Mucins and Cytokeratins as Serum Tumor Markers in Breast Cancer

Structural and functional characteristics of mucins and cytokeratins are shortly described. Thereafter, those commonly used in breast cancer as serum tumor markers are considered. First CA15.3, MCA, CA549, CA27.29 mucins and CYFRA21.1, TPA, TPS cytokeratins alone or in association have been examined in different stages and conditions. Then their usefulness in monitoring disease-free breast cancer patients is evaluated. The central role of the established cut-off and critical change, the "early" treatment of recurrent disease and the potential benefit in survival are other issues that have been highlighted and discussed. The successive sections and subsections deal with the monitoring of advanced disease. In them, the current recommendations and the principal findings on using the above mentioned mucins and cytokeratins have been reported. A computer program for interpreting consecutive measurements of serum tumor markers also has been illustrated. The final part of the chapter is devoted to mucins and cytokeratins as markers of circulating and disseminated tumor cells and their usefulness for prognosis.

Targeting HER family in HER2-positive metastatic breast cancer: potential biomarkers and novel targeted therapies

HER2-targeted therapies have radically changed the prognosis of HER2-positive breast cancer over the last few years. However, resistance to these therapies has been a constant, leading to treatment-failure and new tumor progression. Recently, the kinase-impaired HER3 emerged as a pivotal player in oncogenic signaling, with an important role in both non-treated progression and treatment response. HER2/HER3 dimerization is required for full signaling potential and constitutes the key oncogenic unit. Also, when inhibiting PI3K/AKT pathway (as with anti-HER2 drugs) feedback mechanisms lead to a rebound in HER3 activity, which is one of the main roads to resistance. As current strategies to treat HER2-positive breast cancer are unable to inhibit this feedback response, two great promises emerged: the combination of targeted-therapies and drugs targeting HER3. In this article HER2 and HER3-targeted drugs and possible combinations between them, as well as the biomarkers to predict and monitor these drugs effect, are reviewed.

Treatment patterns among breast cancer patients in the United States using two national surveys on visits to physicians' offices and hospital outpatient departments

BACKGROUND

Despite the availability of previous studies, little research has examined how types of anti-neoplastic agents prescribed differ among various populations and health care characteristics in ambulatory settings, which is a primary method of providing care in the U.S. Understanding treatment patterns can help identify possible disparities and guide practice or policy change.

OBJECTIVES

To characterize patterns of anti-neoplastic agents prescribed to breast cancer patients in ambulatory settings and identify factors associated with receipt of treatment.

METHODS

A cross-sectional analysis using the National Ambulatory Medical Care Survey data in 2006-2010 was conducted. Breast cancer treatments were categorized by class and further grouped as chemotherapy, hormone, and targeted therapy. A visit-level descriptive analysis using visit sampling weights estimated national prescribing trends (n = 2746 breast cancer visits, weighted n = 28,920,657). Multiple logistic regression analyses identified factors associated with anti-neoplastic agent used.

RESULTS

The proportion of visits in which anti-neoplastic agent(s) was/were documented remained stable from 2006 to 2010 (20.47% vs. 24.56%; P > 0.05). Hormones were commonly prescribed (29.69%) followed by mitotic inhibitors (9.86%) and human epidermal growth factor receptor2 inhibitors (5.34%). Patients with distant stage were more likely than patients with in-situ stage to receive treatment (Adjusted Odds Ratio [OR] = 2.79; 95% CI, 1.04-7.77), particularly chemotherapy and targeted therapy. Patients with older age, being ethnic minorities, having comorbid depression, and having U.S. Medicaid insurance were less likely to receive targeted therapy (P < 0.05). Patients with older age, having comorbid obesity and osteoporosis were less likely to receive chemotherapy, while patients seen in hospital-based settings and settings located in metropolitan areas were more likely to receive chemotherapy (P < 0.05).

CONCLUSIONS

Anti-neoplastic treatment patterns differ among breast cancer patients treated in ambulatory settings. Factors predicting treatment include certain socio-demographics, cancer stages, comorbidities, metropolitan areas, and setting.

Predictive molecular markers in metastases to the central nervous system: recent advances and future avenues

Metastases to the central nervous system (CNS) are common in several cancer types. For most primary tumors that commonly metastasize to the CNS, molecular biomarker analyses are recommended in the clinical setting for selection of appropriate targeted therapies. Therapeutic efficacy of some of these agents has been documented in patients with brain metastases, and molecular testing of CNS metastases should be considered in the clinical setting. Here, we summarize the clinically relevant biomarker tests that should be considered in neurosurgical specimens based on the current recommendations of the European Society of Medical Oncology (ESMO) or the National Comprehensive Cancer Network (NCCN) for the most relevant primary tumor types: lung cancer (EGFR mutations, ALK rearrangement, BRAF mutations), breast cancer (HER2 amplification, steroid receptor overexpression), melanoma (BRAF mutations), and colorectal cancer (RAS mutations). Furthermore, we discuss emerging therapeutic targets including novel oncogenic alterations (ROS1 rearrangements, FGFR1 amplifications, CMET amplifications, and others) and molecular features of the tumor microenvironment (including immune-checkpoint molecules such as CTLA4 and PD-1/PD-L1). We also discuss the potential role of advanced biomarker tests such as next-generation sequencing and "liquid biopsies" for patients with CNS metastases.

Efficacy of eribulin in women with metastatic breast cancer: a pooled analysis of two phase 3 studies

Data from two phase 3 studies of eribulin were pooled in analyses initially requested by the European Medicines Agency to assess whether specific patient subgroups, previously treated with an anthracycline and a taxane, benefited from eribulin. Study 305/EMBRACE included women after two-to-five lines of chemotherapy for advanced breast cancer who were randomized to eribulin mesylate (1.4 mg/m(2) on days 1 and 8 every 21 days) or treatment of physician's choice. In Study 301, patients who had received up to two prior chemotherapy regimens for advanced disease were randomized to eribulin (as above) or capecitabine (1.25 g/m(2) b.i.d. on days 1-14 every 21 days). In the pooled population, overall survival (OS), progression-free survival and response rates were analysed in the intent-to-treat population and selected subgroups. Overall, 1,062 patients were randomized to eribulin and 802 patients to control. Median OS was 15.2 months with eribulin versus 12.8 months with control (hazard ratio [HR] 0.85; 95% CI 0.77, 0.95; P = 0.003). In all subgroups assessed, OS data favoured eribulin; significant improvements occurred in some subgroups, notably in women with human epidermal growth factor receptor 2 (HER2)-negative disease (HR 0.82; P = 0.002), although the effect in those with HER2-negative but hormone-receptor-positive disease did not reach statistical significance; benefits were also seen, among others, in those with estrogen-receptor-negative and triple-negative disease. Eribulin improves OS in various patient subgroups with advanced/metastatic breast cancer who had previously received an anthracycline and a taxane. Women with HER2-negative disease are among those who may obtain benefit from eribulin.

