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Hernandez-Aya LF, Gonzalez-Angulo AM. Adjuvant systemic therapies in breast cancer. Surg Clin North Am 2013; 93:473-91. [PMID: 23464697 DOI: 10.1016/j.suc.2012.12.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Although some women with early breast cancer (BC) may be cured with loco-regional treatment alone, up to 20% of patients with early-stage BC will ultimately experience treatment failure and recurrence. A substantial portion of the success in improving clinical outcomes of patients with BC is related to the standardized use of adjuvant therapies. The identification of tumor subtypes with prognostic value has contributed to the idea of tailoring treatments using biologic predictive factors to identify the patients who will most likely respond to therapy and minimize the exposure of "nonresponders" to the side effects of the treatment.
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Affiliation(s)
- Leonel F Hernandez-Aya
- Division of Hematology/Oncology, Comprehensive Cancer Center, University of Michigan Health System, Ann Arbor, MI, USA
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252
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Olszewski AJ, Migdady Y, Boolbol SK, Klein P, Boachie-Adjei K, Sakr BJ, Sikov W, Shao T. Effects of adjuvant chemotherapy in HER2-positive or triple-negative pT1ab breast cancers: a multi-institutional retrospective study. Breast Cancer Res Treat 2013; 138:215-23. [DOI: 10.1007/s10549-013-2423-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 01/17/2013] [Indexed: 11/28/2022]
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Abstract
OPINION STATEMENT About 15-20% of patients with early stage breast cancer present with tumors that have overexpression or amplification of the human epidermal growth factor receptor 2 (HER2) gene. Before 2005, these individuals had an increased risk of recurrence and death, but since then their outcomes have substantially improved with the adoption in most countries of adjuvant trastuzumab as a standard component of therapy for HER2-positive early-stage breast cancer. Consequently, access to high-quality and accurate HER2 testing methods is critical to accurately determine HER2 status, guide treatment decisions, and ultimately improve clinical outcomes. In 2012, the humanized monoclonal anti-HER antibody trastuzumab was the only approved HER2-targeted therapy in the adjuvant setting. Data from the first generation of trials combining it with various chemotherapy regimens showed significant improvements in disease-free and overall survival (DFS/OS). Based on results from five randomized clinical trials, a trastuzumab-containing regimen for up to 1 year is now considered standard for all patients with HER2-positive tumors larger than 1 cm in size who would have fulfilled eligibility to those studies, and this recommendation is sometimes extended to patients with stage I tumors greater than 0.5 cm (T1b). Second generation adjuvant studies with other HER2-targeted agents like lapatinib and pertuzumab are ongoing, and newer drugs like T-DM1 and neratinib are being actively tested in the metastatic setting.
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Affiliation(s)
- Danijela Jelovac
- Breast Cancer Program, The Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD 21231, USA.
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254
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Margalit DN, Sreedhara M, Chen YH, Catalano PJ, Nguyen PL, Golshan M, Overmoyer BA, Harris JR, Brock JE. Microinvasive Breast Cancer: ER, PR, and HER-2/neu Status and Clinical Outcomes after Breast-Conserving Therapy or Mastectomy. Ann Surg Oncol 2012; 20:811-8. [DOI: 10.1245/s10434-012-2640-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Indexed: 11/18/2022]
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Management of small HER2 overexpressing tumours. Breast Cancer Res Treat 2012; 136:289-93. [DOI: 10.1007/s10549-012-2236-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 08/26/2012] [Indexed: 10/27/2022]
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Seal MD, Speers CH, O'Reilly S, Gelmon KA, Ellard SL, Chia SK. Outcomes of women with early-stage breast cancer receiving adjuvant trastuzumab. ACTA ACUST UNITED AC 2012; 19:197-201. [PMID: 22876145 DOI: 10.3747/co.19.960] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Large randomized trials assessing the benefit of adjuvant trastuzumab in early-stage breast cancer positive for the human epidermal growth factor receptor 2 (her2) have demonstrated a significant improvement in survival. The objective of the present study was to describe the outcomes of women who received adjuvant trastuzumab for her2-positive breast cancer in British Columbia since publicly funded population-based use was initiated in July 2005. METHODS Women from British Columbia, newly diagnosed with stage i-iii breast cancer between July 2004 and December 2006, who were positive for her2 overexpression by immunohistochemistry (3+) or amplification by fluorescence in situ hybridization (ratio ≥ 2.0) were included in the study. Data were collected from the prospectively assembled BC Cancer Agency Outcomes Unit, with cases linked to the provincial pharmacy data repository to determine the proportion of women who received adjuvant trastuzumab. RESULTS Our retrospective study identified 703 her2-positive patients, of whom 480 (68%) received trastuzumab. In patients receiving trastuzumab, the 2-year relapse-free survival was 96.1% [95% confidence interval (CI): 93.6% to 97.7%] and the overall survival was 99.3% (95% CI: 97.9% to 99.8%). Among node-negative and -positive patients, the 2-year relapse-free survival was 97.8% and 94.8% respectively (p = 0.09) for the trastuzumab-treated group and 90.9% and 77.3% (p = 0.01) for the group not receiving trastuzumab (n = 223). Site of first distant metastasis was the central nervous system in 19.5% of the entire cohort and in 37.5% of patients treated with trastuzumab. DISCUSSION This population-based analysis of adjuvant trastuzumab use among Canadian women demonstrates highly favorable outcomes at the 2-year follow-up.
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Affiliation(s)
- M D Seal
- BC Cancer Agency-Vancouver, Vancouver, BC
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257
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Constantinidou A, Smith I. Is there a case for anti-HER2 therapy without chemotherapy in early breast cancer? Breast 2012; 20 Suppl 3:S158-61. [PMID: 22015286 DOI: 10.1016/s0960-9776(11)70316-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
Trastuzumab in combination with chemotherapy is now standard of care for patients with early HER2-positive cancers larger than 1 cm. Some patients however may not need or simply may not want chemotherapy with its associated toxicities. For example patients with small (<1 cm.Tla.b) node-negative (NO) HER2-positive cancers were largely excluded from all the large randomized adjuvant trastuzumab trials on the basis of perceived excellent prognosis, yet recently several retrospective studies have suggested that this is not always the case and more active adjuvant treatment including anti-HER2 therapy may be warranted. Subset analysis of one trastuzumab trial (HERA) demonstrated that patients with 1-2 cm cancers derived at least as much clinical benefit from 1-year of adjuvant trastuzumab with chemotherapy as the overall cohort and 2 retrospective audits have confirmed this. Anti-HER2 therapy including both trastuzumab and lapatinib alone has established clinical efficacy in metastatic disease, with response rates of up to 35% and with some long term remissions. Combination anti-HER2 therapy with trastuzumab/lapatinib and with trastuzumab/pertuzumab have also been shown to have efficacy as second line treatment inpatients after trastuzumab. Trastuzumab and Lapatinib have each been shown to improve time to progression and response rate when given with anastrazole and letrozole respectively as first line treatment for metastatic ER-positive HER2-positive disease. In neoadjuvant trials the combination of trastuzumab and pertuzumab without chemotherapy have achieved pathological complete remission rates in a significant minority of patients, suggesting that a subgroup exists for whom anti-HER2 therapy alone may be as effective as with additional chemotherapy. Trials and prospective studies are now warranted to investigate this issue further in selected patients and these must be accompanied by tissue collection to try to identify predictive biomarkers. Meanwhile there is already enough circumstantial evidence to justify anti-HER2 therapy alone in selected patients for whom chemotherapy is contraindicated.
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258
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Tonyali O, Coskun U, Sener N, Inanc M, Akman T, Oksuzoglu B, Ozdemir NY, Yazilitas D, Benekli M, Uner A, Yamac D, Demirci U, Yildiz R, Karaca H, Unal OU, Bal O, Gumus M, Buyukberber S. Nine-week trastuzumab treatment versus 52-week trastuzumab treatment for HER2-positive early-stage breast cancer. J Cancer Res Clin Oncol 2012; 138:2145-51. [PMID: 22878681 DOI: 10.1007/s00432-012-1296-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 07/25/2012] [Indexed: 01/03/2023]
Abstract
PURPOSES Trastuzumab is known to be effective for early and advanced stages of breast cancer but optimal duration for early-stage breast cancer (EBC) is not well known. We evaluated the efficacy and toxicity of 9- and 52-week trastuzumab therapy for EBC retrospectively. METHODS In this multicenter study, the medical records of all patients with EBC were analyzed in 8 centers retrospectively. Totally consecutive, 479 female patients who received trastuzumab in the adjuvant treatment were evaluated for disease-free survival (DFS), overall survival (OS), efficacy, and toxicity. RESULTS There were 181 (37.8 %) and 298 (62.2 %) patients in the 9- and 52-week trastuzumab groups, respectively. Median follow-up was 30.6 months (5.7-68.9) in the 9-week trastuzumab group and 29.3 months (5.9-59.6) in the 52-week trastuzumab group. Thirty-six month DFS was 90 and 85 % (P = 0.132) in the 9- and 52-week trastuzumab treatment groups, respectively, and 36-month OS was 96 and 97 % in the 9- and 52-week trastuzumab groups, respectively (P = 0.779). Symptomatic cardiotoxicity was observed in 1 (0.6 %) patient in the 9-week trastuzumab group and in 4 (1.3 %) patients in the 52-week trastuzumab group. CONCLUSIONS In this study, similar outcomes were found in the 9- and 52-week trastuzumab treatment groups.
