Oncology. 2015; 33: 526
        • Noordhoek I.
        • Treuner K.
        • Putter H.
        • et al.
        Breast Cancer Index Predicts Extended Endocrine Benefit to Individualize Selection of Patients with HR(+) Early-stage Breast Cancer for 10 Years of Endocrine Therapy.
        Clin Cancer Res. 2021; 27: 311-319
        • Zhang Y.
        • Schroeder B.E.
        • Jerevall P.L.
        • et al.
        A Novel Breast Cancer Index for Prediction of Distant Recurrence in HR(+) Early-Stage Breast Cancer with One to Three Positive Nodes.
        Clin Cancer Res. 2017; 23: 7217-7224
        • Bartlett J.M.S.
        • Sgroi D.C.
        • Treuner K.
        • et al.
        Breast Cancer Index Is a Predictive Biomarker of Treatment Benefit and Outcome from Extended Tamoxifen Therapy: Final Analysis of the Trans-aTTom Study.
        Clin Cancer Res. 2022; 28: 1871-1880
        • Sgroi D.C.
        • Sestak I.
        • Cuzuck J.
        • et al.
        Prediction of late disease recurrence and extended adjuvant letrozole benefit by the HOXB13 /IL17BR biomarker.
        J Natl Cancer Inst. 2013; 105: 1036-1042
        • Mamounas E.P.
        • Bandos H.
        • Rastogi P.
        • et al.
        Breast Cancer Index (BCI) and prediction of benefit from extended aromatase inhibitor (AI) therapy (tx) in HR+ breast cancer: NRG oncology/NSABP B-42.
        Journal of Clinical Oncology. 2021; 39: 501
        • Coughlin T.A.
        • Long S.K.
        • Sheen E.
        • Tolbert J.
        How five leading safety-net hospitals are preparing for the challenges and opportunities of health care reform.
        Health Aff (Millwood). 2012; 31: 1690-1697
        • Foldi J.
        • O'Meara T.
        • Marczyk M.
        • et al.
        Defining Risk of Late Recurrence in Early-Stage Estrogen Receptor–Positive Breast Cancer: Clinical Versus Molecular Tools.
        Journal of Clinical Oncology. 2019; 37: 1365-1369
      3. Gradishar, W. J., Moran M.S., Abraham J., et al. NCCN Guidelines Version 3.2021 Breast Cancer. (National Comprehensive Cancer Network, 2021).