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Divekar S, Kritzer R, Shu H, Thakkar K, Hicks J, Mills MG, Makambi K, Dash C, Roy R. Systemic DNA Damage and Repair Activity Vary by Race in Breast Cancer Survivors. Cancers (Basel) 2024; 16:1807. [PMID: 38791886 PMCID: PMC11119753 DOI: 10.3390/cancers16101807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Non-Hispanic Black breast cancer survivors have poorer outcomes and higher mortality rates than White survivors, but systemic biological mechanisms underlying these disparities are unclear. We used circulating leukocytes as a surrogate for measuring systemic mechanisms, which might be different from processes in the target tissue (e.g., breast). We investigated race-based differences in DNA damage and repair, using a novel CometChip assay, in circulating leukocytes from breast cancer survivors who had completed primary cancer therapy and were cancer free. We observed novel race-based differences in systemic DNA damage and repair activity in cancer survivors, but not in cells from healthy volunteers. Basal DNA damage in leukocytes was higher in White survivors, but Black survivors showed a much higher induction after bleomycin treatment. Double-strand break repair activity was also significantly different between the races, with cells from White survivors showing more sustained repair activity compared to Black leukocytes. These results suggest that cancer and cancer therapy might have long-lasting effects on systemic DNA damage and repair mechanisms that differ in White survivors and Black survivors. Findings from our preliminary study in non-cancer cells (circulating leukocytes) suggest systemic effects beyond the target site, with implications for accelerated aging-related cancer survivorship disparities.
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Affiliation(s)
| | | | | | | | | | | | | | - Chiranjeev Dash
- Georgetown University’s Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA; (S.D.); (R.K.); (H.S.); (K.T.); (J.H.); (M.G.M.); (K.M.)
| | - Rabindra Roy
- Georgetown University’s Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA; (S.D.); (R.K.); (H.S.); (K.T.); (J.H.); (M.G.M.); (K.M.)
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2
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Oropeza E, Seker S, Carrel S, Mazumder A, Lozano D, Jimenez A, VandenHeuvel SN, Noltensmeyer DA, Punturi NB, Lei JT, Lim B, Waltz SE, Raghavan SA, Bainbridge MN, Haricharan S. Molecular portraits of cell cycle checkpoint kinases in cancer evolution, progression, and treatment responsiveness. SCIENCE ADVANCES 2023; 9:eadf2860. [PMID: 37390209 PMCID: PMC10313178 DOI: 10.1126/sciadv.adf2860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/26/2023] [Indexed: 07/02/2023]
Abstract
Cell cycle dysregulation is prerequisite for cancer formation. However, it is unknown whether the mode of dysregulation affects disease characteristics. Here, we conduct comprehensive analyses of cell cycle checkpoint dysregulation using patient data and experimental investigations. We find that ATM mutation predisposes the diagnosis of primary estrogen receptor (ER)+/human epidermal growth factor (HER)2- cancer in older women. Conversely, CHK2 dysregulation induces formation of metastatic, premenopausal ER+/HER2- breast cancer (P = 0.001) that is treatment-resistant (HR = 6.15, P = 0.01). Lastly, while mutations in ATR alone are rare, ATR/TP53 co-mutation is 12-fold enriched over expected in ER+/HER2- disease (P = 0.002) and associates with metastatic progression (HR = 2.01, P = 0.006). Concordantly, ATR dysregulation induces metastatic phenotypes in TP53 mutant, not wild-type, cells. Overall, we identify mode of cell cycle dysregulation as a distinct event that determines subtype, metastatic potential, and treatment responsiveness, providing rationale for reconsidering diagnostic classification through the lens of the mode of cell cycle dysregulation..