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Affiliation(s)
- Onder Tonyali
- Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Gazi University, 06500, Besevler, Cankaya, Ankara, Turkey.
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259
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Xue C, Wang X, Peng R, Shi Y, Qin T, Liu D, Teng X, Wang S, Zhang L, Yuan Z. Distribution, clinicopathologic features and survival of breast cancer subtypes in Southern China. Cancer Sci 2012; 103:1679-87. [PMID: 22625227 PMCID: PMC3466418 DOI: 10.1111/j.1349-7006.2012.02339.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 05/17/2012] [Accepted: 05/19/2012] [Indexed: 11/27/2022] Open
Abstract
Breast cancer research and treatment by different subtypes is an inevitable trend. We investigated the clinicopathologic features and outcomes of different breast cancer subtypes in Southern China. A total of 5809 patients with invasive ductal carcinomas were identified. Immunohistochemical (IHC) markers for estrogen receptor (ER), progesterone receptor (PR), Her2/neu, and Ki-67 proliferation index were used to classify cases into five molecular subtypes. Clinicopathologic characteristics and survival rates were analyzed retrospectively. Of all patients, 31.1% were luminal A subtype, 30.4% luminal B (high Ki-67), 13.1% luminal B (Her2/neu+), 9.0% Her2/neu and 16.5% triple negative subtype. Luminal B (high Ki-67) presented primarily in premenopausal patients with the lowest average age (43.0 years). Her2/neu positive tumors were more closely associated with aggressive features including increased tumor size, positive lymph node status and lymphvascular invasion (LVI). Triple negative subtype was characterized by poorer histologic grade. Her2/neu positive cases had presented the worst 5-year disease-free survival (DFS) and overall survival (OS). Multivariate analyses of OS and DFS suggested that there were different negative prognostic factors for the five subtypes. The benefit of the cyclophosphamide, methotrexate, and 5-fluorouracil (5FU) (CMF) regimen was equal to that of anthracycline-based and Taxane-based regimens for patients with luminal A subtype and triple negative subtype, but inferior to anthracycline-based and Taxane-based regimens for those with two luminal B subtypes and Her2/neu subtype. The prognostic significance of traditional markers may differ among subtypes. This study revealed the distinct clinicopathologic characteristics, systemic therapy benefits, prognostic factors and survival rate among different breast cancer subtypes.
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Affiliation(s)
- Cong Xue
- State Key Laboratory of Oncologyin in South China, Guangzhou, China
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260
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Mazouni C, Reitsamer R, Rimareix F, Stranzl H, Uzan C, Garbay JR, Delaloge S, Peintinger F. The positive non-sentinel status is not the main decisional factor for chemotherapy assignment in breast cancer with micrometastatic disease in the sentinel lymph node. J Surg Oncol 2012; 106:703-7. [PMID: 22674094 DOI: 10.1002/jso.23188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 05/15/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND Surgical and systemic treatment modalities for breast cancer (BC) patients with micrometastatic disease in the sentinel lymph node biopsy (SNB) are controversial. The aim of this study was to evaluate decisional factors associated with assignment of adjuvant chemotherapy (CT). PATIENTS AND METHODS In a retrospective multicentric European study we evaluated cases of primary BC patients who underwent SNB. Logistic regression (LR) and recursive partitioning analyses (RPA) were performed to determine factors associated with CT. RESULTS Of the 172 patients with micrometastatic disease, 39.5% received adjuvant CT. In the group treated with CT, patients tended to be younger (P = 0.001), with higher grade (P = 0.001) and HER2 positive tumors (P = 0.006) compared to patients without CT. In multivariate LR, age (P = 0.0027), high grading (P = 0.01) HER2 positivity (P = 0.03), and positive non-SN status (P = 0.03) were significantly associated with CT. RPA demonstrated that tumor grade, and not the non-SN status, was the first split in the partition tree followed by HER2 status, and non-SN status influencing the probability for CT administration. CONCLUSION High tumor grade is the main decisional factor followed by HER2 positivity and then by the positive non-SN status for CT in micrometastatic disease in the SN.
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Affiliation(s)
- Chafika Mazouni
- Department of Breast Medical and Surgical Oncology, Institut Gustave Roussy, Villejuif, France.
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Implications of HER2 amplification in small, node-negative breast cancers: do Asians differ? World J Surg 2012; 36:287-94. [PMID: 22105650 DOI: 10.1007/s00268-011-1353-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We investigated the implications of HER2 amplification in Asian women with small, node-negative breast cancer in low- and middle-income countries (LMCs). METHODS We reviewed the charts patients treated between 1989 and 2009 with breast conservation therapy for node-negative breast cancers measuring ≤ 2 cm. Disease-free survival (DFS), ipsilateral breast tumor recurrence (IBTR), distant disease-free survival (DDFS), and overall survival (OS) rates were estimated using the Kaplan-Meier method and were compared by the log-rank test. Potential covariates-age, tumor grade, hormone receptor status--were analyzed by multivariate analysis. RESULTS A total of 519 patients were studied including 204 (39%) and 315 (61%) patients diagnosed with pT1ab and pT1c tumors, respectively. Median follow-up was 57 months. HER2 amplification was found in 17.1% of all patients and in 16.7% patients with pT1ab tumors. Among patients with T1ab tumors, 73.0 and 9.3% underwent adjuvant hormonal and chemotherapy, respectively; 3 of 34 T1ab patients with HER2-amplified tumors received trastuzumab. HER2 amplification was associated with poorer 5-year DFS (83.7% vs. 95.5%, P < 0.0001), DDFS (87.5% vs. 97.9%, P < 0.0001), and IBTR (8.6% vs. 2.1%, P < 0.0001) rates in patients with pT1 tumors. Multivariate analysis showed that HER2 amplification remained a significant negative prognostic factor for DFS [hazard ratio (HR) 4.1, 95% confidence interval (CI) 2.1-7.8, P < 0.0001], DDFS (HR 6.3, 95% CI 2.4-17.0, P < 0.0001), and IBTR (HR 4.5, 95% CI 2.0-10.0, P < 0.0001) rates. In the pT1ab subgroup, univariate analysis showed that HER2 amplification prognosticated for DFS (85.1% vs. 95.7%, P = 0.022) and IBTR (14.9% vs. 3.5%, P = 0.004) rates but not for the OS (100% vs. 99.2%, P = 0.487) rate. Similar results were obtained after excluding patients given trastuzumab. CONCLUSIONS The decision to use trastuzumab in HER2-amplified pT1ab tumors must balance their poor outcome against intrinsic financial limitations in LMCs. Patient selection criteria needs fine-tuning, and resource-sensitive regimens must be explored.
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263
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Gori S, Clavarezza M, Siena S, Foglietta J, Tarenzi E, Giordano M, Molino A, Graiff C, Fusco V, Alabiso O, Baldini E, Gamucci T, Altavilla G, Dondi D, Venturini M. Adjuvant chemotherapy of pT1a and pT1b breast carcinoma: results from the NEMESI study. BMC Cancer 2012; 12:158. [PMID: 22545982 PMCID: PMC3404902 DOI: 10.1186/1471-2407-12-158] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 04/30/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The prognosis of pT1a-pT1b breast cancer (BC) used to be considered very good, with a 10-y RFS of 90%. However, some retrospective studies reported a 10-y RFS of 81%-86% and suggested benefit from adjuvant systemic therapy. METHODS To evaluate the variables that determined the choice of adjuvant chemotherapy and the type of chemotherapy delivered in pT1a-pT1b BC, we analysed the small tumours enrolled in the NEMESI study. RESULTS Out of 1,894 patients with pathological stage I-II BC enrolled in NEMESI, 402 (21.2%) were pT1a-pT1b. Adjuvant chemotherapy was delivered in 127/402 (31.59%). Younger age, grading G3, high proliferative index, ER-negative and HER2-positive status were significantly associated with the decision to administer adjuvant chemotherapy. An anthracycline without taxane regimen was administered in 59.1% of patients, anthracycline with taxane in 24.4%, a CMF-like regimen in 14.2% and taxane in 2.4%. Adjuvant chemotherapy was administered in 88.4% triple-negative and 73.46% HER2-positive pT1a-pT1b BC. Adjuvant trastuzumab was delivered in 30/49 HER2-positive BC (61.2%). CONCLUSIONS Adjuvant chemotherapy was delivered in 31.59% T1a-pT1b BC treated at 63 Italian oncological centres from January 2008 to June 2008. The choice to deliver chemotherapy was based on biological prognostic factors. Anthracycline-based chemotherapy was administered in 83.5% patients.