Assessment of tumor response to chemotherapy in patients with breast cancer using (18)F-FLT: a meta-analysis

PURPOSE

To determine the diagnostic performance of 3'-deoxy-3'-(18)F-fluorothymidine positron emission tomography/computed tomography (FLT PET/CT) and FLT PET for evaluating response to chemotherapy in patients with breast cancer.

METHODS

Databases such as PubMed (MEDLINE included) and excerpta medica database (EMBASE), were searched for relevant original articles. The included studies were assessed for methodological quality with quality assessment of diagnosis accuracy studies (QUADAS) score tool. Histopathological analysis and/or clinical and/or radiological follow-up for at least 6 months were used as the reference standard. The data were extracted by two reviewers independently to analyze the sensitivity, specificity, summary receiver operating characteristic (SROC) curve, area under the curve (AUC), and heterogeneity.

RESULTS

The present study analyzed a total of 4 selected articles. The pool sensitivity was 0.773 [95% confidence interval (CI): 0.594-0.900]. The pooled specificity was 0.685 (95% CI: 0.479-0.849) on basis of FEM. The pooled LR+, LR-, and DOR were 2.874 (1.492-5.538), 0.293 (0.146-0.589), and 14.891 (3.238-68.475), respectively. The AUC was 0.8636 (±0.0655), and the Q* index was 0.7942 (±0.0636).

CONCLUSIONS

Our results indicate that (18)F-FLT PET/CT or PET is useful to predict chemotherapy response in breast cancer with reasonable sensitivity, specificity and DOR. However, future larger scale clinical trials will be needed to assess the regimen of (18)F-FLT PET/CT or PET in monitoring the response to chemotherapy in breast cancer patients.

Subcutaneous versus intravenous formulation of trastuzumab for HER2-positive early breast cancer: updated results from the phase III HannaH study

BACKGROUND

HannaH (NCT00950300) was a phase III, randomized, international, open-label study that compared pharmacokinetics (PK), efficacy, and safety of two different trastuzumab formulations [subcutaneous (s.c.) and intravenous (i.v.)] in HER2-positive, operable, locally advanced, or inflammatory breast cancer in the neoadjuvant/adjuvant setting. The co-primary end points, to show noninferiority of s.c. versus i.v. trastuzumab in terms of serum concentration (Ctrough) and pathologic complete response (pCR) were met; safety profiles were comparable at 12 months' median follow-up. Secondary end points included safety and tolerability, PK profile, immunogenicity, and event-free survival (EFS). We now report updated safety and efficacy data after a median follow-up of 20 months.

PATIENTS AND METHODS

Patients (N = 596) were treated with eight cycles of neoadjuvant chemotherapy, administered concurrently with 3-weekly s.c. trastuzumab (fixed dose of 600 mg) or the standard weight-based i.v. method. Following surgery, patients continued trastuzumab treatment to complete 1 year of therapy. Updated analyses of PK, efficacy, safety, and immunogenicity data were carried out.

RESULTS

s.c. trastuzumab was generally well tolerated and the incidence of adverse events (AEs), including grade 3 or 4 AEs, between treatment groups was comparable. A slightly higher incidence of serious AEs (SAEs), mainly due to infections, was reported with s.c. treatment {64 [21.5%; 95% confidence interval (CI) 17.0%-26.7%] versus 42 (14.1%; 95% CI 10.4%-18.6%) in the i.v. group}; however, the differences were small and often based on rare events, with no observable pattern across reported events. An early analysis of EFS showed rates of 95% in both groups 1 year postrandomization. Exploratory analyses did not reveal an association between toxicity and body weight or exposure.

CONCLUSIONS

Overall, the safety profile of s.c. trastuzumab was consistent with the previously published data from HannaH and the known safety profile of i.v. trastuzumab. EFS rates were comparable between the i.v. and s.c. groups.

CLINICAL TRIAL NUMBER

NCT00950300.

Human epidermal growth factor receptor 2 testing in primary breast cancer in the era of standardized testing: a Canadian prospective study

PURPOSE

Therapies that target overexpression of human epidermal growth factor receptor 2 (HER2) rely on accurate and timely assessment of all patients with new diagnoses. This study examines HER2 testing of primary breast cancer tissue when performed with immunohistochemistry (IHC) and additional in situ hybridization (ISH) for negative cases (IHC 0/1+). The analysis focuses on the rate of false-negative HER2 tests, defined as IHC 0/1+ with an ISH ratio ≥ 2.0, in eight pathology centers across Canada.

PATIENTS AND METHODS

Whole sections of surgical resections or tissue microarrays (TMAs) from invasive breast carcinoma tissue were tested by both IHC and ISH using standardized local methods. Samples were scored by the local breast pathologist, and consecutive HER2-negative IHC results (IHC 0/1+) were compared with the corresponding fluorescence or silver ISH result.

RESULTS

Overall, 711 surgical excisions of primary breast cancer were analyzed by IHC and ISH; HER2 and chromosome 17 centromere (CEP17) counts were available in all cases. The overall rate of false-negative samples was 0.84% (six of 711 samples). Interpretable IHC and ISH scores were available in 1,212 cases from TMAs, and the overall rate of false-negative cases was 1.6% (16 of 978 cases).

CONCLUSION

Our observation confirms that IHC is an adequate test to predict negative HER2 status in primary breast cancer in surgical excision specimens, even when different antibodies and IHC platforms are used. The study supports the American Society of Clinical Oncology/College of American Pathologists and Canadian testing algorithms of using IHC followed by ISH for equivocal cases.

Upregulation of miR-301a correlates with poor prognosis in triple-negative breast cancer

Identification of biomarkers is important not only for cancer diagnosis, prognosis and treatment, but also provides new insight into cancer biology. The aim of this study was to evaluate the clinical significance of miR-301a in patients with triple-negative breast cancer (TNBC). The expression level of miR-301a was examined by quantitative reverse transcription polymerase chain reaction in 118 pairs of TNBC and adjacent noncancerous tissues. The relationships between miR-301a expression and clinical features, and prognosis of patients with TNBC were analyzed. miR-301a was upregulated in cancer tissues compared with adjacent noncancerous tissues. Furthermore, the level of miR-301a was positively correlated with tumor size, depth of invasion, TNM stage and LNM. High miR-301a expression was significantly associated with larger tumor size and LNM. Multivariate analysis suggested that miR-301a expression was an independent prognostic factor for the survival of patients with TNBC, and the effect remained significant after further stratified by clinical features. In conclusion, miR-301a may be involved in the progression of TNBC and has strong potential to serve as a biomarker for the prognosis of TNBC.

