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Bychkovsky BL, Myers S, Warren LEG, De Placido P, Parsons HA. Ductal Carcinoma In Situ. Hematol Oncol Clin North Am 2024; 38:831-849. [PMID: 38960507 DOI: 10.1016/j.hoc.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
In breast cancer (BC) pathogenesis models, normal cells acquire somatic mutations and there is a stepwise progression from high-risk lesions and ductal carcinoma in situ to invasive cancer. The precancer biology of mammary tissue warrants better characterization to understand how different BC subtypes emerge. Primary methods for BC prevention or risk reduction include lifestyle changes, surgery, and chemoprevention. Surgical intervention for BC prevention involves risk-reducing prophylactic mastectomy, typically performed either synchronously with the treatment of a primary tumor or as a bilateral procedure in high-risk women. Chemoprevention with endocrine therapy carries adherence-limiting toxicity.
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Affiliation(s)
- Brittany L Bychkovsky
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Sara Myers
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Laura E G Warren
- Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Pietro De Placido
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heather A Parsons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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2
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O’Keefe T, Yau C, Iaconetti E, Jeong E, Brabham C, Kim P, McGuire J, Griffin A, Wallace A, Esserman L, Harismendy O, Hirst G. Duration of Endocrine Treatment for DCIS impacts second events: Insights from a large cohort of cases at two academic medical centers. RESEARCH SQUARE 2024:rs.3.rs-3403438. [PMID: 38260526 PMCID: PMC10802747 DOI: 10.21203/rs.3.rs-3403438/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Ductal carcinoma in situ (DCIS) incidence has risen rapidly with the introduction of screening mammography, yet it is unclear who benefits from both the amount and type of adjuvant treatment (radiation therapy, (RT), endocrine therapy (ET)) versus what constitutes over-treatment. Our goal was to identify the effects of adjuvant RT, or ET+/- RT versus breast conservation surgery (BCS) alone in a large multi-center registry of retrospective DCIS cases (N = 1,916) with median follow up of 8.2 years. We show that patients with DCIS who took less than 2 years of adjuvant ET alone have a similar second event rate as BCS. However, patients who took more than 2 years of ET show a significantly reduced second event rate, similar to those who received either RT or combined ET+RT, which was independent of age, tumor size, grade, or period of diagnosis. This highlights the importance of ET duration for risk reduction.
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Affiliation(s)
- Thomas O’Keefe
- Department of Surgery, University of California, San Diego
| | - Christina Yau
- Department of Surgery, University of California, San Francisco, CA
| | - Emma Iaconetti
- Department of Surgery, University of California, San Francisco, CA
| | - Eliza Jeong
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Case Brabham
- Department of Surgery, University of California, San Francisco, CA
| | - Paul Kim
- Department of Surgery, University of California, San Francisco, CA
| | | | - Ann Griffin
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Anne Wallace
- Department of Surgery, University of California, San Diego
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA
| | - Olivier Harismendy
- Moores Cancer Center, Division of Biomedical Informatics, UCSD School of
Medicine University of California, San Diego, La Jolla, CA
| | - Gillian Hirst
- Department of Surgery, University of California, San Francisco, CA
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3
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Schmitz RSJM, van den Belt-Dusebout AW, Clements K, Ren Y, Cresta C, Timbres J, Liu YH, Byng D, Lynch T, Menegaz BA, Collyar D, Hyslop T, Thomas S, Love JK, Schaapveld M, Bhattacharjee P, Ryser MD, Sawyer E, Hwang ES, Thompson A, Wesseling J, Lips EH, Schmidt MK. Association of DCIS size and margin status with risk of developing breast cancer post-treatment: multinational, pooled cohort study. BMJ 2023; 383:e076022. [PMID: 37903527 PMCID: PMC10614034 DOI: 10.1136/bmj-2023-076022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE To examine the association between size and margin status of ductal carcinoma in situ (DCIS) and risk of developing ipsilateral invasive breast cancer and ipsilateral DCIS after treatment, and stage and subtype of ipsilateral invasive breast cancer. DESIGN Multinational, pooled cohort study. SETTING Four large international cohorts. PARTICIPANTS Patient level data on 47 695 women with a diagnosis of pure, primary DCIS between 1999 and 2017 in the Netherlands, UK, and US who underwent surgery, either breast conserving or mastectomy, often followed by radiotherapy or endocrine treatment, or both. MAIN