Ki-67 as a treatment decision modifier in breast cancer

Ki-67 is widely used in breast cancer; however, the fraction of patients in whom it meaningfully alters treatment decisions is not well established. Using a guideline-based approach anchored in National Comprehensive Cancer Network (NCCN) recommendations (v2.2026), we identified clinical scenarios in which Ki-67 directly modifies adjuvant therapy decisions and estimated their prevalence using population-level data and complementary datasets, recognizing that fully annotated datasets capturing all relevant clinicopathological variables remain limited. A back-of-the-envelope calculation suggests that only a small fraction of patients meet the combined criteria of HR+/HER2- subtype, T2 stage, grade 2 histology, and Ki-67 ≥ 20%. This estimate, compared to population-scale (n = 117 990 patients) and curated datasets (n = 1356 patients), indicates that the clinically relevant subset remains in the low single digits (3-5%). Ki-67 impacts care only in specific decision settings, particularly near clinically relevant thresholds where small analytic variation may translate into treatment changes; outside these contexts, its routine use has limited evidence for clinical utility. Its application should therefore be selective, context-dependent, and focused on scenarios in which threshold-adjacent precision is clinically consequential.