Prognostic implication of estrogen receptor content in breast cancer

Feasibility of a Cell Kinetic-Based Adjuvant Chemotherapy Trial in Axillary Node-Negative Breast Cancer

Aims and background

Accumulated information on biologic prognostic indicators and predictors of response to different types of treatment in patients with different tumor characteristics has made it possible to design clinical protocols on biologic bases. Among cell proliferation indices, the thymidine labelling index (TLI) has proved to be an independent and consistent prognostic indicator over time. Moreover, experimental and retrospective analyses of clinical studies have revealed a direct relation between TLI and response to chemotherapy. On the basis of the results, a prospective clinical protocol on axillary node-negative breast cancer was activated in Italy in 1989.

Methods

Patients with low TLI tumors were treated with local-regional therapy alone, whereas patients with high TLI tumors were randomized to receive local-regional therapy followed or not by adjuvant chemotherapy consisting of 6 cycles of CMF.

Results and Conclusions

The present paper reports on the feasibility of a prospective clinical protocol based on a subgroup of patients with specific pathologic (node negative) and biologic (rapidly proliferating) breast cancers. However, patient eligibility was only 11%.

Targeting multiple pathways in breast cancer

SUMMARY Breast cancer (BC) is a highly prevalent disease. Worldwide, it is the most common cancer diagnosed and the leading cause of cancer death in women, making this disease a very important focus of interest and research. There is great heterogeneity in clinical outcomes among women diagnosed with BC, possibly indicating that biological heterogeneity is a major factor interfering with tumor development and progression. Presently, it is known that specific genetic expression patterns divide BC into distinct molecular subtypes. In fact, a better understanding of molecular profiles in BC and more advances in biological technology has divided each BC subtype further into additional subcategories. This means that more pathways are being recognized as important drivers or contributors to BC development and progression. The implication in BC treatment and management can be enormous. A more complete knowledge of the biology of the tumor has many implications. Development of therapies that specifically target the activated pathways can allow the delivery of more effective treatments and spare patients from treatments that would only cause side effects. This article will focus on exploring and reviewing the different molecular pathways involved in each clinically relevant BC subtype, namely hormone receptor-positive, HER2-positive and triple-negative BC. For each BC subtype, novel targeted therapies that are already incorporated in clinical practice, as well as drugs in clinical development, will be described, including the safety profiles of each one. We will highlight the major molecular pathways involved in each BC subtype, providing a rationale for the development of specific targeted therapies. Mechanisms of resistance to conventional therapies by pathway activation will be discussed. Strategies to overcome resistance are also a major focus of this review.

Ki67: a time-varying biomarker of risk of breast cancer in atypical hyperplasia

Uncontrolled proliferation is a defining feature of the malignant phenotype. Ki67 is a marker for proliferating cells and is overexpressed in many breast cancers. Atypical hyperplasia is a premalignant lesion of the breast (relative risk approximately 4.0). Here, we asked if Ki67 expression could stratify risk in women with atypia. Ki67 expression was assessed immunohistochemically by digital image analysis in archival sections from 192 women with atypia diagnosed at the Mayo Clinic 1/1/67-12/31/91. Risk factor and follow-up data were obtained via study questionnaire and medical records. Observed breast cancer events were compared to population expected rates (Iowa SEER) using standardized incidence ratios (SIRs). We examined two endpoints: risk of breast cancer within 10 years and after 10 years of atypia biopsy. Thirty-two (16.7%) of the 192 women developed breast cancer over a median of 14.6 years. Thirty percent (58) of the atypias had >or=2% cells staining for Ki67. In these women, the risk of breast cancer within 10 years after atypia was increased (SIR 4.42 [2.21-8.84]) but not in those with <2% staining. Specifically, the cumulative incidence for breast cancer at 10 years was 14% in the high Ki67 vs. 3% in the low Ki67 group. Conversely, after 10 years, risk in the low Ki67 group rose significantly (SIR 5.69 [3.63-8.92]) vs. no further increased risk in the high Ki67 group (SIR 0.78 [0.11-5.55]). Ki67 appears to be a time-varying biomarker of risk of breast cancer in women with atypical hyperplasia.

Five-Year Update of an Expanded Phase II Study of Dose-Dense and -Intense Doxorubicin, Paclitaxel and Cyclophosphamide (ATC) in High-Risk Breast Cancer

OBJECTIVES

This study evaluated the safety and efficacy of dose-dense and -intense sequential doxorubicin (A), paclitaxel (T) and cyclophosphamide (C) as adjuvant therapy for breast cancer (BC) with >or=4 ipsilateral axillary lymph nodes.

