Evaluation of Local and Distant Recurrence Patterns in Patients with Triple-Negative Breast Cancer According to Age

Classifications of triple-negative breast cancer: insights and current therapeutic approaches

Triple-negative breast cancer (TNBC) is an aggressive and challenging type of cancer, characterized by the absence of specific receptors targeted by current therapies, which limits effective targeted treatment options. TNBC has a high risk of recurrence and distant metastasis, resulting in lower survival rates. Additionally, TNBC exhibits significant heterogeneity at histopathological, proteomic, transcriptomic, and genomic levels, further complicating the development of effective treatments. While some TNBC subtypes may initially respond to chemotherapy, resistance frequently develops, increasing the risk of aggressive recurrence. Therefore, precisely classifying and characterizing the distinct features of TNBC subtypes is crucial for identifying the most suitable molecular-based therapies for individual patients. In this review, we provide a comprehensive overview of these subtypes, highlighting their unique profiles as defined by various classification systems. We also address the limitations of conventional therapeutic approaches and explore innovative biological strategies, all aimed at advancing the development of targeted and effective therapeutic strategies for TNBC.

miRNA signatures affecting the survival outcome in distant metastasis of triple-negative breast cancer

Triple-negative breast cancer (TNBC) constitutes for 10-15% of all breast cancer cases. Tumor heterogeneity, high invasiveness, distant metastasis, lack of estrogen receptors, progesterone receptors, and human epidermal growth factor receptor 2 expression contribute to TNBC associated with poor overall survival outcomes amongst diseased individuals. The disparity in clinico-pathological and metastatic patterns to distant sites has substantially enhanced the incidences of tumor recurrence. Survival outcomes amongst metastatic TNBC patients are worse in comparison to non-metastatic TNBC counterparts. MicroRNAs (miRNAs) have emerged as significant drivers to function either as oncogene or tumor suppressors by exerting modulating effects on the expression of target genes in the TNBC tumor microenvironment. The pleiotropic nature of miRNAs expands their preclinical and clinical utility in combating both metastatic and non-metastatic TNBC cases and thereby improves their survival outcomes. The present review article aims to highlight the varying survival outcomes in metastatic and non-metastatic TNBC cases. The present review article emphasizes the therapeutic and prognostic potential of miRNAs in TNBC to improve survival outcomes by retarding distant metastasis to lung, bone, brain, and lymph nodes.

Treatment Outcomes after Postoperative Radiotherapy in Triple-Negative Breast Cancer: Multi-Institutional Retrospective Study (KROG 17-05)

BACKGROUND

We designed a multi-institutional retrospective study to investigate the previously unreported failure pattern, survivals, and prognostic factors after postoperative radiotherapy (PORT) in triple negative breast cancer (TNBC) patients in South Korea.

MATERIALS AND METHODS

We retrospectively reviewed 699 patients with TNBC who underwent PORT at six institutions between 2008 and 2010. The median follow-up period was 94 months (range: 7-192 months). There were 216, 380, and 100 patients in stages I, II, and III, respectively.

RESULTS

After 94 months post-treatment, all patients with pathologic complete remission after neoadjuvant chemotherapy were alive without any failure. Distant metastasis was the main cause of failure. The 5-year overall survival rate was 91.4%, 5-year loco-regional relapse-free survival rate (LRRFS) was 92.3%, 5-year distant metastasis-free survival rate (DMFS) was 89.4%, and 5-year disease-free survival rate (DFS) was 85.2%. On multivariate (Cox) analysis, T and N stages were significant prognostic factors for survival, and lympho-vascular invasion (LVI) was a significant factor for LRRFS and DMFS. Ki-67 expression was significantly associated with LRRFS and DFS.

CONCLUSION

We verified that T and N stages, LVI, and Ki-67 expression were significantly associated with survival outcomes after PORT in TNBC.

Next-generation biomarkers for prognostic and potential therapeutic enhancement in Triple negative breast cancer

Triple-negative breast carcinoma (TNBC) is one of the most challenging subtypes of breast carcinoma and it has very limited therapeutic options as it is highly aggressive. The prognostic biomarkers are crucial for early diagnosis of the tumor, it also helps in anticipating the trajectory of the illness and optimizing the therapy options. Several therapeutic biomarkers are being used. Among them, the next-generation biomarkers that include Circulating tumor (ct) DNA, glycogen, lipid, and exosome biomarkers provide intriguing opportunities for enhancing the prognosis of TNBC. Lipid and glycogen biomarkers serve as essential details on the development of the tumor along with the efficacy of the treatment, as it exhibits metabolic alteration linked to TNBC. Several types of biomarkers have predictive abilities in TNBC. Elevated levels are associated with worse outcomes. ctDNA being a noninvasive biomarker reveals the genetic composition of the tumor, as well as helps to monitor the progression of the disease. Traditional therapies are ineffective in TNBC due to a lack of receptors, targeted drug delivery provides a tailored approach to overcome drug resistance and site-specific action by minimizing the side effects in TNBC treatment. This enhances therapeutic outcomes against the aggressive nature of breast cancer. This paper includes all the recent biomarkers which has been researched so far in TNBC and the state of art for TNBC which is explored.

