A risk stratification by hormonal receptors (ER, PgR) and HER-2 status in small (< or = 1 cm) invasive breast cancer: who might be possible candidates for adjuvant treatment?

Are We Overtreating Patients With T1a HER2+ Breast Cancer? An Analysis of the National Cancer Database

INTRODUCTION

The potential benefit of systemic therapy in patients with T1a HER2+ cancers is not well understood, and no consensus guidelines exist. We sought to investigate practice patterns of chemotherapy use in this population.

METHODS

From the National Cancer Database (2013-2018), we identified female patients with HER2+ cancers staged as cT1aN0 or pT1aN0 and stratified by receipt of chemotherapy. Using univariate and multivariable analyses we assessed the clinicopathologic features associated with the receipt of chemotherapy. We also compared rates of overall survival (OS).

RESULTS

Of 5176 women with cT1aN0 HER2+ cancers, 88 (2%) received neoadjuvant chemotherapy. Younger age and hormone-receptor (HR) negative tumors were factors independently associated with receipt of neoadjuvant chemotherapy (all P < .001). Of 11,688 women with pT1aN0 HER2+ cancers, 5,588 (48%) received adjuvant chemotherapy. Rates of use increased over the analysis period from 39% in 2013 to 53% in 2018 (P < .001). Factors independently associated with receipt of adjuvant chemotherapy included younger age, having a poorly differentiated tumor, exhibiting lymphovascular invasion, undergoing adjuvant radiation (all P < .001). There were no differences in OS when comparing those who did and did not receive chemotherapy in either group.

CONCLUSIONS

The use of chemotherapy in patients with HER2+ T1a cancers is increasing over time and is, as expected, more common among patients with unfavorable clinicopathologic features. Since no prognostic algorithm currently exists, more prospective data is needed to understand which of these patients may derive benefit from systemic therapy and which may safely avoid the morbidity of chemotherapy.

Correlation of tumour subtype with long-term outcome in small breast carcinomas: a Swedish population-based retrospective cohort study

Purpose

To investigate if molecular subtype is associated with outcome in stage 1 breast cancer (BC).

Methods

Tissue samples from 445 women with node-negative BC ≤ 15 mm, treated in 1986–2004, were classified into surrogate molecular subtypes [Luminal A-like, Luminal B-like (HER2−), HER2-positive, and triple negative breast cancer (TNBC)]. Information on treatment, recurrences, and survival were gathered from medical records.

Results

Tumour subtype was not associated with overall survival (OS). Luminal B-like (HER2−) and TNBC were associated with higher incidence of distant metastasis at 20 years (Hazard ratio (HR) 2.26; 95% CI 1.08–4.75 and HR 3.24; 95% CI 1.17–9.00, respectively). Luminal B-like (HER2−) and TNBC patients also had worse breast cancer-specific survival (BCSS), although not statistically significant (HR 1.53; 95% CI 0.70–3.33 and HR 1.89; 95% CI 0.60–5.93, respectively). HER2-positive BC was not associated with poor outcome despite no patient receiving HER2-targeted therapy, with most of these tumours being ER+.

Conclusions

Stage 1 TNBC or Luminal B-like (HER2−) tumours behave more aggressively. Women with HER2+/ER+ tumours do not have an increased risk of distant metastasis or death, absent targeted treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06691-4.

Perioperative HER2 targeted treatment in early stage HER2-positive breast cancer

Although human epidermal growth factor receptor 2 (HER2)-positive breast cancer was associated with poor prognosis, it has been changed after the development of trastuzumab. There has been great progress in perioperative HER2-targeting treatment, and investigations of several novel drugs and their combinations are ongoing. Adjuvant trastuzumab with or without pertuzumab for 1 year in combination with concomitant chemotherapy has become a standard treatment in high-risk node-negative tumors or node-positive HER2-positive early breast cancer patients without residual disease or who have not received neoadjuvant treatment. For low-risk HER2-positive early breast cancer patients, adjuvant paclitaxel and 1-year trastuzumab are possible alternatives. For residual disease after neoadjuvant treatment, adjuvant trastuzumab emtansine (T-DM1) for 14 cycles is a standard treatment. Non-anthracycline chemotherapy with dual anti-HER2 targeting of trastuzumab and pertuzumab represents one of the preferred neoadjuvant regimens to achieve higher pathologic complete response (pCR) rates and better clinical outcomes. Further research is needed to develop and validate potential biomarkers to predict pCR, which could help escalate or de-escalate anti-HER2 therapy. Trials incorporating novel agents such as T-DM1, trastuzumab deruxtecan (T-DXd), and immune checkpoint inhibitors and trying to de-escalate treatments in neoadjuvant setting are ongoing. In the future, tailored treatments such as no adjuvant therapy, various HER2-directed therapies alone with chemotherapy, combinations of various HER2-directed therapies and chemotherapy, addition of immune checkpoint inhibitors, and omission of surgery will be individualized in HER2-positive early breast cancer patients.

A Novel Risk-Scoring System to Identify the Potential Population Benefiting From Adjuvant Chemotherapy for Node-Negative TNBC Patients With Tumor Size Less Than 1 cm

Background and Objectives

Whether chemotherapy is needed in node-negative triple-negative breast cancer (TNBC) patients with tumor size less than 1 cm is still controversial. In our research, we constructed a novel risk-scoring system to identify the potential TNBC patients benefiting from adjuvant chemotherapy in T1miN0M0, T1aN0M0, and T1bN0M0 stages.

Methods

Relevant data were extracted from the SEER database. We applied Kaplan-Meier curves and the Cox hazards model for survival analysis and developed a nomogram of overall survival. The X-tile software was used for risk stratification. The information of TNBC patients treated in the First Affiliated Hospital of Xi’an Jiaotong University was used for the application of the model.

Results

A total of 4266 patients who met the criteria of our study were included. T stage, age, race, surgery, and radiotherapy state were used to create the nomogram of overall survival. According to the total risk score, the patients were divided into high-risk (score g 73), median-risk (38 ≤ score &lt; 73), and low-risk (score &lt;38) groups. Chemotherapy can prolong the overall survival of patients in the median-risk and high-risk groups, while patients in the low-risk group can be exempted from chemotherapy. In addition, we also used the risk-scoring system in real-world patients as application and verification.

Conclusion

We constructed a novel risk-scoring system that can be used as a chemotherapy decision-making tool for node-negative TNBC patients with tumor size less than 1 cm. Tumor size should not be the only criterion for chemotherapy treatment decision-making.