METHODS

Patients were recruited after BC surgery if >or=4 axillary nodes were involved by metastatic cancer. Planned treatment was A 90 mg/m(2) three times every 14 days (q14d x 3), T 250 mg/m(2) q14d x 3 and C 3 g/m(2) q14d x 3 combined with filgrastim support.

RESULTS

The study enrolled 85 eligible patients. The median number of lymph nodes involved was 9. Mean dose intensity was >94% of planned for each drug. Common grade 3 toxicities included nausea and/or vomiting (24%), mucositis (18%), neuropathy (16%), palmar-plantar erythrodysesthesia (12%), myalgia (6%) and arthralgia (6%). Grade 3/4 neutropenia occurred in 77 (91%) patients, and 32 (38%) patients had neutropenic fever. One patient developed acute leukemia. Sixty-nine (81%) patients are alive, and 59 (69%) patients are alive and free of distant disease at a median follow-up of 5 years.

CONCLUSIONS

ATC is a feasible regimen for adjuvant therapy of high-risk BC, with a relatively low rate of relapse at the 5-year follow up.

Thymidine labeling index: prognostic role in breast cancer

The aim of this study is to evaluate the prognostic role of thymidine labeling index in patients with breast cancer. Cellular proliferation rates in 155 breast cancer specimens were investigated by 3H-thymidine labeling index (3H-TLI). Median age was 47 years (range: 23-76). At presentation, 11 patients (7.1%) had stage I disease, 76 (49%) had stage II, 64 (41.3%) had stage III disease, and 4 (2.6%) had metastatic involvement. Patients were placed in 2 groups based on their proliferative indices. The cut-off level was assigned as the median TLI value of the whole group. Correlations between proliferative activity of the tumors based on 3H-TLI levels and various previously established prognostic factors, as well as the influence of proliferative activity on survival as a clinical outcome, were analyzed. The mean and median TLI values for the whole group of patients were 4.36 +/- 4.96% and 2.76% (range: 0-23.6), respectively. There was a significant association of nuclear grade with TLI (P = 0.04). Patients who were alive with no sign of disease at the final follow-up examination had a significantly lower median TLI rate than those who were either alive with disease or those who had eventually died with disease progression (3.7% versus 1.9%, respectively; P = 0.04). Patients with locally advanced disease (N2 + N3 involvement) had a significantly higher median TLI rate than those with local nodal involvement (N1) (3.4% versus 1.7%, respectively, P = 0.026). Furthermore, TLI levels showed a significant association with overall survival in patients with node-negative disease (P = 0.02). Based on the results of this study, it can be concluded that TLI plays a significant prognostic role in a subset of patients with node-negative breast cancer. Furthermore, TLI appears to have a predictive value for the clinical outcome of patients with breast cancer. These findings may justify a more aggressive therapeutic approach in patients with high TLI levels. Further large-scale, prospective studies are required before a definite conclusion can be reached.reached.

Short-term survival in breast cancer: the experience of the University of Malaya Medical Centre

OBJECTIVE

To study the impact of various clinicopathological factors on short-term survival in a cohort of breast cancer patients treated at the University of Malaya Medical Centre (UMMC).

METHODS

All cases of breast cancer treated at UMMC from January 1999 to June 2001, except for stage IV disease, were included in the study. Survival analysis was carried out using Kaplan-Meier for univariate analysis and Cox regression for multivariate analysis. The log-rank test was used to test the significance of differences between the different survival curves.

RESULTS

A total of 385 patients were included. The mean patient age at presentation was 50.3 years (SD, 11.4); 198 (51.4%) patients had lymph node-positive disease, and 187 (48.6%) had node-negative disease. The mean follow-up period was 18.7 months (SD, 8.8). The Malay ethnic group, tumours of larger size, node-positive disease, more than five positive lymph nodes, oestrogen receptor (ER) negativity and the presence of lymphovascular invasion were significant prognostic factors for shorter recurrence-free survival (RFS) in the univariate analysis. In the multivariate analysis, ER negativity was the only independent adverse prognostic factor for RFS. For overall survival (OS), tumours of larger size, node-positive disease, more than five positive lymph nodes, ER negativity and high grade tumours were associated with significantly shorter OS. However, more than five positive lymph nodes was the only independent prognostic factor for shorter OS in the multivariate analysis. Further multivariate analysis of the patients with node-positive disease showed that the Malay ethnic group, ER negativity and more than five positive lymph nodes were independent prognostic factors for shorter RFS. On the other hand, ER negativity and more than five positive lymph nodes were independent negative prognostic factors for OS in this subgroup of patients.