Effectiveness of targeted therapy in patients with previously untreated metastatic breast cancer: a systematic review and meta-analysis

Breast cancer is the most common cancer and the most frequent cause of death in women. Targeted therapies offer a possibility of effective and individualized therapy based on the molecular profile of the tumor. The aim of this systematic review was to evaluate the efficacy and safety of targeted agents added to chemotherapy or endocrine therapy in patients with previously untreated metastatic breast cancer (MBC) depending on their human epidermal growth factor receptor 2 (HER2) and hormone receptor (HR) status (positive or negative). The systematic literature search was performed in PubMed, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs). Thirteen trials were included. The addition of trastuzumab, pertuzumab, bevacizumab, or lapatinib to chemotherapy significantly (P < .05) improved objective response rate (ORR), time to failure (TTF), and overall survival (OS) in patients with HER2-positive (HER2(+)) disease. Trastuzumab or lapatinib combined with endocrine therapy significantly (P < .05) improved ORR, time to progression (TTP), and progression-free survival (PFS) in patients with HER2(+) and HR(+) disease. In patients with HER2-negative (HER2(-)) cancer, bevacizumab or lapatinib added to chemotherapy significantly (P < .05), improved ORR but did not prolong PFS and OS (P > .05). In patients with HER2(-) and HR(-) disease, trastuzumab combined with chemotherapy did not significantly improve (P > .05) ORR or PFS. Targeted therapies also increased the overall risk of adverse events. So far, there is a lack of published results for everolimus and trastuzumab emtansine trials in patients with previously untreated MBC. The addition of targeted therapy to chemotherapy or endocrine therapy using HER2 and HR status significantly improved ORR, PFS, and OS in patients with previously untreated MBC.

Eribulin mesylate in heavily pretreated metastatic breast cancer patients: current practice in an Italian community hospital

AIM

The aim of this study is to report on the activity and safety of eribulin mesylate in a representative number of pretreated metastatic breast cancer (MBC) patients in current practice. Eribulin mesylate, a new microtubule inhibitor, is approved as monotherapy for the treatment of patients with locally advanced breast cancer or MBC who have progressed after at least two chemotherapeutic regimens for advanced disease.

PATIENTS & METHODS

From February to October 2012, 27 MBC patients, previously treated with anthracyclines and taxanes, were treated with 1.4 mg/m(2) intravenous infusion of eribulin mesylate at a community hospital.

RESULTS

Eight (30%) patients achieved partial response, one achieved complete response and three achieved stable disease. Median duration of response was 2.5 months (95% CI: 1.6-5.7; range: 1.3-5.7). Median overall survival was 8 months (95% CI: 6.1-9.7; range: 0.6-9.9). Reported adverse events were grade 1-2 asthenia (83%), peripheral sensory neuropathy (48%), nausea (37%) and neutropenia (30%).

CONCLUSION

Our retrospective analysis of a clinical practice experience supports the evidence that eribulin mesylate has clinical activity and provides acceptable benefit to heavily pretreated MBC.

[Surgical possibilities in the treatment of advanced and locally recurrent breast cancers]

Stage IV breast cancer is an incurable but treatable condition. Therapy of distant metastatic disease consists primarily of systemic and symptomatic treatments, while the role of surgery is subordinate. Conventional medical treatments result in 18-24 months average overall survival, and about 5-20% 5-year overall survival. However, it seems that in selected cases with solitary or oligometastases, mainly in those which respond well to drug therapy, the aggressive surgical removal of both the primary tumour and visceral metastases results in a survival advantage. After accurate evaluation of the patients, the indication for surgical treatment should be established through a biological and multidisciplinary approach. Other possible indications for surgical treatment are ulceration, bleeding, hygienic conditions undignified of human life, central nervous system metastases, acute neurological disorders, hydro- and pneumothorax greatly reducing respiratory surface and impending fractures. Surgical procedures include simple pleural drainage, minimal invasive techniques, large body cavity surgeries, extensive resection of soft tissue and chest wall due to the primary tumor, and plastic surgical reconstruction as well. Scientific assessment of the oncological value of surgical oncological interventions in stage IV. breast cancer require further multicentric prospective comparative studies. The present paper provides a broad review of the literature on surgical interventions and results in patients with breast cancer and remote metastases, and the surgical options of locally recurrent tumours.

Trends in the surgical procedures of women with incident breast cancer in Catalonia, Spain, over a 7-year period (2005-2011)

Background

Breast cancer (BC) is the most frequent cancer in women, accounting for 28% of all tumors among women in Catalonia (Spain). Mastectomy has been replaced over time by breast-conserving surgery (BCS) although not as rapidly as might be expected. The aim of this study was to assess the evolution of surgical procedures in incident BC cases in Catalonia between 2005 and 2011, and to analyze variations based on patient and hospital characteristics.

Methods

We processed data from the Catalonian Health Service’s Acute Hospital Discharge database (HDD) using ASEDAT software (Analysis, Selection and Extraction of Tumor Data) to identify all invasive BC incident cases according to the codes 174.0-174.9 of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) that were attended for the one-year periods in 2005, 2008 and 2011. Patients were classified according to surgical procedures (BCS vs mastectomy, and immediate vs delayed reconstruction), and results were compared among periods according to age, stage, comorbidity and hospital level.

Results

BC surgical procedures were performed in more than 80% of patients. Surgical cases showed a significant increasing trend in the proportion of women aged 50–69 years, more advanced disease stages, higher comorbidity and they were attended in hospitals of less complexity level throughout the study period. Similar pattern was found for patients treated with BCS, which increased significantly from 67.9% in 2005 to 74.0% in 2011.

Simple lymph node removal increased significantly (from 48.8% to 71.4% and from 63.6% to 67.8% for 2005 and 2011 in conservative and radical surgery, respectively). A slightly increase in the proportion of mastectomized young women (from 28% in 2005 to 34% in 2011) was detected, due to multiple factors. About 22% of women underwent post-mastectomy breast reconstruction, this being mostly immediate.

Conclusions

The use of HDD linked to the ASEDAT allowed us to evaluate BC surgical treatment in Catalonia. A consolidating increasing trend of BCS was observed in women aged 50–69 years, which corresponds with the pattern in most European countries. Among the mastectomized patients, immediate breast reconstructions have risen significantly over the period 2005–2011.

Electronic supplementary material

The online version of this article (doi:10.1186/1756-0500-7-587) contains supplementary material, which is available to authorized users.

A role for the pseudokinase HER3 in the acquired resistance against EGFR- and HER2-directed targeted therapy

Specific inhibition of members of the EGFR (epidermal growth factor receptor) family, particularly EGFR and HER2 (human epidermal growth factor receptor 2), are an important therapeutic strategy in many human cancers. Compared with classical chemotherapy, these targeted therapeutics are very specific and initially effective, but acquired resistance against these targeted therapies is a recurring threat. A growing body of recent work has highlighted a pseudokinase in the EGFR family, HER3, and its ligand, NRG (neuregulin β1), to be of importance in models of resistant cancers, as well as in patients. In the present article, we describe some of the roles in which HER3 can mediate acquired resistance and discuss the current efforts to target HER3 itself in cancer.

Real-world patterns of endocrine therapy for metastatic hormone-receptor-positive (HR+)/human epidermal growth factor receptor-2-negative (HER2-) breast cancer patients in the United States: 2002-2012

OBJECTIVE

Clinical guidelines recommend that patients with HR+/HER2- metastatic breast cancer (mBC), the most prevalent mBC subtype, receive three lines of endocrine therapy (ET) prior to transitioning to chemotherapy (CT) in the absence of need for rapid response, symptomatic visceral disease, or suspected endocrine resistance. Little is known about real-world ET treatment patterns among HR+/HER2- mBC patients.