Efficacy of adjuvant trastuzumab in women with HER2-positive T1a or bN0M0 breast cancer: a population-based cohort study

Adjuvant trastuzumab has been associated with superior survival in women with ≥ T1c or node-positive HER2-positive early-stage breast cancer; however, there is a lack of phase III trials in women with T1a/bN0 disease. Our study aimed to assess the outcomes of women with HER2-positive T1a/bN0 breast cancer who received adjuvant trastuzumab in Saskatchewan, Canada. We evaluated all women diagnosed with HER2-positive T1a/bN0 breast cancer in Saskatchewan between 2008 and 2017. We performed Cox proportional multivariable analysis to determine factors correlated with survival. In addition, inverse probability treatment weighting (IPTW) using propensity score was performed to assess benefit of adjuvant trastuzumab. Ninety-one eligible women with a median age of 61 years (range 30–89) were identified. Thirty-nine (43%) women received adjuvant trastuzumab. Women who received trastuzumab were younger and had a higher rate of T1b disease. Overall, 3% of women who received trastuzumab compared to 12% of women who did not receive trastuzumab developed breast cancer recurrence (p = 0.23). Five-year disease-free survival (DFS) of women who received adjuvant trastuzumab was 94.8% compared to 82.7% of women who did not receive trastuzumab (p = 0.22). Five-year overall survival was 100% of women who received trastuzumab compared to 90.4% of women who did not receive adjuvant trastuzumab (p = 0.038). In the multivariable analysis, grade III tumors were correlated with inferior DFS (hazard ratio [HR] 5.5, 95% CI [1.7–17.7]). The propensity score using the inverse probability of treatment weighting showed that lack of adjuvant trastuzumab was correlated inferior DFS, with an HR of 4 (95% CI 1.05–15.5). Women with HER2-positive T1a/bN0 breast cancer had overall low recurrence of breast cancer. However, the results of this exploratory analysis indicate that women who received adjuvant trastuzumab had better survival.

De-escalation of Systemic Therapy for Early-Stage, Node-Negative Her2+ and Triple-Negative Breast Cancer

Purpose of Review

This review summarizes the most recent data on the management of small, node-negative Her2+ and triple-negative breast cancer.

Recent Findings

Both Her2+ and triple-negative breast cancers are characterized by high rates of recurrence and worse survival outcomes compared to hormone-positive cancers. De-escalation of systemic therapy in early-stage breast cancer is a recent national trend in clinical research. Recent prospective trials support the scaling back of cytotoxic agents and maximization of targeted therapy regimens. Similarly, large retrospective studies on small, node-negative triple-negative breast cancer report the omission of chemotherapy in women with T1a,N0 triple-negative cancers with favorable short term outcomes.

Summary

De-escalation of systemic therapy for Her2+ breast cancer is effective in the management of early-stage, node-negative disease. Future prospective studies on the omission of systemic therapy for triple-negative breast cancer are required to safely adopt into consensus guidelines.

Characteristics and clinical outcome of pT1a-b node-negative breast cancer

OBJECTIVE:

Tumor size, along with other clinicopathological characteristics, has a prognostic role in breast cancer. Recurrence risk tends to rise as tumor size increases. Early T-stage portends a good prognosis. We aimed to investigate the recurrence-free interval rates of T1abN0 group of early breast cancer.

METHODS:

Patients diagnosed with pT1a and T1b, lymph node metastasis-negative breast cancer were included in the study. Clinicopathologic characteristics including recurrence, distant metastasis, and final status of the patients were obtained retrospectively from the patient files.

RESULTS:

A total of 84 patients included. Twenty-six patients (31%) had T1a and 58 patients (69%) had T1b tumors. The 5-year distant relapse-free survival (DRFS) rate of T1ab tumors was 95.2%. The DRFS rate of T1a tumors was 96.2%, while the rate of T1b tumors was 94.8% (p=0.555). The 5-year RFS rate of T1ab tumors was 90.5%. The RFS rate of T1a tumors was 84.6%, whereas the rate of T1b tumors was 93.1% (p=0.359). The 5-year DRFS rate of hormone receptor positive group was 97%, Her-2 positive group was 81.8%, and triple negative group was 100% (p=0.041). The 5-year RFS rate of the hormone receptor positive group was 97%, Her-2 positive group was 72.7%, and triple negative group was 57.1% (p=0.001).

CONCLUSION:

The results of the study provided that both T1a and T1b tumors have a good and similar prognosis.

Molecular Subtype May Be More Associated With Prognosis and Chemotherapy Benefit Than Tumor Size in T1N0 Breast Cancer Patients: An Analysis of 2,168 Patients for Possible De-Escalation Treatment

Purpose

Breast cancer (BC) patients with T1N0 tumors have relatively favorable clinical outcomes. However, it remains unclear whether molecular subtypes can aide in prognostic prediction for such small, nodal-negative BC cases and guide decision-making about escalating or de-escalating treatments.

Patients and Methods

T1N0 BC patients diagnosed between 2009 and 2017 were included and classified into three subgroups according to receptor status: 1) hormonal receptor (HR)+/human epidermal growth factor receptor-2 (HER2)−; 2) HER2+; and 3) triple negative (TN) (HR−/HER2−). Patients’ characteristics and relapse events were reviewed. Kaplan–Meier analysis and Cox regression were used to assess the iDFS and BCSS. The effects of risk factors and adjuvant treatment benefits were evaluated by calculating hazard ratios (HRs) for invasive disease-free survival (iDFS) and breast cancer-specific survival (BCSS) with Cox proportional hazards models.

Results

In total, 2,168 patients (1,435 HR+/HER2−, 427 HER2+, 306 TN) were enrolled. The 5-year iDFS rates were 93.6, 92.7, and 90.6% for HR+/HER2−, HER2+, and TN patients, respectively (P = 0.039). Multivariate analysis demonstrated that molecular subtype (P = 0.043), but not tumor size (P = 0.805), was independently associated with iDFS in T1N0 BC. TN patients [HRs = 1.77, 95% confidence interval (CI) = 1.11–2.84, P = 0.018] had a higher recurrence risk than HR+/HER2− patients. Adjuvant chemotherapy benefit was not demonstrated in all T1N0 patients but interacted with molecular subtype status. TN (adjusted HRs = 2.31, 95% CI = 0.68–7.54) and HER2+ (adjusted HRs = 2.26, 95% CI = 0.95–5.63) patients receiving chemotherapy had superior iDFS rates. Regarding BCSS, molecular subtype tended to be related to outcome (P = 0.053) and associated with chemotherapy benefit (P = 0.005).

Conclusion

Molecular subtype was more associated with disease outcome and chemotherapy benefit than tumor size in T1N0 BC patients, indicating that it may guide possible clinical de-escalating therapy in T1N0 BC.