CONCLUSION

The evaluation of various prognostic factors would provide useful information on disease progression in local patients, especially for the planning of adjuvant therapies and follow-up protocols. Differences in the pattern of breast cancer among the different ethnic groups in Malaysia warrant further studies.

Heterogeneic expression of estrogen receptor between the primary tumor and the corresponding involved lymph nodes in patients with node-positive breast cancer and its implications in patient outcome

BACKGROUND AND OBJECTIVES

The estrogen-receptor (ER) status of breast cancers has typically been evaluated in primary tumors (PTs), and the influence of ER expression in the involved lymph nodes (LNs) on prognosis of the patients with node-positive breast cancer remains unclear. The expression of ER was compared between PT and corresponding involved LNs in patients with node-positive breast cancer.

METHODS

Eighty-seven patients with node-positive breast cancer were immunohistochemically assessed to measure the expression of ER in PT and involved LN with anti-ER monoclonal antibody.

RESULTS

Thirty-five (40.2%) of PTs and 26 (29.9%) of involved LNs were evaluated as ER(+). The ER expression in PTs was significantly correlated with that in involved LNs (P < 0.0001), and the ER expression was almost the same in both the PT and corresponding involved LN in 66 cases (75.9%): both (+), 20 (23.0%); and both (-), 46 (52.9%). However, ER expression differed in 21 cases (24.1%) between involved LN and the corresponding PT: PT-ER(+)/LN-ER(-), 15 (17.2%); and PT-ER(-)/LN-ER(+), 6 (6.9%). The survival of patients with ER(+)-PT was significantly better than that of ER(-)-PT patients (P = 0.0086), but ER expression in involved LN did not have any significant effect on patient survival. Furthermore, when survival periods were grouped by coexpression of ER in the PT and involved LN, the best survival was seen in the PT-ER(+)/LN-ER(-) group (P < 0.001 vs. others). In the patients, who received adjuvant endocrine therapy, the survival of the PT-ER(+) group was significantly better than that of PT-ER(-) group (P = 0.0145), but LN-ER expression did not show any significant influence on the survival rate. Multivariate analysis demonstrated that clinical stage and ER-expression in the PT were significant variables, but ER expression in the involved LN was not.

CONCLUSIONS

The ER expression was discordant between PT and involved LN in about 24% of the breast cancers evaluated, and ER expression in involved LNs had less influence on patient prognosis than ER expression in the corresponding PT.

Potential prognostic value in human breast cancer of cytosolic Nme1 protein detection using an original hen specific antibody

The metastasis-suppressor nme gene (also called nm23), first identified in murine melanoma cells, exists as two forms in human: nme1 and nme2. However, only the lack of expression of nme1 has been related to distant metastasis appearance in human breast cancer. The aim of this work was first to raise specific antibodies to allow the analysis of Nme1 and then, with this specific tool, to evaluate the predictive value of Nme1 detection in cytosolic extracts of human breast tumours. We obtained a hen antibody that specifically reacts with Nme1 without any cross-reaction with Nme2. We analysed the expression of the protein in 59 human breast tumours and found a significant relationship between this expression and oestrogen receptor status (P<0.001). Moreover, Nme1 expression is related to metastasis-free survival (P<0.001) and survival of patients (P<0.001). The determination of Nme1 expression in primary tumours using our antibody should be an interesting predictive test of the metastasis for clinical investigations.

Obesity and subcutaneous fat patterning in relation to survival of postmenopausal breast cancer patients participating in the DOM-project

The effect of obesity and fat distribution on survival of breast cancer patients was studied prospectively in 241 women with a natural menopause who participated in a breast cancer screening project, the DOM-project in Utrecht, The Netherlands. Mean follow-up time was 9.1 years and endpoint of interest was death from breast cancer. Fat distribution was assessed by contrasting groups of subscapular and triceps skinfold thickness. No significant differences in survival time between more obese (Quetelet's index > or = 26 kg/m2) and leaner (Quetelet's index < 26 kg/m2) patients or between patients with central fat distribution and patients with peripheral fat distribution were observed. Analyses were stratified by axillary node status, estrogen receptor status, and way of detection (by first screening or afterwards). Results of the stratified analyses were suggestive of a modifying effect of these factors. The absence of an association between obesity and survival time might be explained by two counteracting mechanisms. On the one hand obesity might be related to impaired survival, due to a tumor growth promoting effect of extra-ovarian estrogens. On the other hand obesity might be related to improved survival in a screened population, because obese patients profit more from screening by earlier detection of tumors than leaner counterparts.