RESEARCH DESIGN AND METHODS

Post-menopausal women with HR+/HER2- mBC were identified in the MarketScan databases (2002Q3-2012Q2). Patients were classified as receiving either ET or CT as their first therapy post-mBC diagnosis. Those receiving ET were studied further and stratified into three subgroups based on which of the following events occurred first: transition to CT, discontinuation of ET (90 days without evidence of ET), or end of data or insurance eligibility.

MAIN OUTCOME MEASURES

Mean numbers of lines of ET and median durations of each line were summarized for the overall sample and subgroups.

RESULTS

Among a total of 19,120 HR+/HER2- mBC patients, 11,545 (60%) initiated an ET; median follow-up time for these patients was 17 months. Seventy-four percent did not receive a second ET. The average patient received 1.36 lines of ET. Among patients with 2+ lines of ET, the duration of each subsequent line was significantly shorter than the previous line. RESULTS were similar in all subgroups.

LIMITATIONS

Clinical characteristics and reasons for treatment choices are unavailable in claims data.

CONCLUSIONS

Fewer than two thirds of patients initiated treatment for HR+/HER2- mBC with ET. Among those who did, most received only one line of ET before discontinuation or transition to CT. Patients who received multiple lines of ET experienced shorter durations of therapy with each line. Real-world treatment with ET falls short of the targets recommended by guidelines, representing unmet need for treatment options that improve the effectiveness of endocrine therapy.

A prognostic factor index for overall survival in patients receiving first-line chemotherapy for HER2-negative advanced breast cancer: an analysis of the ATHENA trial

BACKGROUND

Evidence-based definitions of 'poor-prognosis' or 'aggressive' advanced breast cancer are lacking.

PATIENTS AND METHODS

We developed a prognostic factor index using data from 2203 patients treated with first-line chemotherapy plus bevacizumab for HER2-negative advanced breast cancer.

RESULTS

The risk factors most closely associated with worse OS were: disease-free interval ≤24 months; liver metastases or ≥3 involved organ sites; prior anthracycline and/or taxane therapy; triple-negative breast cancer (TNBC); and performance status 2 or prior analgesic/corticosteroid treatment. Risk of death was increased threefold in patients with ≥3 versus ≤1 risk factors (hazard ratio 3.0 [95% CI 2.6-3.4; p < 0.001]; median 16.0 vs 38.8 months, respectively).

CONCLUSIONS

This prognostic index may enable identification of patients with a poorer prognosis in whom more intensive systemic regimens may be appropriate. The index may also be considered in designing new trials, although it requires validation in other datasets before extrapolation to non-bevacizumab-containing therapy. ClinicalTrials.gov identifier: NCT00448591.

Discordance rate of HER2 status in primary breast carcinomas versus synchronous axillary lymph node metastases: a multicenter retrospective investigation

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) is considered to be a therapeutic and prognostic marker in the management of breast carcinoma (BC), although discordance rates between primary and metastatic or locally recurrent lesions have been reported.

METHODS

One hundred and forty-eight paraffin-embedded BC tissues from patients of mean age 59.27 (33-96) years and corresponding synchronous lymph node metastases were collected and retrospectively studied using immunohistochemistry and fluorescence in situ hybridization to evaluate HER2 status. Fleiss-Cohen weighted k statistics were used to assess the concordance rate between HER2 status of the primary BC and the synchronous metastatic lesions.

RESULTS

The overall concordance rate for HER2 was 95.28%. Eighty-nine cases were concordantly HER2-negative in primary BC and nodal metastases, and 52 cases were HER2-positive in both primary and metastatic tumors. Changes in HER2 status between primary BC and corresponding synchronous metastases were observed in seven (4.72%) cases. Three of the discordant cases were HER2-negative in the primary tumor and HER2-positive in the metastases, while four cases were HER2-positive in the primary BC and HER2-negative in the metastases. No significant correlations were identified between HER2 status and expression of hormone receptors, growth fraction (Ki-67), or other histopathological parameters (pT, pN, grade).

CONCLUSION

Simultaneous determination of HER2 in BC and corresponding metastatic lymph nodes is not mandatory, but may strongly influence the therapeutic management. It was demonstrated that loss of HER2 amplification results in worse post-relapse survival and overall survival in BC patients and, on the other hand, a gain in HER2 expression in metastatic lymph nodes of BC may allow the possibility of a targeted treatment. Thus, our opinion is that significant prognostic information may be obtained by simultaneous assessment of HER2 status in both primary and synchronous metastatic BC.

Monitoring in metastatic breast cancer: is imaging outdated in the era of circulating tumor cells?

In clinical practice imaging technologies such as computed tomography (CT), positron emission tomography (PET)/CT and magnetic resonance imaging (MRI) are well-established methods for monitoring metastatic breast cancer (MBC) patients and for assessing therapeutic efficacy. However, several weeks of treatment are required before these technologies can offer any reliable information on effective disease regression, and, in the meanwhile, the patients are exposed to potentially unnecessary therapy. Circulating tumor cells (CTCs) have been shown to be powerful prognostic and predictive markers and provide clinicians with valuable information. However, in one clinical trial, an early change of chemotherapy based on CTC detection did not result in improved survival. Currently, CTC detection outside clinical trials should be limited to selected clinical situations, i.e. increased treatment toxicity or as risk estimation.

Progression-free survival as a potential surrogate for overall survival in metastatic breast cancer

Background

Progression-free survival (PFS) and time to progression (TTP) are frequently used to establish the clinical efficacy of anti-cancer drugs. However, the surrogacy of PFS/TTP for overall survival (OS) remains a matter of uncertainty in metastatic breast cancer (mBC). This study assessed the relationship between PFS/TTP and OS in mBC using a trial-based approach.

Methods

We conducted a systematic literature review according to the PICO method: ‘Population’ consisted of women with mBC; ‘Interventions’ and ‘Comparators’ were standard treatments for mBC or best supportive care; ‘Outcomes’ of interest were median PFS/TTP and OS. We first performed a correlation analysis between median PFS/TTP and OS, and then conducted subgroup analyses to explore possible reasons for heterogeneity. Then, we assessed the relationship between the treatment effect on PFS/TTP and OS. The treatment effect on PFS/TTP and OS was quantified by the absolute difference of median values. We also conducted linear regression analysis to predict the effects of a new anti-cancer drug on OS on the basis of its effects on PFS/TTP.

Results

A total of 5,041 studies were identified, and 144 fulfilled the eligibility criteria. There was a statistically significant relationship between median PFS/TTP and OS across included trials (r=0.428; P<0.01). Correlation coefficient for the treatment effect on PFS/TTP and OS was estimated at 0.427 (P<0.01). The obtained linear regression equation was ΔOS =−0.088 (95% confidence interval [CI] −1.347–1.172) + 1.753 (95% CI 1.307–2.198) × ΔPFS (R²=0.86).