Survival Outcome and Impact of Chemotherapy in T1 Node-Negative Triple-Negative Breast Cancer: A SEER Database Analysis

Objective

Although triple-negative breast cancer (TNBC) has been considered to be an aggressive disease, the outcome of small-tumor (T1abcN0M0) TNBC and the effect of adjuvant chemotherapy on TNBC survival remain controversial.

Methods

We identified 4565 T1abcN0M0 TNBC patients in the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2010, to December 31, 2015. After propensity score matching (PSM), 3214 patients were finally analyzed. Survival rates were compared among T1a, T1b, and T1c patients and between patients with and without adjuvant chemotherapy.

Results

We classified 424, 1040, and 3101 cases as T1a, T1b, and T1c TNBC, respectively. A total of 2760 (60.5%) patients received adjuvant chemotherapy, accounting for 25.5%, 56.0%, and 66.8% of T1a, T1b, and T1c patients, respectively. Rates of 5-year breast cancer-specific survival (BCSS) for T1a, T1b, and T1c patients receiving chemotherapy were 97.8%, 94.1%, and 94.5%, respectively, compared with 97.2%, 94.0%, and 89.9% in patients without chemotherapy. Patients receiving adjuvant chemotherapy had higher 5-year BCSS (94.5% vs. 89.9%, P = 0.004) in the T1c subgroup, but no significant difference was detected in T1a or T1b patients due to adjuvant chemotherapy.

Conclusion

Small-tumor TNBC showed very good prognosis. Adjuvant chemotherapy improved prognosis in T1c TNBC cases to a greater extent than in T1a and T1b patients. More large-scale clinical trials are needed, and further study should be conducted to determine appropriate adjuvant chemotherapy for T1c TNBC patients.

The role of chemotherapy in patients with T1bN0M0 triple-negative breast cancer: a real-world competing risk analysis

The objective of the present study was to implement Kaplan-Meier analysis, competing risk analysis, and propensity score matching to evaluate whether the patients with T1bN0M0 triple-negative breast (TNBC) could benefit from adjuvant chemotherapy. A total of 1849 patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015. All eligible patients were divided into two cohorts, the chemotherapy (1155 patients) and the no-chemotherapy (694 patients) cohorts. Similar 5-year breast cancer-specific survival (BCSS) was observed in the chemotherapy and no-chemotherapy cohorts (96.1% vs. 96.0%, p=0.820). The results of the competing risk analysis showed a comparable 5-year breast cancer-specific death (BCSD) in both groups (chemotherapy 3.6% vs. no-chemotherapy 3.4%, p=0.778). Also, a higher 5-year other causes death (OCD) was observed in the no-chemotherapy cohort (0.7% vs. 5.4%, p<0.001). Multivariable competing risks regression models showed no association between chemotherapy and BCSS (HR, 1.21; 95%CI, 0.64-2.31; p=0.560). After 1:1 PSM, no significant difference was also observed for BCSD and OCD between two cohorts. The value of adjuvant chemotherapy in patients with T1bN0M0 TNBC is less than the present guidelines recommend, suggesting that de-escalated treatment could be a potentially beneficial strategy in appropriately selected patients.

Prognostic Model and Nomogram for Estimating Survival of Small Breast Cancer: A SEER-based Analysis

BACKGROUND

Different clinicopathologic characteristics could contribute to inconsistent prognoses of small breast neoplasms (T1a/T1b). This study was done to conduct a retrospective analysis and establish a clinical prediction model to predict individual survival outcomes of patients with small carcinomas of the breast.

MATERIALS AND METHODS

Based on the Surveillance, Epidemiology, and End Results (SEER) database, eligible patients with small breast carcinomas were analyzed. Univariate analysis and multivariate analysis were performed to clarify the indicators of overall survival. Pooling risk factors enabled nomograms to be constructed and further predicted 3-year, 5-year, and 10-year survival of patients with small breast cancer. The model was internally validated for discrimination and calibration.

RESULTS

A total of 17,543 patients with small breast neoplasms diagnosed between 2013 and 2016 were enrolled. Histologic grade, lymph node stage, estrogen receptor or progesterone receptor status, and molecular subtypes of breast cancer were regarded as the risk factors of prognosis in a Cox proportional hazards model (P < .05). A nomogram was constructed to give predictive accuracy toward individual survival rate of patients with small breast neoplasms.

CONCLUSIONS

This prognostic model provided a robust and effective method to predict the prognosis of patients with small breast cancer.

The Survival Outcomes of T1aN0M0 Triple-Negative Breast Cancer With Adjuvant Chemotherapy

Purpose: Triple-negative breast cancer (TNBC) is a subtype with distinct heterogeneity, high invasiveness, and poorer prognosis. There is a controversy about adjuvant chemotherapy (ACT) at the T1aN0M0 stage. This study was carried out to assess the survival benefit of ACT for these patients.

Methods: We identified 1,099 patients with T1aN0M0 TNBC who were diagnosed between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariable analyses were conducted to determine factors related to survival. One-to-one (1:1) propensity score matching (PSM) was applied to construct a matched sample consisting of pairs of ACT and non-ACT subjects. Breast cancer–specific survival (BCSS) and overall survival (OS) of the two groups were evaluated by Kaplan–Meier plots and Cox proportional hazard regression models. Stratified analysis according to different variables was also performed.

Results: No obvious differences in demographic or clinical characteristics were found between patients who had ACT and those without ACT therapy in terms of race, marital status, laterality, or radiation therapy. A higher proportion of patients who were older, had a higher histological grade tumor, and who received breast-conserving surgery had adjuvant chemotherapy. The ACT group did not exhibit better survival in BCSS or OS before PSM. After PSM, the ACT and non-ACT groups consisted of 255 patients, respectively, and Kaplan–Meier curves and multivariate analysis both indicate that adjuvant chemotherapy was not associated with better survival in terms of BCSS or OS. Furthermore, we did not observe any survival advantage in any subgroup irrespective of age, race, marital status, histological grade, surgery type, or radiotherapy status.

Conclusions: The study results indicate that there is no strong association between ACT and better survival in T1aN0M0 TNBC. It implies that the chemotherapy decision should be made cautiously and further research into therapeutic strategies are needed in T1aN0M0 TNBC patients.

Do 21-Gene Recurrence Score Influence Chemotherapy Decisions in T1bN0 Breast Cancer Patients?

Purpose: Hormone receptor (HR)-positive breast cancer patients with tumor size ≤1.0 cm and negative node have favorable outcomes. The 21-gene Recurrence Score (RS) could predict response to chemotherapy for HR+ breast cancer, but its role in T1bN0 disease is challenging.

