Guidelines on endocrine therapy of breast cancer EUSOMA

microRNA-221 and tamoxifen resistance in luminal-subtype breast cancer patients: A case-control study

BACKGROUND

Around 70% of breast cancers (BCs) are estrogen receptor-α (ERα)-positive. Adjuvant endocrine therapy is used to reduce estrogen levels and inhibit signal transduction through the ER. The anti-estrogen drugs that are most commonly used in endocrine therapy belong to the selective ER modulator (SERM) class and include tamoxifen. Although it has been used for three decades in cases of early-stage and ERα-positive BC, resistance to tamoxifen is a common problem. microRNAs (miRNAs) have a potential role in demonstrating BC resistance to tamoxifen therapy. Hence, there is a need to investigate the expression of miRNA-221 (miR-221) in luminal-subtype BC patients receiving tamoxifen therapy.

METHODS

This case-control study investigated luminal-subtype BC patients who had undergone endocrine therapy for at least 1 year. The case group comprised patients with local or metastatic recurrence, and the control group comprised patients without local or metastatic recurrence.

RESULTS

There was a significant difference in miR-221 expression (p = 0.005) between the case and control groups. There were no significant differences between the groups that were positive and negative for the progesterone receptor (PR) (p = 0.25), had high and low marker of proliferation Ki-67 levels (p = 0.60), were positive and negative for lymphovascular invasion (p = 0.14), and had stage 2 and stage 3 cancer (p = 0.25).

CONCLUSION

miR-221 expression was higher in tamoxifen-resistant BC cases. miR-221 is a potential biomarker of tamoxifen resistance.

Spotlight on triptorelin in the treatment of premenopausal women with early-stage breast cancer

Endocrine treatment represents the cornerstone of endocrine-sensitive premenopausal early breast cancer. The estrogen blockade plays a leading role in the therapeutic management of hormone receptor-positive breast cancer together with surgery, radiotherapy, and selective antiestrogen treatments. For several years, selective estrogen receptor modulators, such as tamoxifen, have represented the mainstay of therapy. The role of amenorrhea has been extensively elucidated in the past year: the benefit observed with chemotherapy-induced amenorrhea has strengthened its therapeutic role. Luteinizing hormone-releasing hormone (LHRH) has been introduced in oncology practice to induce amenorrhea in order to increase the advantage obtained from endocrine treatment. Triptorelin is one of the most widely used LHRH analogs currently available in clinical practice. It was recently investigated in two major clinical trials that studied the role of complete estrogen blockade in the premenopausal setting. Both showed the clinical benefit due to ovarian suppression treatment, primarily in high-risk patients. Furthermore, triptorelin and other LHRH analogs have recently been investigated in the attempt to preserve the ovarian function in young patients. The medical treatment of early breast cancer is always evolving in the effort to search for safe and efficacious treatments. The role of LHRH analogs is actually well recognized as contributing to the improvement of the medical treatment of premenopausal women with early breast cancer.

Simultaneous Quantitative Detection of Relevant Biomarkers in Breast Cancer by Quantitative Real-Time PCR

The assessment of ERα, PgR and HER2 status is routinely performed today to determine the endocrine responsiveness of breast cancer samples. Such determination is usually accomplished by means of immunohistochemistry and in case of HER2 amplification by means of fluorescent in situ hybridization (FISH). The analysis of these markers can be improved by simultaneous measurements using quantitative real-time PCR (Qrt-PCR). In this study we compared Qrt-PCR results for the assessment of mRNA levels of ERα, PgR, and the members of the human epidermal growth factor receptor family, HER1, HER2, HER3 and HER4. The results were obtained in two independent laboratories using two different methods, SYBR Green I and TaqMan probes, and different primers. By linear regression we demonstrated a good concordance for all six markers. The quantitative mRNA expression levels of ERα, PgR and HER2 also strongly correlated with the respective quantitative protein expression levels prospectively detected by EIA in both laboratories. In addition, HER2 mRNA expression levels correlated well with gene amplification detected by FISH in the same biopsies. Our results indicate that both Qrt-PCR methods were robust and sensitive tools for routine diagnostics and consistent with standard methodologies. The developed simultaneous assessment of several biomarkers is fast and labor effective and allows optimization of the clinical decision-making process in breast cancer tissue and/or core biopsies.

miR-378a-3p modulates tamoxifen sensitivity in breast cancer MCF-7 cells through targeting GOLT1A

Breast cancer is a hormone-dependent cancer and usually treated with endocrine therapy using aromatase inhibitors or anti-estrogens such as tamoxifen. A majority of breast cancer, however, will often fail to respond to endocrine therapy. In the present study, we explored miRNAs associated with endocrine therapy resistance in breast cancer. High-throughput miRNA sequencing was performed using RNAs prepared from breast cancer MCF-7 cells and their derivative clones as endocrine therapy resistant cell models, including tamoxifen-resistant (TamR) and long-term estrogen-deprived (LTED) MCF-7 cells. Notably, miR-21 was the most abundantly expressed miRNA in MCF-7 cells and overexpressed in TamR and LTED cells. We found that miR-378a-3p expression was downregulated in TamR and LTED cells as well as in clinical breast cancer tissues. Additionally, lower expression levels of miR-378a-3p were associated with poor prognosis for tamoxifen-treated patients with breast cancer. GOLT1A was selected as one of the miR-378a-3p candidate target genes by in silico analysis. GOLT1A was overexpressed in breast cancer specimens and GOLT1A-specific siRNAs inhibited the growth of TamR cells. Low GOLT1A levels were correlated with better survival in patients with breast cancer. These results suggest that miR-378a-3p-dependent GOLT1A expression contributes to the mechanisms underlying breast cancer endocrine resistance.

