An enhanced and efficient approach for feature selection for chronic human disease prediction: A breast cancer study

Computer-aided diagnosis (CAD) systems play a vital role in modern research by effectively minimizing both time and costs. These systems support healthcare professionals like radiologists in their decision-making process by efficiently detecting abnormalities as well as offering accurate and dependable information. These systems heavily depend on the efficient selection of features to accurately categorize high-dimensional biological data. These features can subsequently assist in the diagnosis of related medical conditions. The task of identifying patterns in biomedical data can be quite challenging due to the presence of numerous irrelevant or redundant features. Therefore, it is crucial to propose and then utilize a feature selection (FS) process in order to eliminate these features. The primary goal of FS approaches is to improve the accuracy of classification by eliminating features that are irrelevant or less informative. The FS phase plays a critical role in attaining optimal results in machine learning (ML)-driven CAD systems. The effectiveness of ML models can be significantly enhanced by incorporating efficient features during the training phase. This empirical study presents a methodology for the classification of biomedical data using the FS technique. The proposed approach incorporates three soft computing-based optimization algorithms, namely Teaching Learning-Based Optimization (TLBO), Elephant Herding Optimization (EHO), and a proposed hybrid algorithm of these two. These algorithms were previously employed; however, their effectiveness in addressing FS issues in predicting human diseases has not been investigated. The following evaluation focuses on the categorization of benign and malignant tumours using the publicly available Wisconsin Diagnostic Breast Cancer (WDBC) benchmark dataset. The five-fold cross-validation technique is employed to mitigate the risk of over-fitting. The evaluation of the proposed approach's proficiency is determined based on several metrics, including sensitivity, specificity, precision, accuracy, area under the receiver-operating characteristic curve (AUC), and F1-score. The best value of accuracy computed through the suggested approach is 97.96%. The proposed clinical decision support system demonstrates a highly favourable classification performance outcome, making it a valuable tool for medical practitioners to utilize as a secondary opinion and reducing the overburden of expert medical practitioners.

Clinicopathological Profile of Breast Cancer at a Tertiary Cancer Center in Jharkhand, India: A Descriptive Cohort Study

Introduction Breast cancer is the most common cancer in females worldwide including Indian urban areas. There is no concrete data on breast cancer epidemiology from the state of Jharkhand, India. Materials and methods The present study is a retrospectively conducted descriptive cohort study. A total of 759 patients were selected from the database from 2012 to 2022. The parameters taken for the study were age, sex, stage at the time of presentation, histological type, estrogen receptor (ER) status, progesterone receptor (PR) status, human epidermal growth receptor 2 (HER2) neu status (HER2/neu), site of metastasis for stage 4 diseases, parity, and significant family history. Results The median age for patients was 49 years (range: 19-91 years), with a clustering of 74.83% of cases between 31 and 60 years of age. Most of the patients were in stage III, with 365 (48.08%) cases. Bone was the commonest site of metastasis and was found in 41.25% of total cases. The total number of hormone receptor-positive patients was 384 (56.2%), the number of HER2/neu positive patients was 210 (30.7%), and triple-negative breast cancer was found in 184 cases (26.93%). Conclusion The pattern found in our Jharkhand patients was very much similar to other Indian studies with slightly more clustering of younger cases. The cases in India are almost a decade younger than the Western population and the same was replicated in our study. This is one of the largest studies on breast cancer profile and epidemiology from the eastern part of India. Most of our patients presented late, leading to a higher number of locally advanced (stage III) and metastatic (stage IV) cases. More awareness is required at the population level, including strict implementation of a robust screening program by our government, for improving the overall outcome.

A Clinicopathological Analysis of Molecular Subtypes of Breast Cancer using Immunohistochemical Surrogates: A 6-Year Institutional Experience from a Tertiary Cancer Center in North India