Methods: T1bN0 breast cancer patients diagnosed between January 2014 and June 2019 with RS results were included and categorized as Low- (RS < 18), Intermediate- (RS 18–30), or High-risk (RS > 30) groups. Univariate and multivariate analysis were used to assess factors associated with RS distribution and chemotherapy recommendation. Chemotherapy decisions change and patient adherence after 21-gene RS testing were also evaluated.

Results: Among 237 patients with T1bN0 tumors, proportions of Low-, Intermediate-, and High-risk RS were 19.8, 63.3, and 16.9%, respectively. Multivariate analysis found that ER expression (P = 0.011), PR expression (P < 0.001), and Ki-67 index (P = 0.001) were independently associated with RS distribution. Adjuvant chemotherapy was recommended for 31.6% of patients, which was more frequently given to patients with higher tumor grade [Odds ratio (OR) = 2.99 for grade II, OR = 59.19 for grade III, P = 0.006], lymph vascular invasion (OR = 8.22, P = 0.032), Luminal-B subtype (OR = 5.68, P < 0.001), and Intermediate-to High-risk RS (OR = 10.01 for Intermediate-risk, OR = 192.42 for High-risk, P < 0.001). Chemotherapy decision change was found in 18.6% of patients, mainly in those with Intermediate- to High-risk RS tumor with the majority from no-chemotherapy to chemotherapy. The treatment compliance rate after the 21-gene RS testing with MDT was 95.4%.

Conclusion: RS category was related to ER, PR, and Ki-67 expression, which was recognized as an independent factor of chemotherapy recommendation in T1bN0 breast cancer. The 21-gene RS testing would lead to a chemotherapy decision change rate of 18.6% as well as a high treatment adherence, which can be applied in T1bN0 patients.

Early stage triple negative breast cancer: Management and future directions

Triple negative breast cancer is the most aggressive kind of breast cancer with high risk of recurrences and poor outcomes. Systemic chemotherapy has significantly improved long term outcomes in early stage patients; however, metastatic recurrences still develop in a significant number of patients. Anthracycline and taxane based chemotherapy regimens are standard of care for early stage patients. Neoadjuvant treatment is preferred due to the ability to assess pathologic responses providing important prognostic information and guidance in adjuvant therapy decisions. Carboplatin addition to the anthracycline and taxane backbone is associated with a significant improvement in pathologic complete response but is associated with more toxicity. Understanding the immune microenvironment of triple negative disease is an exciting field and immune checkpoint inhibitors have shown great promise in further improving response rates in early stage patients. Patients with residual disease after neoadjuvant chemotherapy have a significantly higher risk of recurrence compared to those with complete responses. Adjuvant capecitabine for these high-risk patients have shown significant improvement in long term outcomes and is routinely used in this setting. Given the heterogeneity within triple negative tumors, molecular subtypes with variable genomic makeup and chemo sensitivities have been identified and will likely aid in further clinical developmental therapeutics.

Targeted therapeutic options and future perspectives for HER2-positive breast cancer

Over the past 2 decades, there has been an extraordinary progress in the regimens developed for the treatment of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Trastuzumab, pertuzumab, lapatinib, and ado-trastuzumab emtansine (T-DM1) are commonly recommended anti-HER2 target agents by the U.S. Food and Drug Administration. This review summarizes the most significant and updated research on clinical scenarios related to HER2-positive breast cancer management in order to revise the guidelines of everyday clinical practices. In this article, we present the data on anti-HER2 clinical research of neoadjuvant, adjuvant, and metastatic studies from the past 2 decades. We also highlight some of the promising strategies that should be critically considered. Lastly, this review lists some of the ongoing clinical trials, findings of which may soon be available.

Performance of survivin mRNA as a biomarker for breast cancer among Vietnamese women

Objective

This study aimed to perform the reverse-transcription polymerase chain reaction (RT-PCR) to express the survivin mRNA among patients with breast cancer in Vietnam and identify some potential associated clinical and pathological factors.

Methods

Peripheral blood (PB) samples and tissues on 43 patients with breast cancer and 21 patients with fibroids were obtained. The Real-time RT-PCR and gene sequencing techniques were employed to detect survivin gene in breast cancer cell lines and cancer tissues.

Results

Survivin mRNA transcription was detected in 32/43 (74,4%) of breast cancer tissues and 19/43 (44,2%) of PB samples of breast cancer patients, while it was detected in only 14,3 % fibrosis tissues and 0% in the blood of fibrosis patients. Survivin mRNA on the peripheral blood of breast cancer patients increased with tumor size, and stage of cancer (p < 0.05). In terms of breast cancer tissue, no difference was found in the rate of survivin mRNA expression in according to age, distant metastasis, lymph node, stages of cancer, and histopathology (p > 0.05).

Conclusions

Results provide the initial evidence of the expression of survivin mRNA in breast cancer patients in Vietnam, suggesting the role of survivin mRNA in breast cancer molecular pathology.

WITHDRAWN: Performance of survivin mRNA as a biomarker for breast cancer among Vietnamese women

Ahead of Print article withdrawn by publisher.

Would 1.0 cm be a more suitable cutoff to subdivide pT1 tumors in hormone receptor-negative and HER2-positive breast cancer?

BACKGROUND

HER2+ and hormone receptor (HoR)-negative breast cancer usually associated with poor outcome. However, it remained elusive for the prognosis of small (T1a-T1c) HER2+/HoR- breast cancer. The present study retrospectively analyzed the Surveillance, Epidemiology, and End Results (SEER) database to explore the clinicopathological characteristics and prognosis of T1a-T1c HER2+/HoR- breast cancer.

MATERIAL AND METHODS

Data for patients diagnosed with either HER2-/HoR+or HER2+/HoR- T1a-T1c breast cancer between 2010 and 2012 were obtained from SEER program. Survival analyses were conducted by Kaplan-Meier method and Cox proportion hazard regression.

RESULTS

Totally, 2648 HER2+/HoR- and 56387 HER2-/HoR+T1a-T1c breast cancer patients were enrolled. There was a clear trend that tumor size had a positive correlation with advanced AJCC stage (P < 0.001) and N-stage (P < 0.001). T1a and T1b HER2+/HoR- breast cancer had great homogeneity in that these two subgroups had comparable survival and both showed no significant survival difference with its counterpart of HER2-/HoR+subtype. Conversely, T1c HER2+/HoR- breast cancers revealed worse prognosis than T1a/T1b HER2+/HoR- and T1c HER2-/HoR+tumors (BCSS HR 3.847, P < 0.001; OS HR 2.055, P < 0.001).