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Affiliation(s)
- Stefania Gori
- Oncologia Medica, Ospedale Santa Maria della Misericordia, Azienda Ospedaliera di Perugia, Perugia, Italy
- Division of Medical Oncology, Ospedale S. Maria della Misericordia, Azienda Ospedaliera Perugia, via Dottori 1, Perugia, 06122, Italy
| | | | - Salvatore Siena
- Struttura Complessa di Oncologia Falck, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | - Jennifer Foglietta
- Oncologia Medica, Ospedale Santa Maria della Misericordia, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Emiliana Tarenzi
- Struttura Complessa di Oncologia Falck, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | | | - Annamaria Molino
- U.O.C. di Oncologia dell’Ospedale Civile Maggiore, Azienda Ospedaliera-Universitaria di Verona, Verona, Italy
| | | | - Vittorio Fusco
- Oncologia, Azienda Ospedaliera di Alessandria, Alessandria, Italy
| | - Oscar Alabiso
- SC Oncologia, Azienda Ospedaliero-Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Teresa Gamucci
- UO Oncologia Medica, Ospedale S.S. Trinità, Sora (FR), Sassari, Italy
| | | | - Davide Dondi
- Medical & Scientific Department, Sanofi-Aventis, Milan, Italy
| | - Marco Venturini
- Oncologia, Ospedale Sacro Cuore-Don Calabria, Negrar, (VR), Italy
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Abstract
A 53-year-old postmenopausal woman was found to have a new area of microcalcification at the 10 o'clock position of her right breast during a routine screening mammogram. Ultrasound-guided core biopsy revealed a grade 2 invasive ductal carcinoma, estrogen receptor (ER)+ (90%), progesterone receptor positive (20%), and human epidermal growth factor receptor (HER)-2+ (3+ by immunohistochemistry). A right breast lumpectomy and sentinel node biopsy were performed. The invasive tumor measured 0.7 cm, no lymphovascular space invasion was identified, surgical margins were uninvolved, and the sentinel lymph nodes were negative for tumor. She was evaluated postoperatively in the medical oncology clinic to discuss an adjuvant treatment strategy. The question for our colleagues is: should she be offered adjuvant chemotherapy and trastuzumab prior to adjuvant radiation and 5 years of hormonal therapy?
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265
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Li J, Liu X, Tong Z. Clinical features and survival analysis of T1mic, a, bN0M0 breast cancer. Jpn J Clin Oncol 2012; 42:471-6. [PMID: 22493058 DOI: 10.1093/jjco/hys046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyze the clinicopathological features and prognosis of T1mic, a, bN0M0 breast cancer. METHODS The clinical data and survival status of 4487 cases of operable breast cancer treated in our hospital from 2002 to 2005 were collected, including 372 cases with T1mic, a, bN0M0 breast cancers. These patients were divided into four subtypes: Luminal A, Luminal B, triple-negative and human epidermal growth factor receptor 2-positive. Disease-free survival and risk factors for recurrence were identified. RESULTS We identified 372 eligible patients. The median follow-up was 78 months (range: 5-106 months). Univariate analysis showed age, adjuvant endocrine therapy, hormonal receptor and human epidermal growth factor receptor 2 were prognostic factors. Multivariate analysis showed that hormonal receptor and human epidermal growth factor receptor 2 were prognostic factors. In the hormonal receptor-positive group, human epidermal growth factor receptor 2-positive patients (Luminal B) had a four times higher recurrence risk than human epidermal growth factor receptor 2 negative (Luminal A) patients. However, there was no statistically significant difference between hormonal receptor-negative groups (triple-negative and human epidermal growth factor receptor 2-positive). CONCLUSIONS Hormonal receptor and human epidermal growth factor receptor 2 were independent factors of 5-year disease-free survival for patients with T1mic, a, bN0M0 breast cancer. The Luminal B group had a worse prognosis than the Luminal A group, but there was no statistically significant difference between triple-negative and human epidermal growth factor receptor 2-positive groups.
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Affiliation(s)
- Junnan Li
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, Huanhuxi Road, Hexi District, Tianjin, China.
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266
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Abstract
OPINION STATEMENT Over the recent years, there has been an increasing recognition that triple-negative breast cancer constitutes a separate, albeit heterogeneous, entity arising from distinct oncogenic pathways. Despite its aggressive clinical behavior, triple-negative disease responds favorably to cytotoxic chemotherapy resulting in high response rates. Nonetheless, the relapse rates are high and, in the absence of targeted therapies to significantly alter its natural history, the prognosis can be poor. Most of the trials conducted in the past that led to the formulation of the current guidelines have indiscriminately lumped triple-negative disease with receptor-positive subtypes. Therefore, there are relatively scant data regarding how standard approaches specifically apply for triple-negative disease. By virtue of its chemosensitive nature and high probability of achieving a complete pathologic response, neoadjuvant chemotherapy in early-stage/operable and locally-advanced/inoperable triple-negative disease is highly recommended. The indications for adjuvant chemotherapy are the same as in receptor-positive tumors, although endocrine therapies or agents targeting Her2 signaling have no established role in triple-negative disease. The optimal chemotherapy is not entirely clear; however, by virtue of their efficacy in breast cancer in general, anthracycline-containing regimens are the most widely used. The incorporation of taxanes in the regimen is supported by retrospective analyses. There is scant evidence to recommend any particular agent in the metastatic setting, although the combination of ixabepilone with capecitabine was shown to be active specifically in triple-negative disease. Given the uncertainty in the optimal management of triple-negative disease, the shortcomings of contemporary regimens, and the strong rationale of novel therapies, participation in clinical trials should be strongly considered at any stage of the disease.
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267
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Schillaci R, Guzmán P, Cayrol F, Beguelin W, Díaz Flaqué MC, Proietti CJ, Pineda V, Palazzi J, Frahm I, Charreau EH, Maronna E, Roa JC, Elizalde PV. Clinical relevance of ErbB-2/HER2 nuclear expression in breast cancer. BMC Cancer 2012; 12:74. [PMID: 22356700 PMCID: PMC3342900 DOI: 10.1186/1471-2407-12-74] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/22/2012] [Indexed: 11/25/2022] Open
Abstract
Background The biological relevance of nuclear ErbB-2/HER2 (NuclErbB-2) presence in breast tumors remains unexplored. In this study we assessed the clinical significance of ErbB-2 nuclear localization in primary invasive breast cancer. The reporting recommendations for tumor marker prognostic studies (REMARK) guidelines were used as reference. Methods Tissue microarrays from a cohort of 273 primary invasive breast carcinomas from women living in Chile, a Latin American country, were examined for membrane (MembErbB-2) and NuclErbB-2 expression by an immunofluorescence (IF) protocol we developed. ErbB-2 expression was also evaluated by immunohistochemistry (IHC) with a series of antibodies. Correlation between NuclErbB-2 and MembErbB-2, and between NuclErbB-2 and clinicopathological characteristics of tumors was studied. The prognostic value of NuclErbB-2 in overall survival (OS) was evaluated using Kaplan-Meier method, and Cox model was used to explore NuclErbB-2 as independent prognostic factor for OS. Results The IF protocol we developed showed significantly higher sensitivity for detection of NuclErbB-2 than IHC procedures, while its specificity and sensitivity to detect MembErbB-2 were comparable to those of IHC procedures. We found 33.6% NuclErbB-2 positivity, 14.2% MembErbB-2 overexpression by IF, and 13.0% MembErbB-2 prevalence by IHC in our cohort. We identified NuclErbB-2 positivity as a significant independent predictor of worse OS in patients with MembErbB-2 overexpression. NuclErbB-2 was also a biomarker of lower OS in tumors that overexpress MembErbB-2 and lack steroid hormone receptors. Conclusions We revealed a novel role for NuclErbB-2 as an independent prognostic factor of poor clinical outcome in MembErbB-2-positive breast tumors. Our work indicates that patients presenting NuclErbB-2 may need new therapeutic strategies involving specific blockage of ErbB-2 nuclear migration.
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Affiliation(s)
- Roxana Schillaci
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Buenos Aires, Argentina
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Whitfield R, Kollias J, De Silva P, Zorbas H, Maddern G. Use of trastuzumab in Australia and New Zealand: results from the National Breast Cancer Audit. ANZ J Surg 2012; 82:234-9. [PMID: 22510180 DOI: 10.1111/j.1445-2197.2011.05998.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Trastuzumab increases disease-free and overall survival in HER-2-positive, early breast cancer. In 2007, the National Breast and Ovarian Cancer Centre recommended that patients with HER-2 positive cancers (node positive or node negative tumours >1 cm) be offered adjuvant trastuzumab with chemotherapy. The aim of this study was to evaluate recent trends in trastuzumab therapy in Australia and New Zealand. METHODS Following data were obtained from the National Breast Cancer Audit for patients treated between 2006 and 2008: tumour size, number of cases recorded per surgeon per year, location of hospital, HER-2 receptor status, age, lymph node status, chemotherapy and trastuzumab treatment. RESULTS Data were available from 23,290 patients. During the study period, the percentage of breast cancers tested for HER-2 rose from 77% to 91%. Patients over 70 had fewer HER-2 tests than their younger counterparts. Fourteen percent of tumours were HER-2 positive; the proportion treated with trastuzumab in 2006, 2007 and 2008 was 50%, 66% and 74%, respectively. Significantly more node-positive patients (77%) were given trastuzumab than node-negative patients (52%). All the patients prescribed trastuzumab also received chemotherapy. Patients under 70 years, patients treated in Australia and patients treated by higher caseload surgeons were more likely to be prescribed trastuzumab than those over 70, patients in New Zealand and patients treated by lower caseload surgeons. CONCLUSIONS Trastuzumab-prescribing trends conform to the published guidelines. However, older patients and those with HER-2 positive, node-negative tumours >1 cm may be undertreated in some cases.
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Affiliation(s)
- Robert Whitfield
- Department of Breast, Endocrine & Surgical Oncology, Royal Adelaide Hospital, North Terrace, SA, Australia.