How do I follow patients with early breast cancer after completing adjuvant therapy

OPINION STATEMENT

With improvements in the detection and treatment of breast cancer, more women are surviving after diagnosis. Patients who complete adjuvant therapy require ongoing follow-up to manage toxicities, to detect recurrences early, and to provide ongoing physical and psychosocial support. Routine surveillance should be implemented, with attention to educating patients about symptoms of recurrence, such as weight loss, cough, and bone pain. An intensive surveillance strategy with the routine use of laboratory and radiographic studies does not improve outcomes and raises the cost of follow-up. Patients should have annual mammograms in conjunction with physical exam and history at appropriate intervals that increase the farther out patients are from treatment. Attention also should be focused on other routine health maintenance and cancer screening, such as colonoscopy, gynecologic examinations, and bone health/DEXA scans. In the early posttreatment period, medical oncologists are best equipped to follow these patients. However, as women live longer after a breast cancer diagnosis and treatment, transitioning care to a primary care physician or nurse practitioner is appropriate, provided these practitioners are educated about late treatment effects and managing side effects of treatment, which may continue as long as a decade. A multidisciplinary follow-up strategy with excellent communication between providers can ensure safe, convenient, and quality care to the growing population of breast cancer survivors. As the treatment of breast cancer evolves into personalized strategies based on the biologic characteristics of individual tumors, future studies will be needed to determine if a single surveillance strategy is sufficient or if individualized surveillance based on risk can improve outcomes and costs of long-term follow-up care.

Global microRNA expression profiling of high-risk ER+ breast cancers from patients receiving adjuvant tamoxifen mono-therapy: a DBCG study

PURPOSE

Despite the benefits of estrogen receptor (ER)-targeted endocrine therapies in breast cancer, many tumors develop resistance. MicroRNAs (miRNAs) have been suggested as promising biomarkers and we here evaluated whether a miRNA profile could be identified, sub-grouping ER+ breast cancer patients treated with adjuvant Tamoxifen with regards to probability of recurrence.

EXPERIMENTAL DESIGN

Global miRNA analysis was performed on 152 ER+ primary tumors from high-risk breast cancer patients with an initial discovery set of 52 patients, followed by two independent test sets (N = 60 and N = 40). All patients had received adjuvant Tamoxifen as mono-therapy (median clinical follow-up: 4.6 years) and half had developed distant recurrence (median time-to-recurrence: 3.5 years). MiRNA expression was examined by unsupervised hierarchical clustering and supervised analysis, including clinical parameters as co-variables.

RESULTS

The discovery set identified 10 highly significant miRNAs that discriminated between the patient samples according to outcome. However, the subsequent two independent test sets did not confirm the predictive potential of these miRNAs. A significant correlation was identified between miR-7 and the tumor grade. Investigation of the microRNAs with the most variable expression between patients in different runs yielded a list of 31 microRNAs, eight of which are associated with stem cell characteristics.

CONCLUSIONS

Based on the large sample size, our data strongly suggests that there is no single miRNA profile predictive of outcome following adjuvant Tamoxifen treatment in a broad cohort of ER+ breast cancer patients. We identified a sub-group of Tamoxifen-treated breast cancer patients with miRNA-expressing tumors associated with cancer stem cell characteristics.

Fulvestrant in the management of postmenopausal women with advanced, endocrine-responsive breast cancer

Fulvestrant is a pure estrogen antagonist that binds, blocks and downgrades the estrogen receptor (ER). Its unique mechanism of action is its antitumor activity after progression on prior endocrine therapy. Fulvestrant has shown activity in ER-dependent cells that are ligand independent. Fulvestrant has been approved at 250 mg/month for postmenopausal women with hormone-sensitive advanced breast cancer after progression or recurrence on antiestrogen therapy. The fulvestrant 500 mg regimen has just received approval by the EMA and the US FDA, supported by dose-dependent ER downregulation and the recent results of the clinical trial CONFIRM. Fulvestrant in combination with systemic lowering of estrogen has shown no improvement over fulvestrant alone. Combination therapy with inhibitors of growth factor signaling may have greater efficacy and is under exploration. To enhance the benefit of fulvestrant and improve outcomes for individuals with ER-positive breast cancer, greater understanding of resistance mechanisms is required. A key issue is identification of patients with ER-positive disease who retain sensitivity to antiestrogen therapy after progression on tamoxifen and/or aromatase inhibitors.

Geographic variation in breast cancer care in Switzerland

PURPOSE

Regional disparities in breast cancer outcomes have been reported in Switzerland. The purpose of this study is to investigate geographic variation in early diagnosis and management of breast cancer.

METHODS

We used data from a representative sample of 4820 women diagnosed with invasive breast cancer between January 1, 2003 and December 31, 2005 identified by seven Swiss population based cancer registries. We collected retrospectively detailed information on mode of detection, tumor characteristics and treatments. Differences across geographic regions were tested for statistical significance using chi-square tests and uni- and multivariate logistic regression.

RESULTS

Considerable disparities in early detection and management of early breast cancer were found across regions. In particular, the proportion of early detected cancer varied from 43% in Valais to 27% in St. Gallen-Appenzell. Mastectomy rates varied from 24% in Geneva to 38% in St. Gallen-Appenzell and Grisons-Glarus. Higher reconstruction rates were observed in regions with lower rates of mastectomy. The use of sentinel node procedure in patients with nodal negative disease was high in Geneva and low in Eastern Switzerland. Differences in compliance with recommendations on the use of endocrine therapy and chemotherapy were less pronounced but statistically significant.

CONCLUSIONS

This analysis shows considerable geographic variation in breast cancer care in a health system characterized by high expenditures, universal access to services and high decentralization. Further study into the causes and effects of this variation on short- and long term patient outcomes is needed.

Adherence to quality indicators and survival in patients with breast cancer

BACKGROUND

International initiatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to breast cancer care protocol is unknown.