OUTCOME MEASURES The main outcomes were 10 year cumulative incidence of ipsilateral invasive breast cancer and ipsilateral DCIS estimated in relation to DCIS size and margin status, and adjusted hazard ratios and 95% confidence intervals, estimated using multivariable Cox proportional hazards analyses with multiple imputed data RESULTS: The 10 year cumulative incidence of ipsilateral invasive breast cancer was 3.2%. In women who underwent breast conserving surgery with or without radiotherapy, only adjusted risks for ipsilateral DCIS were significantly increased for larger DCIS (20-49 mm) compared with DCIS <20 mm (hazard ratio 1.38, 95% confidence interval 1.11 to 1.72). Risks for both ipsilateral invasive breast cancer and ipsilateral DCIS were significantly higher with involved compared with clear margins (invasive breast cancer 1.40, 1.07 to 1.83; DCIS 1.39, 1.04 to 1.87). Use of adjuvant endocrine treatment was not significantly associated with a lower risk of ipsilateral invasive breast cancer compared to treatment with breast conserving surgery only (0.86, 0.62 to 1.21). In women who received breast conserving treatment with or without radiotherapy, higher DCIS grade was not significantly associated with ipsilateral invasive breast cancer, only with a higher risk of ipsilateral DCIS (grade 1: 1.42, 1.08 to 1.87; grade 3: 2.17, 1.66 to 2.83). Higher age at diagnosis was associated with lower risk (per year) of ipsilateral DCIS (0.98, 0.97 to 0.99) but not ipsilateral invasive breast cancer (1.00, 0.99 to 1.00). Women with large DCIS (≥50 mm) more often developed stage III and IV ipsilateral invasive breast cancer compared to women with DCIS <20 mm. No such association was found between involved margins and higher stage of ipsilateral invasive breast cancer. Associations between larger DCIS and hormone receptor negative and human epidermal growth factor receptor 2 positive ipsilateral invasive breast cancer and involved margins and hormone receptor negative ipsilateral invasive breast cancer were found. CONCLUSIONS The association of DCIS size and margin status with ipsilateral invasive breast cancer and ipsilateral DCIS was small. When these two factors were added to other known risk factors in multivariable models, clinicopathological risk factors alone were found to be limited in discriminating between low and high risk DCIS.
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Affiliation(s)
- Renée S J M Schmitz
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | | | | | - Yi Ren
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Chiara Cresta
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Jasmine Timbres
- School of Cancer and Pharmaceutical Science, King's College London, London, UK
| | - Yat-Hee Liu
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Danalyn Byng
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Thomas Lynch
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
| | - Brian A Menegaz
- Department of Surgical Oncology, Baylor College of Medicine, Houston, TX, USA
| | | | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Biostatistics Shared Resource Duke Cancer Institute, Durham, NC, USA
| | - Jason K Love
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Schaapveld
- Division of Psycho-oncology and Epidemiology, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Proteeti Bhattacharjee
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Marc D Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
- Department of Mathematics, Duke University, Durham, NC, USA
| | - Elinor Sawyer
- School of Cancer and Pharmaceutical Science, King's College London, London, UK
| | - E Shelley Hwang
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
| | - Alastair Thompson
- Department of Surgical Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jelle Wesseling
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
- Division of Diagnostic Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Department of Pathology, Leiden University Medical Centre, Leiden, Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, 1066 Amsterdam, Netherlands
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, Netherlands
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O'Keefe TJ, Chau H, Harismendy O, Wallace AM. Risk factors for breast cancer mortality after ductal carcinoma in situ diagnosis differ from those for invasive recurrence. Surgery 2023; 173:305-311. [PMID: 36435650 DOI: 10.1016/j.surg.