Puneet Kaur SomalObjective  Classification of breast cancer into different molecular subtypes has important prognostic and therapeutic implications. The immunohistochemistry surrogate classification has been advocated for this purpose. The primary objective of the present study was to assess the prevalence of the different molecular subtypes of invasive breast carcinoma and study the clinicopathological parameters in a tertiary care cancer center in rural North India. Materials and Methods  All female patients diagnosed with invasive breast cancer and registered between January 1, 2015, and December 31, 2020, were included. Patients with bilateral cancer, missing information on HER2/ER/PR receptor status, absence of reflex FISH testing after an equivocal score on Her 2 IHC were excluded. The tumors were classified into different molecular subtypes based on IHC expression as follows-luminal A-like (ER- and PR-positive, Her2-negative, Ki67 < 20%), luminal B-like Her2-negative (ER-positive, Her2-negative and any one of the following Ki67% ≥ 20% or PR-negative/low, luminal B-like Her2-positive (ER- and HER2-positive, any Ki67, any PR), Her2-positive (ER- and PR-negative, Her2-positive) and TNBC (ER, PR, Her2-negative). Chi square test was used to compare the clinicopathological parameters between these subtypes. Results  A total of 1,625 cases were included. Luminal B-like subtype was the most common (41.72%). The proportion of each subtype was luminal A (15.69%), luminal B Her2-negative (23.93%), luminal B Her2-positive (17.78%), Her2-positive (15.26%), TNBC (27.32%). Majority of the tumors were Grade 3 (75.81%). Nodal metastases were present in 59%. On subanalysis of the luminal type tumors without Her2 expression (luminal A-like and luminal B-like (Her2-negative), luminal A-like tumors presented significantly with a lower grade ( p  < 0.001) and more frequent node-negative disease in comparison to luminal B-like (Her2-negative) tumors. In comparison to other subtypes, TNBC tumors were more frequently seen in the premenopausal age group ( p  < 0.001) and presented with node-negative disease ( p  < 0.001). Conclusion  This is one of the largest studies that enumerates the prevalence of various molecular subtypes of breast cancer in North India. Luminal B-like tumors were the most common followed by TNBC. TNBC tumors presented more commonly in premenopausal age group and with node negative disease in comparison to other subtypes.

Upregulation of the ferroptosis-related STEAP3 gene is a specific predictor of poor triple-negative breast cancer patient outcomes

Objective

This study was designed to assess ferroptosis regulator gene (FRG) expression patterns in patients with TNBC based on data derived from The Cancer Genome Atlas (TCGA). Further, it was utilized to establish a TNBC FRG signature, after which the association between this signature and the tumor immune microenvironment (TIME) composition was assessed, and relevant prognostic factors were explored.

Methods

The TCGA database was used to obtain RNA expression datasets and clinical information about 190 TNBC patients, after which a prognostic TNBC-related FRG signature was established using a least absolute shrinkage and selection operator (LASSO) Cox regression approach. These results were validated with separate data from the Gene Expression Omnibus (GEO). The TNBC-specific prognostic gene was identified via this method. The STEAP3 was then validated through Western immunoblotting, immunohistochemical staining, and quantitative real‐time polymerase chain reaction (RT-qPCR) analyses of clinical tissue samples and TNBC cell lines. Chemotherapy interactions and predicted drug sensitivity studies were investigated to learn more about the potential clinical relevance of these observations.

Results

These data revealed that 87 FRGs were differentially expressed when comparing TNBC tumors and healthy tissue samples (87/259, 33.59%). Seven of these genes (CA9, CISD1, STEAP3, HMOX1, DUSP1, TAZ, HBA1) are significantly related to the overall survival of TNBC patients. Kaplan-Meier analyses and established FRG signatures and nomograms identified CISD1 and STEAP3 genes of prognostic relevance. Prognostic Risk Score values were positively correlated with the infiltration of CD4+ T cells (p = 0.001) and myeloid dendritic cells (p =0.004). Further evidence showed that STEAP3 was strongly and specifically associated with TNBC patient OS (P&lt;0.05). The results above were confirmed by additional examinations of STEAP3 expression changes in TNBC patient samples and cell lines. High STEAP3 levels were negatively correlated with half-maximal inhibitory concentration (IC50) values for GSK1904529A (IGF1R inhibitor), AS601245 (JNK inhibitor), XMD8−85 (Erk5 inhibitor), Gefitinib, Sorafenib, and 5-Fluorouracil (P &lt; 0.05) in patients with TNBC based on information derived from the TCGA-TNBC dataset.

Conclusion

In the present study, a novel FRG model was developed and used to forecast the prognosis of TNBC patients accurately. Furthermore, it was discovered that STEAP3 was highly overexpressed in people with TNBC and associated with overall survival rates, laying the groundwork for the eventually targeted therapy of individuals with this form of cancer.

Breast Cancer Subtypes Classification with Hybrid Machine Learning Model

BACKGROUND

 Breast cancer is the most prevailing heterogeneous disease among females characterized with distinct molecular subtypes and varied clinicopathological features. With the emergence of various artificial intelligence techniques especially machine learning, the breast cancer research has attained new heights in cancer detection and prognosis.

OBJECTIVE

 Recent development in computer driven diagnostic system has enabled the clinicians to improve the accuracy in detecting various types of breast tumors. Our study is to develop a computer driven diagnostic system which will enable the clinicians to improve the accuracy in detecting various types of breast tumors.

METHODS

 In this article, we proposed a breast cancer classification model based on the hybridization of machine learning approaches for classifying triple-negative breast cancer and non-triple negative breast cancer patients with clinicopathological features collected from multiple tertiary care hospitals/centers.