OBJECTIVE

This study explores whether 100% adherence to a set of quality indicators applied to individuals with breast cancer is associated with better survival.

RESEARCH DESIGN AND SUBJECTS

Ten quality indicators (4 diagnosis-related and 6 treatment-related indicators) were used to measure the quality of care in 1378 breast cancer patients treated from 1995 to 2001. Adherence to each indicator was based on the number of procedures performed divided by the number of patients eligible for that procedure. The main analysis of adherence was dichotomous (ie, 100% adherence vs. <100% adherence).

MEASURES

The outcome measures studied were 5-year overall survival and progression-free survival, calculated using the Kaplan-Meier method. The Cox's proportional hazard regression model was used for univariate and multivariate analyses.

RESULTS

Most patients received care that demonstrated good adherence to the quality indicators. Multivariate analysis revealed that 100% adherence to entire set of quality indicators was significantly associated with better overall survival [hazard ratio (HR): 0.46; 95% confidence interval (CI): 0.33-0.63] and progression-free survival (HR 0.51; 95% CI, 0.39-0.67). One hundred percent adherence to treatment indicators alone was also associated with statistically significant improvements in overall and progression-free survivals.

CONCLUSIONS

Our study strongly supports that 100% adherence to evidence supported quality-of-care indicators is associated with better survival rates for breast cancer patients and should be a priority for practitioners.

Fulvestrant (Faslodex) -- how to make a good drug better

Fulvestrant (Faslodex); AstraZeneca Pharmaceuticals, Wilmington, DE) is an estrogen receptor (ER) antagonist with a novel mode of action; it binds, blocks, and increases degradation of ER. Fulvestrant (at the approved dose [250 mg/month]) is at least as effective as anastrozole (1 mg/day) in the treatment of postmenopausal women with hormone receptor-positive advanced breast cancer (HR(+) ABC) progressing or recurring on antiestrogen therapy, and is also an active first-line treatment. Although fulvestrant (250 mg/month) is clearly effective, it takes 3-6 months to achieve steady-state plasma levels. Steady-state concentrations are approximately twofold higher than those achieved with a single dose; reaching this earlier, for example, via a loading-dose (LD) regimen (250 mg/month plus 500 mg on day 0 and 250 mg on day 14 of month 1), may allow responses to be achieved more quickly and limit the possibility of early relapse. Fulvestrant high-dose (HD) regimens (500 mg/month) offer the possibility of greater antitumor activity, because (a) ER downregulation is a dose-dependent process (an approximately 70% reduction is observed with a single 250 mg dose of fulvestrant) and (b) evidence correlates greater ER downregulation with superior efficacy. A fulvestrant HD regimen offers the potential of achieving near 100% ER downregulation. There is also potential to increase fulvestrant-ER binding by reducing plasma estrogen levels, for example, with concomitant aromatase inhibitor treatment. Several ongoing trials use LD, HD, and combination regimens; results from these studies are awaited with interest. Meanwhile, fulvestrant (250 mg/month) remains a valuable additional endocrine treatment for postmenopausal women with HR(+) ABC recurring or progressing on antiestrogen therapy.

Management of arthralgias associated with aromatase inhibitor therapy

For the upfront adjuvant therapy of postmenopausal estrogen receptor-positive breast cancer, the third-generation aromatase inhibitors (AIS) have shown a more favourable overall risk-benefit profile than has tamoxifen. Benefits of the ais include less frequent gynecologic, cerebrovascular, and thromboembolic adverse events; greater disease-free survival; and lower tumour recurrence. Although approximately 25% of postmenopausal women with early breast cancer report experiencing symptoms of arthralgia with ai therapy, 68-month data from the Arimidex, Tamoxifen, Alone or in Combination trial showed that, compared with tamoxifen, anastrozole treatment was associated with only a modest increase in the incidence of joint symptoms. The events, which were mostly mild-to-moderate in intensity, led to treatment withdrawal in 2% of patients on anastrozole as compared with 1% in the tamoxifen arm. The symptoms and changes correlate with clinical, biochemical, and radiologic findings in symptomatic women. To determine appropriate intervention, it is therefore essential to perform a comprehensive evaluation of musculoskeletal complaints to distinguish natural menopause-related degenerative disease from AI-related effects. The present review explores the advantages of differential diagnosis with an emphasis on history and physical and musculoskeletal examination; laboratory investigations are used to corroborate or rule out clinical impressions. The transient symptoms associated with the ais are manageable with an appropriate combination of lifestyle changes, including exercise and joint protection in conjunction with pharmacologic approaches.

Introduction of a breast cancer care programme including ultra short hospital stay in 4 early adopter centres: framework for an implementation study

Background

Whereas ultra-short stay (day care or 24 hour hospitalisation) following breast cancer surgery was introduced in the US and Canada in the 1990s, it is not yet common practice in Europe. This paper describes the design of the MaDO study, which involves the implementation of ultra short stay admission for patients after breast cancer surgery, and evaluates whether the targets of the implementation strategy are reached. The ultra short stay programme and the applied implementation strategy will be evaluated from the economic perspective.

Methods/design

The MaDO study is a pre-post-controlled multi-centre study, that is performed in four hospitals in the Netherlands. It includes a pre and post measuring period of six months each with six months of implementation in between in at least 40 patients per hospital per measurement period.

Primary outcome measure is the percentage of patients treated in ultra short stay. Secondary endpoints are the percentage of patients treated according to protocol, degree of involvement of home care nursing, quality of care from the patient's perspective, cost-effectiveness of the ultra short stay programme and cost-effectiveness of the implementation strategy. Quality of care will be measured by the QUOTE-breast cancer instrument, cost-effectiveness of the ultra short stay programme will be measured by means of the EuroQol (administered at four time-points) and a cost book for patients. Cost-effectiveness analysis will be performed from a societal perspective. Cost-effectiveness of the implementation strategy will be measured by determination of the costs of implementation activities.