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/12/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Breast cancer mortality after ductal carcinoma in situ is rare, making it difficult to predict which patients are at risk and to identify whether risk factors for this outcome are the same as those for invasive recurrence. We aimed to identify whether risk factors for invasive recurrences are similar to those for breast cancer death after a diagnosis of pure ductal carcinoma in situ. METHODS The Surveillance, Epidemiology, and End Results Program was queried for female patients diagnosed with pure ductal carcinoma in situ. Cumulative incidence was estimated by treatment group using competing risks. Competing risks regression was then performed for the development of in-breast invasive recurrence with competing risks of breast and non-breast cancer death. Competing risks regression was then again performed for development of breast cancer mortality with the competing risk of non-breast cancer death. RESULTS A total of 29,515 patients were identified. Of them, 164 patients suffered breast cancer mortality without an intervening invasive recurrence, and 44 suffered breast cancer mortality after an invasive in-breast recurrence. On competing risks analysis for invasive in-breast recurrence, significant factors included lesion size >5 cm (hazard ratio = 1.59, 95% confidence interval 1.24-2.04, P < .001), diffuse disease (hazard ratio = 0.0005, 95% confidence interval 0.0003-0.0007, P < .001), other race (hazard ratio = 1.29, 95% confidence interval 1.10-1.52, P = .002), Black race (hazard ratio = 1.21, 95% confidence interval 1.01-1.46, P = .04), age at diagnosis (hazard ratio = 0.99, confidence interval 0.98-1.00, P = .02), low-grade disease (hazard ratio = 0.79, 95% confidence interval 0.64-0.96, P = .02), lumpectomy with radiation (hazard ratio = 0.67, 95% confidence interval 0.58-0.77, P < .001), and mastectomy (hazard ratio = 0.36, 95% confidence interval 0.30-0.44, P < .001). Significant factors for breast cancer mortality included age at diagnosis (hazard ratio = 1.04, 95% confidence interval 1.03-1.05, P < .001), Black race (hazard ratio = 2.88, 95% confidence interval 2.08-3.99, P < .001), diffuse disease (hazard ratio = 6.02, 95% confidence interval 1.39-26.07, P = .02), lumpectomy with radiation (hazard ratio = 0.51, 95% confidence interval 0.36-0.72, P < .001), and mastectomy (hazard ratio = 0.60, 95% confidence interval 0.50-0.92, P = .02). CONCLUSION Our results suggested that risk factors for in-breast invasive recurrence after a diagnosis of pure ductal carcinoma in situ differ from risk factors for breast cancer mortality and development of metastatic recurrence. In-breast invasive recurrence is not the only consideration for breast cancer specific mortality in ductal carcinoma in situ patients.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA.
| | - Harrison Chau
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA
| | - Olivier Harismendy
- Moores Cancer Center and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Anne M Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla, CA
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5
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Gil Del Alcazar CR, Trinh A, Alečković M, Rojas Jimenez E, Harper NW, Oliphant MU, Xie S, Krop ED, Lulseged B, Murphy KC, Keenan TE, Van Allen EM, Tolaney SM, Freeman GJ, Dillon DA, Muthuswamy SK, Polyak K. Insights into Immune Escape During Tumor Evolution and Response to Immunotherapy Using a Rat Model of Breast Cancer. Cancer Immunol Res 2022; 10:680-697. [PMID: 35446942 PMCID: PMC9177779 DOI: 10.1158/2326-6066.cir-21-0804] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/25/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
Abstract
Animal models are critical for the preclinical validation of cancer immunotherapies. Unfortunately, mouse breast cancer models do not faithfully reproduce the molecular subtypes and immune environment of the human disease. In particular, there are no good murine models of estrogen receptor-positive (ER+) breast cancer, the predominant subtype in patients. Here, we show that Nitroso-N-methylurea-induced mammary tumors in outbred Sprague-Dawley rats recapitulate the heterogeneity for mutational profiles, ER expression, and immune evasive mechanisms observed in human breast cancer. We demonstrate the utility of this model for preclinical studies by dissecting mechanisms of response to immunotherapy using combination TGFBR inhibition and PD-L1 blockade. Short-term treatment of early-stage tumors induced durable responses. Gene expression profiling and spatial mapping classified tumors as inflammatory and noninflammatory, and identified IFNγ, T-cell receptor (TCR), and B-cell receptor (BCR) signaling, CD74/MHC II, and epithelium-interacting CD8+ T cells as markers of response, whereas the complement system, M2 macrophage phenotype, and translation in mitochondria were associated with resistance. We found that the expression of CD74 correlated with leukocyte fraction and TCR diversity in human breast cancer. We identified a subset of rat ER+ tumors marked by expression of antigen-processing genes that had an active immune environment and responded to treatment. A gene signature characteristic of these tumors predicted disease-free survival in patients with ER+ Luminal A breast cancer and overall survival in patients with metastatic breast cancer receiving anti-PD-L1 therapy. We demonstrate the usefulness of this preclinical model for immunotherapy and suggest examination to expand immunotherapy to a subset of patients with ER+ disease. See related Spotlight by Roussos Torres, p. 672.