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Affiliation(s)
- Elena Oropeza
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Sinem Seker
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Sabrina Carrel
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Aloran Mazumder
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Daniel Lozano
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Athena Jimenez
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | | | | | - Nindo B. Punturi
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Jonathan T. Lei
- Lester and Sue Smith Breast Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Bora Lim
- Lester and Sue Smith Breast Cancer Center, Baylor College of Medicine, Houston, TX, USA
- Department of Oncology/Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Susan E. Waltz
- Department of Cancer Biology, University of Cincinnati, Cincinnati, OH, USA
- Research Service, Cincinnati Veteran's Affairs Medical Center, 3200 Vine St., Cincinnati, OH, USA
| | | | | | - Svasti Haricharan
- Aging and Cancer Immunology, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
- NCI-designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
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3
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Yap YS. Outcomes in breast cancer-does ethnicity matter? ESMO Open 2023; 8:101564. [PMID: 37290358 DOI: 10.1016/j.esmoop.2023.101564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Ethnic or racial differences in breast cancer (BC) survival outcomes have been reported, but current data are largely restricted to comparisons between African Americans and non-Hispanic whites. Most analyses have traditionally been based on self-reported race which may not always be accurate, or are oversimplified in their classification. With increasing globalization, quantification of the genetic ancestry from genomic data may offer a solution to infer the complex makeup from admixture of races. Focusing on the larger and the latest studies, we will discuss recent findings on the differing host and tumor biology that may be driving these disparities, in addition to the extrinsic environmental or lifestyle factors. Socioeconomic disparities with lower cancer literacy may lead to late presentation, poorer adherence to treatment, and other lifestyle factors such as unhealthy diet, obesity, and inadequate physical activity. These hardships may also result in greater allostatic load, which is in turn associated with aggressive BC features in disadvantaged populations. Epigenetic reprogramming may mediate the effects of the environment or lifestyle factors on gene expression, with ensuing differences in BC characteristics and outcome. There is increasing evidence that germline genetics can influence somatic gene alterations or expression, as well as modulate the tumor or immune microenvironment. Although the precise mechanisms remain elusive, this may account for the varying distribution of different BC subtypes across ethnicities. These gaps in our knowledge highlight the need to interrogate the multiomics landscape of BC in diverse populations, ideally in large-scale collaborative settings with standardized methodology for the comparisons to be statistically robust. Together with improving BC awareness and access to good quality health care, a holistic approach with insights of the biological underpinnings is much needed to eradicate ethnic disparities in BC outcomes.
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Affiliation(s)
- Y-S Yap
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore.
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Bauer M, Vetter M, Stückrath K, Yohannes M, Desalegn Z, Yalew T, Bekuretsion Y, Kenea TW, Joffe M, van den Berg EJ, Nikulu JI, Bakarou K, Manraj SS, Ogunbiyi OJ, Ekanem IO, Igbinoba F, Diomande M, Adebamowo C, Dzamalala CP, Anele AA, Zietsman A, Galukande M, Foerster M, dos-Santos-Silva I, Liu B, Santos P, Jemal A, Abebe T, Wickenhauser C, Seliger B, McCormack V, Kantelhardt EJ. Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa. Cancer Immunol Res 2023; 11:720-731. [PMID: 37058582 PMCID: PMC10552870 DOI: 10.1158/2326-6066.cir-22-0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/18/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023]
Abstract
The low overall survival rates of patients with breast cancer in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis, and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients' prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded breast cancer samples, including samples of the "African Breast Cancer-Disparities in Outcomes (ABC-DO) Study," were analyzed. The immune cell phenotypes, their spatial distribution in the TME, and immune escape mechanisms of breast cancer samples from SSA and Germany (n = 117) were investigated using histomorphology, conventional and multiplex IHC, and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TIL) in the 1,237 SSA breast cancer samples, while the distribution of TILs in different breast cancer IHC subtypes showed regional diversity, particularly when compared with German samples. Higher TIL densities were associated with better survival in the SSA cohort (n = 400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in breast cancer samples from Western SSA. Features of nonimmunogenic breast cancer phenotypes were associated with reduced patient survival (n = 131). We therefore conclude that regional diversity in the distribution of breast cancer subtypes, TME composition, and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies. See related Spotlight by Bergin et al., p. 705.
