Er pos and pr neg breast cancer

1. DR. R. RAJKUMAR III YR POST GRADUATE DEPARTMENT OF MEDICAL ONCOLOGY JOURNAL CLUB 13/09/2012

2. Question 1 Important prognostic factors in breast cancer include: A. Lymph node status, hormone receptor status, and TNM stage B. Histologic subtype C. Family History D. Age at diagnosis

3. Question 2 Genomic Analysis: A. Determines familial breast cancer risk B. Oncotype DX technology is useful in ER+ and ER- breast cancers C. Helps determine the best adjuvant chemotherapy regimen D. Has been validated in retrospective studies

4. Question 3 HORMONAL THERAPY FOR ER + PR – BREAST CANCER 1.TAMOXIFEN 2.AROMATASE INHIBITORS 3.NOVEL TARGETED AGENTS 4.DONT KNOW

5. Outcomes of Adjuvant Chemotherapy in Breast Cancer Walgren et al. JCO 2005;23:7342-7349

6. Lum A Lum B Basal Her2 claudin low Changing Portraits Concept evolution

7. Adjuvant Systemic Therapy for Breast Cancer: Decision Making Prognostic Factors Estimate outcome independent of systemic treatment Reflect tumor biology: Who should be treated? Predictive Factors Reflect a relative resistance or sensitivity to specific therapy What specific treatment(s) should be offered to an individual?

8. Breast Cancer Prognostic Factors Accepted TNM Stage Axillary Nodal Status Tumor Size Tumor Grade ER Content Oncotype DX (?) Investigational Gene expression arrays Proteomics Pharmacogenetics Novel imaging Other

9. Breast Cancer Predictive Factors Accepted ER status Grade HER 2 overexpression Oncotype DX (?) Investigational Gene expression arrays Proteomics Pharmacogenetics Novel imaging Other

10. Sotiriou, C. et al. NEJM, 2009. Luminal A Luminal B HER2+ Basal-like Intrinsic Breast Cancer Subtypes described by Perou et al. Express ↑ amounts Of luminal cyto- Keratins & genetic Markers of luminal Epithelial cells of Normal tissue Express ↑ levels of EGFR, c-kit, & growth factors like hepatocyte growth factor and IGF

11. Figure 1a. Sorlie T, Tibshirani R, Parker J, et al: Repeated observation of breast tumor subtypes in independent gene expression data sets. Proc Natl Acad Sci U S A 100:8418-23, 2003

12. St. Gallen 2007 Highly Endocrine Responsive Non–endocrine Responsive Incompletely Endocrine Responsive High ER and PgR and ER and PgR both absent Low ER and PgR or No HER2 overexpression and PgR absent or Low Ki-67 HER2 overexpression or High Ki-67 ER = estrogen receptor; PgR = progesterone receptor. Goldhirsch et al. Ann Oncol . 2007;18:1133.

13. St. Gallen – Endocrine Responsiveness “Practical” Clinical Subgroups ER and PR absent ER and PR low/int and/or any of these Both receptors high levels PgR absent UPA/PAI-1 high HER-2 overexpressed Increased proliferation High grade No No No No No Chemo only options Chemo adds to hormonal Chemo doesn’t work Absent Endocrine- responsiveness Uncertain Sure

14. The Level of ER Expression Is Predictive The higher the level of expression, the greater the benefit from endocrine treatment The higher the level of expression, the lesser the added benefit of chemotherapy

15. Added Value of PgR Status in Assessing Endocrine Responsiveness Estrogens ER Estrogen-responsive elements Cell cycle PgR synthesis

16. Added Value of PgR Status Assessment Quality control of ER status assessment ER-/PgR+ tumors do not exist (almost!) ER 10%/PgR 90% is very unusual (and likely related to poor sensitivity of ER staining) Prognosis (among ER+ tumors) Effectiveness of endocrine therapies (and chemotherapy in premenopausal patients) Response to AI? AI = aromatase inhibitor. Viale et al. J Clin Oncol . 2007;25:3846.