Breast cancer in the elderly

OBJECTIVE/METHODS

To determine the clinical behavior and outcome of breast cancer in the elderly, a series of 184 women older than age 69 years who received treatment for locoregional breast cancer at The University of Texas M. D. Anderson Cancer Center between 1976 and 1985 were studied for a median of 80 months.

RESULTS

The results indicate that elderly women can tolerate standard surgical therapy and survive disease-free for many years; the breast cancer-specific survival rate of patients in this study was 79% at 7 years. Although 33% of patients had stage I disease, only 10% underwent breast conservation surgery. Despite 46% of patients having stage II and 21% having stage III breast cancer, fewer than 13% received systemic adjuvant therapy. Noncompliance with breast screening guidelines was evident in that only 3% of patients had tumors detected by routine screening mammograms and only 12% by routine physical examinations.

CONCLUSIONS

Women with breast cancer should be informed of treatment options and the advantages and disadvantages of each choice based on physiologic rather than chronologic age.

Prognostic factors in node-positive operable breast cancer patients receiving adjuvant chemotherapy

A retrospective analysis of prognostic factors in 214 consecutive node-positive (N+) operable breast cancer patients, receiving Melphalan + 5-fluorouracil adjuvant chemotherapy between 1980 and 1984 was performed. Median follow-up was 95 months. Actuarial disease-free interval (DFI) and survival (S) were determined according to age, menopausal status, histology, size of primary tumor (T), multifocality, tumor location, hormonal receptor status, number of N+, size of N+, tumor spread in axillary fat, and interval between surgery and onset of adjuvant chemotherapy. On univariate analysis two factors were prognostic for DFI and S: number of N+ and T size. A comparison between traditionally classified T1 and T2 patients revealed no significant difference, but when the cut-off point was shifted from 2 cm to 3 cm, T size represented a highly significant prognostic factor. In patients with T less than or equal to 3 cm 5-year DFI was 54% and 5-year S was 76%, while in patients with T greater than 3 cm the respective values were 23% (p less than 0.001) and 41% (p less than 0.001). These significant DFI and S differences persisted after adjustment for number of N+ by bivariate analysis. Multivariate analysis supported the importance of T greater than 3 cm as a strong adverse predictor. Four adverse variables, T greater than 3 cm, number of N+ greater than or equal to 4, multifocality, and tumor spread in axillary fat were used to divide our patients into three subsets with significantly different DFI: Group I, with none of the above factors; Group II, with only one factor present; and Group III, with more than one factor present (5 years DFI 66%, 45%, and 21%, respectively; p less than 0.001).

Steroid receptors in breast cancer

Recent advances in steroid receptor structure and function now indicate that oestrogen binds to the oestrogen receptor (ER) molecule at a specific site, denoted region E. This allows binding of the oestrogen-ER complex to DNA via cysteine residues in region C of the ER molecule, which tetrahedrally co-ordinate zinc. This modulates transcription and stimulates cell growth. A number of newly discovered growth factors are also regulated by ER, as is the progesterone receptor. Steroid receptor concentrations in tissues can now be measured on smaller tissue samples using enzyme immunoassay or on cells obtained by fine needle aspiration using monoclonal antibody technology. The prognostic value of steroid receptor is limited, but still constitutes the best marker for predicting response to endocrine therapy. The role of steroid receptors in selecting patients for adjuvant therapy is discussed.

Epidermal growth factor receptors in intracranial and breast tumours: their clinical significance

A method to determine the binding of epidermal growth factor (EGF) to the particulate fraction of the cell has been established and evaluated using rat liver, human placenta, and tumours of human breast and brain. Little EGF receptor (EGFR) activity was detected in normal or benign tumour tissues except for meningioma (positive in 95% samples), but EGFR were present in 43% of 131 breast tumours and 75% of 55 primary cerebral tumours. Despite the strong inverse correlation between EGFR activity and oestrogen receptors in breast tumours and a tendency for high levels of EGFR activity to be associated with glioblastoma multiforme, analysis showed that EGFR was of little prognostic significance in patients with tumours of either breast or brain.