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Affiliation(s)
- Carlos R. Gil Del Alcazar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anne Trinh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Maša Alečković
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ernesto Rojas Jimenez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nicholas W. Harper
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael U.J. Oliphant
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shanshan Xie
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ethan D. Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bethlehem Lulseged
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katherine C. Murphy
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tanya E. Keenan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Broad Institute, Cambridge, Massachusetts
| | - Eliezer M. Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Broad Institute, Cambridge, Massachusetts
| | - Sara M. Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Broad Institute, Cambridge, Massachusetts
| | - Gordon J. Freeman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Deborah A. Dillon
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Senthil K. Muthuswamy
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kornelia Polyak
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Broad Institute, Cambridge, Massachusetts
- Harvard Stem Cell Institute, Cambridge, Massachusetts
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6
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Rosenberg SM, Gierisch JM, Revette AC, Lowenstein CL, Frank ES, Collyar DE, Lynch T, Thompson AM, Partridge AH, Hwang ES. "Is it cancer or not?" A qualitative exploration of survivor concerns surrounding the diagnosis and treatment of ductal carcinoma in situ. Cancer 2022; 128:1676-1683. [PMID: 35191017 PMCID: PMC9274613 DOI: 10.1002/cncr.34126] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/15/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Of the nearly 50,000 women in the United States who undergo treatment for ductal carcinoma in situ (DCIS) annually, many may not benefit from treatment. To better understand the impact of a DCIS diagnosis, patients self-identified as having had DCIS were engaged regarding their experience. METHODS In July 2014, a web-based survey was administered through the Susan Love Army of Women breast cancer listserv. The survey included open-ended questions designed to assess patients' perspectives about DCIS diagnosis and treatment. Deductive and inductive codes were applied to the responses; common themes were summarized. RESULTS Among the 1832 women included in the analytic sample, the median age at diagnosis was 60 years. Four primary themes were identified: 1) uncertainty surrounding a DCIS diagnosis, 2) uncertainty about DCIS treatment, 3) concern about treatment side effects, and 4) concern about recurrence and/or developing invasive breast cancer. When diagnosed, participants were often uncertain about whether they had cancer or not and whether they should be considered a "survivor." Uncertainty about treatment manifested as questioning the appropriateness of the amount of treatment received. Participants expressed concern about the "cancer spreading" or becoming invasive and that they were not necessarily "doing enough" to prevent recurrence. CONCLUSIONS In a large, national sample, participants with a history of DCIS reported confusion and concern about the diagnosis and treatment, which caused worry and significant uncertainty. Developing strategies to improve patient and provider communications regarding the nature of DCIS and acknowledging gaps in the current knowledge of management options should be a priority.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer M Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Carol L Lowenstein
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth S Frank
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Thomas Lynch
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Alastair M Thompson
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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7