CONCLUSION

T1a and T1b HER2+/HoR- breast cancer had favorable prognosis and great homogeneity, indicating 1.0 cm may be a suitable cutoff for subclassification of T1 cancer. Future randomized clinical trials were warranted to verify this hypothesis and elucidate the biological behavior of small T1 tumor to facilitate precise medicine.

Triple-Negative Breast Cancer: Who Should Receive Neoadjuvant Chemotherapy?

Progress in the treatment of triple-negative breast cancer remains an important challenge. Given the aggressive biology and high risk of distant recurrence, systemic chemotherapy is warranted in most patients. Neaodjuvant chemotherapy benefits patients with locally advanced disease by downsizing the tumor and increasing the probability of breast-conserving surgery. Clinical and pathologic responses provide important prognostic information, which makes neoadjuvant therapy an attractive approach for all patients with triple-negative breast cancer. Clinical research in the neoadjuvant setting is focused on improvement in pathologic complete response rates and outcomes of patients with residual disease.

Cell cycle protein Bora serves as a novel poor prognostic factor in multiple adenocarcinomas

Cell cycle protein Bora has been identified to integrate the functions of three major mitotic kinases: Cyclin-dependent kinase-1, Polo-like kinase-1, and Aurora A kinase. Overexpression of Bora disrupts spindle assembly and causes genomic instability. However, the clinical relevance of Bora in cancer remains unclear. In this study, we examined the expression of Bora and its association with clinical characteristics in breast (n = 538), lung (n = 144) and gastric (n = 77) adenocarcinomas. We found that Bora was overexpressed in primary breast cancer tissues compared to paired non-cancerous tissues. Bora overexpression was observed at a higher proportion in triple-negative breast cancer (TNBC, 77.63%) compared with non-TNBC subtypes (42.76%, P < 0.0001). Kaplan-Meier survival analysis indicated that Bora overexpression was associated with unfavourable overall survival (OS, P < 0.0001) and disease-free survival (DFS, P = 0.007) in breast cancer. In addition, Bora subclassified patients with distinct clinical outcomes in both stages (II/III) and subtypes (HR+, HER2+) of breast cancer. Consistently, Bora was associated with adverse prognosis in lung (P = 0.005 for OS and DFS P = 0.001 for DFS) and gastric adenocarcinomas (P < 0.0001 for OS, and P < 0.0001 for DFS). Moreover, Bora was positively correlated with proliferation index Ki67 in breast and gastric cancer (P < 0.001, P = 0.005, respectively). Multivariate analyses further revealed that Bora was an independent prognostic parameter for OS and DFS in all three types of adenocarcinomas. In conclusion, our findings demonstrated that Bora was overexpressed and served as an independent biomarker for poor prognosis in multiple adenocarcinomas.

Benefit of adjuvant chemotherapy with or without trastuzumab in pT1ab node-negative human epidermal growth factor receptor 2-positive breast carcinomas: results of a national multi-institutional study

PURPOSE

Benefit of adjuvant trastuzumab-based chemotherapy for node-positive and/or >1 cm human epidermal growth factor receptor 2-positive (HER2+) breast carcinomas has been clearly demonstrated in randomized clinical trials. Yet, evidence that adjuvant chemotherapy with or without trastuzumab is effective in pT1abN0 HER2+ tumors is still limited. The primary objective of this study was to investigate the impact of adjuvant chemotherapy ± trastuzumab on outcome in this subpopulation.

PATIENTS AND METHODS

A total of 356 cases of pT1abN0M0 HER2 + breast cancers were retrospectively identified from a large cohort of 22,334 patients, including 1248 HER2+ patients who underwent primary surgery at 17 French centers, between December 1994 and January 2014. The primary end point was disease-free survival (DFS). A multivariate Cox model was built, including adjuvant chemotherapy, tumor size, hormone receptor status, and Scarff Bloom Richardson (SBR) grade.

RESULTS

A total of 138 cases (39%) were treated with trastuzumab-based chemotherapy, 29 (8%) with chemotherapy alone, and 189 (53%) received neither trastuzumab nor chemotherapy. Adjuvant chemotherapy ± trastuzumab was associated with a significant DFS benefit (3-year 99 vs. 90%, and 5-year 96 vs. 84%, Hazard ratio, HR 0.26 [0.10-0.67]; p = 0.003, logrank test) which was maintained in multivariate analysis (HR 0.19 [0.07-0.52]; p = 0.001). Metastasis-free survival was also increased (HR 0.25 [0.07-0.86]; p = 0.018, logrank test) at 3-year (99 vs. 95%) and 5-year (98 vs. 89%) censoring. Exploratory subgroup analysis found DFS benefit to be significant in hormone receptor-negative, hormone receptor-positive, and pT1b tumors, but not in pT1a tumors.

CONCLUSIONS

Adjuvant chemotherapy ± trastuzumab is associated with a significantly reduced risk of recurrence in subcentimeter node-negative HER2+ breast cancers. Most of the benefit may be driven by pT1b tumors.

Biologic subtype is a more important prognostic factor than nodal involvement in patients with stages I and II breast carcinoma

Purpose

Nodal infiltration has been one of the most important prognostic factors in breast cancer. In recent decades, risk stratification has greatly changed, and is applied in accordance with hormone receptor and human epidermal growth factor receptor 2 (HER2) status. We compared the prognostic power of tumor subtype to nodal involvement in early breast cancer.

Methods

We reviewed the medical records of 505 patients who had curative surgery for stage I or II breast cancer. We analyzed clinicopathologic factors according to tumor subtype and nodal involvement. Tumors were classified into 4 subtypes according to immunohistochemical status of estrogen receptor, progesterone receptor, HER2, and Ki67 labeling index. Disease-free survival (DFS) and overall survival were analyzed.

Results

There were 363 node-negative patients (71.9%) and 142 node-positive patients (28.1%). Luminal A, Luminal B, HER2, and triple-negative breast cancer subtypes were composed of 207 (41.0%), 147 (29.1%), 42 (8.3%), and 109 patients (21.6%), respectively. The median follow-up period was 89.5 months. Node negative-luminal A subtype showed the best prognosis with regard to 5-year DFS, and the pN1-triple negative subtype was associated with the shortest DFS (95.1% vs. 67.8%; hazard ratio, 9.554; P < 0.001). However, the node negative-triple negative subtype was associated with a worse 5-year DFS than the pN1-luminal A subtype ([86.4%; hazard ratio, 2.647; P = 0.048] vs. [93.2%; hazard ratio, 2.061; P = 0.194]).