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Affiliation(s)
- Marcus Bauer
- Department of Pathology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Martina Vetter
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kathrin Stückrath
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Meron Yohannes
- Department of Medical Laboratory Science, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zelalem Desalegn
- Department of Microbiology, Immunology & Parasitology, School of Medicine, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tewodros Yalew
- Department of Pathology, Tikur Anbessa Specialized University Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yonas Bekuretsion
- Department of Pathology, Tikur Anbessa Specialized University Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tariku W. Kenea
- Department of Surgery, Aira General Hospital, Aira, Ethiopia
| | - Maureen Joffe
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) Ltd, Johannesburg, South Africa and U Witwatersrand, Faculty of Health Sciences, Strengthening Oncology Services Research Unit
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eunice J van den Berg
- Department of Anatomical Pathology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Julien I. Nikulu
- Ligue congolaise contre le cancer, l’Unité Pilote du GFAOP, Lubumbashi, Democratic Republic of the Congo
| | - Kamate Bakarou
- Service d’anatomie, Cytologie Pathologique au C.H.U. du point G BP:333, Bamako, Mali
| | - Shyam S. Manraj
- Central Health Laboratory, Victoria Hospital, Candos, Mauritius
| | - Olufemi J. Ogunbiyi
- Department of Pathology, University College Hospital, Ibadan, Oyo state, Nigeria
| | - Ima-Obong Ekanem
- Department of Pathology, Calabar Cancer Registry, University of Calabar Teaching Hospital, Calabar, Nigeria
| | | | - Mohenou Diomande
- Service d’anatomie et cytologie pathologiques, Abidjan, Côte d’Ivoire
| | - Clement Adebamowo
- Department of Epidemiology and Public Health, and the Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore
| | | | | | - Annelle Zietsman
- AB May Cancer Centre, Windhoek Central Hospital, Windhoek, Namibia
| | - Moses Galukande
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Milena Foerster
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Isabel dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM)
| | - Biying Liu
- African Cancer Registry Network, Oxford, United Kingdom
| | - Pablo Santos
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | - Tamrat Abebe
- Department of Medical Laboratory Science, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Claudia Wickenhauser
- Department of Pathology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Barbara Seliger
- Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Translational Immunology, Medical School ‘Theodor Fontane, Brandenburg an der Havel, Germany
- Fraunhofer Institute for Immunology, Leipzig, Germany
| | - Valerie McCormack
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, Lyon, France
| | - Eva J. Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Gynecology, University Hospital Halle, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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5
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Richardson A, Darst B, Wojcik G, Wagle N, Haricharan S. Research Silos in Cancer Disparities: Obstacles to Improving Clinical Outcomes for Underserved Patient Populations. Clin Cancer Res 2023; 29:1194-1199. [PMID: 36638200 PMCID: PMC10073283 DOI: 10.1158/1078-0432.ccr-22-3182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/08/2022] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
Despite much vaunted progress in cancer therapeutics and diagnostics, outcomes for many groups of non-White patients with cancer remain worse than those for their White compatriots. One reason for this is the lack of inclusion and representation of non-White patients in clinical trials, preclinical datasets, and among researchers, a shortfall that is gaining wide recognition within the cancer research community and the lay public. Several reviews and editorials have commented on the negative impacts of the status quo on progress in cancer research toward medical breakthroughs that help all communities and not just White patients with cancer. In this perspective, we describe the existence of research silos focused either on the impact of socioeconomic factors proceeding from systemic racism on cancer outcomes, or on genetic ancestry as it affects the molecular biology of cancer developing in specific patient populations. While both these research areas are critical for progress toward precision medicine equity, breaking down these silos will help us gain an integrated understanding of how race and racism impact cancer development, progression, and patient outcomes. Bringing this comprehensive approach to cancer disparities research will undoubtedly improve our overall understanding of how stress and environmental factors affect the molecular biology of cancer, which will lead to the development of new diagnostics and therapeutics that are applicable across cancer patient demographics.