17. PgR The absence of P g R may reflect hyperactive crosstalk between ER and growth factor signaling pathways — HER1 and HER2 — compared with ER+/P g R+ breast cancers

18. 10 30 40 50 60 75 90 4-y DFS (%) Subpopulation by PgR% Tamoxifen Letrozole STEPP for Central PgR (ER-Expressing) in the BIG 1-98 Trial STEPP = subpopulation treatment effect pattern plot.

19. Is ER/PgR Status Assayed Well in Clinical Practice? Inconsistent allocation to “ER/PgR-negative” No immunoreactive cells? Less than 10% immunoreactive cells? Less than 20% immunoreactive cells? A different threshold for different clinical questions/settings? Conflicting results >15% disagreement between different laboratories (false negative)

20. False-Positive Assays? Local Central N % N % ER+/PgR+ 3124 71.0 3330 75.7 ER+/PgR- 965 21.9 832 18.9 ER+/PgR? 220 5.0 48 1.1 ER-/PgR+ 80 1.8 13 0.3 ER-/PgR- 5 0.1 103 2.3 ER-/PgR? 1 <0.1 ER?/PgR+ 2 <0.1 23 0.5 ER?/PgR- 7 0.2 ER?/PgR? 3 <0.1 42 1.0

21. Oncotype DX 21-Gene Recurrence Score (RS) Assay PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2 ESTROGEN ER PR Bcl2 SCUBE2 INVASION Stromelysin 3 Cathepsin L2 HER2 GRB7 HER2 BAG1 GSTM1 REFERENCE Beta-actin GAPDH RPLPO GUS TFRC CD68 16 Cancer and 5 Reference Genes From 3 Studies Category RS (0-100) Low risk RS <18 Int risk RS ≥18 and <31 High risk RS ≥31 Paik et al. N Engl J Med. 2004;351:2817-2826 . RS = + 0.47 x HER2 Group Score - 0.34 x ER Group Score + 1.04 x Proliferation Group Score + 0.10 x Invasion Group Score + 0.05 x CD68 - 0.08 x GSTM1 - 0.07 x BAG1

22. 23 Recurrence Score in N-, ER+ patients Standardized Quantitative Onco type DX Assay 1 ) Paik et al NEJM 2004, 2) Habel et al Breast Cancer Research 2006 3) Paik et al JCO 2006, 4) Gianni et al JCO 2005 Lower RS’s Lower likelihood of recurrence Greater magnitude of TAM benefit Minimal, if any, chemotherapy benefit Higher RS’s Greater likelihood of recurrence Lower magnitude of TAM benefit Clear chemotherapy benefit

23. Oncotype DX Extensively Studied: Study Experience in >3700 Patients Study Type No. Pts Providence Exploratory 136 Rush* Exploratory 78 NSABP B-20 Exploratory 233 NSABP B-14* Prospective 668 MD Anderson* Prospective 149 Kaiser Permanente* Prospective Case-Control 790 Cases/Controls NSABP B-14 Prospective Placebo vs Tam 645 Milan* Exploratory 89 NSABP B-20* Prospective Tam vs Tam+Chemo 651 ECOG 2197* Exploratory and Prospective 776 SWOG 8814 Prospective Tam vs Tam+Chemo 367 *Published studies

24. Schema: TAILORx Node- Neg , ER-Pos Breast Cancer RS < 10 Hormone Therapy Registry RS 11-25 Randomize Hormone Rx vs Chemotherapy + Hormone Rx RS >25 Chemotherapy + Hormone Rx Oncotype DX Assay Register Specimen banking Primary study group

25. Mammaprint: Development of the 70-Gene Signature DNA microarray analysis of 78 breast primary tumors (untreated) Pts were <55 years of age with T1-2/N0 disease Pts selected based on outcome: Distant metastases within 5 years Statistical analysis, “supervised classification,” identified 231 genes correlated with disease outcome  Top 70 genes selected Genes that regulate cell cycle, invasion, metastasis, & angiogenesis Patients categorized as “good prognosis” or “poor prognosis.” Found to be a better predictor of distant metastases within 5 years than all clinical variables in this study Odds ratio (distant metastases): poor to good prognosis groups = 15 Van ’t Veer, L. Nature , 2002.