Conclusion

Node negative-triple negative breast cancer was associated with a poorer prognosis than pN1-luminal A subtype. Tumor subtype has greater prognostic power compared to nodal status in early breast cancer.

[Perception of pT1a,b pN0 breast tumor prognosis by the French oncology community: Results of the EURISTIC national survey]

The prognosis of infracentimetric breast cancers (BC) is heterogeneous. The EURISTIC survey describes how French oncology specialists perceive the prognosis of pT1a,b pN0 BCs. A self-administered questionnaire has been sent to over 2000 French BC specialists. Six hundred and sixty-three physicians responded. Fifty-eight percent do not consider tumor size as a key prognostic criterion. They consider that the cutoff for poor prognosis is 22mm, 10mm and 7mm for hormone receptors (HRs)+, HER2+ and triple-negative (TN) tumors respectively. Eighty-three percent of respondents consider that a HR+ pT1a,b tumor has a good prognosis (21% and 8% for HER2+ and TN respectively). Factors perceived as most detrimental are: HER2 overexpression (29% of respondents); HR- (20%); high grade (20%); TN status (14%); high KI67 (5%); presence of lymphovascular invasion (3%); young age (2%) and high mitotic index (1%). For French specialists, immunohistochemical characteristics, in particular hormone and HER2 status, are strong prognostic factors in BCs below 1cm.

Analysis of Risk of Recurrence by Subtype in ≤ 1-cm Breast Tumors

INTRODUCTION

Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer with higher recurrence rates than other breast cancer subtypes. Increasing numbers of women are being diagnosed with early-stage breast cancer because of improvements in screening mammography. TNBC is known to be highly sensitive to chemotherapy; however, the benefit of adjuvant chemotherapy among women with ≤ 1-cm, lymph node-negative TNBC is unknown.

MATERIALS AND METHODS

We evaluated the recurrence rates and recurrence-free survival of 437 women diagnosed with stage T1a-T1bN0 breast cancer from 1997 to 2009 at 2 institutions, with a median follow-up time of 6.2 years. Furthermore, we examined the treatment regimens of these women and evaluated the association of adjuvant chemotherapy with recurrence-free survival.

RESULTS

Chemotherapy was administered more often to younger women and to women with high-grade, human epidermal growth factor receptor 2-positive or TNBC. Recurrence-free survival did not differ significantly between TNBC and estrogen receptor-positive breast cancer (hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.10-1.04; P = .058). After appropriate adjustments, no significant differences were detected in recurrence-free survival between the women who had received chemotherapy and those who had not among the women with TNBC (P = .132) or within any of the breast cancer subtypes (HR, 0.6; 95% CI, 0.2-1.9; P = .392).

CONCLUSION

Prospective trials of this subcentimeter node-negative breast cancer population are warranted to guide adjuvant chemotherapy decisions.

Outcomes of HER2-positive early breast cancer patients in the pre-trastuzumab and trastuzumab eras: a real-world multicenter observational analysis. The RETROHER study

Addition of trastuzumab to adjuvant chemotherapy has dramatically reduced the risk of recurrence and has become the standard of care for human epidermal growth factor receptor 2 (HER2)-positive early breast cancer patients. Since most data on trastuzumab benefits come from clinical trials, conducted in selected patient populations, we performed a retrospective analysis of HER2-positive early breast cancer patients treated in the "pre-trastuzumab" and "trastuzumab" eras, with the aim to determine patients' outcomes in real-world practice. 925 consecutive HER2-positive breast cancer patients treated with adjuvant chemotherapy in ten Italian oncologic centers were identified. Patients who had received adjuvant chemotherapy alone (cohort A, 352 patients), and patients who had received adjuvant chemotherapy followed or combined with trastuzumab (cohort B, 573 patients) were analyzed. Relapse rate at 3 years, relapse-free survival, and overall survival were significantly more unfavorable in the cohort A than in the cohort B (p < 0.0001). In multivariate analysis, factors related to relapse were younger age, advanced stage at diagnosis, absence of hormonal and of trastuzumab therapy. The benefit derived from the addition of trastuzumab was independent of nodal status and hormonal receptors expression. A subgroup analysis including 163 "triple positive" tumors with high levels of estrogen and progesterone receptor (TP50) suggested that addition of trastuzumab to adjuvant chemotherapy and hormonal therapy did not translate into better outcomes. In our analysis, trastuzumab benefit was confirmed in all but a small subset of TP50 tumors subgroups. In this subset further investigations are needed.

Chemotherapy use and surgical treatment by receptor subtype in node-negative T1a and T1b female breast cancers, Iowa SEER Registry, 2010 to 2012

BACKGROUND

Patients with small node-negative breast tumors who are younger or who have human epidermal growth factor receptor 2-positive (HER2(+)) or triple-negative breast cancer (TNBC) subtypes are at increased risk of recurrence. Concurrently, systemic treatment recommendations have evolved. Less is known about how frequently cytotoxic chemotherapy is given to these patients. Mastectomy rates have also increased. This study reports the recent incidence of T1a,bN0M0 breast cancer and the characteristics associated with chemotherapy delivery and the surgery selected.

PATIENTS AND METHODS

This retrospective cohort is composed of invasive female breast cancers diagnosed with American Joint Committee on Cancer (AJCC) stage T1a,bN0M0 during 2010 to 2012 from the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. Chemotherapy use and surgery were identified by the registry. Univariate and multivariate analyses were performed to determine patient differences across subtype and factors associated with treatment.

RESULTS

The study included 1687 patients. This represented 27.6% of all AJCC stages I(a-c) to III breast cancer in 2010 to 2012, up from 18% in 1990 (P < .0001). Of 1456 patients with known subtype, 8.8% and 6.4% had HER2(+) and TNBC disease, respectively. Chemotherapy was given to 7.5% of women with T1aN0M0 and 12.7% of T1bN0M0 tumors. The likelihood of systemic treatment was associated with breast cancer subtype, tumor differentiation, and age in a multivariate model. The mastectomy rate was 31.8%.

CONCLUSION

Small node-negative breast cancers continue to grow significantly as a percentage of invasive breast cancer diagnoses. In 2010 to 2012 in Iowa, systemic chemotherapy correlated with risk factors associated with recurrence: age, subtype, and tumor differentiation. Relatively high rates of mastectomy were seen.

Outcomes by tumor subtype and treatment pattern in women with small, node-negative breast cancer: a multi-institutional study

PURPOSE

Treatment decisions for patients with T1a,bN0M0 breast cancer are challenging. We studied the time trends in use of adjuvant chemotherapy and survival outcomes among these patients.