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O'Keefe TJ, Harismendy O, Wallace AM. Large and diffuse ductal carcinoma in situ: potentially lethal subtypes of "preinvasive" disease. Int J Clin Oncol 2022; 27:121-130. [PMID: 34618239 PMCID: PMC10874643 DOI: 10.1007/s10147-021-02036-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Trials for DCIS have not explored whether outcomes for patients with large disease burden requiring mastectomy are comparable to those of patients with lumpectomy-amenable disease. We aim to identify whether patients with DCIS larger than 5 cm and diffuse-type DCIS differ in breast cancer mortality (BCM) from patients with disease less than 5 cm. METHODS Patients diagnosed with DCIS in the SEER program were assessed to identify factors prognostic of breast-cancer-specific survival using competing risks regression. RESULTS 44,849 patients met criteria for the cumulative incidence estimate. On competing risks cumulative incidence approximation, the 10-year estimate for BCM for each group was 1.3%, 1.3%, 2.3%, and 5.1%, respectively, and the difference among groups was significant (p = 0.017). On competing risks regression of patients with known covariates, both diffuse-type disease and disease larger than 5 cm (hazard ratio [HR] = 6.2 and 1.7, p = 0.013 and p = 0.042, respectively) were associated with increased risk of BCM. After matching, DCIS > 5 cm and diffuse disease were associated with increased BCM relative to disease < 5 cm (HR = 1.69, p = 0.04). Among patients undergoing mastectomy for disease larger than 5 cm or diffuse disease, the 10-year cumulative incidence for BCM was 0.5% among patients undergoing bilateral mastectomy and 2.4% for patients undergoing unilateral mastectomy. CONCLUSION Patients with large and diffuse DCIS represent uncommon but poorly studied DCIS subgroups with worse prognoses than patients with disease smaller than 5 cm. Further studies are needed to elucidate the appropriate treatment for these patients.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA.
| | - Olivier Harismendy
- Division of Biomedical Informatics, Department of Medicine, Moores Cancer Center, University of California San Diego, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA
| | - Anne M Wallace
- Division of Breast Surgery and The Comprehensive Breast Health Center, University of California San Diego, 0819, 3855 Health Sciences Dr, La Jolla, CA, 92037, USA
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8
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Tumour-infiltrating lymphocytes in non-invasive breast cancer: A systematic review and meta-analysis. Breast 2021; 59:183-192. [PMID: 34273666 PMCID: PMC8319525 DOI: 10.1016/j.breast.2021.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background The role of tumour infiltrating lymphocytes (TILs) as a biomarker in non-invasive breast cancer is unclear. This meta-analysis assessed the prognostic impact of TIL levels in patients with non-invasive breast cancer. Methods Systematic literature search was performed to identify studies assessing local recurrence in patients with non-invasive breast cancer according to TIL levels (high vs. low). Subgroup analyses per local recurrence (invasive and non-invasive) were performed. Secondary objectives were the association between TIL levels and non-invasive breast cancer subtypes, age, grade and necrosis. Odds ratios (ORs) and 95% confidence intervals (CI) were extracted from each study and a pooled analysis was conducted with random-effect model. Results Seven studies (N = 3437) were included in the present meta-analysis. High-TILs were associated with a higher likelihood of local recurrence (invasive or non-invasive, N = 2941; OR 2.05; 95%CI, 1.03–4.08; p = 0.042), although with a lower likelihood of invasive local recurrence (N = 1722; OR 0.69; 95%CI, 0.49–0.99; p = 0.042). High-TIL levels were associated with triple-negative (OR 3.84; 95%CI, 2.23–6.61; p < 0.001) and HER2-positive (OR 6.27; 95%CI, 4.93–7.97; p < 0.001) subtypes, high grade (OR 5.15; 95%CI, 3.69–7.19; p < 0.001) and necrosis (OR 3.09; 95%CI, 2.33–4.10; p < 0.001). Conclusions High-TIL levels were associated with more aggressive tumours, a higher likelihood of local recurrence (invasive or non-invasive) but a lower likelihood of invasive local recurrence in patients with non-invasive breast cancer. The prognostic role of TILs in non-invasive breast cancer is unknown. We observed an association between high-TILs and local recurrence. High-TILs were associated with triple-negative and HER2+ subtypes, high grade and necrosis. Non-invasive lesions with aggressive characteristics may also be more immunogenic. Patients with low-TILs showed a higher likelihood of presenting an invasive recurrence.