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269
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Martin-Castillo B, Oliveras-Ferraros C, Vazquez-Martin A, Cufí S, Moreno JM, Corominas-Faja B, Urruticoechea A, Martín ÁG, López-Bonet E, Menendez JA. Basal/HER2 breast carcinomas: integrating molecular taxonomy with cancer stem cell dynamics to predict primary resistance to trastuzumab (Herceptin). Cell Cycle 2012; 12:225-45. [PMID: 23255137 DOI: 10.4161/cc.23274] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
High rates of inherent primary resistance to the humanized monoclonal antibody trastuzumab (Herceptin) are frequent among HER2 gene-amplified breast carcinomas in both metastatic and adjuvant settings. The clinical efficacy of trastuzumab is highly correlated with its ability to specifically and efficiently target HER2-driven populations of breast cancer stem cells (CSCs). Intriguingly, many of the possible mechanisms by which cancer cells escape trastuzumab involve many of the same biomarkers that have been implicated in the biology of CS-like tumor-initiating cells. In the traditional, one-way hierarchy of CSCs in which all cancer cells descend from special self-renewing CSCs, HER2-positive CSCs can occur solely by self-renewal. Therefore, by targeting CSC self-renewal and resistance, trastuzumab is expected to induce tumor shrinkage and further reduce breast cancer recurrence rates when used alongside traditional therapies. In a new, alternate model, more differentiated non-stem cancer cells can revert to trastuzumab-refractory, CS-like cells via the activation of intrinsic or microenvironmental paths-to-stemness, such as the epithelial-to-mesenchymal transition (EMT). Alternatively, stochastic transitions of trastuzumab-responsive CSCs might also give rise to non-CSC cellular states that lack major attributes of CSCs and, therefore, can remain "hidden" from trastuzumab activity. Here, we hypothesize that a better understanding of the CSC/non-CSC social structure within HER2-overexpressing breast carcinomas is critical for trastuzumab-based treatment decisions in the clinic. First, we decipher the biological significance of CSC features and the EMT on the molecular effects and efficacy of trastuzumab in HER2-positive breast cancer cells. Second, we reinterpret the genetic heterogeneity that differentiates trastuzumab-responders from non-responders in terms of CSC cellular states. Finally, we propose that novel predictive approaches aimed at better forecasting early tumor responses to trastuzumab should identify biological determinants that causally underlie the intrinsic flexibility of HER2-positive CSCs to "enter" into or "exit" from trastuzumab-sensitive states. An accurate integration of CSC cellular states and EMT-related biomarkers with the currently available breast cancer molecular taxonomy may significantly improve our ability to make a priori decisions about whether patients belonging to HER2 subtypes differentially enriched with a "mesenchymal transition signature" (e.g., luminal/HER2 vs. basal/HER2) would distinctly benefit from trastuzumab-based therapy ab initio.
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Affiliation(s)
- Begoña Martin-Castillo
- Unit of Clinical Research, Catalan Institute of Oncology-Girona (ICO-Girona), Catalonia, Spain
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270
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Abstract
T1ab N0 breast cancer generally has excellent prognosis. Adverse prognostic factors include HER2+ disease, ER-negative disease, high-grade histology, T1b, and young age of patient. These patients are largely excluded from most trials, and to date, no prospective studies for this group yet reported. Treatment guidelines are vague and treatment inconsistent. As yet, in the HER2+ population, little experience with targeted therapy has been reported. Prospective trials are needed.
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Affiliation(s)
- Anthony D Elias
- From the University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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271
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IENI A, GIUFFRÈ G, LANZAFAME S, NUCIFORO G, CURDUMAN M, VILLARI L, ROZ E, CERTO G, CABIBI D, SALOMONE E, LABATE A, MESSINA D, FRANCO V, ADAMO V, TUCCARI G. Morphological and biomolecular characteristics of subcentimetric invasive breast carcinomas in Sicily: A multicentre retrospective study in relation to trastuzumab treatment. Oncol Lett 2012; 3:141-146. [PMID: 22740870 PMCID: PMC3362342 DOI: 10.3892/ol.2011.425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 08/30/2011] [Indexed: 11/06/2022] Open
Abstract
Little information from clinical trials is available regarding the efficacy of trastuzumab treatment in subcentimetric breast carcinomas (BCs). The aim of this study was to verify the existence of correlations between HER2 and hormone receptor status, Ki67 values, grade, histotype and node involvement in a cohort of pT1a,b BCs from an area not widely covered by screening campaigns. A total of 410 pT1a,b BC formalin-fixed paraffin-embedded samples collected from eight Sicilian Anatomo-Pathological Units (APUs) were classified according to the WHO classification and tumour grading was established. Estrogen and progesterone receptor status, Ki67 labelling index and HER2 status were available. Relationships between immunohistochemical data and clinicopathological characteristics were investigated using the Chi-square test; the cohort was analysed with respect to pT1a and pT1b BC as well as to node status. Ductal infiltrating carcinoma was the prevalent histotype in the pT1a and pT1b stages; G2 was a more common tumour grade, with a range between 64.6% and 70% of pT1a and pT1b, respectively. Taking into consideration the lymph node involvement of pT1a,b BC, only 17.1% cases were node-positive without a relevant difference between pT1a and pT1b. No significant differences between pT1a and pT1b BC cases emerged in relation to Ki67 LI, hormone receptors and HER2 status. T1a,b BC cases were stratified by node involvement and a significant relationship was observed with grade as well as with HER2 status. A significant relationship for pT1a cases emerged only for tumour grade, while pT1b cases showed a significant correlation exclusively with HER2 status. Our data clearly support the operative guidelines of the National Comprehensive Cancer Network. Therefore, the combined treatment with trastuzumab plus chemotherapy should be administered only to patients with pT1b or larger BCs. In small HER2-positive pT1a or microinvasive BC, this therapy should be considered on a case-by-case basis, considering tumour grade as the first characteristic.
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Affiliation(s)
- A. IENI
- Department of Human Pathology, University of Messina, A.O.U. Polyclinic G. Martino, Messina
| | - G. GIUFFRÈ
- Department of Human Pathology, University of Messina, A.O.U. Polyclinic G. Martino, Messina
| | - S. LANZAFAME
- Department of Diagnostic-Forensic Pathology and Public Health, University of Catania, Polyclinic G. Rodolico, Catania
| | | | | | | | - E. ROZ
- La Maddalena Oncology Hospital, Palermo
| | - G. CERTO
- Cappellani Pathology Division, Messina
| | - D. CABIBI
- Department of Human Pathology, University of Palermo, A.O.U. Polyclinic Giaccone, Palermo
| | | | - A. LABATE
- Cappellani Pathology Division, Messina
| | - D. MESSINA
- Pathology Division, Sant’Antonio Abate Hospital, Trapani, Italy
| | - V. FRANCO
- Department of Human Pathology, University of Palermo, A.O.U. Polyclinic Giaccone, Palermo
| | - V. ADAMO
- Department of Human Pathology, University of Messina, A.O.U. Polyclinic G. Martino, Messina
| | - G. TUCCARI
- Department of Human Pathology, University of Messina, A.O.U. Polyclinic G. Martino, Messina
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272
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Li J, Gonzalez-Angulo AM, Allen PK, Yu TK, Woodward WA, Ueno NT, Lucci A, Krishnamurthy S, Gong Y, Bondy ML, Yang W, Willey JS, Cristofanilli M, Valero V, Buchholz TA. Triple-negative subtype predicts poor overall survival and high locoregional relapse in inflammatory breast cancer. Oncologist 2011; 16:1675-83. [PMID: 22147002 DOI: 10.1634/theoncologist.2011-0196] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Numerous studies have demonstrated that expression of estrogen/progesterone receptor (ER/PR) and human epidermal growth factor receptor (HER)-2 is important for predicting overall survival (OS), distant relapse (DR), and locoregional relapse (LRR) in early and advanced breast cancer patients. However, these findings have not been confirmed for inflammatory breast cancer (IBC), which has different biological features than non-IBC. METHODS We retrospectively analyzed the records of 316 women who presented to MD Anderson Cancer Center in 1989-2008 with newly diagnosed IBC without distant metastases. Most patients received neoadjuvant chemotherapy, mastectomy, and postmastectomy radiation. Patients were grouped according to receptor status: ER(+) (ER(+)/PR(+) and HER-2-; n = 105), ER(+)HER-2(+) (ER(+)/PR(+) and HER-2(+); n = 37), HER-2(+) (ER(-)/PR(-) and HER-2(+); n = 83), or triple-negative (TN) (ER(-)PR(-)HER-2(-); n = 91). Kaplan-Meier and Cox proportional hazards methods were used to assess LRR, DR, and OS rates and their associations with prognostic factors. RESULTS The median age was 50 years (range, 24-83 years). The median follow-up time and median OS time for all patients were both 33 months. The 5-year actuarial OS rates were 58.7% for the entire cohort, 69.7% for ER(+) patients, 73.5% for ER(+)HER-2(+) patients, 54.0% for HER=2(+) patients, and 42.7% for TN patients (p < .0001); 5-year LRR rates were 20.3%, 8.0%, 12.6%, 22.6%, and 38.6%, respectively, for the four subgroups (p < .0001); and 5-year DR rates were 45.5%, 28.8%, 50.1%, 52.1%, and 56.7%, respectively (p < .001). OS and LRR rates were worse for TN patients than for any other subgroup (p < .0001-.03). CONCLUSIONS TN disease is associated with worse OS, DR, and LRR outcomes in IBC patients, indicating the need for developing new locoregional and systemic treatment strategies for patients with this aggressive subtype.