PATIENTS AND METHODS

This was a prospective cohort study within the National Comprehensive Cancer Network Database that included 4,113 women with T1a,bN0M0 breast cancer treated between 2000 and 2009. Tumors were grouped by size (T1a, T1b), biologic subtype defined by hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status, and receipt of chemotherapy with or without trastuzumab.

RESULTS

Median follow-up time was 5.5 years. Eight percent of patients with HR-positive/HER2-negative tumors were treated with chemotherapy. Fifty-two percent of those with HER2-positive or HR-negative/HER2-negative breast cancers received chemotherapy, with an increase over the last decade. Survival outcomes diverged by subtype and size, but the 5-year distant relapse-free survival (DRFS) did not exceed 10% in any subgroup. The 5-year DRFS for patients with T1a tumors untreated with chemotherapy ranged from 93% to 98% (n = 49 to 972), and for patients with T1b tumors, it ranged from 90% to 96% (n = 17 to 2,005). Patients with HR-positive/HER2-negative disease had the best DRFS estimates, and patients with HR-negative/HER2-negative tumors had the lowest. In this observational, nonrandomized cohort study, the 5-year DRFS for treated patients with T1a tumors was 100% for all subgroups (n = 12 to 33), and for patients with T1b tumors, it ranged from 94% to 96% (n = 88 to 241).

CONCLUSION

Women with T1a,b tumors have an excellent prognosis without chemotherapy. Size and tumor subtype may identify patients in whom the rate of recurrence justifies consideration of chemotherapy. These patients represent an optimal group for evaluating less toxic adjuvant regimens to maintain efficacy while minimizing short- and long-term risks.

Clinical significance of HER2-positive and triple-negative status in small (≤ 1 cm) node-negative breast cancer

BACKGROUND

Data regarding the clinical significance of HER2(+) and TN status in patients with small node-negative tumors are limited and conflicting. It remains unclear who, among those with small lesions, might benefit from more aggressive adjuvant therapy.

PATIENTS AND METHODS

We identified all node-negative breast cancer patients with tumor size ≤ 1 cm diagnosed between January 1, 1995 and December 31, 2008 using our institutional breast service database. Patients were classified according to their receptor status into 3 groups: (1) hormone receptor (HR)-positive (estrogen receptor [ER]- or progesterone receptor [PR]-positive, HER2(-)); (2) HER2(+) (immunohistochemistry 3(+) or fluorescence in situ hybridization amplification ≥ 2); and (3) TN (ER(-), PR(-), and HER2(-)). RFS was calculated using Kaplan-Meier methods.

RESULTS

Among 656 patients with tumors ≤ 1 cm, 494 (75%) of the patients were HR(+), 107 (16%) were HER2(+), and 55 (9%) were TN. Median age was 59 years (range, 27-92 years). Median follow-up was 3.5 years. The 5-year RFS rates were 98.2%, 97.1%, and 83.5% in patients with HR(+), HER2(+), and TN tumors, respectively (P < .001). In multivariate analysis, TN status was associated with worse RFS (hazard ratio, 6.70; 95% confidence interval [CI], 3.02-14.86), and HER2(+) was not (hazard ratio, 1.64; 95% CI, 0.73-3.69).

CONCLUSION

TN, but not HER2(+) status, was associated with worse RFS in patients with T1abN0 tumors, and adjuvant chemotherapy might be considered in patients with TN breast cancer.

HER2 overexpression a major risk factor for recurrence in pT1a-bN0M0 breast cancer: results from a French regional cohort

The management of pT1a-bN0M0 breast cancer remains an area of controversy. Data from 714 patients classified as having pT1a-bN0M0 breast cancer and treated, from 1999 to 2004 in the Languedoc-Roussillon France, were analyzed. The human epidermal growth factor receptor 2 (HER2) status analyses were centralized. The objective of this study was to describe the prognosis of pT1a-bN0M0 breast cancer according to HER2 distribution and hormonal status. The median follow-up was 6.4 years. Ten-year overall survival was 94%. HER2 overexpression was observed in 6.1% of the patients. The 10-year prognosis of patients with HER2-positive tumors was worse than that of those with HER2-negative (disease-free survival 73% vs. 89%, P < 0.0001). Tumor size (T1a/T1b) was not a relevant prognostic factor. The co-expression of HER2 with hormonal receptors (HR) was associated with high recurrence at 10 years. In both univariate and multivariate analyses, the most relevant prognostic factor for this population was HER2 amplification. In multivariate analysis, patients with HER2-positive tumors had higher risk of mortality (HR, 3.89; 95% CI, 1.58–9.56). In pT1a-bN0M0 breast cancers, HER2 amplification or overexpression is a risk factor for recurrence. In HER2-positive breast cancers, HR expression is associated with a poor prognosis despite the hormone therapy. For this population, a personalized management may be required.

For or against adjuvant trastuzumab for pT1a-bN0M0 breast cancer patients with HER2-positive tumors: a meta-analysis of published literatures

BACKGROUND

Although the prognosis of patients with small (≤1cm) tumors is generally favorable, emerging data suggests that biological behavior varies between intrinsic subtypes in such patients. Furthermore, it still remains unclear whether HER2-positive pT1a-bN0M0 patients could benefit from adjuvant trastuzumab. For further evaluation, we sought to conduct a meta-analysis so as to get a better understanding of the prognosis for HER2-positive pT1a-bN0M0 patients and their survival benefit from adjuvant trastuzumab, accordingly, offering the implications for current practice.

METHODS

The PubMed database, the online proceedings of the American Society of Clinical Oncology (ASCO) Annual Meetings, the online proceedings of the San Antonio Breast Cancer Symposium, and the CD proceedings of the International St. Gallen Breast Cancer Conference were searched for all relevant studies published before September 2012. Relative risks (RRs) were used to compare the prognosis of different intrinsic subtypes for pT1a-bN0M0 breast cancer. Analyses were also performed to estimate the association between adjuvant trastuzumab and various survival outcomes.

RESULTS

With eight eligible studies identified, this meta-analysis demonstrated a deleterious effect of HER2+ phenotype on disease-free survival (DFS; RR = 3.677, 95% CI 2.606-5.189, p <0.001) and distant disease-free survival (DDFS; RR = 3.824, 95% CI 2.249-6.501, p<0.001) as compared to HR+/HER2- subgroup. However, significant difference failed to be achieved in terms of any endpoint between HER2+ and triple negative breast cancer (TNBC). Besides, a marked improvement in DFS was observed with the addition of trastuzumab for HER2-positive pT1a-bN0M0 patients (RR = 0.323, 95% CI 0.191-0.547, p<0.001).