26. EORTC-BIG MINDACT TRIAL DESIGN 6,000 Node negative women Dr Martine Piccart-Gephart JBI, Brussels Evaluate Clinical-Pathological risk and 70-gene signature risk Clinical-pathological and 70-gene both HIGH risk Discordant cases Clin-Path HIGH 70-gene LOW Clinical-pathological and 70-gene both LOW risk Use Clin-Path risk to decide Chemo or not Use 70-gene risk to decide Chemo or not Adjuvant Chemotherapy (+ endocrine Tx if ER+) N=3300 (55%) N=600 (10%) Adjuvant Endocrine therapy only N=2100 (35%) Clin-Path LOW 70-gene HIGH Randomize The goal of this trial is to show that MammaPrint can spare 20-30% of patients from adjuvant chemo

27. 70-gene Signature 21-gene Signature 2-Gene Ratio Intrinsic Subtypes Analysis Approach Supervised Supervised Supervised Unsupervised Tissue Type Fresh or Frozen Formalin-Fixed, Parafin-embedded Formalin-Fixed, Parafin-embedded Formalin-Fixed, Parafin-embedded Technique DNA microarrays Q-RT-PCR Q-RT-PCR Q-RT-PCR Prognostic Untreated pts age<60, T1-2, LN- Untreated & TAM-treated ER+/LN- TAM-treated, ER+/LN- untreated TAM-treated Predictive NO Benefit to TAM +/- CMF/MF Response to TAM NO Validation Retrospective Retrospective Retrospective Retrospective Prospective Trials MINDACT TAILORX NONE NONE

28. Reading: Handbook of cell signaling, Ed RA Bradshaw and EA Dennis, 2003. Chapter 275 Cheskis, BJ, 2004. Regulation of cell signaling cascades by steroid hormones Steroid Hormone Receptor Signaling Steroid hormones are produced by endocrine glands Essential regulators of: reproduction, secondary sex characteristics Development, differentiation Glucose metabolism Response to stress and salt balance

29. Nuclear Receptor Superfamily large family of structurally related ligand-inducible transcription factors, including: steroid receptors (SRs), thyroid/retinoids receptors (TR, RARs and RXRs), vitamin D receptors (VDR), estrogen receptors (ERa and ERb), and orphan receptors for which no ligand has been yet identified. While having in common a modular structure, they are activated by distinct lipophilic small molecules such as glucocorticoids, progesterone, estrogens, retinoids, and fatty acid derivatives

30. Steroid Hormone Signaling

31. Estrogen Receptors ER- a Uterus, testis, pituitary, ovary, epididymis, and adrenal gland. ER- b (Kuiper et al . 1996) brain, kidney, prostrate, ovary, lung, bladder, intestine, and epididymis. 88% identity with rat ER-b; 47% identity with human ER-a Both ERs are localized to membrane, cytosol, and nucleus. ER a and b differ in C-terminal ligand binding domains and N-terminal transactivation domains. Highest homology in DNA binding domain. Estrogen-related orphan receptors (ERR) a, b, g

32. Estrogen Receptors http://www.bio.cmu.edu/Courses/BiochemMols/ER/#ERchime

33. Estrogen Receptor

34. ER effects on different cell types

35. Steroid receptor coactivators and ER-dependent gene transcription TATA ERE Estradiol -bound ER Transcription Histone Acetylase Activity P/CAF CBP SRC Family AIB1

36. Estradiol Coactivator AF1 ER E E E + AF1 + AF2 ACTIVE Receptor dimerization Nuclear localization of fully active ER to ERE Coactivator ERE RNA POLII FULLY ACTIVATED TRANSCRIPTION (tumor cell division) AF1 and AF2 recruit coactivators E AF2 AF1 E Adapted from: Wakeling AE. Endocr-Relat Cancer 2000; 7: 17–28. Mode of Action of Estradiol