Conclusion

Results of this study indicate a significant association between PFS/TTP and OS in mBC, which may justify the use of PFS/TTP in the approval for commercialization and reimbursement of new anti-cancer drugs in this cancer setting.

RECK controls breast cancer metastasis by modulating a convergent, STAT3-dependent neoangiogenic switch

Metastasis is the primary cause of cancer-related death in oncology patients. A comprehensive understanding of the molecular mechanisms that cancer cells usurp to promote metastatic dissemination is critical for the development and implementation of novel diagnostic and treatment strategies. Here we show that the membrane protein RECK (Reversion-inducing cysteine-rich protein with kazal motifs) controls breast cancer metastasis by modulating a novel, non-canonical and convergent signal transducer and activator of transcription factor 3 (STAT3)-dependent angiogenic program. Neoangiogenesis and STAT3 hyperactivation are known to be fundamentally important for metastasis, but the root molecular initiators of these phenotypes are poorly understood. Our study identifies loss of RECK as a critical and previously unknown trigger for these hallmarks of metastasis. Using multiple xenograft mouse models, we comprehensively show that RECK inhibits metastasis, concomitant with a suppression of neoangiogenesis at secondary sites, while leaving primary tumor growth unaffected. Further, with functional genomics and biochemical dissection we demonstrate that RECK controls this angiogenic rheostat through a novel complex with cell surface receptors to regulate STAT3 activation, cytokine signaling, and the induction of both vascular endothelial growth factor and urokinase plasminogen activator. In accordance with these findings, inhibition of STAT3 can rescue this phenotype both in vitro and in vivo. Taken together, our study uncovers, for the first time, that RECK is a novel regulator of multiple well-established and robust mediators of metastasis; thus, RECK is a keystone protein that may be exploited in a clinical setting to target metastatic disease from multiple angles.

Optimal sequencing of anti-HER2 therapy throughout the continuum of HER2-positive breast cancer: evidence and clinical considerations

With the advent of the monoclonal antibody trastuzumab over 2 decades ago for breast cancer therapy, the outcome of patients with human epidermal growth factor receptor (HER) 2-positive disease has improved dramatically. Based on its substantial efficacy and good tolerability, trastuzumab has become the therapeutic gold standard for early as well as advanced breast cancer. Nevertheless, despite adjuvant trastuzumab, patients do experience recurrence and require further anti-HER2-targeted therapy. Next to the small molecule tyrosine kinase inhibitor lapatinib, which was the first approved therapy option after trastuzumab failure, several new anti-HER2 agents are currently already available for clinical use [i.e. pertuzumab, T-DM1 (trastuzumab emtansine)] or are still being evaluated (e.g. afatinib, neratinib). Recent evidence from neoadjuvant as well as metastatic therapy suggests that dual blockade may be superior to single-agent HER2 blockade. While the number of available or potential therapies has increased considerably, no additional predictive biomarkers beyond HER2 have been validated for the use of the different anti-HER2 therapies. Moreover, novel therapeutic concepts such as the antibody-drug conjugate T-DM1 warrant excellent determination methodology for HER2 and suggest re-evaluation of tumor biology upon first metastasis. The clinical challenge remains to optimally choose, utilize, and sequence anti-HER2 therapy in early as well as metastatic breast cancer. This article will provide evidence-based guidance for sequencing anti-HER2 therapy throughout the continuum of breast cancer therapy.

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late-arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.

Disease management patterns for postmenopausal women in Europe with hormone-receptor-positive, human epidermal growth factor receptor-2 negative advanced breast cancer

BACKGROUND

International guidelines for hormone-receptor-positive (HR(+)), human epidermal growth factor receptor-2 negative (HER2(-)) advanced breast cancer (BC) recommend sequential lines of hormonal therapy (HT), and only recommend chemotherapy for patients with extensive visceral involvement or rapidly progressive disease. This study evaluated actual physician-reported treatments for advanced BC in Europe.

METHODS

We conducted a retrospective chart review of 355 postmenopausal women with HR(+), HER2(-) advanced BC who progressed on ≥1 line of HT (adjuvant or advanced) and completed ≥1 line of chemotherapy (advanced). Treatment choice was evaluated for each line of therapy.

RESULTS

Of 355 patients, 111 (31%) received first-line chemotherapy, whereas 218 (61%) and 26 (7%) switched from HT to chemotherapy in second and third line, respectively. More patients receiving first-line HT had bone metastases (73% vs 27% chemotherapy). Patients treated with first-line chemotherapy had more brain (12% vs 3% HT) or extensive liver (13% vs 6% HT) metastases. Subgroup analysis of 188 patients who received first-line HT and had de novo advanced BC or relapsed/recurrent disease more than 1 year after adjuvant therapy found that the majority (89%; n = 167) of these patients switched to chemotherapy in second line. However, among these 167 patients, 27% had no significant changes in metastases between first and second line. Among the 73% of patients who had significant changes in metastases, 20% had no brain metastases or extensive visceral disease.

CONCLUSIONS

Our study suggests that the guideline-recommended use of multiple HT lines is open to interpretation and that optimal treatment for European postmenopausal women with HR(+), HER2(-) advanced BC who responded to HT may not be achieved.

Measures of outcome in metastatic breast cancer: insights from a real-world scenario

No gold standard treatment exists for metastatic breast cancer (MBC). Clinical decision making is based on knowledge of prognostic and predictive factors that are extrapolated from clinical trials and, sometimes, are not reliably transferable to a real-world scenario. Moreover, misalignment between endpoints used in drug development and measures of outcome in clinical practice has been noted. The roles of overall survival (OS) and progression-free survival (PFS) as primary endpoints in the context of clinical trials are the subjects of lively debate. Information about these parameters in routine clinical practice is potentially useful to design new studies and/or to interpret the results of clinical research. This study analyzed the impact of patient and tumor characteristics on the major measures of outcome across different lines of treatment in a cohort of 472 patients treated for MBC. OS, PFS, and postprogression survival (PPS) were analyzed. The study showed how biological and clinical characteristics may have different prognostic value across different lines of therapy for MBC. After first-line treatment, the median PPS of luminal A, luminal B, and human epidermal growth factor receptor 2 (HER2)-positive groups was longer than 12 months. The choice of OS as a primary endpoint for clinical trials could not be appropriate with these subtypes. In contrast, OS could be an appropriate endpoint when PPS is expected to be low (e.g., triple-negative subtype after the first line; other subtypes after the third line). The potential implications of these findings are clinical and methodological.

Radiotherapy in patients with distant metastatic breast cancer

Background

The study evaluates frequency of and indications for disease-related radiotherapy in the palliative breast cancer (BC) situation and analyzes in which phase of the palliative disease course radiotherapy was applied.

Patients & methods

340 patients who developed distant metastatic disease (DMD) and died (i.e. patients with completed disease courses) were analyzed.