Discussion

This study will reveal barriers and facilitators for implementation of the ultra short stay programme. Moreover, the results of the study will provide information about the cost-effectiveness of the ultra short stay programme and the implementation strategy.

Trial registration

Current Controlled Trials ISRCTN77253391.

Guidelines for the Use of Tumor Marmers in Breast Cancer

Najbolje validovani markeri karcinoma dojke pripadaju tkivnim markerima i uključuju receptore za estrogen (ER), receptore za progesteron (PR), HER-2, urokinaza plazminogen aktivator (uPA) i plazminogen aktivator inhibitor 1 (PAI-1). Kod svih novodijagnostikovanih pacijenata sa karcinomom dojke određivanje ER, PR i HER-2 je danas obavezno. Mada je merenje uPA i PAI-1 tehnički validovano, do danas nije klinički rasprostranjeno i to uglavnom zbog zahteva za minimalnom količinom svežeg ili sveže zamrznutog tkiva. Određivanje ovih proteina može da se iskoristi kao pomoć pri selekciji »limfni čvor negativnih« pacijenata s karcinomom dojke kojima nije potrebna adjuvantna hemoterapija. Mada se dosta koristi u postoperativnom praćenju i praćenju terapije u poodmaklom oboljenju, klinička vrednost CA 15-3 i drugih serumskih markera nije joŠ uvek validovana u studijama nivoa dokaza I. Nedavna poboljšanja u razumevanju biologije karcinoma dojke i paralelno povećanje mogućih opcija tretmana treba da vode ka poboljšanju ishoda ove veoma hetrogene bolesti. Onkolozi joŠ uvek imaju teškoće u odabiru specifičnih strategija tretmana prema molekularnim karakteristikama oboljenja svakog pacijenta ponaosob.

Increased Expression of Urokinase-Type Plasminogen Activator mRNA Determines Adverse Prognosis in ErbB2-Positive Primary Breast Cancer

Purpose

To evaluate and validate mRNA expression markers capable of identifying patients with ErbB2-positive breast cancer associated with distant metastasis and reduced survival.

Patients and Methods

Expression of 60 genes involved in breast cancer biology was assessed by quantitative real-time PCR (qrt-PCR) in 317 primary breast cancer patients and correlated with clinical outcome data. Results were validated subsequently using two previously published and publicly available microarray data sets with different patient populations comprising 295 and 286 breast cancer samples, respectively.

Results

Of the 60 genes measured by qrt-PCR, urokinase-type plasminogen activator (uPA or PLAU) mRNA expression was the most significant marker associated with distant metastasis-free survival (MFS) by univariate Cox analysis in patients with ErbB2-positive tumors and an independent factor in multivariate analysis. Subsequent validation in two microarray data sets confirmed the prognostic value of uPA in ErbB2-positive tumors by both univariate and multivariate analysis. uPA mRNA expression was not significantly associated with MFS in ErbB2-negative tumors. Kaplan-Meier analysis showed in all three study populations that patients with ErbB2-positive/uPA–positive tumors exhibited significantly reduced MFS (hazard ratios [HR], 4.3; 95% CI, 1.6 to 11.8; HR, 2.7; 95% CI, 1.2 to 6.2; and, HR, 2.8; 95% CI, 1.1 to 7.1; all P < .02) as compared with the group with ErbB2-positive/uPA–negative tumors who exhibited similar outcome to those with ErbB2-negative tumors, irrespective of uPA status.

Conclusion

After evaluation of 898 breast cancer patients, uPA mRNA expression emerged as a powerful prognostic indicator in ErbB2-positive tumors. These results were consistent among three independent study populations assayed by different techniques, including qrt-PCR and two microarray platforms.

Combined ovarian ablation and aromatase inhibition as first-line therapy for hormone receptor-positive metastatic breast cancer in premenopausal women: report of three cases

Aromatase inhibitors have become well established for the treatment of postmenopausal women with hormone receptor-positive metastatic breast cancer and for adjuvant hormonal therapy for primary breast cancer. Benefit of aromatase inhibition has not yet been extended to premenopausal women. Ovarian ablation by oophorectomy, ovarian radiation or hormonal suppression is the initial recommended treatment for hormone receptor-positive metastatic breast cancer in premenopausal women. The addition of tamoxifen improves the benefit of ovarian ablation/ovarian suppression. Addition of aromatase inhibitors to luteinizing hormone-releasing hormone analogs has been reported to significantly decrease circulating estrogens and produce tumor responses in only a very small number of patients over the last 15 years. We treated three premenopausal patients with hormone receptor-positive metastatic breast cancer with combined oophorectomy or ovarian irradiation and anastrozole. One patient remained free of progression for 4 years, while the other two remained free of progression for more than 5 and 3 years, respectively. We also note that monthly zoledronic acid for 4 years produced sclerosis of vertebral body metastasis. We conclude that combined ovarian ablation and aromatase inhibition is a feasible treatment modality that deserves more attention and further investigation for hormone receptor-positive metastatic breast cancer in premenopausal women.