RESULTS

 The results of genetic algorithm and support vector machine (GA-SVM) hybrid model was compared with classics feature selection SVM hybrid models like support vector machine-recursive feature elimination (SVM-RFE), LASSO-SVM, Grid-SVM, and linear SVM. The classification results obtained from GA-SVM hybrid model outperformed the other compared models when applied on two distinct hospital-based datasets of patients investigated with breast cancer in North West of African subcontinent. To validate the predictive model accuracy, 10-fold cross-validation method was applied on all models with the same multicentered datasets. The model performance was evaluated with well-known metrics like mean squared error, logarithmic loss, F1-score, area under the ROC curve, and the precision-recall curve.

CONCLUSION

 The hybrid machine learning model can be employed for breast cancer subtypes classification that could help the medical practitioners in better treatment planning and disease outcome.

Correlation of prognostic factors of carcinoma breast with Ki 67 proliferation assay

Prognostic factors are important for the diagnosis of breast cancer as it helps in identification of high risk patients.  The objective of the study is to assess the proliferation index, Ki-67 and correlate it with other markers. The present study was a cohort study conducted in the Department of General Surgery at Tertiary Care Teaching Hospital over a period of 1 year with a sample size of 98. All the patients meeting the inclusion and exclusion criteria are recruited sequentially by convenient sampling until the sample size is attained, with the agreement of the institutional ethics committee. A total of 98 patients with a mean age of 53.61 ± 12.48 years were studied in the final analysis. The mean duration of lump was 4.62 ± 2.18 months and only 6.12% had the complaint of pain.  Majority of them had stage IIIB carcinoma at 43.88%, followed by stage IIA at 27.55%, 15.31% stage IIB, 13.27% stage IIIA.  At cut off 20, 69(70.40%) had ki67 proliferation index ≥20 and 29(29.59%) had<20. Correlation of Ki-67 Index with expression of estrogen receptor status had a p value of 0.019 and with progesterone receptor status, p 0.003 which was significant. 

Triple Negative Breast Cancer: A Mountain Yet to Be Scaled Despite the Triumphs

Metastatic progression and tumor recurrence pertaining to TNBC are certainly the leading cause of breast cancer-related mortality; however, the mechanisms underlying TNBC chemoresistance, metastasis, and tumor relapse remain somewhat ambiguous. TNBCs show 77% of the overall 4-year survival rate compared to other breast cancer subtypes (82.7 to 92.5%). TNBC is the most aggressive subtype of breast cancer, with chemotherapy being the major approved treatment strategy. Activation of ABC transporters and DNA damage response genes alongside an enrichment of cancer stem cells and metabolic reprogramming upon chemotherapy contribute to the selection of chemoresistant cells, majorly responsible for the failure of anti-chemotherapeutic regime. These selected chemoresistant cells further lead to distant metastasis and tumor relapse. The present review discusses the approved standard of care and targetable molecular mechanisms in chemoresistance and provides a comprehensive update regarding the recent advances in TNBC management.

Prognostic role of microRNA 182 and microRNA 18a in locally advanced triple negative breast cancer

Background

The study assessed the epigenetic regulation and the role of microRNA (miR) expression in locally advanced triple negative breast cancers (TNBC) and comparison with the clinico-pathological variables and survival.

Methods

Fifty patients of locally advanced TNBC during the period 2011–2013 were included. Expression level of test microRNA (miR-182 and miR-18a) was determined using Taqman quantitative Real time polymerase chain reaction (qRT-PCR) from formalin fixed paraffin embedded biopsy blocks. Clinical and demographic information and survival data was retrieved from the Hospital medical records.

Results

An improved clinical complete response (cCR) was observed in patients with age ≥ 45 years (80%), premenopausal status (70%), tumor size < 6 cms (80%), nodal status N0-N1 (95%) and grade II-III tumor (80%). A statistically significant correlation was observed on comparison of cCR with menopausal status (p-value 0.020), T category (p-value 0.018) and the clinical nodal status (p-value 0.003). pCR also correlated with clinical nodal status (p-value 0.008). Epigenetically, miR-18a under expression (< 8.84) was most commonly associated with tumor size < 6 cms (76.7%), clinical nodal status N0-N1 (90%), cCR (60%) and pCR (53.3%). A similar trend was observed with miR-182. Statistical significance was observed with T category (p-values 0.003 and 0.004), clinical nodal status (p-values 0.001 and 0.001), clinical response (p-values 0.002 and 0.002) and pathological response (p-values 0.007 and 0.006) with respect to miR-18a and miR-182, respectively. Also, the menopausal status significantly correlated with the miR-182 expression (p-value 0.009). miR-182 overexpression (≥ 6.32) was not observed in any of the postmenopausal patients. A univariate cox proportional hazard regression model also showed statistical interactions (p-values <0.004).