Results

165 patients (48.5%) received palliative radiotherapy (255 series, 337 planning target volumes) as a part of palliative care. The most common sites for radiotherapy were the bone (217 volumes, 64.4% of all radiated volumes) and the brain (57 volumes, 16.9%). 127 series (49.8%) were performed in the first third of the metastatic disease survival (MDS) period; 84 series (32.8%) were performed in the last third. The median survival after radiotherapy was 10 months. Patients who had received radiation were younger compared to those who had no radiation (61 vs. 68 years, p < 0.001) and had an improved MDS (26 vs. 14 months, p < 0.001). Compared to rapidly progressive disease courses with short survival times, in cases where effective systemic therapy achieved a longer MDS (≥24 months), radiotherapy was significantly more often a part of the multimodal palliative therapy (52.1% vs. 37.1%, p = 0.006).

Conclusions

In a cohort of BC patients with DMD, nearly one half of the patients received radiotherapy during the palliative disease course. In a palliative therapy approach, which increasingly allows for treatment according to the principles of a chronic disease, radiotherapy has a clearly established role in the therapy concept.

CA15-3 is a useful serum tumor marker for diagnostic integration of hybrid positron emission tomography with integrated computed tomography during follow-up of breast cancer patients

BACKGROUND

The aim of this study was to evaluate the value of CA15-3 for the diagnostic integration of molecular imaging findings performed with hybrid positron emission tomography and computed tomography (PETCT) technology.

METHODS

We retrospectively selected 45 patients with a median age of 60 years (range 39-85 years) and a previous history of breast cancer (BC) who had already been treated with surgery and other treatments. Three measurements of CA15-3 were collected within 1 year before PETCT examination, at 6-9 months 3-6 months and 0-3 months before PETCT. The prolonged clinical outcome or imaging follow-up was used to define disease relapse. An increase in tumor marker value was compared with PETCT findings and disease relapse. Sensitivity and specificity for both tests were calculated with respect to clinical outcome.

RESULTS

Disease relapse was detected in 16 out of 45 BC patients. CA15-3 and PETCT showed 75% sensitivity with a specificity percentage of 76% for CA15-3 and 79% for PETCT. Serum CA15-3 expression levels were significantly higher in BC patients with multiple metastatic sites with hepatic involvement. Analysis of serial CA15-3 serum levels showed an increase in CA15-3 3-6 months before PETCT could identify BC patients at risk for relapse (AUC = 0.81). Moreover, patients receiving anti-hormonal or chemotherapy medications with negative PETCT and positive CA15-3 relapsed after a median time of 158 days compared to patients who were negative for both tests and who were free from disease for at least 1 year.

CONCLUSIONS

Our results showed that serial increases in CA15-3 can be used to predict positive PETCT results in BC patients during follow-up. Increased levels of CA15-3 may be considered an early warning sign in patients needing accurate molecular imaging investigations, as they are at higher risk of recurrence. In cases of elevated levels, multiple lesions or liver involvement may exist. Also, patients receiving chemotherapeutic or anti-hormonal treatment who have negative PETCT scans and increased CA15-3 serum levels should be considered at risk for relapse, because the CA15-3-linked biochemical signal of the presence of a tumor can predict positive metabolic imaging.

Subcutaneous Administration of Monoclonal Antibodies in Oncology

Treatment with monoclonal antibodies (mabs) has become an established component of oncological therapy. The monoclonal antibodies available for this purpose are mainly administered intravenously in individually adapted doses according to body weight over longer treatment times. For other chronic diseases such as, for example, diabetes mellitus, the subcutaneous administration of drugs is an established therapy option. For the subcutaneous administration of larger volumes as needed for mab solutions the extracellular matrix of the subcutaneous tissue represents a problem. The co-formulation with recombinant human hyaluronidase makes the relatively pain-free administration of larger fluid volumes and thus the subcutaneous administration of monoclonal antibodies possible, as illustrated by the development of a subcutaneous formulation of trastuzumab. This constitutes a less invasive, time-optimised and flexible form of administration for patients with HER2-positive breast cancer that, with its fixed dosing possibilities, contributes to therapeutic safety. The example of trastuzumab shows that the subcutaneous administration of monoclonal antibodies can simplify oncological long-term therapy not only for the patients but also for the medical personnel.

ERα directly activated the MDR1 transcription to increase paclitaxel-resistance of ERα-positive breast cancer cells in vitro and in vivo

Chemotherapy is commonly used to treat early-stage invasive and advanced-stage breast cancer either before or after surgery. Increasing evidence from clinical analysis and in vitro studies has shown that ER-positive breast cancer cells are insensitive to chemotherapy. Complete understanding of how ERα mediates drug resistance is prerequisite to improvement of the chemotherapeutic efficacy. Over-expression of P-glycoprotein (P-gp) encoded by MDR1 gene is one of the major causes of drug resistance. The association between ERα and MDR1 in breast cancer is still unclear and the limited reports are conflict. This study systematically explored intrinsic link between ERα and the P-gp over-expression in paclitaxel-resistant ERα(+) breast cancer cell lines and mouse model in molecular details. Our data showed that ERα activated the MDR1 transcription in MCF-7/PTX breast cancer cells by binding to ERE1/2 and interacting with Sp1 that bridged to the downstream CG-rich element within the MDR1 promoter. Knockdown of MDR1 restrained the effect of ERα in MCF-7 cells and sensitized the cells to paclitaxel. Treatment of ICI 182,780 that selectively suppressed ERα significantly decreased the MDR1 expression and increased the sensitivity of drug resistant breast cancer cells and xenograft tumors to paclitaxel. Our data strongly demonstrated that ERα was able to increase drug resistance of breast cancer cells through activating MDR1 transcription. This novel mechanism provides new insight to how the ERα signaling regulates response of ERα(+) breast tumors to chemotherapy, which may be exploited for developing novel therapeutic strategies for breast cancer in the future.

Breast cancer, DPYD mutations and capecitabine-related ileitis: description of two cases and a review of the literature

Despite many treatment advances, metastatic breast cancer remains an incurable disease and is the third leading cause of cancer-related deaths in Europe. Capecitabine has become a standard treatment option for metastatic breast cancer, as a single agent or in combination. Hand-foot syndrome and diarrhoea are the most frequently reported side effects, while capecitabine-related ileitis is very rare. Deficiency of dihydropyrimidine dehydrogenase activity leads to severe toxicities after administration of 5-fluorouracil or its prodrugs. We report two cases of patients with metastatic breast cancer who developed ileitis after treatment with capecitabine. One patient had a DPYD gene abnormality.

