H&E to recurrence score: A step forward, but not yet a substitute for genomic testing

Shamai and colleagues developed a multimodal deep-learning model that predicts Oncotype DX recurrence scores from routine H&E slides and clinicopathological variables in hormone receptor‑positive, HER2‑negative early breast cancer. Validated across the TAILORx trial and six external cohorts (over 5000 patients), the model achieved an AUC of 0.898 for identifying recurrence score ≥26 and recapitulated genomic assay patterns of chemotherapy benefit. Notably, 31% of clinically high-risk postmenopausal women were downgraded to low risk by AI, suggesting potential to reduce overtreatment. However, several limitations preclude immediate clinical substitution for genomic testing. First, intratumoural heterogeneity leads to discordant predictions with unclear management guidance. Second, the model's chemotherapy benefit estimates rely on TAILORx's age-based menopausal surrogates, which may not reflect real-world hormonal status or LHRH agonist use. Third, predictive value in node-positive disease remains untested in randomised datasets such as RxPONDER. Additionally, calibration uncertainty near risk thresholds and global scalability issues (including IHC requirements and digital pathology infrastructure) persist. While this represents a landmark step toward democratising precision oncology, the AI tool should currently serve as a complementary decision aid, with genomic testing remaining the gold standard for intermediate, borderline, or discordant cases.