Conclusion

miR-182 and miR-18a overexpression correlates with worse clinical and pathological tumor characteristics in locally advanced TNBC and hence could be used to predict the outcomes and prognosis in these patients.

Prevalence of Molecular Subtypes of Breast Cancer in India: a Systematic Review and Meta-analysis

In the last two decades, India has witnessed a substantial increase in the incidence of breast cancer and associated mortality. Studies on the prevalence of molecular subtypes of breast cancer in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the prevalence of molecular subtypes of breast cancer. A complete literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms ((molecular classification) OR (molecular subtypes)) AND (breast cancer)) OR (breast carcinoma)) AND (prevalence)) AND (India). Two reviewers independently reviewed the retrieved studies. The screened studies satisfying the eligibility were included. The quality of included studies was assessed using the selected STROBE criteria. The overall pooled prevalence of luminal A, luminal B, HER2-enriched, and triple-negative breast cancer (TNBC) subtypes of breast cancer were 0.33 (95% CI 0.23-0.44), 0.17 (95% CI 0.12-0.23), 0.15 (95% CI 0.12-0.19), and 0.30 (95% CI 0.27-0.33), respectively. Subgroup analyses were performed by mean age of patients, time period, region, and sample size of the study. Among molecular subtypes of breast cancer, luminal A was the most prevalent subtype followed by TNBC, luminal B, and HER2-enriched subtypes. The overall prevalence of TNBC in India is high compared to other regions of the world. Additional research is warranted to identify the determinants of high TNBC in India. Differentiating TNBC from other molecular subtypes is important to guide therapeutic management of breast cancer.

Breast cancer in Andaman and Nicobar Islands: A retrospective analysis

Background

Breast cancer is the most common cancer in India among women. This study was conducted to describe the demographic, clinical, histopathological, endocrinological and survival pattern of breast cancer patients in Andaman and Nicobar Islands.

Methods

The study was done in Medical Oncology department of GB pant hospital. Data was retrieved from the case sheets of patients who consulted from 1st February 2015 to 31st January 2018. As this hospital is the only referral hospital, the patients are representative of all cancer patients in the Island, and the population base is well defined.

Results

During the study period, 85 breast cancer patients were treated. Of the 82 female patients, the standardized incidence rates in 2015, 2016 and 2017 were 8.82, 13 and 14.42 per 100,000 women respectively. The prevalence and mortality rates in 2015, 2016, 2017 were 14.88, 27.96, 40.37, and 1.1, 2.74, 0.55 per 100,000 women respectively. Metastasis was detected at the time of diagnosis in 18.8% of patients. Estrogen receptor (ER) and progesterone receptor (PR) positivity was reported in 55.9% of patients, HER 2 positivity in 28.1% and triple negativity in 27.3%. The overall survival at 12, 24, and 36 months follow-up were 88.9%, 84.3% and 52.7% respectively. In univariable analysis, the hazard ratios were significantly higher for patients with metastasis and diagnosis before 2015.

Conclusion

As compared to the country, breast cancer incidence was lower in the Islands with better survival. Stage at diagnosis was the most important factor determining survival in these patients.

Meta-Analysis of Prevalence of Triple-Negative Breast Cancer and Its Clinical Features at Incidence in Indian Patients With Breast Cancer

PURPOSE

Breast cancer is the most common cancer in women in India, with higher incidence rates of aggressive subtypes, such as triple-negative breast cancer (TNBC).

METHODS

A systematic review was performed to compute pooled prevalence rates of TNBC among patients with breast cancer, and clinical features at presentation were systematically compared with non-TNBC in an Indian cohort of 20,000 patients.

RESULTS

Combined prevalence of TNBC among patients with breast cancer was found to be on the higher side (27%; 95% CI, 24% to 31%). We found that the estrogen receptor (ER) expression cutoff used to determine ER positivity had an influence on the pooled prevalence and ranged from 30% (ER/progesterone receptor [PR] cut ff at 1%) to 24% (ER/PR cutoff at 10%). Odds for TNBC to present in the younger age-group were significantly higher (pooled odds ratio [OR], 1.35; 95% CI, 1.08 to 1.69), with a significantly younger mean age of incidence (weighted mean difference, -2.75; 95% CI, -3.59 to -1.92). TNBC showed a significantly higher odds of presenting with high grade (pooled OR, 2.57; 95% CI, 2.12 to 3.12) and lymph node positivity (pooled OR, 1.39; 95% CI, 1.21 to 1.60) than non-TNBC.