37. Fig.15-12

38. Transcriptional Activation HRE HREs are short cis-acting sequences located within the promoters or enhancers of target genes. HREs: inverted repeats of AGGTCA (ER and ERRs) inverted repeats of AGAACA (for GR, MR, PR, and AR)

39. J. Biol. Chem., Vol. 276, Issue 40, 36869-36872, October 5, 2001 Hall et al.

40. Genomic versus Non-genomic changes in gene expression delayed (hrs-days) requires nuclear receptor prevented by transcription and translation inhibitors changes in existing enzyme activity and/or protein structure rapid (sec-min) unknown cytosolic mechanisms not affected by transcription and translation inhibitors

41. Cross-talk between signal transduction and endocrine pathways Adapted from Johnston 2005 SOS RAS RAF Basal transcription machinery p160 ERE ER target gene transcription ER CBP P P P P ER P p90 RSK Akt P MAPK P Cell survival Cytoplasm Nucleus ER PI3-K P P P P P P Cell growth MEK P Plasma membrane AI HER2 IGFR Growth factor Estrogen Trastuzumab

42. P Ras p85 p110 ER E E ER E P P P Transcription ErbB ErbB ER-Responsive Element P MAPK Akt Ligand

43. CHARACTERISTICS OF ER + PR- BREAST CANCER MORE AGGRESSIVE PHENOTYPE LARGER IN SIZE OLDER PATIENTS >60 YRS HIGHER BMI HIGHER S PHASE FRACTION GREATER GENOMIC INSTABILITY HIGHER LEVELS OF EGFR & HER1 HER2 TAMOXIFEN RESISTANCE

44. ER +/PR  tumors are resistant to tamoxifen (ATAC) From Cui et al. JCO 23:7721, 2005

45. ER+/PR+ ER+/PR+ Negative PR is a marker of high HER1/HER2 levels and tamoxifen resistance Arpino et al. JNCI 97:1254, 2005

46. ER+/PR+ ER+/PR+ ER+/PR  ER+/PR  Negative PR is a marker of high HER1/HER2 levels and tamoxifen resistance Arpino et al. JNCI 97:1254, 2005

47. The Molecular Portrait Hypothesis You can recognize the Mona Lisa by her smile and her nose and her eyes and even her hands – if you are really good, but not the sky or the trees

48. Tamoxifen Chemotherapy Anth , Taxane , Platimun Postmenopausal Women with HR+ breast Cancer Aromatase Inhibitor Biologic agents Her2, EGFR, VEGF, Parp The Promise of Personalized Medicine in Breast Cancer

49. Question 1 Important prognostic factor in breast cancer include lymph node status, hormone receptor status, and TNM staging Histologic subtype and family history have not been independently validated prognostically, and age at diagnosis is neither prognostic nor predictive Stearns et.al., BCRT 1998; 52: 239-259 Harris, L et.al., J Clin Oncol 2007 Nov 20; 25 (83) 5287-312

50. Question 2 Genomic analysis has been validated in retrospective studies Available genomic analytic assays (Oncotype DX, Mammaprint) do not determine familial risk. Oncotype DX has been validated only in ER+ breast cancers. Neither assay determines type of adjuvant chemotherapy. Paik, S et.al., N Eng J Med 2004 Dec 30; 351(27): 2817-26 Paik, S et.al., J Clin Oncol 2006 Aug 10; 24(23): 3726-34 Albain, K et.al., SABCS 2007 abstr #10

51. Question 3 HORMONAL THERAPY FOR ER + PR – BREAST CANCER 1. AI - 52% lower risk for recurrence 2. EGFR INHIBITORS , m TOR INHIBITORS, PI3K INHIBITORS, IGF INHIBITORS anastrozole plus gefinitib - 49% clinical benefit.