Trends in endocrine therapy and chemotherapy for early breast cancer: a focus on the premenopausal patient

PURPOSE

The majority of breast cancers are diagnosed at an early stage, and treatment is focused on cure and prolonging disease-free survival. Local therapy (surgery and/or radiation treatment) is standard, along with systemic adjuvant therapy that may effectively prevent or delay relapse and death in early-stage disease. In premenopausal women, adjuvant therapeutic approaches include combination cytotoxic chemotherapy and endocrine therapy. Cyclophosphamide, methotrexate and 5-fluorouracil (CMF) was the established chemotherapy regimen; however, newer regimens have more recently been introduced that may offer some benefit over CMF including anthracycline-containing regimens [e.g. cyclophosphamide, epirubicin and 5-fluorouracil (CEF)], and taxane-containing regimens. For women with oestrogen receptor (ER)-positive disease, a second option is endocrine therapy that aims to suppress mitogenic oestrogen signalling. Until recently, 5 years of tamoxifen was regarded as the standard adjuvant endocrine treatment in ER-positive disease. Ovarian ablation is also effective in premenopausal women, and can be achieved by surgery, radiotherapy, or via the use of a luteinising hormone-releasing hormone analogue such as goserelin. Combining tamoxifen and goserelin treatment provides more effective oestrogen blockade than either drug alone. However, as the third-generation aromatase inhibitors (AIs) have demonstrated improved efficacy over tamoxifen in postmenopausal women with early and advanced disease, combination treatment with goserelin plus an AI may provide optimal oestrogen blockade in premenopausal patients.

CONCLUSIONS

This review assesses the relative merits of chemotherapeutic and endocrine approaches for the treatment of early breast cancer, and summarises relevant ongoing clinical trials, with an emphasis on the premenopausal setting.

Serum tumor markers in breast cancer: are they of clinical value?

BACKGROUND

Although multiple serum-based tumor markers have been described for breast cancer, such as CA 15-3, BR 27.29 (CA27.29), carcinoembryonic antigen (CEA), tissue polypeptide antigen, tissue polypeptide specific antigen, and HER-2 (the extracellular domain), the most widely used are CA 15-3 and CEA.

METHODS

The literature relevant to serum tumor markers in breast cancer was reviewed. Particular attention was given to systematic reviews, prospective randomized trials, and guidelines issued by expert panels.

RESULTS

Because of a lack of sensitivity for early disease and lack of specificity, none of the available markers is of value for the detection of early breast cancer. High preoperative concentrations of CA 15-3 are, however, associated with adverse patient outcome. Although serial determinations of tumor markers after primary treatment for breast cancer can preclinically detect recurrent/metastatic disease with lead times of approximately 2-9 months, the clinical value of this lead time remains to be determined. Serum markers, however, are the only validated approach for monitoring treatment in patients with advanced disease that cannot be evaluated by use of conventional criteria.

CONCLUSIONS

CA 15-3 is one of the first circulating prognostic factors for breast cancer. Preoperative concentrations thus might be combined with existing prognostic factors for predicting outcome in patients with newly diagnosed breast cancer. At present, the most important clinical application of CA 15-3 is in monitoring therapy in patients with advanced breast cancer that is not assessable by existing clinical or radiologic procedures.

The Role of Ovarian Ablation in the Management of Breast Cancer

In recent years the role of ovarian ablation as a therapeutic modality not only in the prevention but also in the treatment of breast cancer has reemerged after its initial use more than a century ago. BRCA-1 and BRCA-2 mutation carriers have an 85% lifetime risk of developing breast cancer. Bilateral salpingo-oophorectomy is effective in reducing the risk of developing breast cancer in both BRCA-1 and BRCA-2 mutation carriers by 50%. Tamoxifen reduces the risk of breast cancer in BRCA-2 mutation carriers, but not in BRCA-1 mutation carriers. Breast cancer arising in BRCA-1 mutation carriers is often estrogen receptor (ER) negative, unlike breast cancer developing in BRCA-2 mutation carriers. Sixty percent of premenopausal patients with breast cancer have ER-positive disease and 25% of breast cancer patients are premenopausal at diagnosis. The Early Breast Cancer Trialists' Collaborative Group review has shown ovarian ablation to be an effective adjuvant therapy for premenopausal breast cancer patients less than 50 years of age. But the Early Breast Cancer Trialists' overview also shows the benefit of ovarian ablation is uncertain if these patients also receive chemotherapy. Does the overview underestimate the efficacy of ovarian ablation? Some patients in these trials were ER negative. Most women less than 50 years of age who receive adjuvant chemotherapy become menopausal. So there is a need to test ovarian function suppression in the group who can benefit, or in other words, those that remain premenopausal after chemotherapy and have endocrine responsive breast cancer.

Role of aromatase inhibitors in breast cancer

Primarily, the role of the aromatase inhibitors has been investigated in postmenopausal women with breast cancer, although it is also now being assessed in premenopausal patients following ovarian ablation/suppression. Aromatase inhibitors markedly suppress endogenous oestrogens without directly interacting with oestrogen receptors, and thus have a different mechanism of action to the antioestrogen, tamoxifen. The inhibitors may be divided into subgroups according to their structure (steroidal and nonsteroidal), and there appears to be a lack of cross-resistance between the classes of aromatase inhibitors enabling them to be used sequentially and potentially to prolong endocrine hormone therapy. In addition, with increased efficacy and favourable safety and tolerability profiles, the aromatase inhibitors are starting to challenge tamoxifen as first choice endocrine treatment in a number of settings. Potential differences in side-effect profiles may appear between the steroidal and nonsteroidal aromatase inhibitors when used in long-term settings. Thus, it has been suggested that the steroidal agents have favourable end organ effects; for example, the steroidal inhibitor, exemestane, has minimal negative effects on bone and lipid metabolism in animal and clinical studies. This paper provides an overview of the current and future roles of aromatase inhibitors for breast cancer treatment.