CONCLUSION

Systematic review and meta-analysis of 34 studies revealed a high degree of heterogeneity in prevalence of TNBC within Indian patients with breast cancer, yet pooled prevalence of TNBC is high in India. High proportions of patients with TNBC present with aggressive features, such as high grade and lymph node positivity, compared with patients without TNBC. We emphasize the need for standardized methods for accurate diagnosis in countries like India.

Droplet digital polymerase chain reaction offers an improvisation over conventional immunohistochemistry and fluorescent in situ hybridization for ascertaining Her2 status of breast cancer

Background

Droplet digital polymerase chain reaction (DDPCR) is a recent modality for detecting Her2 expression which is quantitative, cheaper, easier to standardize, and free from interobserver variation.

Purpose

The purpose of this study is to incorporate DDPCR in the current diagnostic paradigm with clinical benefit.

Materials and Methods

Fifty-four consecutive patients were tested by immunohistochemistry (IHC), fluorescent in situ hybridization (FISH), and DDPCR. With FISH result as gold standard, receiver operating characteristic curves for DDPCR ratio were analyzed to label Her2-negative, equivocal, and positive cases as DDPCR score 1, 2, and 3, respectively. Proportion of patients labeled unequivocally as Her2 positive or negative was defined to have "clinically benefitted" from the test. Drawing parallel to inter-relationships between DDPCR, IHC, and FISH in the test cohort, four diagnostic pathways were defined - (1) initial IHC followed by FISH, (2) initial DDPCR followed by FISH, (3) initial IHC followed by DDPCR followed by FISH, and (4) initial DDPCR followed by IHC followed by FISH.

Results

Clinical benefit of DDPCR as an initial test in the test cohort was 57%, while it was 65% if used as a second-line test among those with an initial inconclusive IHC result. Sensitivity analysis in the simulation cohort revealed that if DDPCR cost was ≤0.6 times the cost of IHC, then a three-step pathway with DDPCR upfront would near certainly prove most cost beneficial. If DDPCR cost was >0.6 but ≤2 times the cost of IHC, then a three-step pathway with DDPCR as second-line test had a higher probability to prove most cost beneficial. If DDPCR cost was >2 times the cost of IHC, then conventional pathway had a higher probability to prove most cost-effective.

Conclusion

Incorporating DDPCR in the current clinical diagnostic paradigm has the potential to improve its cost-effectiveness and benefit.

Luminal B is the Most Common Intrinsic Molecular Subtypes of Invasive Ductal Breast Carcinoma Patients in East Kalimantan, Indonesia

Objective: Breast carcinoma has no longer been considered as a single and standalone disease. Its subtypes have been known to vary in terms of risk factors, natural histories, and responses to therapies. In particular, intrinsic molecular subtypes based on St. Gallen International Expert Consensus 2013 have classified breast carcinoma into luminal A, luminal B, HER2+, and triple-negative, depending on the expression of ER, PgR, HER2, and Ki-67. Research on intrinsic molecular subtypes of breast carcinoma in Indonesia, however, are rarely conducted, which then triggers the intention to conduct this study. Methods: In this work, a retrospective study was conducted on 92 formalin-fixed paraffin-embedded samples of invasive ductal breast carcinoma patients. These samples were from patients at Abdul Wahab Sjahranie County General Hospital Samarinda, East Kalimantan, Indonesia, in 2016. Next, immunohistochemical staining using anti-ER, PgR, HER2, and Ki-67 antibodies was applied to classify intrinsic molecular subtypes. Then, an association between clinical and immunohistochemical factors with intrinsic molecular subtypes of breast carcinoma were analyzed using Chi-square test. Results: Looking at results of the retrospective study, luminal B was discovered as the most common intrinsic molecular subtypes of breast carcinoma (42.39%) in East Kalimantan, Indonesia. The next ranks of breast carcinoma subtypes in the region included HER2+ (39.13%), triple-negative (10.87%), and luminal A (7.61%). In fact, there was a significant association between age (p = 0.019) with intrinsic molecular subtypes of breast carcinoma. Conclusion: The study found luminal B as the most common intrinsic molecular subtypes of Indonesian breast carcinoma in the region under investigation. In the future, the higher positivity rate of luminal B in breast carcinoma patients compared to prior studies would require further investigations.

Clinicopathological profile of breast cancer: An institutional experience

INTRODUCTION

This study was undertaken to evaluate the clinicopathological characteristics of patients with breast cancer at our institute, a tertiary-care cancer center in northern India.

MATERIALS AND METHODS

This retrospective study included all patients with breast cancer registered at our institute from January 1st, 2014 to December 31st, 2016. We retrieved data (demographic, baseline clinical characteristics, pathology, and treatment details) from prospectively maintained clinical case records. Patients with incomplete case records or missing baseline information were excluded.