CONCLUSION

This meta-analysis clarifies that intrinsic subtypes might be a reliable marker to predict the prognosis in pT1a-bN0M0 breast cancer. Besides, even for such early stage HER2-positive patients, adjuvant trastuzumab might bring significant survival benefit.

Detectability and clinicohistological characteristics of small (≤1 cm) invasive breast cancer

PURPOSE

To investigate the detectability and imaging characteristics of primary tumors according to imaging modalities and to identify clinical features and histological prognostic factors for axillary metastases in patients with small (≤1cm, T1a and T1b) invasive breast cancer.

MATERIALS AND METHODS

A total of 221 patients with histologically confirmed small invasive cancers were included for the statistical analysis. At mammography, ultrasonography and MRI, the detectability, and imaging characteristics of primary tumors were compared in patients with or without axillary metastases. Clinical features and histological prognostic factors for axillary metastases were investigated.

RESULTS

Of 221 patients examined, axillary metastasis was found in 42 (19%) at the time of surgery. There was no significant difference in detectability of small tumors using ultrasonography and MRI between patients with and without axillary metastasis. However, mammography had a higher positive rate of primary tumors in patients with axillary metastasis than without metastasis (92.9% vs. 77.1%, p=0.023). Patients with axillary metastasis in small cancers showed more common architectural distortion than negative (p=0.0147) or mass (p=0.0356) on mammography. Clinical features were not different in the two groups. Only lymphovascular invasion was independently associated with axillary metastasis (p=0.0051, 95% CI, 1.527-11.597).

CONCLUSION

The detectability of small invasive breast cancers among patients with and without axillary metastasis is different with mammography, but not with US and MRI. Lymphovascular invasion is only a predictor for axillary metastasis in small invasive cancers.

Association of HER2 Overexpression and Prognosis in Small (T1N0) Primary Breast Cancers

BACKGROUND

There is some controversy regarding the precise role and need for adjuvant therapy in patients with pT1a/pT1bN0 breast cancer, although studies have indicated that a HER2-positive status is one of the most powerful poor prognostic factors.

PATIENTS AND METHODS

We retrospectively evaluated disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS) among 960 patients diagnosed between 2000 and 2008 with T1N0 primary breast cancer treated at 3 German centers, and determined prognostic risk factors. Univariate analysis was used to determine associations with potential risk factors.

RESULTS

With a median follow-up of 23 months, DFS was 94.8%, DDFS 96.3%, and OS 97.5%. Risk factors for decreased 1-year DFS were: peritumoral lymphatic invasion (L1) (p = 0.031), negative hormone receptor status (p = 0.003), non-use of hormonal therapy (p = 0.001), and a positive HER2 status (p = 0.003). Amongst the HER2-positive patients only 2.7% (n = 1/37) of those treated with trastuzumab had a DFS event compared with 20% (n = 10/50) without trastuzumab.

CONCLUSION

Patients with HER2-positive T1 breast cancer should be considered for inclusion in prospective trials of trastuzumab in combination with chemotherapy to determine the risk-to-benefit ratio and association with other prognostic factors.

Recurrence risk in small, node-negative, early breast cancer: a multicenter retrospective analysis

PURPOSE

Recurrences and deaths are known to occur, even if less frequently, in small, node-negative breast cancer patients, and decision on adjuvant treatments remains controversial. In the present analysis, we evaluate recurrence risk in patients with pT1 a, b, c, node-negative, breast cancer, accordingly with some prognostic biological factors.

METHODS

We retrospectively evaluated 900 node-negative patients (pT1a, b, c) surgery treated between 2000 and 2009 in four Italian oncologic centers. We defined 3 different cohorts: ER positive (ER+); Her-2 positive (Her-2+); and triple negative (TN).

RESULTS

pT1a was seen in 7.6% of patients, 37.7 % pT1b, 54.8 % pT1c. Concerning the 3 different cohorts, 58.2 % were ER+; 10.8 % were Her-2+; 8.2 % were TN. Overall, chemotherapy was given to 3.0 %, 27.2 %, 69.8 % of pT1a, b, c, respectively, and to 22.7 %, 58.8 %, 68.9 % of ER+, Her-2+, TN subgroups. At a median follow-up of 67 months, 5-year DFS was 96.3 %, 89.2 %, 89.4 % in pT1a, b, c, respectively (100 %, 93.6 %, 89.8 % in ER+; 100 %, 78.7 %, 85.0 % in Her-2+; 100 %, 76.8 %, 85.2 % in TN) (p = ns). At multivariate analysis, histologic grade and Ki-67 resulted independent prognostic factors. Overall, 5-year OS was 98 %, without differences among pT1a, b, c, or among the 3 cohorts.

CONCLUSIONS

Overall, 5-year DFS was very favorable in this series of small, node-negative breast cancers, but Her-2+ and TN cohorts have a higher recurrence rate than ER+ cohort (p < 0.0001); pT1c, but also pT1b, in Her-2+ and TN subgroups, have a worse outcome, and effective chemotherapy treatment should be considered in these unfavorable subgroups.

Implications of HER2 amplification in small, node-negative breast cancers: do Asians differ?

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.

Role of HER2-neu as a prognostic factor for survival and relapse in pT1a-bN0M0 breast cancer: a systematic review of the literature with a pooled-analysis

High levels of human epidermal growth receptor 2 (HER2) expression are associated with recurrence and death in breast cancer (BC) patients. We have performed a systematic review and meta-analysis in order to evaluate the prognosis for HER2+ pT1a-bN0M0 BC patients. A search of PubMed and Embase was performed. Studies were included if they reported hazard ratios (HRs) with a 95% confidence interval (CI) for multivariate analyses of relapse or survival in pT1a-bN0M0, HER2+ BC patients treated with surgery and chemotherapy and/or endocrine therapy, but not with trastuzumab. A total of 764 patients from seven studies were included in the meta-analysis. In the pooled analysis, HER2 had a detrimental effect on relapse-free (HR 4.68, 95% CI 3.05-7.18; p<0.00001) and distant relapse-free survival, with a HR of 5.6 (95% CI 2.65-11.85; p<0.00001). HER2+ status was also linked to increased risk of death (HR 3.4, 95% CI 0.86-13.41; p=0.08) and worst BC-specific survival (HR 2.61, 95% CI 1.51-4.51; p=0.0006), but these data were presented in few studies. HER2+ pT1a-bN0M0 BC is associated with a dismal prognosis. In these patients, HER2 has to be taken into account when deciding on adjuvant therapy, and trastuzumab should be considered.

Management of Small T1a/b N0 Breast Cancers

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.

Effect of HER2 status on risk of recurrence in women with small, node-negative breast tumours

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.