What Oncoscore (Oncology score) is considered alarming for cancer recurrence or metastasis?

What Oncotype DX Score is Alarming?

An Oncotype DX Recurrence Score (RS) ≥26 is considered alarming and indicates high-risk disease requiring serious consideration of adjuvant chemotherapy in hormone receptor-positive, HER2-negative breast cancer. 1

Risk Stratification by Oncotype DX Score

The Oncotype DX assay stratifies patients into three distinct risk categories based on recurrence score 1:

• Low risk: RS ≤10 - 3-year recurrence rate of 12% 1
• Intermediate risk: RS 11-25 - 3-year recurrence rate of 18% 1
• High risk: RS ≥26 - 3-year recurrence rate of 22% 1

The Critical Threshold: RS ≥26

Scores of 26 or higher represent the alarming threshold where chemotherapy benefit becomes substantial. 1 However, important nuances exist within this high-risk category:

RS 26-30 (Upper Intermediate/Lower High Risk)

• This represents a gray zone where chemotherapy benefit remains controversial 2, 3
• Adjuvant chemotherapy improves breast cancer-specific survival, particularly in patients with high-grade tumors 3
• Among lymph node-negative patients with RS 26-30,5-year secondary invasive breast event rates were 25% with chemotherapy versus 33% without chemotherapy (not statistically significant) 2
• The benefit appears most pronounced in poorly differentiated or undifferentiated disease 3

RS ≥31 (Definitively High Risk)

• This represents unequivocally alarming scores requiring chemotherapy 2
• Among lymph node-negative patients with RS ≥31,91% received chemotherapy 2
• The 5-year rate of secondary invasive breast events was 0% both with and without chemotherapy in one small cohort, though sample size limits interpretation 2

Clinical Context Matters

The alarming nature of high Oncotype DX scores must be interpreted alongside traditional risk factors 1:

• Tumor grade: High RS scores correlate strongly with grade III tumors (mean RS 23.2 for grade III vs 14.1 for grade I) 4
• Ki67 proliferative index: Higher Ki67 (>20) significantly associates with RS ≥25 4
• Nottingham Prognostic Index: Poor NPI scores correlate with higher recurrence scores 4

A critical pitfall: The Oncotype DX score shows minimal correlation with traditional risk calculators like Adjuvant! (r = 0.13), meaning clinical variables alone cannot reliably predict which patients will have alarming scores 5

Practical Algorithm for High-Risk Scores

When encountering an alarming Oncotype DX score:

1. RS ≥31: Strongly recommend adjuvant chemotherapy regardless of other factors 2
2. RS 26-30: Recommend chemotherapy, especially if:
   • Tumor grade is III 3
   • Ki67 is >20% 4
   • Patient is younger 3
   • Tumor size is larger 3
3. Consider aggressive endocrine therapy with ovarian suppression as an alternative or addition in select cases with RS 26-30 who decline or cannot tolerate chemotherapy 2

The key takeaway: An Oncotype DX score of 26 or higher is alarming and warrants aggressive treatment consideration, with scores ≥31 representing unequivocal high-risk disease requiring chemotherapy in the absence of contraindications.