RESULTS

We included 550 patients with breast cancer. The median age was 48 years (23-85). The median clinical tumor size was 5.0 cm. The TNM (AJCC-7th edition) stage distribution was stage I, 22 (4%); stage II, 182 (33%); stage III, 247 (44.9%); and stage IV, 99 (18%). Locally advanced breast cancer constituted 40% of the cases. Bone (48 [48.5%]) was the most common site for metastasis followed by lung. Infiltrating ductal carcinoma (528 [96%]) was the most common histologic subtype. Majority of patients, 325 (59%), were positive for estrogen receptor/progesterone receptor whereas 160 (29%) patients were HER2/neu positive. Triple negative breast cancer (TNBC) constituted 28% (154) of patients. In the nonmetastatic subgroup, 343 (76%) patients underwent modified radical mastectomy. Neoadjuvant chemotherapy (NACT) was given in 120 (26.6%) patients, of these 23 (19%) achieved pathological complete remission. Sequential anthracyline and taxane were used as NACT/adjuvant chemotherapy in most cases. Of the eligible patients, 48 (30%) received anti-HER2/neu therapy.

CONCLUSION

This is one of the largest comprehensive data from a single center in India. Majority of our patients are younger in age and have advanced disease. TNBC and HER2/neu positive breast cancer are more common in our population.

Current Treatment Options for Human Epidermal Growth Factor Receptor 2-Directed Therapy in Metastatic Breast Cancer: An Indian Perspective

Human epidermal growth factor receptor 2 (HER2)-positive is an aggressive subtype of breast cancer and has historically been associated with poor outcomes. The availability of various anti-HER2 therapies, including trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine (TDM-1), has remarkably improved the clinical outcomes in patients with HER2-positive metastatic breast cancer (mBC). However, there is a need to optimize treatment within this population, given the wide variability in clinical presentation. Additionally, geographical and socio-economic considerations too need to be taken into account. To clarify and collate evidence pertaining to HER2-positive metastatic breast cancer, a panel of medical and clinical oncologists from across India developed representative clinical scenarios commonly encountered in clinical practice in the country. This was followed by two meetings wherein each clinical scenario was discussed in detail and relevant evidence appraised. The result of this process is presented in this manuscript as evidence followed by therapeutic recommendations of this panel for management of HER2-positive mBC in the Indian population.

Improving accuracy of breast cancer biomarker testing in India

There is a global mandate even in countries with low resources to improve the accuracy of testing biomarkers in breast cancer viz. oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2neu) given their critical impact in the management of patients. The steps taken include compulsory participation in an external quality assurance (EQA) programme, centralized testing, and regular performance audits for laboratories. This review addresses the status of ER/PR and HER2neu testing in India and possible reasons for the delay in development of guidelines and mandate for testing in the country. The chief cause of erroneous ER and PR testing in India continues to be easily correctable issues such as fixation and antigen retrieval, while for HER2neu testing, it is the use of low-cost non-validated antibodies and interpretative errors. These deficiencies can however, be rectified by (i) distributing the accountability and responsibility to surgeons and oncologist, (ii) certification of centres for testing in oncology, and (iii) initiation of a national EQA system (EQAS) programme that will help with economical solutions and identifying the centres of excellence and instill a system for reprimand of poorly performing laboratories.

Clinical utility of RT-PCR in assessing HER 2 gene expression versus traditional IHC and FISH in breast cancer patients

BACKGROUND

IHC and FISH are used for categorizing HER 2 status in breast cancer at the protein and DNA level, respectively. HER 2 expression at the RNA level is quantitative, cheaper, easier to standardize and free from interobserver variation.

METHODS

115 consecutive patients were tested by IHC, FISH and RT-PCR (test cohort). Assuming FISH result to be the response variable, ROC curves for RT-PCR ratio were analyzed to label HER 2 negative, equivocal and positive cases as RT-PCR score 1, 2 and 3, respectively. Inter-relationships between RT-PCR, IHC and FISH were defined. 'Clinical benefit' of a test was defined as proportion of patients labeled unequivocally as HER 2 positive or negative. Population for 1 year was simulated constraint to previous reports of HER 2 positivity and IHC category distribution by a meta-analysis of previous studies that evaluated concordance between IHC and FISH to determine HER 2 status (simulation cohort). Four diagnostic pathways in the simulation cohort were defined-(1) initial IHC, followed by FISH (conventional pathway); (2) initial RT-PCR, followed by FISH; (3) initial IHC, followed by RT-PCR and then by FISH; (4) initial RT-PCR, followed by IHC and then by FISH. The clinical benefit of IHC and RT-PCR in the four pathways was analyzed and sensitivity analysis for incremental cost-effectiveness ratio and cost-benefit comapring RT-PCR against IHC, both as first-line tests and among those with IHC score 2 as a reflex second-line test was performed by the Monte Carlo technique.