Obesity and body fat distribution and breast cancer prognosis

This study addresses the effect of obesity and body fat distribution on axillary lymph node involvement, tumor size, and estrogen receptor (ER) level in breast cancer patients. Anthropometric measurements were prospectively obtained on 248 consecutively and newly diagnosed women with invasive breast cancer. The anthropometric measurements evaluated were abdomen, thigh, subscapular, and midaxillary skinfolds; weight; and height. Weight and Quetelet Index (kg/m2) were significantly (P = 0.001) associated with lymph node involvement in postmenopausal patients. The abdomen:thigh skinfold ratio was significantly higher in premenopausal patients (P = 0.004) and postmenopausal (P = 0.03) without axillary node involvement compared with women with 4+ axillary node involvement. The abdomen:thigh skinfold was higher (P = 0.05) in women with smaller breast cancers (less than 2.0 cm) and higher ER levels. Weight and Quetelet Index did not affect tumor size or ER level. This study demonstrated that obese postmenopausal women who developed breast cancer tend to have more axillary node involvement than their leaner counterparts. Generalized obesity did not affect tumor size or ER level. Premenopausal and postmenopausal women with upper body fat distribution appear to be a subset of women who have a more favorable prognosis as measured by less lymph node involvement, smaller tumors, and higher levels of ER in their tumors.

Expression of glutathione S-transferase B1, B2, Mu and Pi in breast cancers and their relationship to oestrogen receptor status

The concentrations of glutathione S-transferase (GST) B1 and B2 (Alpha), Pi and Mu have been measured by radioimmunoassay in cytosols from 28 oestrogen receptor (ER) rich an 30 ER-poor breast tumours. GST B1, B2 and Pi was detected in all 58 breast tumour cytosols whilst GST Mu was found in only 28. Of the GSTs, Pi was expressed most strongly in all cytosols and the concentration was significantly higher in ER-poor tumour cytosols than in ER-rich tumours (P less than 0.01). As with GST Pi, the highest levels of GST B1 and GST B2 were found in ER-poor tumour cytosols; the levels of GST B1 and GST B2 were positively correlated (r = 0.66, P less than 0.001). No quantitative or qualitative association was found between ER status and GST Mu which was expressed in 46% of ER-rich and 50% of ER-poor tumour cytosols. No relationship could be found between GST expression and age, menopausal status, lymph node involvement or tumour T stage in the subgroup of patients in whom this information was available. These data suggest that a common mechanism is responsible for GST induction in ER-poor tumours and that the nulled Mu phenotype has no increased susceptibility to developing breast cancer.

Oestrogen receptor status of primary breast carcinomas and their metastases. Relation to pattern of spread and survival after recurrence

Immunohistochemical antibody techniques for detection of oestrogen receptors (ER) were applied to formalin fixed, paraffin embedded sections from 62 primary breast cancers, the metastases of their original regional lymph nodes (29 cases), bone marrow carcinosis (43 cases) and liver metastases (20 cases). Forty per cent of the primary tumours and 31% of the regional lymph node metastases were ER positive; in contrast, less than 20% of liver and bone marrow metastases were ER positive. The ER status of regional lymph node metastases was concordant with that of the primary tumour in 90% of the cases. The concordance rate was 75% for liver metastases and 58% for bone metastases. Patients with ER positive primary tumours had recurrence significantly more often in bone; ER negative tumours recurred more often in the liver. The survival after recurrence (SAR) was significantly related to the ER status of the primary tumour and to that of the regional lymph node metastases. In contrast, the SAR was not associated with the ER status of bone marrow carcinosis or liver metastases. Cox analyses showed that age and ER status of the primary tumour were the most important independent prognostic factors compared to other clinical, therapeutic, pathoanatomical and biochemical features. The study supports the hypothesis that tumour cell clones with different ER content are selected and adapted to grow in various anatomical sites. Moreover, the ER status of the primary tumour seems to be more important for the prognosis than the ER status of bone and liver metastases.