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Affiliation(s)
| | - Burcu Darst
- Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA
| | - Genevieve Wojcik
- Dept of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Nikhil Wagle
- Dept of Medicine, Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Svasti Haricharan
- Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA
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6
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Lovejoy LA, Shriver CD, Haricharan S, Ellsworth RE. Survival Disparities in US Black Compared to White Women with Hormone Receptor Positive-HER2 Negative Breast Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2903. [PMID: 36833598 PMCID: PMC9956998 DOI: 10.3390/ijerph20042903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Black women in the US have significantly higher breast cancer mortality than White women. Within biomarker-defined tumor subtypes, disparate outcomes seem to be limited to women with hormone receptor positive and HER2 negative (HR+/HER2-) breast cancer, a subtype usually associated with favorable prognosis. In this review, we present data from an array of studies that demonstrate significantly higher mortality in Black compared to White women with HR+/HER2-breast cancer and contrast these data to studies from integrated healthcare systems that failed to find survival differences. Then, we describe factors, both biological and non-biological, that may contribute to disparate survival in Black women.
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Affiliation(s)
- Leann A. Lovejoy
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, PA 15963, USA
| | - Craig D. Shriver
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Svasti Haricharan
- Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Rachel E. Ellsworth
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
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7
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Walens A, Van Alsten SC, Olsson LT, Smith MA, Lockhart A, Gao X, Hamilton AM, Kirk EL, Love MI, Gupta GP, Perou CM, Vaziri C, Hoadley KA, Troester MA. RNA-Based Classification of Homologous Recombination Deficiency in Racially Diverse Patients with Breast Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:2136-2147. [PMID: 36129803 PMCID: PMC9720427 DOI: 10.1158/1055-9965.epi-22-0590] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/03/2022] [Accepted: 09/14/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Aberrant expression of DNA repair pathways such as homologous recombination (HR) can lead to DNA repair imbalance, genomic instability, and altered chemotherapy response. DNA repair imbalance may predict prognosis, but variation in DNA repair in diverse cohorts of breast cancer patients is understudied. METHODS To identify RNA-based patterns of DNA repair expression, we performed unsupervised clustering on 51 DNA repair-related genes in the Cancer Genome Atlas Breast Cancer [TCGA BRCA (n = 1,094)] and Carolina Breast Cancer Study [CBCS (n = 1,461)]. Using published DNA-based HR deficiency (HRD) scores (high-HRD ≥ 42) from TCGA, we trained an RNA-based supervised classifier. Unsupervised and supervised HRD classifiers were evaluated in association with demographics, tumor characteristics, and clinical outcomes. RESULTS : Unsupervised clustering on DNA repair genes identified four clusters of breast tumors, with one group having high expression of HR genes. Approximately 39.7% of CBCS and 29.3% of TCGA breast tumors had this unsupervised high-HRD (U-HRD) profile. A supervised HRD classifier (S-HRD) trained on TCGA had 84% sensitivity and 73% specificity to detect HRD-high samples. Both U-HRD and S-HRD tumors in CBCS had higher frequency of TP53 mutant-like status (45% and 41% enrichment) and basal-like subtype (63% and 58% enrichment). S-HRD high was more common among black patients. Among chemotherapy-treated participants, recurrence was associated with S-HRD high (HR: 2.38, 95% confidence interval = 1.50-3.78). CONCLUSIONS HRD is associated with poor prognosis and enriched in the tumors of black women. IMPACT RNA-level indicators of HRD are predictive of breast cancer outcomes in diverse populations.
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Affiliation(s)
- Andrea Walens
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Sarah C. Van Alsten
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Linnea T. Olsson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Markia A. Smith
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Alex Lockhart
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xiaohua Gao
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Alina M. Hamilton
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Erin L. Kirk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Michael I. Love
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gaorav P. Gupta
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Charles M. Perou
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cyrus Vaziri
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Katherine A. Hoadley
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Melissa A. Troester
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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