FINDINGS

115 patients comprised the study population. While none with IHC score of 0 or 1 was FISH positive for HER 2, all cases with IHC score of 3 were FISH positive. 43 cases were assigned IHC score of 2. Thus, 72 patients benefited from the initial IHC testing [clinical benefit 62.6%], with the overall concordance between IHC and FISH being 100% for those with IHC score of 0, 1 and 3 (conclusive IHC categories). For RT-PCR with 100% concordance, 15.7% (115-97 = 18) patients would have benefited from RT-PCR testing if it was used as a first-line test. If RT-PCR would have been used as a second-line test among those with IHC score 2 (n = 43), then only 6 patients would have been assigned a conclusive RT-PCR category (category 1 or 3) translating to a clinical benefit of 14% (6/43) as a second-line test. As a second-line test it had 51% probability to prove more cost-effective than the conventional pathway, provided the cost of RT-PCR was 0.4 times the cost of IHC. Also in a three-step pathway, RT-PCR upfront would have 56% probability of higher cost-benefit provided the cost of RT-PCR was 0.1 times the cost of IHC.

CONCLUSION

RT-PCR results were found to be suboptimal to IHC in terms of discriminative ability and clinical benefit; thus, it is unlikely to replace IHC as a first-line test in the near future.

Alarming Burden of Triple-Negative Breast Cancer in India

Breast cancer is the most prevalent cancer among women worldwide. Among the different breast cancer subtypes, triple-negative breast cancer (TNBC), which is more prevalent among younger age women, is the most aggressive form. Numerous clinicopathologic studies performed throughout the world strongly support the utterly poor prognoses and high recurrence rate of TNBC. The present report details a thorough data survey from Google and PubMed on the burden of TNBC worldwide and other associated factors, with special emphasis on its ever increasing incidence among Indian women. Our analysis revealed that the proportion of TNBC ranges from 6.7% to 27.9% in different countries, with the highest reported percentage in India among all, followed by Indonesia, Algeria, and Pakistan. Most of the other countries (Netherlands, Italy, London, Germany) had a TNBC incidence less than the mean level (ie, 15%). The high incidence of TNBC in the Indian population is associated with vivid risk factors, which primarily include lifestyle, deprivation status, obesity, family history, high mitotic indexes, and BRCA1 mutations. The treatment of TNBC is greatly hampered due to the lack of targeted therapies. Hence, it requires earnest attention towards extensive research for the prevention and development of treatment modalities with high efficacy.

Molecular Subtypes of Breast Cancers from Myanmar Women: A Study of 91 Cases at Two Pathology Centers

Background: Breast cancer is the most common cancer in Myanmar women. Revealing the hormonal receptor status, human epidermal growth factor receptor 2 (HER2) and Ki-67 expression is useful for estimating patient prognosis as well as determination of treatment strategy. However, immunohistochemical features and classification of molecular subtypes in breast cancers from Myanmar remain unknown. Methods: The clinicopathological features of 91 breast cancers from Myanmar women were examined. Immunohistochemistry was performed on tissue specimens with antibodies to estrogen receptor (ER), progesterone receptor (PgR), HER2, Ki-67, cytokeratin (CK)5/6 and CK14. Immunohistochemistry-based molecular subtyping was conducted. Results: Breast cancers in Myanmar women were relatively large, high grade with frequent metastatic lymph nodes. Of the 91 patients, tumors with ER positive, PgR positive, and HER2 positive were 57.1%, 37.4%, and 28.6%, respectively. The most prevalent subtype was luminal B (HER2-) (39.6%), followed by HER2 (22.0%), triple negative (TN)-basal-like (12.1%), luminal A (11.0%), TN-null (8.8%) and luminal B (HER2+) (6.6%). The mean Ki-67 expression of 91 cases was 33.9% (33.9% ± 19.2%) and the median was 28% (range; 4%-90%). The mean Ki-67 expression of luminal A, luminal B, HER2 and TN-basal-like/ null was 7%, 30%, 40%, and 57%/43%, respectively. A higher Ki-67 expression significantly correlated with a higher grade, larger size and higher stage of malignancy. Conclusions: We, for the first time, investigated the histopathological features of breast cancers from Myanmar women. Myanmar breast cancers appeared to be aggressive in nature, as evidenced by high frequency of poor-prognosis subtypes with high level of Ki-67 expression.