Survival with breast cancer: the importance of estrogen receptor quantity

The survival of 1184 British Columbian women whose primary breast cancers were diagnosed and assayed for estrogen receptor (ER) between 1975 and 1981 was studied. Median follow-up was 60 months. ER concentrations yielded greater prognostic information than simple positive and negative categories. When ER data were divided into four strata: less than or equal to 1, 2-9, 10-159 and greater than or equal to 160 fmol/mg cytosol protein, the association of higher ER with prolonged survival was highly significant (P less than 0.0001) and independent of TNM stage, nodal status and menopausal status. ER less than or equal to 1 and ER = 2-9 groups were distinct with respect to overall disease-specific survival. Patient age did not predict survival when controlled for ER. Prolonged recurrence-free survival was associated with higher ER (P = 0.0001) for at least 5 years after diagnosis. This significant trend persisted after adjustments for nodal status, TNM stage, menopausal status and the type of systemic adjuvant therapy.

Non-palpable invasive breast carcinomas from the Stockholm screening project

Sixty-six non-palpable, invasive mammary adenocarcinomas from the Stockholm mammography screening project were studied with respect to histopathology. In 53 of these tumors estrogen receptor (ER) content was estimated and in 30 of them also the DNA distribution pattern. The tumors were predominantly of low or intermediate histological malignancy grade and ER-rich, whereas the distribution of DNA ploidy equalled that found in a non-selected tumor material. Only 2 tumors recurred during follow-up (median 51 months), indicating that non-palpable breast carcinomas represent a prognostically favourable subset in spite of a relatively high proportion of aneuploid tumors.

Factors at presentation influencing the prognosis in breast cancer

Presentation data on 607 breast cancer patients treated by a variety of modalities at Guy's Hospital, London, have been analysed using the Cox proportional hazards model, to identify factors associated with length of overall survival. When deaths attributable to causes other than breast cancer were treated as censoring events, the significant factors were found to be stage, mode of treatment, menstrual status and tumour size. The analysis was repeated for the subgroup of 326 patients treated by modified radical mastectomy. Four variables: stage, age at menarche, menstrual status and age were found to be significantly associated with both overall survival and length of distant recurrence-free interval. These factors have been combined to create a prognostic index which has been used to define subgroups of patients with different prognosis. The index has been validated on a separate group of 457 modified radical mastectomy patients treated at the same hospital.

Steroid hormone receptors and prognosis in breast cancer

The importance of steroid receptors for the prognosis of mammary carcinoma has been evaluated by investigating the course of disease in 163 patients for a median follow up time of 66 months after mastectomy. Multivariate analysis including estrogen receptor (ER), progesterone receptor (PgR), the presence of 8S and 4S ER together or 4S ER only, and the lymph node status revealed only the latter to have significant (p less than 0.001) predictive potency. Lymph node positive (N-pos) patients had a 3.3 (1.7-6.2) fold risk of death and 2.8 (1.7-4.7) fold risk of recurrence relative to node negative (N-neg) patients. When we compared overall survival (OAS) and disease-free survival (DFS) in the various receptor-positive groups with the groups that displayed neither ER nor PgR, significant differences in prognosis were only seen in N-neg patients. PgR did not turn out to be a better prognostic factor than ER, nor was the 8S ER a sign of increased OAS and DFS compared to total ER. However, the number of patients in this group was too small to allow a definite statement.

Histological grade and steroid receptor content of primary breast cancer--impact on prognosis and possible modes of action

The clinical course of breast cancer was related to degree of anaplasia (DA) and steroid receptor (SR) content of primary tumours in 743 patients (pts) with clinical recurrence, initially enrolled in the DBCG-77 protocols. The oestrogen receptor (ER) and the progesterone receptor (PgR) content was known in 110 and 67 pts. The recurrence-free interval, survival after recurrence, and the overall survival were all prolonged in patients with well differentiated tumours or with high SR content. The tumour growth rates were estimated as clinical rates of progression (i.e., the time elapsed from a single distant metastasis until dissemination). The progression rate was prolonged in relatively well differentiated as well as in receptor rich tumours. The extent of dissemination, as indicated by the number of metastatic sites, was not associated with either DA or SR content. However, the anatomical distribution of metastases varied with both DA and SR content: signs of poor prognosis (high DA or low SR content) were associated with occurrence of visceral metastases. In contrast, SR rich tumours had a propensity for recurrence in bone. The results suggest that the impact on prognosis of the features examined here includes both variations in growth rate and metastatic pattern.

