DR. R. RAJKUMAR III YR POST GRADUATE DEPARTMENT OF MEDICAL ONCOLOGY

JOURNAL CLUB

13/09/2012

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

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

Question 3

HORMONAL THERAPY FOR ER+ PR – BREAST CANCER

• 1.TAMOXIFEN• 2.AROMATASE INHIBITORS• 3.NOVEL TARGETED AGENTS• 4.DONT KNOW

Copyright © American Society of Clinical Oncology

Outcomes of Adjuvant Chemotherapy in Breast Cancer

Walgren et al. JCO 2005;23:7342-7349

Lum A Lum B Basal Her2

claudin low

Changing Portraits

Concept evolution

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?

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

Breast Cancer Predictive Factors· Accepted

– ER status– Grade – HER 2 overexpression– Oncotype DX (?)

· Investigational– Gene expression arrays– Proteomics– Pharmacogenetics– Novel imaging– Other

11Sotiriou, C. et al. NEJM, 2009.

Luminal ALuminal B

HER2+Basal-like

Intrinsic Breast CancerSubtypes described by

Perou et al.

Express ↑ amountsOf luminal cyto-Keratins & geneticMarkers of luminalEpithelial cells ofNormal tissue

Express ↑ levels of EGFR, c-kit, & growth factors like hepatocyte growth factor and IGF

12

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

13

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 overexpressionor

High Ki-67

ER = estrogen receptor; PgR = progesterone receptor.Goldhirsch et al. Ann Oncol. 2007;18:1133.

14

St. Gallen – Endocrine Responsiveness “Practical” Clinical Subgroups

ER and PR absent ER and PR low/intand/or any of these

Both receptorshigh levels

• PgR absent• UPA/PAI-1 high• HER-2 overexpressed• Increased proliferation• High grade

NoNoNoNoNo

Chemo only options Chemo adds to hormonal

Chemo doesn’t work

Absent

Endocrine-responsiveness

Uncertain Sure

15

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

16

Added Value of PgR Status in Assessing Endocrine Responsiveness

Estrogens ER

Estrogen-responsive elements

Cell cycle PgR synthesis

17

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 chemotherapyin premenopausal patients)

· Response to AI?

AI = aromatase inhibitor.Viale et al. J Clin Oncol. 2007;25:3846.

19

0

20

40

60

80

100

0 9910 30 40 50 60 75 90

4-y

DF

S (

%)

Subpopulation by PgR%

TamoxifenLetrozole

STEPP for Central PgR (ER-Expressing) in the BIG 1-98 Trial

STEPP = subpopulation treatment effect pattern plot.

20

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)

21

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- 50.1 103 2.3

ER-/PgR? 0 0 1<0.1

ER?/PgR+ 2<0.1 23 0.5

ER?/PgR- 0 0 70.2

ER?/PgR? 3<0.1 42 1.0

22

Oncotype DX 21-Gene Recurrence Score (RS) Assay

PROLIFERATIONKi-67

STK15Survivin

Cyclin B1MYBL2

ESTROGENERPR

Bcl2SCUBE2

INVASIONStromelysin 3Cathepsin L2

HER2GRB7HER2

BAG1GSTM1

REFERENCEBeta-actinGAPDHRPLPO

GUSTFRC

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

23

23

Recurrence Score in N-, ER+ patients

Standardized Quantitative Oncotype DX Assay

0%

5%

10%

15%

20%

25%

30%

35%

40%

0 5 10 15 20 25 30 35 40 45 50

Recurrence Score

Dis

tan

t R

ecu

rren

ce a

t 10

Yea

rs

Low Risk Group High Risk Group Intermediate Risk Group

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

24

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

25

Schema: TAILORx

Node-Neg, ER-Pos Breast CancerNode-Neg, ER-Pos Breast Cancer

RS <10HormoneTherapyRegistry

RS <10HormoneTherapyRegistry

RS 11-25Randomize

Hormone Rxvs

Chemotherapy + Hormone Rx

RS 11-25Randomize

Hormone Rxvs

Chemotherapy + Hormone Rx

RS >25Chemotherapy

+Hormone Rx

RS >25Chemotherapy

+Hormone Rx

Oncotype DX AssayOncotype DX AssayRegister

Specimen banking

Primary study group

26

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.