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Affiliation(s)
- Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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273
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Tanaka K, Kawaguchi H, Nakamura Y, Taguchi K, Nishiyama K, Ohno S. Effect of HER2 status on risk of recurrence in women with small, node-negative breast tumours. Br J Surg 2011; 98:1561-5. [PMID: 22059233 DOI: 10.1002/bjs.7639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Adjuvant trastuzumab for small, node-negative, human epidermal growth factor receptor 2 (HER2)-positive breast cancer remains controversial. The purpose of this study was to investigate the risk of recurrence in women with pathological tumour node (pTN) T1 N0 tumours. METHODS Patients with pT1 N0 breast cancer diagnosed at the National Kyushu Cancer Centre between 2001 and 2007 were reviewed. Patients were categorized according to HER2 status. RESULTS Four hundred and fifty-four patients who had pT1 N0 tumours, and had not received adjuvant trastuzumab, were identified. The HER2-negative and -positive groups comprised 376 and 78 patients (17·2 per cent) respectively. At a median follow-up of 46·3 months, there were 18 recurrences.The 5-year relapse-free survival (RFS) rates were 97·2 and 88 per cent in the HER2-negative and -positive groups respectively (P < 0·001). Multivariable analysis identified HER2-positive tumour as an independent predictor of RFS in patients with pT1 N0 tumours (hazard ratio 6·65, 95 per cent confidence interval 2·53 to 17·49; P < 0·001). CONCLUSION Women with pT1 N0 HER2-positive breast cancer have a high risk of recurrence.
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Affiliation(s)
- K Tanaka
- Department of Breast Oncology, National Kyushu Cancer Centre, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan.
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274
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Exploring the use and impact of adjuvant trastuzumab for HER2-positive breast cancer patients in a large UK cancer network. Do the results of international clinical trials translate into a similar benefit for patients in South East Wales? Br J Cancer 2011; 106:32-8. [PMID: 22108523 PMCID: PMC3251855 DOI: 10.1038/bjc.2011.506] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Trastuzumab was approved in the United Kingdom for adjuvant treatment of human epidermal growth factor receptor 2 (HER2)+ breast cancer in 2006 at significant economic cost and with limited evidence in smaller T1N0 tumours. The South East Wales Cancer Network covers a population of 1 420 000 and maintains a database of treatments used. We examined this database to ensure the outcome of Trastuzumab use is as expected, especially in patients with T1N0 cancers. Ethods: M Case notes of patients with HER2+ disease eligible for adjuvant Trastuzumab over 2005–2008 were reviewed. Disease-free survival (DFS) and overall survival (OS) were calculated with the Kaplan–Meier method using SPSS (version 16.0.01 for Windows, SPSS, Chicago, IL, USA). Results: A total of 239 of 338 (70.7%) eligible HER2+ patients received treatment. At 3 years, the DFS of the treated group was 90.3% vs 73.3% and the OS was 98.5% vs 87.6%. In all, 47 of 92 stage I patients received Trastuzumab. Despite a trend towards worse prognostic factors in the treated group the DFS was 100% vs 84.1% and the OS was 100% vs 93.3%. Conclusion: Our results are comparable to those from landmark Trastuzumab trials. As evidence continues to emerge that smaller HER2+ cancers may behave aggressively our analysis of stage I tumours adds further support to the use of Trastuzumab in these patients.
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275
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Bachelot T, Bouzid K, Delozier T, Lortholary A, Petit T. État des lieux et mise à jour des traitements systémiques adjuvants. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2080-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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276
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Adjuvant therapy for HER2+ breast cancer: practice, perception, and toxicity. Breast Cancer Res Treat 2011; 131:713-21. [PMID: 22065290 DOI: 10.1007/s10549-011-1862-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 10/25/2011] [Indexed: 01/03/2023]
Abstract
Multiple adjuvant regimens are used for HER2+ breast cancer, but experience in routine practice is not reported. We evaluated whether oncologists' perceptions of these regimens matches clinical experience. We surveyed Wisconsin medical oncologists throughout the state regarding factors impacting selection of TCH (docetaxel, carboplatin, and trastuzumab) or anthracycline-based therapy. We also reviewed 200 cases of HER2+ breast cancer treated at the University of Wisconsin and the Marshfield Clinic and collected data on patient and tumor characteristics, chemotherapy regimen, and toxicities. Two-thirds of surveyed oncologists prefer anthracycline-based therapy, particularly for node-positive cancers. However, TCH was preferred for early-stage (T1a-bN0) tumors. Half of oncologists use prophylactic G-CSF with TCH. In the 200 cases reviewed at our centers, acute toxicity occurred more frequently with TCH. There were fewer dose modifications or delays for AC-TH (doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab) than TCH (31% vs. 47%, P = 0.07), possibly due to higher use of prophylactic G-CSF with AC-TH (77% vs. 34% with TCH, P < 0.001). Fifteen patients received prophylactic G-CSF during TCH; none developed neutropenic fever. In contrast, 25% developed neutropenic fever during TCH without G-CSF. There were modest declines in median left ventricular ejection fraction reaching 9% with AC-TH and 3% with TCH at 12 months, but early cessation of trastuzumab was similar for both regimens. We conclude that TCH and AC-TH are common adjuvant regimens used for HER2+ breast cancer. The preference of TCH for early-stage disease and anthracycline-based therapy for node-positive disease suggests that many oncologists perceive that TCH is safer and AC-TH more effective. Myelosuppression from TCH is greater than AC-TH, but can be mitigated with routine G-CSF.
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277
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Livi L, Meattini I, Saieva C, Franzese C, Di Cataldo V, Greto D, Franceschini D, Scotti V, Bonomo P, Nori J, Sanchez L, Vezzosi V, Bianchi S, Cataliotti L, Biti G. Prognostic value of positive human epidermal growth factor receptor 2 status and negative hormone status in patients with T1a/T1b, lymph node-negative breast cancer. Cancer 2011; 118:3236-43. [DOI: 10.1002/cncr.26647] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 09/21/2011] [Accepted: 09/26/2011] [Indexed: 02/01/2023]
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278
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Jacot W, Gutowski M, Azria D, Romieu G. Adjuvant early breast cancer systemic therapies according to daily used technologies. Crit Rev Oncol Hematol 2011; 82:361-9. [PMID: 22024387 DOI: 10.1016/j.critrevonc.2011.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 06/18/2011] [Accepted: 09/13/2011] [Indexed: 01/04/2023] Open
Abstract
Prognosis of early breast cancer patients is significantly improved with the use of adjuvant therapies. Various guidelines have been proposed to select patients who will derive the most benefit from such treatments. However, classifications have limited usefulness in subsets of patients such as those with node negative breast cancer. The 2007 St. Paul de Vence Clinical Practice Recommendations proposed to consider adjuvant therapy in accordance with the 10-year relapse-free survival reduction estimated by Adjuvant! Online. However, many limitations remain regarding the use of Adjuvant! Online. Among them, adverse prognostic and/or predictive factors such as vascular invasion, mitotic activity, progesterone receptor negativity, and HER-2 expression are not incorporated in the routine clinical decision process. Our group has therefore issued guidelines based on the consideration of both Adjuvant! Online calculations and the prognostic and/or predictive effects of these markers. In addition, web-accessible comprehensive tables summarizing these recommendations are provided.
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Affiliation(s)
- W Jacot
- Val d'Aurelle Comprehensive Cancer Centre, Montpellier, France.
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279
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Perez EA, Spano JP. Current and emerging targeted therapies for metastatic breast cancer. Cancer 2011; 118:3014-25. [DOI: 10.1002/cncr.26356] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 04/27/2011] [Accepted: 05/10/2011] [Indexed: 11/09/2022]
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280
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Oakman C, Sapino A, Marchiò C, Pestrin M, Biganzoli L, Di Leo A. Chemotherapy with or without trastuzumab. Ann Oncol 2011; 21 Suppl 7:vii112-9. [PMID: 20943603 DOI: 10.1093/annonc/mdq283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The prognosis of pT1N0M0/stage I breast cancer has generally been considered so favourable that these patients are not routinely offered adjuvant systemic therapy. However, biological heterogeneity within pT1N0M0 dictates diverse outcomes within the subgroup. HER2 gene amplification or protein overexpression is uncommon in pT1N0M0 disease, but, when present, is clearly associated with a higher risk of recurrence. The role of anti-HER2 therapy in these patients is controversial. Few women with node-negative, small tumours were included in the adjuvant trastuzumab trials. There are no robust data on trastuzumab in this patient subset, although subgroup analyses suggest that proportional benefits are independent of T and N. With current guidelines and scheduling, committing to adjuvant trastuzumab involves concurrent chemotherapy, 1 year of treatment and potential cardiotoxicity. A further challenge with anti-HER2 therapy is the potential benefit in patients with demonstrable HER2 positivity within a predominantly HER2-negative tumour. The decision for therapy requires a yes/no answer, but HER2 status derives from a continuum of gene copy number and protein expression. The diagnostic threshold is made more complex by heterogeneity of the HER2 status within a tumour. This review focuses on available data for HER2-positive pT1N0M0 disease and explores the significance of intratumoural HER2 heterogeneity.