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9
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Genomic Predictors for Radiation Sensitivity and Toxicity in Breast Cancer—from Promise to Reality. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00382-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Castle PE, Pierz AJ, Adcock R, Aslam S, Basu PS, Belinson JL, Cuzick J, El-Zein M, Ferreccio C, Firnhaber C, Franco EL, Gravitt PE, Isidean SD, Lin J, Mahmud SM, Monsonego J, Muwonge R, Ratnam S, Safaeian M, Schiffman M, Smith JS, Swarts A, Wright TC, Van De Wyngard V, Xi LF. A Pooled Analysis to Compare the Clinical Characteristics of Human Papillomavirus-positive and -Negative Cervical Precancers. Cancer Prev Res (Phila) 2020; 13:829-840. [PMID: 32655005 DOI: 10.1158/1940-6207.capr-20-0182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/16/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
Given that high-risk human papillomavirus (HPV) is the necessary cause of virtually all cervical cancer, the clinical meaning of HPV-negative cervical precancer is unknown. We, therefore, conducted a literature search in Ovid MEDLINE, PubMed Central, and Google Scholar to identify English-language studies in which (i) HPV-negative and -positive, histologically confirmed cervical intraepithelial neoplasia grade 2 or more severe diagnoses (CIN2+) were detected and (ii) summarized statistics or deidentified individual data were available to summarize proportions of biomarkers indicating risk of cancer. Nineteen studies including 3,089 (91.0%) HPV-positive and 307 (9.0%) HPV-negative CIN2+ were analyzed. HPV-positive CIN2+ (vs. HPV-negative CIN2+) was more likely to test positive for biomarkers linked to cancer risk: a study diagnosis of CIN3+ (vs. CIN2; 18 studies; 0.56 vs. 0.24; P < 0.001) preceding high-grade squamous intraepithelial lesion cytology (15 studies; 0.54 vs. 0.10; P < 0.001); and high-grade colposcopic impression (13 studies; 0.30 vs. 0.18; P = 0.03). HPV-negative CIN2+ was more likely to test positive for low-risk HPV genotypes than HPV-positive CIN2+ (P < 0.001). HPV-negative CIN2+ appears to have lower cancer risk than HPV-positive CIN2+. Clinical studies of human high-risk HPV testing for screening to prevent cervical cancer may refer samples of HPV test-negative women for disease ascertainment to correct verification bias in the estimates of clinical performance. However, verification bias adjustment of the clinical performance of HPV testing may overcorrect/underestimate its clinical performance to detect truly precancerous abnormalities.
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Affiliation(s)
- Philip E Castle
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, New York.