Impact of metastatic estrogen receptor and progesterone receptor status on survival

Hormone responsive breast cancer is usually determined by the presence of estrogen receptors (ER) or progesterone receptors (PR) on primary invasive breast cancers. Adjuvant and metastatic hormone therapy are recommended based on primary ER and PR determination. Little information is available to determine if primary hormone receptors correlate with metastatic disease and if survival is influenced by metastatic receptor status. We retrospectively compared primary to metastatic tumor ER and PR content from 200 metastatic breast cancer patients. ER and PR analyses were available in both primary and metastatic disease in 200 and 173 patients, respectively. There was a correlation between both the ER and PR in the primary and metastatic lesion (p < 0.001). However, in 60 of 200 (30%) patients, discordance between primary and metastatic ER was noted. Tumors from 68 of 173 (39.3%) showed discordance for PR. In 39 (19.5%) patients, the ER primary status was positive and metastatic status was negative and in 21 (10.5%) patients, the primary status was negative and metastatic status was positive. Survival from the time of metastatic diagnosis was calculated. Those patients with ER positive primary and metastatic tumors (Positive/Positive) or only the metastatic lesion (Negative/Positive) had similar median survival (1131 and 1111 days, respectively). However, patients with tumors that changed from positive primary to negative metastasis (Positive/Negative) experienced significantly shorter median survival (669 days, p < 0.05). Likewise, median survival (580 days) was significantly shorter for patients with primary and metastasis ER negative (Negative/Negative, p < 0.001) compared to Positive/Positive (p < 0.001) or compared to Negative/Positive (p < 0.02). The changes in PR status were not associated with a change in survival. We found a significant discordance between hormone receptor content of primary versus metastatic breast cancer. The ER status of the metastatic lesion was a better predictor of survival. Therefore, optimal metastatic treatment cannot be determined solely on primary ER and PR analysis.

Systematic review of LHRH agonists for the adjuvant treatment of early breast cancer

There is increasing use of luteinising hormone-releasing hormone (LHRH) agonists in the adjuvant treatment of breast cancer (J. Clin. Oncol. 19(2) (2001) 343). However, few mature studies are available and there is uncertainty regarding the optimal use of these agents. We performed a systematic review to address the role of LHRH agonists in the adjuvant treatment of pre-menopausal women with early breast cancer. As ovarian suppression is unlikely to benefit women with ER-negative tumours, the review is limited to women with ER-positive disease. The objectives of this review were to address the following issues; the role of LHRH agonists compared to tamoxifen (TAM), LHRH agonists in place of chemotherapy and LHRH agonists integrated into chemo-hormonal regimens. We identified 11 randomised trials. In three trials, adjuvant suppression of ovarian function using LHRH agonists, with or without TAM, had similar benefits at 5-6 years follow-up in terms of disease-free survival (DFS) and overall survival (OS) to adjuvant CMF chemotherapy (J. Clin. Oncol 20(24) (2002) 4628; J. Natl. Cancer Inst. 95(24) (2003) 1833; Anticancer Res. 22 (2002) 2325; In: San Antonio Breast Cancer Symposium, San Antonio, TX, 2003, Abstr 40). These findings suggest that ovarian suppression using LHRH agonists (+/-TAM) is a reasonable alternative to CMF chemotherapy in women with oestrogen receptor (ER) positive tumours. The role of chemotherapy in addition to LHRH agonists is not clearly defined and mature results of four trials are awaited (J. Clin. Oncol. 20(24) (2002) 4621; J. Clin. Oncol. 18(14) (2000) 2718; Proc. Am. Soc. Clin. Oncol. 2000, Abstr 279; Proc. Am. Soc. Clin. Oncol. 20 (2001) Abstr 104; Proc. Am. Soc. Clin. Oncol. 2001, Abstr. 1777). Data is also inadequate at the time of publication to inform decisions about the efficacy of LHRH agonists in comparison with TAM for the treatment of ER-positive early breast cancer (Proc. Am. Soc. Clin. Oncol. 21 (2001) Abstr. 103; Eur. J. Surg. Oncol. 28(5) (2002) 505; Proc. Am. Soc. Clin. Oncol. 22 (2003), Abstr. 15).

Evolving treatment approaches for early breast cancer

Treatment approaches for early breast cancer continue to evolve as key trials involving adjuvant chemotherapy and hormonal therapy provide results that can inform clinical practice. The administration of a taxane, either in combination with or following doxorubicin and cyclophosphamide, has been shown to significantly improve disease-free survival (DFS) and overall survival (OS). In addition, a dose-dense treatment approach (reducing the inter-treatment interval) was found to be more effective than conventionally scheduled treatment in terms of DFS and OS. As treatment schemes evolve, supportive care becomes increasingly important to manage the toxicities of chemotherapy, such as anemia and impaired cognition. In addition to chemotherapy, the use of hormonal therapy continues to evolve, with studies demonstrating the benefit of the aromatase inhibitors and serum estrogen receptor down-regulation.

Predictive Markers in Breast and Other Cancers: A Review

Background: Unpredictable efficacy and toxicity are hallmarks of most anticancer therapies. Predictive markers are factors that are associated with response or resistance to a particular therapy.

Methods: The English literature relating to predictive markers in oncology was reviewed. Particular attention was paid to metaanalyses, systematic reviews, prospective trials, and guidelines issued by expert panels.

Results: The prototype predictive tests in oncology are the estrogen receptor (ER) and progesterone receptor (PR), which are used to select patients with breast cancer likely to respond to hormone therapy. A more recently introduced predictive marker is HER-2 for selecting patients with advanced breast cancer for treatment with the therapeutic antibody trastuzumab (Herceptin). In adjuvant breast cancer, overproduction of HER-2 may also indicate an enhanced sensitivity to high-dose anthracycline-based regimens. On the other hand, in both early and advanced breast cancer, high concentrations of HER-2 appear to correlate with a lower probability of response to hormone therapy. Although many different anticancer drugs appear to mediate tumor regression by inducing apoptosis, there is currently no consistent evidence that any of the molecules implicated in this process can be used as predictive markers.

Conclusions: Currently, the only recommended predictive markers in oncology are ER and PR for selecting endocrine-sensitive breast cancers and HER-2 for identifying breast cancer patients with metastatic disease who may benefit from trastuzumab. For malignancies other than breast cancers, validated predictive markers do not exist at present.

