MammaPrint predicts chemotherapy benefit in HR+HER2- early breast cancer: FLEX Registry Real-World Data

Gene expression assays help personalize adjuvant chemotherapy decisions for hormone receptor-positive, HER2-negative (HR+HER2-) early breast cancer (EBC). The 70-gene risk of distant-recurrence signature, MammaPrint, demonstrated clinical utility in guiding chemotherapy de-escalation in genomically Low Risk patients in the MINDACT trial. This study evaluates MammaPrint as a continuous predictor of chemotherapy benefit in HR+HER2- EBC using Real-World Data (RWD) from the FLEX Registry. The study evaluated 1,002 patients treated with endocrine therapy (ET) only or ET with chemotherapy (ET+CT) enrolled in FLEX (NCT03053193) with 5-year median follow-up. Propensity-score matching balanced treatment groups by menopausal status, T-stage, and nodal-status. The primary endpoint was Distant Recurrence-Free Interval (DRFI). Regression and Cox proportional hazards models assessed chemotherapy benefit across MammaPrint Index (MPI) Risk. Most patients were post-menopausal (70.1%), node-negative (70.0%), and had grade-2 tumors (51.2%). The regression models showed that MPI strongly predicted 5-year DRFI in ET only (R2=0.99, p < 0.001) and ET+CT (R2=0.90, p < 0.001) groups, corresponding to an average absolute chemotherapy benefit of 5.6% in High 1 and 10.9% in High 2. Minimal improvement in DRFI with chemotherapy was observed for Low (1.7%) and UltraLow (<1.0%) Risk groups. A multivariate Cox model with an MPI-by-treatment interaction term demonstrated that increasing MPI Risk was associated with greater chemotherapy benefit on DRFI (HR = 0.15, p = 0.047). Chemotherapy benefit was significantly associated with pre-menopausal status, but not age, T-stage, nodal-status, or grade. These RWD from the FLEX Registry demonstrate that MPI is predictive of both DRFI prognosis and chemotherapy benefit in HR+HER2- EBC. (NCT03053193).