| | - Amanda J Pierz
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, New York
| | - Rachael Adcock
- Queen Mary University of London, Centre for Cancer Prevention, London, United Kingdom
| | | | - Partha S Basu
- International Agency for Research on Cancer, Screening Group, Lyon, France
| | - Jerome L Belinson
- Preventive Oncology International and the Cleveland Clinic, Cleveland, Ohio
| | - Jack Cuzick
- Queen Mary University of London, Centre for Cancer Prevention, London, United Kingdom
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - Catterina Ferreccio
- Advanced Center for Chronic Diseases, ACCDiS, Santiago, Chile
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Sandra D Isidean
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - John Lin
- HPV Research Group, University of Washington, Seattle, Washington
| | - Salaheddin M Mahmud
- Rady Faculty of Health Sciences, Department of Community Health, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Joseph Monsonego
- Institute of the Cervix, Federation Mutualiste Parisienne, Paris, France
| | - Richard Muwonge
- International Agency for Research on Cancer, Screening Group, Lyon, France
| | - Samuel Ratnam
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | | | - Mark Schiffman
- Division of Cancer Epidemiology & Genetics, NIH, NCI, Bethesda, Maryland
| | - Jennifer S Smith
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Avril Swarts
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas C Wright
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Vanessa Van De Wyngard
- Advanced Center for Chronic Diseases, ACCDiS, Santiago, Chile
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Long Fu Xi
- HPV Research Group, University of Washington, Seattle, Washington
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11
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Aron DC. Precision medicine in an imprecise and complex world: Magic bullets, hype, and the fuzzy line between health and disease. J Eval Clin Pract 2020; 26:1534-1538. [PMID: 31863633 DOI: 10.1111/jep.13306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/08/2019] [Indexed: 12/14/2022]
Affiliation(s)
- David Clark Aron
- Interprofessional Improvement Research Evaluation and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Research University, Cleveland, Ohio
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12
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O'Keefe TJ, Blair SL, Hosseini A, Harismendy O, Wallace AM. HER2-Overexpressing Ductal Carcinoma In Situ Associated with Increased Risk of Ipsilateral Invasive Recurrence, Receptor Discordance with Recurrence. Cancer Prev Res (Phila) 2020; 13:761-772. [PMID: 32493703 DOI: 10.1158/1940-6207.capr-20-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/04/2020] [Accepted: 05/29/2020] [Indexed: 01/01/2023]
Abstract
The impact of HER2 status in ductal carcinoma in situ (DCIS) on the risk of progression to invasive ductal carcinoma (IDC) has been debated. We aim to use a national database to identify patients with known HER2 status to elucidate the effect of HER2 overexpression on ipsilateral IDC (iIDC) development. We performed survival analysis on patient-level data using the U.S. NCI's Surveillance Epidemiology and End Results program. We identified patients diagnosed with DCIS who underwent lumpectomy and had known HER2 status. Competing risks analysis was performed. A total of 1,540 patients had known HER2 status and met inclusion criteria. Median age at diagnosis was 60, median follow-up time was 44.5 months. A total of 417 (27.1%) patients were HER2 positive and 1,035 (67.2%) were HER2 negative. Twenty-two (1.4%) patients developed iIDC and 27 (1.8%) developed ipsilateral in situ or contralateral disease. The estimated cumulative incidence of iIDC at 5 years was 1.9% for all patients, 1.2% for HER2-negative and borderline patients, and 3.9% for HER2-positive patients. On multivariate competing risks regression, two factors were significant for iIDC: radiation (protective) therapy within 24 months (HR, 0.05; P = 0.00006) and HER2 overexpression (increased likelihood; HR, 2.72; P = 0.044). Patients with HER2-positive DCIS were more likely to have recurrences with receptor discordance. HER2 may serve as a prognostic factor for invasive recurrence and was the only lesion-related factor to significantly relate to iIDC development. It may also be associated with receptor discordance of recurrences. Further large studies will be needed to confirm these results.
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Affiliation(s)
- Thomas J O'Keefe
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California.
| | - Sarah L Blair
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
| | - Ava Hosseini
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
| | - Olivier Harismendy
- Moores Cancer Center and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Anne M Wallace
- Division of Breast Surgery And The Comprehensive Breast Health Center, University of California San Diego, La Jolla, California
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13
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Hwang ES, Malek V. Estimating the magnitude of clinical benefit of local therapy in patients with DCIS. Breast 2020; 48 Suppl 1:S34-S38. [PMID: 31839157 DOI: 10.1016/s0960-9776(19)31120-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
DCIS represents a heterogeneous disease with a wide range of outcomes according to biology. Without treatment, it is estimated that only 20-30% of DCIS will progress to invasive cancer. Long-term outcomes following treatment are at least as favorable as those for some other early stage cancer types such as prostate cancer, for which active surveillance is routinely offered as a standard of care option. However, active surveillance has not yet been tested in relation to DCIS. Worldwide, there are three international trials (LORIS, COMET, LORD) which are evaluating whether DCIS with favorable biologic features may be managed with close monitoring, with treatment only undertaken upon disease progression. These trials will determine whether there may be some women with low-risk DCIS who do not substantially benefit from treatment and who could thus be safely managed with close surveillance. If active monitoring for DCIS is deemed to be safe and feasible, additional work must be done to optimally implement this approach, involving effective communication between patients and their physicians about the risks and benefits of treatment versus surveillance. Importantly, these treatment decisions must take into account patient factors such as risk tolerance, age, and competing causes of mortality. Tailoring treatment to biology for early screen-detected cancers such as DCIS is an important goal of ongoing research. An improved understanding of the biology and clinical implications of this heterogeneous disease will improve the overall health and quality of life for hundreds of thousands of future women who will be diagnosed with DCIS.