Goserelin

Goserelin (Zoladex), a gonadotropin-releasing hormone analogue, reduces plasma/serum estrogen levels in pre- or perimenopausal women (to postmenopausal levels), and is indicated in hormone receptor-positive early breast cancer in this population group. Adjuvant goserelin monotherapy has similar efficacy to adjuvant chemotherapy in pre- or perimenopausal women with early, hormone receptor-positive breast cancer. Furthermore, the addition of goserelin to adjuvant chemotherapy appeared to offer an advantage over chemotherapy alone in younger patients. Fewer patients remained amenorrheic after goserelin therapy than after chemotherapy. Complete endocrine blockade provided by the addition of tamoxifen to therapy including goserelin appears to improve outcomes. Thus, goserelin offers a valuable addition to the currently available options for treating pre- or perimenopausal women with hormone therapy-responsive early breast cancer, particularly for women wishing to regain ovarian function after treatment.

Tumor Markers in Breast Cancer – European Group on Tumor Markers Recommendations

Recommendations are presented for the routine clinical use of serum and tissue-based markers in the diagnosis and management of patients with breast cancer. Their low sensitivity and specificity preclude the use of serum markers such as the MUC-1 mucin glycoproteins (CA 15.3, BR 27.29) and carcinoembryonic antigen in the diagnosis of early breast cancer. However, serial measurement of these markers can result in the early detection of recurrent disease as well as indicate the efficacy of therapy. Of the tissue-based markers, measurement of estrogen and progesterone receptors is mandatory in the selection of patients for treatment with hormone therapy, while HER-2 is essential in selecting patients with advanced breast cancer for treatment with Herceptin (trastuzumab). Urokinase plasminogen activator and plasminogen activator inhibitor 1 are recently validated prognostic markers for lymph node-negative breast cancer patients and thus may be of value in selecting node-negative patients that do not require adjuvant chemotherapy.

Immunohistochemical evaluation of hormone receptors in breast cancer: which scoring system is suitable for highly sensitive procedures?

To evaluate hormone receptors immunohistochemically, standardized staining procedures and scoring systems are required. The authors previously reported that highly sensitive procedures affected basic factors for technical validation. The aim of the present study was to show the characteristics of scoring systems for highly sensitive procedures. To examine how highly sensitive procedures enhance the staining intensity and increase the positive cell population, two different staining methods were compared. To evaluate scoring systems, three systems--cell counting score, modified immunoreactive score, and H score--were compared using the same samples stained by an autostaining system. It was found that the highly sensitive procedure increased the positive cell population, especially in breast cancers with a low enzyme immunoassay (EIA) level of less than 100 fmol/mg, and strengthened the staining intensity. This enhancement led to a correlation in a logarithmic curve rather than a linear correlation by all three scoring systems. The results showed that scoring systems including a factor of staining intensity did not have an absolute advantage because boosted staining intensity by highly sensitive procedure did not reflect EIA value or protein contents accurately. To the authors' knowledge, there is no report discussing the nonlinear correlation between biochemical and immunohistochemical assay by highly sensitive procedures; however, it is important to select a scoring system and threshold based on nonlinear correlation.

Same gain, less pain: potential patient preferences for adjuvant treatment in premenopausal women with early breast cancer

The aim of this study was to determine the treatment preferences (adjuvant goserelin or cyclophosphamide, methotrexate and fluorouracil (CMF) chemotherapy) of healthy premenopausal women should they hypothetically develop oestrogen-receptor (ER) positive early breast cancer. Two hundred pre or peri-menopausal women read two scenarios describing goserelin or chemotherapy. Information included: How and where treatments were administered, side-effects, their likely persistence and impact on fertility. Women stated their unprompted initial and final preferences with reasons for the choices made. Respondents showed an overwhelming preference for goserelin. 156 (78%) women favoured goserelin, 22 (11%) chemotherapy and 22 (11%) remained undecided (P<0.0001). Primary reasons for preferring goserelin for were 105 (71%) avoidance of chemotherapy side-effects, especially hair loss, perceived convenience and less disruption to normal life 54 (36%). The minority who preferred chemotherapy, valued the treatment finishing more quickly. These results together with clinical trial data showing equivalence of goserelin with CMF regimens suggest that premenopausal women with ER-positive tumours should at least be offered the choice of either adjuvant hormone therapy or chemotherapy.

[Association of estrogen and progesterone receptor levels and the expected response to chemotherapy and hormone therapy in breast carcinoma with increased expression of human epidermal growth factor 2]

The predictive value of Human Epidermal growth factor Receptor 2 (HER-2) on the response to chemotherapy and endocrine therapy in breast cancer patients has not yet been determined. The expression of other biomarkers in breast cancer can further influence the response to therapy. The aim of our study was to investigate if status of steroid receptors (SR) influenced the response to anthracycline-containing chemotherapy and tamoxifen in a group of HER-2 positive advanced breast cancer patients. Forty breast cancer patients, who were entered into the various prospective clinical trials conducted at the Institute of Oncology and Radiology of Serbia during their metastatic phase of disease, were involved into this analysis. Steroid receptors content were determined both by biochemical method and immunohistochemical (ICH) method, while HER-2 content were determined only by ICH method. Twelve out of 40 women were sequentially treated by anthracycline-containing chemotherapy and, always upon disease progression, with antiestrogen tamoxifen. The objective response to anthracycline therapy was obtained in 4 out of 12 patients (RR = 0.33, CI 95% = 0.05-0.61). In three of them the response to tamoxifen was noticed, as well. Of 8 anthracycline resistant patients in this group, 7 patients also had disease progression as best response to tamoxifen despite the fact that most of them (5 out of 7 tamoxifen resistant women) had positive SR status. Our results showed a trend (Fisher test, p = 0.06) that clinical response to anthracycline-containing chemotherapy might be of some predictive value for the response to subsequent tamoxifen therapy in HER-2 positive advanced breast cancer patients. However, these results were obtained on a small number of patients, so further investigation is warranted.