Geranylgeranylacetone blocks doxorubicin-induced cardiac toxicity and reduces cancer cell growth and invasion through RHO pathway inhibition

Doxorubicin is a widely used chemotherapy for solid tumors and hematologic malignancies, but its use is limited due to cardiotoxicity. Geranylgeranylacetone (GGA), an antiulcer agent used in Japan for 30 years, has no significant adverse effects, and unexpectedly reduces ovarian cancer progression in mice. Because GGA reduces oxidative stress in brain and heart, we hypothesized that GGA would prevent oxidative stress of doxorubicin cardiac toxicity and improve doxorubicin's chemotherapeutic effects. Nude mice implanted with MDA-MB-231 breast cancer cells were studied after chronic treatment with doxorubicin, doxorubicin/GGA, GGA, or saline. Transthoracic echocardiography was used to monitor systolic heart function and xenografts evaluated. Mice were euthanized and cardiac tissue evaluated for reactive oxygen species generation, TUNEL assay, and RHO/ROCK pathway analysis. Tumor metastases were evaluated in lung sections. In vitro studies using Boyden chambers were performed to evaluate GGA effects on RHO pathway activator lysophosphatidic acid (LPA)-induced motility and invasion. We found that GGA reduced doxorubicin cardiac toxicity, preserved cardiac function, prevented TUNEL-positive cardiac cell death, and reduced doxorubicin-induced oxidant production in a nitric oxide synthase-dependent and independent manner. GGA also reduced heart doxorubicin-induced ROCK1 cleavage. Remarkably, in xenograft-implanted mice, combined GGA/doxorubicin treatment decreased tumor growth more effectively than doxorubicin treatment alone. As evidence of antitumor effect, GGA inhibited LPA-induced motility and invasion by MDA-MB-231 cells. These anti-invasive effects of GGA were suppressed by geranylgeraniol suggesting GGA inhibits RHO pathway through blocking geranylation. Thus, GGA protects the heart from doxorubicin chemotherapy-induced injury and improves anticancer efficacy of doxorubicin in breast cancer.

Pertuzumab: a review of its use for first-line combination treatment of HER2-positive metastatic breast cancer

Pertuzumab (Perjeta®) is a humanized anti-HER2 monoclonal antibody that binds to the extracellular dimerization subdomain of the HER2 receptor and reduces HER2 intracellular signalling by preventing HER2 from forming heterodimers with other HER receptors. Inhibition of HER2 signalling results in a reduction of tumour cell proliferation, invasiveness and survival. Pertuzumab and trastuzumab bind to different sites on the HER2 receptor and have complementary antitumour activities; they act synergistically in inhibiting the growth of HER2-overexpressing breast cancer cell lines in vitro. The efficacy of intravenous pertuzumab (840 mg loading dose, then 420 mg every 3 weeks) in combination with trastuzumab plus docetaxel in the first-line treatment of HER2-positive metastatic breast cancer was demonstrated in the randomized, double-blind, placebo-controlled, multinational, phase III CLEOPATRA trial. Pertuzumab in combination with trastuzumab and docetaxel significantly increased independently assessed median progression-free survival (primary endpoint), objective response rate and overall survival compared with placebo in combination with trastuzumab and docetaxel. Pertuzumab had an acceptable tolerability profile when added to trastuzumab and docetaxel in the pivotal CLEOPATRA trial. Thus, pertuzumab is a valuable addition to the growing list of anti-HER2 targeted therapies for breast cancer.

Where does radioimmunotherapy fit in the management of breast cancer?

Breast cancer is one of the most commonly diagnosed malignancies and is the main cause of death in women aged 40-49 years. Metastatic breast cancer is a heterogeneous disease that has a variety of different clinical presentations, ranging from solitary metastatic lesion to diffuse and multiple organ involvement. The biological heterogeneity of metastatic breast cancer has led to its unpredictable clinical behavior. One of the major challenges, therefore, is to identify predictive and prognostic models facilitating the selection of patients who can benefit from more aggressive and potentially curative options. This article provides an overview of the current management of metastatic breast cancer with focused emphasis on radioimmunotherapy.

18F-fluorodeoxyglucose--positron emission tomography/computed tomography aids staging and predicts mortality in patients with muscle-invasive bladder cancer

OBJECTIVE

To investigate the association between extravesical (18)F-fluorodeoxyglucose (FDG) avid lesions on FDG-positron emission tomography/computed tomography (PET/CT) and mortality in patients with muscle-invasive bladder cancer.

METHODS

An international, bi-institutional cohort study of 211 patients with muscle-invasive bladder cancer who underwent staging CT and FDG-PET/CT imaging. On the basis of the presence of extravesical FDG-avid lesions suspicious for malignancy on PET/CT images, patients were divided into a PET/CT-positive and PET/CT-negative group. Data on staging and mortality were retrospectively analyzed from prospective databases. Kaplan-Meier analyses were performed to compare overall (OS) and disease-specific survival (DSS) between the groups. Multivariable Cox regression models were used to investigate the association between extravesical PET/CT lesions and mortality. Extravesical lesions suspicious for malignancy on conventional CT were included in the models.

RESULTS

Of the 211 patients, 98 (46.4%) had 1 or more extravesical lesions on PET/CT, 113 (53.5%) had a negative PET/CT. Conventional CT revealed extravesical lesions in 51 patients (24.4%). Median follow-up was 18 months. Patients with a positive PET/CT had a significantly shorter OS and DSS (median OS: 14 vs 50 months, P = .001; DSS: 16 vs 50 months, P <.001). In multivariable analysis, the presence of extravesical lesions on PET/CT was an independent prognostic indicator of mortality (OS: hazard ratio = 3.0, confidence interval 95% 1.7-5.1). This association was not statistically significant for conventional CT (hazard ratio = 1.6 (95% confidence interval 0.9-2.7).

CONCLUSION

On the basis of our results, the presence of extravesical FDG-avid lesions on PET/CT might be considered an independent indicator of mortality.

Pathology-confirmed granuloma mimicking liver metastasis of breast cancer

For patients with breast cancer, obtaining tissue samples from liver lesion becomes more and more important for both differential diagnosis and subsequent treatment. However, the procedure is not considered as mandatory routine and is not frequently performed. We here reported about a patient with breast cancer history and a solitary liver metastasis that was clinically diagnosed by both magnetic resonance imaging (MRI) and position emission tomography - computed tomography (PET-CT). However, pathologic diagnosis after partial hepatectomy (between sections VII and VIII) revealed multifocal granulomas. The case further addresses the importance of core needle biopsy, or surgical biopsy, for obtainment of a histological diagnosis, especially in the presence of a solitary lesion, even when the lesion has a typical medical imaging supporting metastasis, and uptake of radioactive 18F-fluorodeoxyglucose (18F-FDG) by PET-CT.