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14
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Tay THC, Ng WY, Ong KW, Wong CY, Tan BKT, Yong WS, Madhukumar P, Tan VKM, Lim SZ, Sim Y. Impact of hormonal status on ductal carcinoma in situ of the breast: Outcome and prognostic factors. Breast J 2019; 26:937-945. [DOI: 10.1111/tbj.13738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | - Wai Yee Ng
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Kong Wee Ong
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Chow Yin Wong
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Benita Kiat Tee Tan
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Wei Sean Yong
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Preetha Madhukumar
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Veronique Kiak Mien Tan
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Sue Zann Lim
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Yirong Sim
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
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15
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Chen G, Ding XF, Pressley K, Bouamar H, Wang B, Zheng G, Broome LE, Nazarullah A, Brenner AJ, Kaklamani V, Jatoi I, Sun LZ. Everolimus Inhibits the Progression of Ductal Carcinoma In Situ to Invasive Breast Cancer Via Downregulation of MMP9 Expression. Clin Cancer Res 2019; 26:1486-1496. [PMID: 31871301 DOI: 10.1158/1078-0432.ccr-19-2478] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/06/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated the role of everolimus in the prevention of ductal carcinoma in situ (DCIS) to invasive ductal carcinoma (IDC) progression. EXPERIMENTAL DESIGN The effects of everolimus on breast cancer cell invasion, DCIS formation, and DCIS progression to IDC were investigated in a 3D cell culturing model, intraductal DCIS xenograft model, and spontaneous MMTV-Her2/neu mouse model. The effect of everolimus on matrix metalloproteinase 9 (MMP9) expression was determined with Western blotting and IHC in these models and in patients with DCIS before and after a window trial with rapamycin. Whether MMP9 mediates the inhibition of DCIS progression to IDC by everolimus was investigated with knockdown or overexpression of MMP9 in breast cancer cells. RESULTS Everolimus significantly inhibited the invasion of human breast cancer cells in vitro. Daily intragastric treatment with everolimus for 7 days significantly reduced the number of invasive lesions from intraductal DCIS foci and inhibited DCIS progression to IDC in the MMTV-Her2/neu mouse mammary tumor model. Mechanistically, everolimus treatment decreased the expression of MMP9 in the in vitro and in vivo models, and in breast tissues from patients with DCIS treated with rapamycin for 1 week. Moreover, overexpression of MMP9 stimulated the invasion, whereas knockdown of MMP9 inhibited the invasion of breast cancer cell-formed spheroids in vitro and DCIS in vivo. Knockdown of MMP9 also nullified the invasion inhibition by everolimus in vitro and in vivo. CONCLUSIONS Targeting mTORC1 can inhibit DCIS progression to IDC via MMP9 and may be a potential strategy for DCIS or early-stage IDC therapy.
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Affiliation(s)
- Guang Chen
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas. .,Department of Pharmacology, School of Medicine, Taizhou University, Taizhou, Zhejiang, China
| | - Xiao-Fei Ding
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Laboratory for Biological Medicine, School of Medicine, Taizhou University, Taizhou, Zhejiang, China
| | - Kyle Pressley
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Hakim Bouamar
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Bingzhi Wang
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Guixi Zheng
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Larry E Broome
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Alia Nazarullah
- Department of Pathology, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Andrew J Brenner
- Department of Medicine, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Virginia Kaklamani
- Department of Medicine, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ismail Jatoi
- Department of Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Lu-Zhe Sun
- Department of Cell Systems and Anatomy, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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