Adjuvant endocrine therapy

Endocrine therapy remains a cornerstone of systemic therapy for breast cancer even though it was first introduced more than a century ago. In the past three decades a large number of randomized trials involving several tens of thousands of patients have been performed to determine the role of endocrine therapy in the adjuvant setting. The results of these studies indicate that hormonal therapy should be considered the standard adjuvant systemic treatment for the majority of patients with invasive breast cancer irrespective of age, menopausal status or tumour stage. This chapter aims to describe the "state of the art" relative to the use of adjuvant endocrine therapy with special focus on a number of salient issues, including: (i) the role of ovarian ablation and luteinising hormone releasing hormone (LHRH) analogues among pre-menopausal patients; (ii) optimal duration of tamoxifen; (iii) adjuvant therapy with third-generation, selective aromatase inhibitors; (iv) predictive biomarkers; (v) side-effects; (vi) combination endocrine therapy; (vii) future development of endocrine therapy.

Goserelin (‘Zoladex’)—offering patients more choice in early breast cancer

The luteinising hormone-releasing hormone analogue goserelin ('Zoladex') suppresses ovarian oestrogen production in pre- and perimenopausal women. Goserelin is a biodegradable, sustained-release 3.6 mg depot that is administered by subcutaneous injection every 28 days. Clinical trials in premenopausal women with hormone-sensitive early breast cancer have demonstrated that goserelin alone, or in combination with tamoxifen, is at least as effective as cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy. Goserelin plus tamoxifen after cyclophosphamide, doxorubicin and 5-fluorouracil (CAF) chemotherapy resulted in improved disease-free survival compared with CAF alone. These trials have also shown that goserelin is well tolerated and is associated with less acute toxicity than cytotoxic chemotherapy. Early improvements in quality of life over the first 3-6 months of goserelin treatment support the use of this agent as an alternative to chemotherapy in this patient population. Patients should be provided with information on the benefits and risks associated with available treatment options so that they can be involved in the decision-making process.

Ovarian ablation as a treatment for breast cancer

Ovarian ablation is an effective treatment for premenopausal women with hormone receptor positive breast cancer. It can be achieved permanently by surgery or radiotherapy and reversibly by LhRH agonists. This paper discusses the evidence that it is an effective adjuvant therapy and defines the place of oophorectomy in the management of such patients. The achievement of an amenhorreic state is important and chemotherapy may well exert some of its effects by causing ovarian suppression. The use of LhRH agonists in managing such patients is discussed.

Ovarian ablation in the adjuvant treatment of premenopausal and perimenopausal breast cancer

BACKGROUND

Ovarian ablation has been employed in the treatment of breast cancer for many decades and, more recently, its value as an adjuvant treatment for premenopausal women with early-stage disease has been clearly demonstrated. This review examines the different methods of achieving ovarian ablation and assesses the relevance of ovarian suppression as a treatment aim.

METHODS

Medline searches were used to identify recent key articles relating to the adenoma-carcinoma sequence. Further relevant articles were obtained by manual scanning of the reference lists of selected papers.

RESULTS AND CONCLUSION

Ovarian ablation has historically been achieved by surgical or radiological intervention. Although beneficial in premenopausal disease, these methods produce permanent ablation that results in a premature menopause, which may be associated with long-term adverse events. A series of trials have recently demonstrated the benefits of luteinizing hormone releasing hormone (LHRH) agonists, such as goserelin and leuprorelin, as adjuvant treatment for premenopausal hormone-sensitive disease. LHRH agonists produce a reliable suppression of ovarian oestrogen production of equivalent efficacy to adjuvant chemotherapy in hormone-sensitive disease. Effective ovarian suppression is marked by amenorrhoea, but studies have suggested that permanent amenorrhoea is not necessary to confer benefit in the treatment of early breast cancer. LHRH agonists therefore represent a beneficial therapeutic option for premenopausal patients with hormone-sensitive early disease.

American Society of Clinical Oncology technology assessment of pharmacologic interventions for breast cancer risk reduction including tamoxifen, raloxifene, and aromatase inhibition

OBJECTIVE

To update an evidence-based technology assessment of chemoprevention strategies for breast cancer risk reduction. POTENTIAL INTERVENTIONS: Tamoxifen, raloxifene, aromatase inhibition, and fenretinide.

OUTCOMES

Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefit.

EVIDENCE

A comprehensive, formal literature review was conducted for relevant topics. Testimony was collected from invited experts and interested parties. The American Society of Clinical Oncology (ASCO) prescribed technology assessment procedure was followed.

VALUES

More weight was given to published randomized trials. BENEFITS/HARMS: A woman's decision regarding breast cancer risk reduction strategies is complex and will depend on the importance and weight attributed to information regarding both cancer- and noncancer-related risks and benefits.

CONCLUSIONS

For women with a defined 5-year projected breast cancer risk of > or= 1.66%, tamoxifen (at 20 mg/d for 5 years) may be offered to reduce their risk. Risk/benefit models suggest that greatest clinical benefit with least side effects is derived from use of tamoxifen in younger (premenopausal) women (who are less likely to have thromboembolic sequelae and uterine cancer), women without a uterus, and women at higher breast cancer risk. Data do not as yet suggest that tamoxifen provides an overall health benefit or increases survival. In all circumstances, tamoxifen use should be discussed as part of an informed decision-making process with careful consideration of individually calculated risks and benefits. Use of tamoxifen combined with hormone replacement therapy or use of raloxifene, any aromatase inhibitor or inactivator, or fenretinide to lower the risk of developing breast cancer is not recommended outside of a clinical trial setting. This technology assessment represents an ongoing process and recommendations will be updated in a timely matter.

VALIDATION

The conclusions were endorsed by the ASCO Health Services Research Committee and the ASCO Board of Directors.