Predictive value of nuclear DNA content in breast cancer in relation to clinical and morphologic factors. A retrospective study of 227 consecutive cases

The predictive value of nuclear DNA content in breast cancer in relation to clinical and morphologic factors was studied in 227 consecutive cases of invasive breast adenocarcinomas with follow-up periods of 8 to 13 years. The results show that, with the use of Cox multivariate analysis nuclear DNA content provided significant prognostic information additional to that given by all other clinical and histomorphologic variables taken together. This fact indicates that the DNA content of breast cancer cells reflects biological properties, associated with the malignant behavior of the tumor, other than those determining the stage of the disease. Nuclear DNA content was strongly correlated to histopathologic grading of the ductal carcinomas, with poorly differentiated tumors more likely to be aneuploid. On the other hand, no clear correlation was found to exist between nuclear DNA content and axillary node status, indicating that these two factors are independent prognostic parameters. It is noteworthy that DNA content provided additional prognostic information within both the node-negative and node-positive patient groups. In summary, the results shown here indicate that nuclear DNA content, as an objective biological marker of tumor aggressiveness, can significantly improve our prognostic capabilities within the currently designated stages.

Steroid receptors, cellular kinetics, and lymph node status as prognostic factors in breast cancer

Steroid receptor status, cellular kinetics, abnormal proto-oncogene presence, and lymph node metastases all have been shown to provide prognostic information in breast cancer. The factors guide the choice of therapy and predict the course of the disease. Both disease-free survival and overall survival are predicted by these variables. Steroid receptors are the most reliable predictor of hormonal responsiveness. Lymph node involvement is crucial in determining the extent of the disease and the need for adjuvant therapy. Cellular kinetics and abnormal proto-oncogene presence predict tumor aggressiveness. Together these prognostic factors provide considerable information to the clinician.

Oestrogen receptor activity in breast cancer detected at a prevalence screening examination

In view of the possible introduction of screening programmes, this study compares oestrogen receptor (ER) levels in a series of women whose primary tumour was detected by screening and an age-matched consecutive series of women whose tumours were diagnosed after symptomatic presentation. Because of missing data and other statistical considerations, the comparison was made using T1 and T2 categories of tumour only. Some differences were found: the distribution of ER levels was significantly different in the two groups, with more extreme values in the symptomatic series; the screening series, however, had more moderate/rich ER levels than the symptomatic group. Tumours of special pathological type (for example, tubular, cribriform, lobular, medullary, and mucoid) were more likely to be ER-moderate or -rich, and there were more of these tumours in the screening series. The relationship of these findings to tumour growth rate is discussed. The study highlights the difficulty of obtaining sufficient tissue for conventional DCC biochemical assays from the small non-invasive tumours found by screening, and suggests that newer alternative methods employing monoclonal antibodies may be required for such types of tumour.

Prognostic significance of oestrogen and progestogen receptor activities in breast cancer

The prognostic significance of the tumour activities of 2 steroid receptors, those for oestrogen (ER) and for progestogen (PgR), has been studied in 372 patients with breast cancer, in whom follow-up was available for 2-6 years (median 41 months). Of 252 patients with operable disease, 75.8 per cent had ER-positive tumours and 46.4 per cent had PgR-positive tumours, though a small additional fraction (6.3 per cent) had an equivocal PgR assay result. For the 236 patients with unequivocal receptor status, the relationships between disease-free interval or overall survival and receptor activity and other factors were evaluated by univariate and multivariate analyses. The latter revealed that only tumour size, node status, menstrual status and ER status related significantly to both disease-free interval and survival, though adjuvant therapy also related to disease-free interval, and tumour grade related to survival. It is concluded that measurements of PgR activity do not add to the prognostic significance of ER status.

Relationship between certain radiographic and biologic characteristics in breast cancer

The relationship between mammographic appearance of microcalcifications and tumor stage, malignancy grade, estrogen receptor (ER) content and nuclear DNA pattern was studied in 92 mammary carcinomas. The results indicate that no complementary prognostic guidance can be obtained from the radiographic appearance of a tumor apart from a high probability of a spiculated cancer being ER-rich. The finding of a relatively high proportion of aneuploid and ER-poor carcinomas among tumors with microcalcifications indicates that this radiographic characteristic might be associated with increased growth potential.