Assessment of tumor characteristics and factors affecting survival in patients with primary metastatic breast carcinoma: a Multicenter Study of the Anatolian Society of Medical Oncology

Primary metastatic breast cancer (PMBC) comprises 3-10% of all BCs. PMBC is a heterogeneous disease. To date, little is known about the tumor characteristics, treatment results, and overall survival (OS) of patients with PMBC. Patients were considered to have PMBC if distant metastasis was evident within 3 months of the initial diagnosis of BC. Between September 2007 and April 2013, 466 PMBC patients were included in this study and analyzed retrospectively. The median age of the patients was 50 (18-90) years. Bone/soft tissue metastases were more frequent in the hormone receptor (HR)(+) human epidermal growth factor receptor (HER)2(-) group compared with the HR(-)HER2(-) and HR(-)HER2(+) groups (p < 0.001), whereas visceral organ metastasis was more frequent in the HR(-)HER2(-) and HR(-)HER2(+) groups (p < 0.001). The OS was affected by Eastern Cooperative Oncology Group performance status, tumor histology, receptor status, and the site of metastasis (p < 0.001, p < 0.001, p < 0.001, and p = 0.011, respectively). According to the first-line systemic treatment choices of the patients, the longest median OS was observed in the HR(+)HER2(+) group who received hormonotherapy combined with trastuzumab after chemotherapy (86 months, 95% CI 23.8-148.1) and the shortest median OS was observed in the HR(-)HER2(-) group who received chemotherapy only (24 months, 95% CI 17.9-30.0) (p < 0.001). Bisphosphonate therapy or radiotherapy had no significant effect on OS (p = 0.733, 0.603). In multivariate analysis, hormonotherapy, chemotherapy + trastuzumab, trastuzumab + hormonotherapy following chemotherapy, and surgery were the most important prognostic factors for OS, respectively (p < 0.001, p = 0.025, p = 0.027, p = 0.029). The general characteristics of the primary tumor are important for the prognosis and survival of patients with PMBC. Interestingly, patients who underwent primary breast tumor surgery, even those at the metastatic stage upon admission, had the longest survival.

Evaluating the role of nab-paclitaxel (Abraxane) in women with aggressive metastatic breast cancer

Nab-paclitaxel (Abraxane(®)) is an albumin-bound form of paclitaxel that utilizes the natural properties of albumin to improve paclitaxel delivery to the tumor. It is licensed for use in metastatic breast cancer (MBC) at a dose of 260 mg/m(2) Q3W based on its superior therapeutic index versus conventional paclitaxel 175 mg/m(2) Q3W demonstrated in a Phase III study. In a post-hoc analysis, nab-paclitaxel treatment was associated with rapid and dramatic tumor responses in patients with poor prognostic factors (visceral dominant disease, ≥3 metastatic lesions), suggesting it may be a preferred treatment for these patients. Moreover, significant efficacy has been seen with nab-paclitaxel 100 and 150 mg/m(2) QW 3/4, suggesting it may be possible to tailor use of this agent in the future.

Multitargeted antiangiogenic tyrosine kinase inhibitors combined to chemotherapy in metastatic breast cancer: a systematic review and meta-analysis

PURPOSE

We undertook a meta-analysis of randomized trials to evaluate the efficacy of multitargeted antiangiogenic tyrosine kinase inhibitors (MATKIs) in addition to chemotherapy in metastatic breast cancer.

METHODS

PubMed, Web of Knowledge databases and the ASCO meeting abstracts were searched for eligible literature published up to August 30, 2013. The endpoints included progression-free survival (PFS), overall survival (OS), overall response rate (ORR) and toxicities. Pooled hazard ratios (HRs) for survival outcomes and odds ratio (ORs) for dichotomous data with 95 % confidence intervals (CIs) were derived.

RESULTS

Eight studies including 2,077 participants were analyzed. Compared to chemotherapy alone, adding MATKIs to chemotherapy resulted in a 14 % risk reduction of PFS events. However, the benefit did not reach statistical significance (HR 0.86; 95 % CI 0.70-1.04, P=0.126). Also, no OS benefit was observed (HR 1.03; 95 % CI 0.89-1.18, P=0.724). The addition of MATKIs significantly increased the ORR (OR 1.57; 95 % CI 1.30-1.91, P=0.000). Subgroup analysis revealed that sorafinib showed a significantly greater effect on PFS in patients with HER2 negative metastatic breast cancer (HR 0.67; 95 % CI 0.55-0.82, P=0.000) in comparison to chemotherapy alone. Additionally, sunitinib seemed to have no substantial efficacy for metastatic breast cancer. Toxicities were more frequent in patients receiving MATKIs.

CONCLUSION

Overall, regimens consisting of MATKIs seemed not to be superior to chemotherapy alone in terms of PFS and OS, although significant improvement in ORR was observed. However, the addition of sorafenib significantly improved PFS. Further studies are needed to corroborate this finding.

[Personalized medicine and breast cancer: anticipatory medicine, prognostic evaluation and therapeutic targeting]

Breast cancer is now considered as a large collection of distinct biological entities, the management of which is increasingly personalized. Personalized medicine - defined as a medicine, which uses molecular profiles, notably genetic profiles, from patients and/or tumors to tailor therapeutic decisions - is now introduced in the management of breast cancer at any stages: screening and prevention of hereditary forms, prognostic and predictive evaluation of early breast cancer, and, more recently, novel clinical trials in advanced breast cancer, where genetic characterization of tumor tissue based on genomics, including next-generation sequencing tools, is used to drive specific therapeutic targeting.

Predictive and prognostic biomarkers with therapeutic targets in breast, colorectal, and non-small cell lung cancers: a systemic review of current development, evidence, and recommendation

Appropriate evidence-based roles of prognostic and predictive biomarkers of known therapeutic targets in breast, colorectal, and non-small cell lung cancers in adults are reviewed, with summary of evidence for use and recommendation. Current development in biomarker studies is also discussed. Computerized literature searches of PubMed (National Library of Medicine), the Cochrane Collaboration Library, and commonly accepted US and international guidelines (American Society of Clinical Oncology, European Society for Medical Oncology, and National Comprehensive Cancer Network) were performed from 2001 to 2012. Literature published before 2001 was noted for historical interest but not evaluated. Literature review was focused on available systematic reviews and meta-analyses of published predictive (associated with treatment response and/or efficacy) and prognostic (associated with disease outcome) biomarkers of known therapeutic targets in colorectal, breast, and non-small cell lung cancers. In general, significant health outcomes (e.g. predicted response to therapy, overall survival, disease-free survival, quality of life, lesser toxicity, and cost-effectiveness) were used for making recommendations. Four breast cancer biomarkers were evaluated, two of which (2D6 genotyping, Oncotype Dx) were considered emerging with insufficient evidence. Seven colorectal cancer biomarkers were evaluated, five of which (EGFR gene expression, K-ras G13D gene mutation, B-raf V600E gene mutation, dihydropyrimidine dehydrogenase deficiency, and UGT1A1 genotyping) were considered emerging. Seven non-small cell lung cancer biomarkers were evaluated, five of which were emerging (EGFR gene expression, ERCC gene expression, RRM1 gene expression, K-ras gene mutation, and TS gene expression). Of all 18 biomarkers evaluated, the following showed evidence of clinical utility and were recommended for routine use in practice: ER/PR and HER2 for breast cancer; K-ras gene mutation (except G13D gene mutation) for colorectal cancer; mismatch repair deficiency or microsatellite instability for colorectal cancer; and EGFR and EML4-ALK gene mutations for non-small cell lung. Not all recommendations for these biomarkers were uniformly supported by all guidelines.