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Affiliation(s)
- C Oakman
- Sandro Pitigliani Medical Oncology Unit, Department of Oncology, Hospital of Prato, Istituto Toscano Tumori, Prato, Italy
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281
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Gennari A, Pietri E, Amadori D. Case histories: breast cancer. EJC Suppl 2011. [DOI: 10.1016/s1359-6349(11)70008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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282
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Mukohara T. Role of HER2-Targeted Agents in Adjuvant Treatment for Breast Cancer. CHEMOTHERAPY RESEARCH AND PRACTICE 2011; 2011:730360. [PMID: 22295205 PMCID: PMC3263614 DOI: 10.1155/2011/730360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 03/04/2011] [Accepted: 06/16/2011] [Indexed: 01/05/2023]
Abstract
Approximately 20% of breast cancers overexpress human epidermal growth factor receptor 2 (HER2) protein, mainly as a result of gene amplification. The receptor tyrosine kinase is believed to play a critical role in the pathogenesis and further proliferation of these tumors. The application of trastuzumab, a humanized monoclonal antibody against the extracellular domain of HER2 protein, to HER2-positive metastatic breast cancer has significantly improved treatment outcomes. Following this success, several phase III trials have evaluated the role of trastuzumab in the adjuvant setting, with the result that trastuzumab use is now the standard of care for most HER2-positive early breast cancer patients. In this paper, we review these pivotal phase III trials. We also discuss unresolved issues in adjuvant treatment with trastuzumab, including target patient population, sequential or concurrent use with chemotherapy or radiation, treatment duration, cardiotoxicity, and the possibility of eliminating chemotherapy. Following confirmation of its ability to partially overcome trastuzumab resistance, we also discuss the role of lapatinib in adjuvant use.
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Affiliation(s)
- Toru Mukohara
- Department of Medical Oncology/Hematology, Cancer Center, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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283
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Kiess AP, McArthur HL, Mahoney K, Patil S, Morris PG, Ho A, Hudis CA, McCormick B. Adjuvant trastuzumab reduces locoregional recurrence in women who receive breast-conservation therapy for lymph node-negative, human epidermal growth factor receptor 2-positive breast cancer. Cancer 2011; 118:1982-8. [PMID: 21887681 DOI: 10.1002/cncr.26484] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 07/04/2011] [Accepted: 07/11/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer have a higher risk of locoregional recurrence (LRR), even in the setting of early stage, lymph node-negative disease. In this sequential, retrospective study, the authors evaluated whether adjuvant trastuzumab was associated with reduced LRR in women with lymph node-negative, HER2-positive disease who received breast-conservation therapy (BCT). METHODS By using an institutional database, 197 women were identified who had lymph node-negative, HER2-positive breast cancer measuring ≤5 cm diagnosed between 2002 and 2008 and who received BCT, including whole-breast irradiation. Two cohorts were compared: 70 women who did not receive trastuzumab (the no-trastuzumab cohort) and 102 women who did receive trastuzumab (the trastuzumab cohort). Kaplan-Meier methods were used to estimate LRR-free survival. RESULTS The 2 cohorts were similar in age, tumor size, histology, and hormone receptor status. Chemotherapy was received by 73% of the no-trastuzumab cohort and by 100% of the trastuzumab cohort. In both groups, 99% of patients completed radiotherapy with a median dose of 60 Gray. The median recurrence-free follow-up was 86 months for the no-trastuzumab cohort and 47 months for the trastuzumab cohort. The 3-year LRR-free survival rate was 90% (95% confidence interval, 83%-97%) for the no-trastuzumab cohort and 99% (95% confidence interval, 97%-100%) for the trastuzumab cohort. In the no-trastuzumab cohort, LRR occurred in 7 patients (median time to LRR, 14 months). In the trastuzumab cohort, there was 1 LRR at 14 months. CONCLUSIONS Even among women with lower risk breast cancer, the relatively high locoregional failure rates associated with positive HER2 status could be reduced markedly with adjuvant trastuzumab chemotherapy. Within 3 years, a 10% LRR rate without trastuzumab and a 1% LRR rate with trastuzumab were observed in women with lymph node-negative disease who received BCT.
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Affiliation(s)
- Ana P Kiess
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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284
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Thomssen C, Scharl A, Harbeck N. AGO Recommendations for Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Update 2011. Breast Care (Basel) 2011; 6:299-313. [PMID: 22164127 PMCID: PMC3225216 DOI: 10.1159/000331459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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285
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Possible available treatment option for early stage, small, node-negative, and HER2-overexpressing breast cancer. Breast Cancer 2011; 19:95-103. [DOI: 10.1007/s12282-011-0296-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 07/21/2011] [Indexed: 11/25/2022]
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286
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Theriault RL, Litton JK, Mittendorf EA, Chen H, Meric-Bernstam F, Chavez-Macgregor M, Morrow PK, Woodward WA, Sahin A, Hortobagyi GN, Gonzalez-Angulo AM. Age and survival estimates in patients who have node-negative T1ab breast cancer by breast cancer subtype. Clin Breast Cancer 2011; 11:325-31. [PMID: 21764391 DOI: 10.1016/j.clbc.2011.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/10/2011] [Accepted: 05/11/2011] [Indexed: 11/28/2022]
Abstract
AIM This article evaluates the risk of recurrence for patients who have small node-negative breast cancer by age and tumor subtype. METHODS One thousand twelve patients with a T1a,bN0 breast cancer diagnosed between 1990 and 2002 who did not receive chemotherapy or trastuzumab were included. Patients and tumor characteristics were compared using the χ(2) or Wilcoxon's rank sum tests. Survival outcomes were estimated with the Kaplan-Meier method and compared using the log-rank statistic. Cox proportional hazards models were used to determine association of breast cancer subtypes and age at diagnosis with other covariates. RESULTS Median age was 51.5 years. There were 771 hormone receptor (HR)-positive, 98 HER2-positive, and 143 triple-negative breast cancers (TNBC). Six hundred ninety-three patients were > 50 years, and 33 patients were ≤ 35 years. For 5-year survival estimates, there were 118 deaths and overall survival was 94.6% (95% confidence interval [CI] = 93.2%, 96.1%). After adjusting for breast cancer subtype and other tumor characteristics, patients ≤ 35 had 2.51 (95% CI = 1.21-5.22) times greater risk of worse recurrence-free survival (RFS), and 2.60 (95% CI = 1.05-6.46) times greater risk of worse distant RFS (DRFS) compared to patients > 50 years old. Compared to patients with HR-positive disease, patients with HER2-positive breast cancer had 4.98 (95% CI = 2.91-8.53) times the risk of worse RFS and 4.70 (95% CI = 2.51-8.79) times greater risk of worse DRFS, and patients with TNBC had 2.71 (95% CI = 1.59-4.59) times greater risk of worse RFS and 2.08 (95% CI = 1.04-4.17) times greater risk of worse DRFS. CONCLUSIONS In this cohort, patients with T1a,bN0 breast cancer, young age and breast cancer subtype were significantly associated with RFS and DRFS.
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Affiliation(s)
- Rachel L Theriault
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Verma S, Lavasani S, Mackey J, Pritchard K, Clemons M, Dent S, Latreille J, Lemieux J, Provencher L, Verma S, Chia S, Wang B, Rayson D. Optimizing the management of HER2-positive early breast cancer: the clinical reality. ACTA ACUST UNITED AC 2011; 17:20-33. [PMID: 20697511 DOI: 10.3747/co.v17i4.700] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Breast cancer positive for HER2 (human epidermal growth factor receptor 2) is associated with a poor prognosis for patients with both early-stage and metastatic breast cancer. Trastuzumab has been shown to be effective and is now considered the standard of care for early-stage patients with HER2-positive breast cancer. In that population, trastuzumab has been studied in six randomized clinical trials. Overall, use of this agent leads to a significant reduction in risk of disease recurrence and improvement in overall survival. Despite the strong evidence for the use of trastuzumab in managing HER2-positive early breast cancer (EBC), a number of clinical controversies remain. The authors of this paper undertook a review of the available scientific literature on adjuvant trastuzumab to produce practical considerations from Canadian oncologists. The panel focused their discussion on five key areas: Management of node-negative disease with tumours 1 cm or smaller in size. Management of HER2-positive EBC across the spectrum of the disease (that is, nodal and steroid hormone receptor status, tumour size) Timing of trastuzumab therapy with chemotherapy for early-stage disease: concurrent or sequential. Treatment duration of trastuzumab for EBC. The role of non-anthracycline trastuzumab-based regimens.
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Affiliation(s)
- Su Verma
- University of Toronto, Toronto, ON.
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288
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Singh KK, Shukla PC, Quan A, Lovren F, Pan Y, Wolfstadt JI, Gupta M, Al-Omran M, Leong-Poi H, Teoh H, Verma S. Herceptin, a recombinant humanized anti-ERBB2 monoclonal antibody, induces cardiomyocyte death. Biochem Biophys Res Commun 2011; 411:421-6. [PMID: 21749857 DOI: 10.1016/j.bbrc.2011.06.169] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 06/25/2011] [Indexed: 12/11/2022]
Abstract
P53 protein levels are elevated by trastuzumab and the biologically similar rat ERBB2/HER2/NEU antibody; and that this coincides with enhanced apoptosis, increased cleaved caspase-3 levels and diminished cardiac function. We also demonstrate that MDM2 may be a regulatory target of anti-ERBB2 thereby implicating the MDM2/p53 axis as a potential molecular component for the undesirable cardiac outcomes noted with trastuzumab. Finally, we show that these MDM2/p53-mediated events are independent of both the ERK1/2 and Akt systems. In conclusion, our findings suggest that the adverse cardiac events observed with trastuzumab may stem from its negative regulation of MDM2 events which impairs p53 degradation resultantly promoting apoptosis leading to cardiac dysfunction. These observations may have important therapeutic implications since they suggest that anticancer agents that inhibit MDM2 and its downstream actions may curb tumor progression at the expense of increasing cardiac stress.