27

EORTC-BIG MINDACT TRIAL DESIGN6,000 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 HIGH70-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

AdjuvantChemotherapy

(+ endocrine Tx if ER+)

N=3300 (55%) N=600 (10%)

Adjuvant Endocrinetherapy only

N=2100 (35%)

Clin-Path LOW70-gene HIGH

Randomize

The goal of this trial is to show that MammaPrint can spare 20-30% of patients from adjuvant chemo

28

70-gene Signature

21-geneSignature

2-GeneRatio

IntrinsicSubtypes

AnalysisApproach

Supervised Supervised Supervised Unsupervised

Tissue Type Fresh or FrozenFormalin-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

PredictiveNO

Benefit to TAM +/- CMF/MF

Response to TAMNO

Validation Retrospective Retrospective Retrospective Retrospective

ProspectiveTrials MINDACT TAILORX NONE NONE

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

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

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.

ERa 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

Estrogen Receptors

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

Estrogen Receptor

ER effects on different cell types

Steroid receptor coactivators and ER-dependent gene transcription

TATA

ERE

Estradiol-bound ERTranscription

HistoneAcetylaseActivity

P/CAFCBP

SRCFamily AIB1

Estradiol

CoactivatorAF1

ERE

EE+

AF1 + AF2

ACTIVE

Receptordimerization

Nuclear localization offully active ER

to ERE

Coactivator

ERE RNAPOLII

FULLY ACTIVATEDTRANSCRIPTION(tumor cell division)

AF1 and AF2recruit

coactivators

E

AF2

AF1

E

Adapted from: Wakeling AE. Endocr-Relat Cancer 2000; 7: 17–28.

Mode of Action of Estradiol

Fig.15-12

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)

J. Biol. Chem., Vol. 276, Issue 40, 36869-36872, October 5, 2001

Hall et al.

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

Cross-talk between signal transduction and endocrine pathways

Adapted from Johnston 2005

SOSRAS

RAF

Basaltranscriptionmachineryp160

ERE ER target gene transcription

ER CBPPP P P

ER

Pp90RSK

AktP

MAPKP

Cellsurvival

Cytoplasm

Nucleus

ER

PI3-KP

P

PPP

P

Cellgrowth

MEKP

Plasmamembrane

AI

HER2

IGFRGrowth factorEstrogen

Trastuzumab

P

Ras

p8

5

p110 ERE

E

ERE

P

P

P

Transcription

ErbB ErbB

ER-Responsive Element

P

MAPKAkt

Ligand

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

ER+/PR tumors are resistant to tamoxifen (ATAC)

From Cui et al. JCO 23:7721, 2005

ER+/PR+

ER+/PR+

Negative PR is a marker of high HER1/HER2levels and tamoxifen resistance

Arpino et al. JNCI 97:1254, 2005

ER+/PR+

ER+/PR+

ER+/PR

ER+/PR

Negative PR is a marker of high HER1/HER2levels and tamoxifen resistance

Arpino et al. JNCI 97:1254, 2005

The Molecular Portrait Hypothesis

You can recognize theMona 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

Tamoxifen

ChemotherapyAnth, Taxane,

Platimun

Postmenopausal Women with HR+

breast Cancer

Aromatase Inhibitor

Biologic agentsHer2, EGFR, VEGF, Parp

The Promise of Personalized Medicine in Breast Cancer

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: 239-259Harris, L et.al., J Clin Oncol 2007 Nov 20; 25 (83) 5287-312

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): 2817-26Paik, S et.al., J Clin Oncol 2006 Aug 10; 24(23): 3726-34Albain, K et.al., SABCS 2007 abstr #10

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.