Fundamental research leading to improved endocrine therapy for breast cancer

Whilst endocrine therapy has a long-established role in the management of patients with advanced breast cancer, current therapies produce remission in, at best, only between 30 and 40% of cases. The most efficient use of hormonal measures therefore requires the accurate identification of individuals with hormone-responsive tumours. Oestrogen receptor measurements are useful but not fully discriminatory and additional predictive factors are required. Markers, such as specific hormonally induced proteins and mRNA, and antagonistic systems, such as epidermal growth factor receptors and cyclic AMP binding proteins are currently being evaluated. In terms of therapy, surgical manoeuvres such as adrenalectomy and hypophysectomy have already been replaced by the medical administration of anti-oestrogens, progestogens and drug regimes such as aminoglutethimide-hydrocortisone. Although castration by surgery or radiation remains the first-line treatment in premenopausal women with advanced disease, the advent of depot preparations of LHRH agonists offers the opportunity of performing medical ovariectomies which have the added advantage of being reversible. As a result of laboratory studies, more potent anti-oestrogens and more specific "suicide" aromatase inhibitors are entering into clinical practice. These can be expected to increase efficacy of treatment whilst reducing its side-effects. Research using cell-lines of human breast cancer also suggests that anti-progestins and agents capable of antagonizing steroid-induced growth factors will inhibit tumour growth. Such novel therapies potentially could make a major impact in the endocrine management of breast cancer. Lastly, although the primary management of early breast cancer predominantly involves non-hormonal modalities, clinical trials are now providing evidence of survival benefit from adjuvant endocrine therapy. The knowledge accrued from the use of newer endocrine agents in advanced cancer could therefore ultimately be relevant to the treatment of earlier stages of the disease.

Body weight, serum cholesterol, and stage of primary breast cancer

To determine if body weight and serum cholesterol are associated with advanced primary breast cancer, the authors compared levels of both by TNM stage and estrogen receptor protein (ERP) concentration in a population of 148 premenopausal and 167 postmenopausal white women with histologically confirmed Stage I, II, and IIIa breast cancer. The women were admitted to Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City between 1982 and 1984. Overweight, whether measured as body weight in pounds, Quetelet index, or body surface area, was not found to be associated with TNM tumor stage, tumor size, extent of axillary node disease, or ERP concentration at mastectomy. Elevated serum cholesterol, either alone or in combination with overweight, also showed no association. When assessed in light of earlier studies, the study findings suggest that if overweight, as defined in this study, and/or elevated serum cholesterol do influence early breast cancer recurrence, they do so other than through an association with advanced primary disease. Suggestions for future research are proposed.

Prognostic implication of labeling index versus estrogen receptors and tumor size in node-negative breast cancer

The paper analyzes the relation among tumor size (T), estrogen receptor (ER) status, and labeling index (LI) and their relative merits in predicting the relapse-free (RFS) and overall survival (OS) in 215 node-negative women with primary breast cancer. All patients were subjected to Halsted or modified radical mastectomy; none received postoperative irradiation or systemic adjuvant therapy. The 5-year RFS was 75.3% and OS 89.0%. When singly tested, LI and ER were able to significantly predict RFS and OS. In contrast, T influenced only RFS but not OS. The multivariate analysis showed that, in the presence of the two other variables, only LI retained its prognostic significance both for time to relapse (p = 0.0044) and survival (p = 0.035). From the present findings, LI appears to be a new important prognostic variable in the selection of high risk patients for whom adjuvant systemic therapy should perhaps be part of their primary treatment.

The relation between survival and age at diagnosis in breast cancer

We analyzed the relation between age at diagnosis and relative survival (ratio of observed to expected survival) in 57,068 women in Sweden in whom breast cancer was diagnosed in 1960 to 1978 (about 98 percent of all cases). Women who were 45 to 49 years old had the best prognosis, with a relative survival exceeding that of the youngest patients (less than 30 years) by 7.6 to 12.9 percent at different periods of observation. Relative survival declined markedly after the age of 49--particularly in women aged 50 to 59--and the oldest women (greater than 75) had the worst rate. The difference in relative survival between those older than 75 and those 45 to 49 increased from 8.6 percent at 2 years to 12.2, 20.3, and 27.5 percent after 5, 10, and 15 years of follow-up, respectively. The long-term annual mortality rate due to breast cancer approached 1 to 2 percent at the premenopausal ages but exceeded 5 percent throughout the period of observation in the oldest age group. An understanding of the biologic basis for the complex relation between age and prognosis might provide a better understanding of the natural history of breast cancer in women.