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Affiliation(s)
- Krishna K Singh
- Division of Cardiac Surgery, The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
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289
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Le cancer du sein sans envahissement ganglionnaire. Au-delà des consensus internationaux : une approche pragmatique. Bull Cancer 2011; 98:807-25. [DOI: 10.1684/bdc.2011.1395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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290
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High recurrence risk and use of adjuvant trastuzumab in patients with small, HER2-positive, node-negative breast cancers. Int J Clin Oncol 2011; 17:131-6. [PMID: 21681642 DOI: 10.1007/s10147-011-0269-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Accepted: 05/30/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Five randomized trials of adjuvant trastuzumab have reported significant improvements in recurrence-free survival (RFS) and overall survival. However, patients with node-negative tumors 1 cm or smaller were excluded from these trials. We assessed the recurrence risk and benefit of adjuvant therapy in such patients with small tumors. METHODS We identified patients with node-negative breast tumors 1 cm or smaller between April 2003 and December 2007. Patients were categorized according to HER2 status and pathological tumor size (pT <5 mm vs. 5-10 mm), hormone receptor (HR) status and adjuvant chemotherapy. The primary endpoint was RFS. RESULTS Of 267 patients included in the analysis, 42 had HER2-positive tumors. The median follow-up was 4.3 years. RFS was worse in patients with HER2-positive tumors than HER2-negative tumors (90.5 vs. 97.7% at 5 years; P = 0.031). In the group with HER2-positive tumors, there were no recurrences in patients with pT<5 mm, but 4 recurrences in those with pT 5-10 mm. RFS was worse in patients with pT 5-10 mm than pT <5 mm (79.0 vs. 100%, P = 0.025). Furthermore 3 recurrences occurred in patients without adjuvant trastuzumab, and 1 recurrence occurred as soon as adjuvant trastuzumab was finished. Our results appear to establish the efficacy of adjuvant trastuzumab therapy. HR status and use of adjuvant chemotherapy were not significantly associated with RFS. CONCLUSIONS Patients with HER2-positive, node-negative breast tumors 1 cm or smaller (especially 0.5-1.0 cm) have a significant recurrence risk and the decision to employ adjuvant trastuzumab therapy should be discussed with patients based on our results and those of other studies.
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291
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McArthur HL, Mahoney KM, Morris PG, Patil S, Jacks LM, Howard J, Norton L, Hudis CA. Adjuvant trastuzumab with chemotherapy is effective in women with small, node-negative, HER2-positive breast cancer. Cancer 2011; 117:5461-8. [PMID: 21681735 DOI: 10.1002/cncr.26171] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 02/21/2011] [Accepted: 03/07/2011] [Indexed: 11/05/2022]
Abstract
BACKGROUND Several large, randomized trials established the benefits of adjuvant trastuzumab with chemotherapy. However, the benefit for women with small, node-negative HER2-positive (HER2+) disease is unknown, as these patients were largely excluded from these trials. Therefore, a retrospective, single-institution, sequential cohort study of women with small, node-negative, HER2+ breast cancer who did or did not receive adjuvant trastuzumab was conducted. METHODS Women with ≤ 2 cm, node-negative, HER2+ (immunohistochemistry 3+ or fluorescence in situ hybridization ≥ 2) breast cancer were identified through an institutional database. A "no-trastuzumab" cohort of 106 trastuzumab-untreated women diagnosed between January 1, 2002 and May 14, 2004 and a "trastuzumab" cohort of 155 trastuzumab-treated women diagnosed between May 16, 2005 and December 31, 2008 were described. Survival and recurrence outcomes were estimated by Kaplan-Meier methods. RESULTS The cohorts were similar in age, median tumor size, histology, hormone receptor status, hormone therapy, and locoregional therapy. Chemotherapy was administered in 66% and 100% of the "no trastuzumab" and "trastuzumab" cohorts, respectively. The median recurrence-free and survival follow-up was: 6.5 years (0.7-8.5) and 6.8 years (0.7-8.5), respectively, for the "no trastuzumab" cohort and 3.0 years (0.5-5.2) and 3.0 years (0.6-5.2), respectively, for the "trastuzumab" cohort. The 3-year locoregional invasive recurrence-free, distant recurrence-free, invasive disease-free, and overall survival were 92% versus 98% (P = .0137), 95% versus 100% (P = .0072), 82% versus 97% (P < .0001), and 97% versus 99% (P = .18) for the "no trastuzumab" and "trastuzumab" cohorts, respectively. CONCLUSIONS Women with small, node-negative, HER2+ primary breast cancers likely derive significant benefit from adjuvant trastuzumab with chemotherapy.
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Affiliation(s)
- Heather L McArthur
- Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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292
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Stickeler E. Prognostic and Predictive Markers for Treatment Decisions in Early Breast Cancer. ACTA ACUST UNITED AC 2011; 6:193-198. [PMID: 21779224 DOI: 10.1159/000329471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Breast cancer clinically represents a heterogeneous disease. Over the last decades, the integration of prognostic and predictive markers in treatment decisions has led to a more individualized and optimized therapy. While prognosis describes the risk of disease recurrence and disease-related death after diagnosis without the influence of therapy, prediction illustrates the probability of efficacy or response of a specific therapeutic measure. The substantial decline in breast cancer mortality seen over the last 20 years is primarily due to the delivery of adjuvant systemic therapy. It is important that clinical decisions are made to minimize overtreatment, under-treatment, and incorrect treatment. Improved understanding of breast cancer biology together with the utilization of classical biomarkers and the identification of new markers or profiles is increasingly defining who should receive cancer therapy and what therapy offers the best efficacy. The molecular targets as the prerequisite for successful concepts of specific therapies like anti-estrogens, antibodies, or small molecules, have therefore high clinical value in regards to prognosis as well as prediction.
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293
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Moreira C, Kaklamani V. Lapatinib and breast cancer: current indications and outlook for the future. Expert Rev Anticancer Ther 2011; 10:1171-82. [PMID: 20735304 DOI: 10.1586/era.10.113] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lapatinib is an oral dual erbB 1/2 tyrosine kinase inhibitor that inhibits human EGF receptor 2 (HER2) and blocks the EGF receptor. Studies have shown that in patients with metastatic HER2-positive breast cancer that is resistant to trastuzumab, the addition of lapatinib to capecitabine improves progression-free survival and appears to lengthen overall survival. Furthermore, lapatinib has been studied in patients with involvement of the CNS and has been associated with stable disease and some responses. Its combination with letrozole provided an improvement in progression-free survival compared with single-agent letrozole in women with hormone receptor-positive, HER2-positive metastatic breast cancer. More recently, data suggested that the combination of lapatinib with trastuzumab significantly improves overall survival in women with metastatic breast cancer compared with single-agent lapatinib. Current indications in the USA for the use of lapatinib are for the treatment of metastatic HER2-positive breast cancer, both in combination with capecitabine in patients who have received taxane, anthracycline and traztuzumab, and in combination with letrozole for postmenopausal patients with hormone receptor- and HER2-overexpressing breast cancer. Common side effects of lapatinib include diarrhea and rash. Studies to date have found a less than 2% risk for cardiotoxicity, although most cardiac events that occurred during the studies were not attributed to lapatinib. It is important to consider that most of the patients in existing studies had already been treated with trastuzumab with no significant cardiotoxicity; therefore, future studies will show how trastuzumab-naive patients tolerate lapatinib. Ongoing research is evaluating the role of lapatinib in the adjuvant setting as a single agent or in combination with trastuzumab.
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Affiliation(s)
- Cynthia Moreira
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine of Northwestern University and the Robert H Lurie Comprehensive Cancer Center, 676 North St Clair Street, Suite 850, Chicago, IL 60611, USA
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294
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Albert JM, Gonzalez-Angulo AM, Guray M, Sahin A, Tereffe W, Woodward WA, Strom EA, Hunt KK, Tucker SL, Buchholz TA. Patients with only 1 positive hormone receptor have increased locoregional recurrence compared with patients with estrogen receptor-positive progesterone receptor-positive disease in very early stage breast cancer. Cancer 2011; 117:1595-601. [PMID: 21472707 DOI: 10.1002/cncr.25694] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/24/2010] [Accepted: 09/03/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND Estrogen receptor (ER) and progesterone receptor (PR) are important prognostic and predictive biomarkers in breast cancer. Patients with tumors positive for either receptor are generally considered hormone receptor-positive for treatment decisions. However, some data suggest that patients with ER(+) /PR(-) or ER(-) /PR(+) tumors may have worse outcomes than those with ER(+) /PR(+) tumors. Few data correlate these biomarkers with locoregional (LR) recurrence. METHODS The authors retrospectively reviewed records of 635 patients with T1a,bN0 disease who received definitive treatment at their institution between 1997 and 2002 and had archival tissue blocks for prospective assessment of ER/PR expression. They compared clinical outcomes of the 479 patients with ER(+) /PR(+) disease to the 156 patients with ER(+) /PR(-) or ER(-) /PR(+) disease. RESULTS LR recurrence rates were higher in patients with 1 receptor positive compared with ER(+) /PR(+) (7-year rate: 8.8% vs 2.5%, P = .024). There was no difference between the 2 groups in the rates of distant metastasis (DM) (P = .531) or overall survival (P = .491). One positive receptor predicted for LR recurrence in patients who did not receive hormonal therapy (P = .046), but not in patients who received hormonal therapy (P = .296). On multivariate analysis, 1 positive receptor predicted for LR recurrence in the overall group (hazard ratio, 2.81; 95% confidence interval, 1.06-7.48; P = .038). CONCLUSIONS Patients with T1a,bN0 breast cancer with only 1 positive hormone receptor have increased rates of LR recurrence compared with patients with ER(+) /PR(+) disease, although this difference may be reduced or eliminated with systemic treatment. In contrast, the authors found no evidence of an increased rate of DM in these patients with favorable disease stage.