Relationship between HER2 Proto-oncogene Status and Prognostic Factors of Breast Cancer in the West of Iran

BACKGROUND

Breast cancer is a very common health problem in Iranian women. The HER2-neu gene is a transmembrane receptor tyrosine kinase with homology to members of the EGF receptor family. The aim of this study was to investigate the association between HER2-neu oncogene status with prognostic factors of breast cancer in Kermanshah province, Iran.

MATERIALS AND METHODS

Relationship between HER2-neu and prognostic factors of 130 cases of breast cancer were evaluated during two years in Imam Reza hospital in Kermanshah, Iran. Data were analyzed using descriptive statistics and the T-test and Mann-Whitney U non-parametric test using SPSS 19.

RESULTS

The mean age for the patients was 46.0±8.0 years, all being female. Among the predictive factors for breast cancer were family history, stage of disease, involvement of the lymphovascular system, number of involved lymph nodes in axillaries, grading and hormone receptor status with HER2-neu oncogene had direct correlation and between factors, tumor location, patient age and histological characteristics and HER2-neu oncogene had no significant relationship. We found significant correlation between HER2 with ER and PR and also HER2 with ER, PR negative.

CONCLUSIONS

HER2-neu is risk factor that can be a good prognostic and also predictive factor. For these reasons, we recommend that it be evaluated for all types of BC.

Clinicopathological Study of Triple Negative Breast Cancers

INTRODUCTION

Triple Negative Breast Cancers (TNBC) are a subset of breast cancers which are composed of different molecular subtypes. The most common is the basal like subtype, which has an adverse prognosis and limited treatment options.

AIM

This study was undertaken to assess the clinico-pathologic and immunohistochemical subtypes of triple negative breast cancers and assess how each of these subtypes correlate with clinical behaviour and survival outcomes.

MATERIALS AND METHODS

Fifty-three (22.2%) of 238 cases of primary invasive breast carcinomas diagnosed from January 2010 to June 2011 were found to be negative for immunohistochemical markers- ER, PR and HER2. These fifty three cases were included in the study and were classified into four histological subtypes proposed by Ishikawa et al. Basal markers- CK5/6, EGFR and CK14 were done on these cases and they were further classified immunohistochemically into basal and non basal subtypes. The morphological features, disease free survival and overall survival were evaluated for both basal and non basal subtypes.

RESULTS

Majority (96%) of TNBC cases were classified according to WHO as invasive ductal carcinoma (NOS). Type C Ishikawa histological subtype was found to be the commonest subtype in both basal and non-basal TNBC. Of 53 TNBC cases, basal immunohistochemical markers were performed on 47 cases only because of paucity of tissue. Of these 47 cases, thirty-five (74.4%) were found to be of basal like subtype and all these cases were picked up by a combination of CK5/6 and EGFR.

CONCLUSION

High grade morphological features, hormonal markers with additional use of basal markers can help identify the basal like subtype of TNBC, thereby predicting breast cancer survival. The combination of CK5/6 and EGFR identified all cases of basal subtype. EGFR in addition also has potential therapeutic implications. The morphological features and survival outcomes were not significantly different between basal and non-basal phenotypes.

Prevalence of Triple-Negative Breast Cancer in India: Systematic Review and Meta-Analysis

Purpose

There is considerable variation in prevalence rates of triple-negative breast cancer (TNBC) reported by various studies from India. We performed a systematic review and literature-based meta-analysis of these studies.

Methods

We searched databases of Medline, Scopus, EMBASE, and Web of Science for studies that reported on the prevalence of TNBC in India that were published between January 1, 1999, and December 31, 2015. We extracted relevant information from each study by using a standardized form. We pooled study-specific estimates by using random-effects meta-analysis to provide summary estimates. We explored sources of heterogeneity by using subgroup analyses and metaregression.

Results

Data were obtained from 17 studies that involved 7,237 patients with breast cancer. Overall combined prevalence of TNBC was 31% (95% CI, 27% to 35%). There was substantial heterogeneity across the studies (I² of 91% [95% CI, 88% to 94%]; P < .001) that was not explained by available study level characteristics, including study location, definition of human epidermal growth factor receptor 2 or estrogen receptor, mean age of participants, proportion of patients with premenopausal cancer, grade 3 disease, or tumor size > 5 cm. Overall combined prevalence of hormone receptor–positive and human epidermal growth factor receptor 2–positive breast cancer was 48% (95% CI, 42% to 54%) and 27% (95% CI, 24% to 31%), respectively. There was no evidence of publication bias.

Conclusion

Prevalence of TNBC in India is considerably higher compared with that seen in Western populations. As many as as one in three women with breast cancer could have triple-negative disease. This finding has significant clinical relevance as it may contribute to poor outcomes in patients with breast cancer in India. Additional research is needed to understand the determinants of TNBC in India.