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Affiliation(s)
- Jeffrey M Albert
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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295
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Palmieri C, Shah D, Krell J, Gojis O, Hogben K, Riddle P, Ahmad R, Tat T, Fox K, Porter A, Mahmoud S, Kirschke S, Shousha S, Gudi M, Coombes RC, Leonard R, Cleator S. Management and outcome of HER2-positive early breast cancer treated with or without trastuzumab in the adjuvant trastuzumab era. Clin Breast Cancer 2011; 11:93-102. [PMID: 21569995 DOI: 10.1016/j.clbc.2011.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 09/21/2010] [Accepted: 09/24/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adjuvant trastuzumab (AT) is known to significantly improve survival of women with HER2(+) early breast cancer. This study explores the use and nonuse of AT in early breast cancer, as well as the efficacy in a neoadjuvant and adjuvant population, within a routine clinical setting. PATIENTS AND METHODS Histopathology reports of invasive breast cancer resected at Imperial College Healthcare NHS Trust (ICHT) between January 2006 and December 2008 were reviewed. HER2(+) patients were identified and their case notes reviewed. In addition, patients who received AT at our center but underwent surgery elsewhere were included in the efficacy and safety analyses. RESULTS The local HER2(+) rate was 13.1%, with 54.5% of these patients receiving AT. A total of 128 patients received AT (85 local and 43 referrals from elsewhere). Neoadjuvant chemotherapy (CT) followed by postoperative AT was associated with a significantly increased risk of recurrence compared with adjuvant CT and then AT (hazard ratio [HR] 18.6 [95% CI, 1.8-152.2]; P = .013). The proportion of patients who were disease free at 3 years from primary therapy was 96.4% (95% CI, 89.8%-100%) for adjuvant therapy, compared with 72.0% (95% CI, 56.5%-91.6%) for neoadjuvant therapy. AT was omitted in 49 HER2(+) patients; the main reason for AT omission was clinical judgment that the breast cancer was low risk. Patients treated with AT had a significantly decreased risk of recurrence (HR 0.27 [95% CI, 0.08-0.97]; P = .04) compared with the untreated patients. The majority of untreated relapses were in patients in whom there was an original intent to use AT. The proportion alive at 3 years for adjuvant CT, neoadjuvant CT, and untreated AT was 100%, 74.5%, and 92.7% respectively. CONCLUSION The overall efficacy and safety of AT in our routine clinical setting is comparable to the large randomized trials. HER2(+) patients who underwent neoadjuvant CT had a significantly increased risk of disease recurrence compared with patients treated with adjuvant CT followed by trastuzumab. Untreated patients had an increased risk of recurrence.
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Affiliation(s)
- Carlo Palmieri
- Cancer Research UK Laboratories, Division of Cancer, Imperial College London, UK.
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296
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Prognosis in women with small (T1mic,T1a,T1b) node-negative operable breast cancer by immunohistochemically selected subtypes. Breast Cancer Res Treat 2011; 127:713-20. [DOI: 10.1007/s10549-011-1465-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/16/2011] [Indexed: 10/18/2022]
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297
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Kelly CM, Pritchard KI, Trudeau M, Andreopoulou E, Hess K, Pusztai L. Coping with uncertainty: T1a,bN0M0 HER2-positive breast cancer, do we have a treatment threshold? Ann Oncol 2011; 22:2387-2393. [PMID: 21406473 DOI: 10.1093/annonc/mdq786] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent retrospective studies have suggested that patients with T1a,bN0M0 human epidermal growth factor receptor 2 (HER2)-positive breast cancer are at a higher risk for recurrence and might benefit from adjuvant trastuzumab. The absolute benefits associated with treating this subgroup are uncertain. DESIGN We reviewed recent studies examining the prognostic value of HER2 in patients with node-negative T1a,b HER2-positive breast cancer. We calculated the number needed to treat (NNT) using baseline risk estimates for untreated T1a,bN0M0 breast cancer and the number needed to harm (NNH) using the incidence of cardiac events in each of the adjuvant trastuzumab clinical trials. RESULTS Several studies were identified, each with limitations inherent to retrospective database analyses: small cohort sizes, lack of systematic HER2 testing in older specimens, variations in the use of adjuvant therapy and definitions of study end points, and lack of information relating to comorbidities. The 5-year disease-free survival in the pre-trastuzumab era ranged from 77% to 95%. Comparisons between small HER2 -positive and small HER2 -negative cancers showed numerically worse outcome for the HER2-positive cohort in some but not all studies. In many instances, the NNH was larger (26-250) than the NNT (13-35); however, in a subset of patients, the NNH was lower (6) than the NNT (13-35). CONCLUSIONS Better prediction tools to estimate more precisely the risk for death due to comorbid illness versus breast cancer are needed. In some patients, the risks of therapy could outweigh the benefits. Treatment selection for T1a,bN0 HER2-positive cancers remains in the transition area between evidence- and subjective judgment-based medicine.
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Affiliation(s)
- C M Kelly
- Department of Medical Oncology, Waterford Regional Hospital, Waterford, Ireland.
| | - K I Pritchard
- Department of Medical Oncology/Hematology, Division of Medical Oncology/Hematology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - M Trudeau
- Department of Medical Oncology/Hematology, Division of Medical Oncology/Hematology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - K Hess
- Department of Biostatistics, Division of Quantitative Sciences, M.D. Anderson Cancer Center, Houston, USA
| | - L Pusztai
- Department of Breast Medical Oncology
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298
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Her-2 prognostic value in very early-stage breast cancer: a single-institution retrospective analysis. Med Oncol 2011; 29:459-65. [PMID: 21359639 DOI: 10.1007/s12032-011-9869-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 02/13/2011] [Indexed: 10/18/2022]
Abstract
To evaluate overall survival, distant metastases-free survival and local relapse-free survival rates in a subgroup of patients affected by breast cancer expressing Her-2/neu. Data of 195 women affected by very early-stage breast cancer (pT1a-b pN0) who underwent whole breast radiotherapy after conservative surgery with or without chemotherapy and/or hormone therapy between January 2000 and December 2006 were evaluated. Chi-square test was used to compare the distribution of variables (age, tumour histology, oestrogens and progesterone receptors, tumour grading and adjuvant chemotherapy) between Her-2-positive and Her-2-negative patients. Survival rates were analysed with Kaplan-Meier curves; impact of variables on poor outcome was evaluated with Cox regression method. Median follow-up time was 63.5 months (range 13.8-113.6). Her-2/neu-positive patients (32/16.4%), compared to Her-2/neu-negative patients (163/83.6%), were younger (P = 0.0001), were affected by ductal infiltrating carcinoma (P = 0.039), had negative oestrogens receptors (P = 0.0001) and were not treated with chemotherapy (P = 0.001). Her-2-positive patients had lower overall survival (P = 0.00001) and lower distant metastases-free survival (P = 0.00001) compared to Her-2-negative patients, but no difference in local relapse-free survival was found between the two groups (P = 0.28). After multivariate analysis, Her-2-positive status was a prognostic factor for overall survival (P = 0.00001) and for distant metastases-free survival (P = 0.0001), but not for local relapse-free survival (P = 0.97). Her-2-positive patients have lower overall survival and distant metastases-free survival when compared to Her-2 negative patients but similar local relapse-free survival rates. These patients could be treated with conservative surgery, if feasible, but should receive more aggressive and tailored systemic adjuvant therapies.
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299
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Human epidermal growth factor receptor-2-positive breast cancer: current management of early, advanced, and recurrent disease. Curr Opin Obstet Gynecol 2011; 23:37-43. [DOI: 10.1097/gco.0b013e3283414e87] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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300
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Liebrich C, Unger G, Dlugosch B, Hofmann S, Petry KU. Adopting Guidelines into Clinical Practice: Implementation of Trastuzumab in the Adjuvant Treatment of Breast Cancer in Lower Saxony, Germany, in 2007. ACTA ACUST UNITED AC 2011; 6:43-50. [PMID: 21547025 DOI: 10.1159/000324048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
SUMMARY: BACKGROUND: Few studies have assessed the quality of medical care in breast cancer patients outside clinical studies and certified centres in German-speaking countries. We used ONkeyLINE, a voluntary tumour registry, to evaluate the rate of adoption into clinical practice of guidelines on the adjuvant use of trastuzumab and to estimate the reliability of ONkeyLINE in assessing quality of care. MATERIAL AND METHODS: Data from ONkeyLINE were analysed to answer questions on the quality of breast cancer care in daily practice in 2007. The influence of age and area (rural/urban) on treatment patterns was also evaluated. RESULTS: Data from approximately 85% of patients diagnosed with breast cancer in Lower Saxony in 2007 were documented in ONkeyLINE. Within 1 year, more than 77% of patients received adjuvant trastuzumab according to the updated guidelines. Variations in chemotherapy and trastuzumab according to age were evident, in part but not fully attributable to comorbidities in the elderly. Access to trastuzumab therapy in rural areas was as high as in urban areas. CONCLUSIONS: Adoption of national guidelines into clinical practice was observed at a reasonable but still unsatisfactory rate in Lower Saxony. Although voluntary, ONkeyLINE covered most breast cancer cases and proved to be a reliable tool for assessing quality of care.
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