Risk factors and prognostic factors of brain metastasis of triple-negative breast cancer: A single-center retrospective study

OBJECTIVE

This retrospective study is to explore the risk factors and prognostic factors of brain metastases of triple-negative breast cancer (TNBC) in a single center.

METHODS

Clinical data of patients with stages I-III TNBC were collected. The Kaplan-Meier method, log-rank test, and stepwise COX regression were performed.

RESULTS

The 437 patients with stages I-III TNBC were followed up for five years. Among them, 89 cases (20.4%) developed brain metastases, and they were followed up for 2 years after brain metastasis. The cumulative brain metastasis rates of TNBC patients at six months, one year, two years, three years, and five years were 1.38%, 5.75%, 12.94%, 17.63%, and 21.26%, respectively. Multivariate analysis suggested that the first diagnosis age ≤35 years old, advanced pathological stage, lymph node metastasis, and Ki-67 ≥30% represented the risk factors for brain metastasis. In contrast, the surgical method was a protective factor for brain metastasis. The median survival time after brain metastasis was 4.87 months. The survival rates at one, three, six, 12, and 24 months were 84.27%, 60.67%, 34.83%, 15.69%, and 6.64%, respectively. The age >60 years at first diagnosis, Ki-67 ≥30%, local recurrence, and distant metastasis were closely related to the poor prognosis of TNBC patients with brain metastases, while radiotherapy alone, systemic therapy, and combined chemotherapy and radiotherapy represented the prognostic protective factors.

CONCLUSIONS

Patient age, Ki-67 level, metastasis, and treatment methods are the risk factors and prognostic factors for brain metastasis of TNBC. Surgical resection of the primary lesion during the first treatment is essential to reduce the incidence of brain metastases. Close postoperative follow-up (such as brain magnetic resonance imaging [MRI]) within 2-3 years after surgery is recommended to improve the prognosis.

The 3q Oncogene SEC62 Predicts Response to Neoadjuvant Chemotherapy and Regulates Tumor Cell Migration in Triple Negative Breast Cancer

In the absence of targeted treatment options, neoadjuvant chemotherapy (NACT) is applied widely for triple-negative breast cancer (TNBC). Response to NACT is an important parameter predictive of oncological outcomes (progression-free and overall survival). An approach to the evaluation of predictive markers enabling therapy individualization is the identification of tumor driver genetic mutations. This study was conducted to investigate the role of SEC62, harbored at 3q26 and identified as a driver of breast cancer pathogenesis, in TNBC. We analyzed SEC62 expression in The Cancer Genome Atlas database, and immunohistologically investigated SEC62 expression in pre- and post-NACT tissue samples from 64 patients with TNBC treated at the Department of Gynecology and Obstetrics/Saarland University Hospital/Homburg between January 2010 and December 2018 and compared the effect of SEC62 on tumor cell migration and proliferation in functional assays. SEC62 expression dynamics correlated positively with the response to NACT (p ≤ 0.01) and oncological outcomes (p ≤ 0.01). SEC62 expression stimulated tumor cell migration (p ≤ 0.01). The study findings indicate that SEC62 is overexpressed in TNBC and serves as a predictive marker for the response to NACT, a prognostic marker for oncological outcomes, and a migration-stimulating oncogene in TNBC.

Significance of Oct-4 transcription factor as a pivotal therapeutic target for CD44+ /24- mammary tumor initiating cells: Aiming at the root of the recurrence

Breast cancer (BC) remains one of the deadliest and frequently diagnosed metastatic cancers worldwide. Cancer stem cells (CSCs) are the cell population within the tumor niche, having an epithelial to mesenchymal (EMT) transition phenotype, high self-renewal, vigorous metastatic capacity, drug resistance, and tumor relapse. Identification of targets for induction of apoptosis is essential to provide novel therapeutic approaches in BC. Our earlier studies showed that Vitamin C induces apoptotic cell death by losing redox balance in TNBC CSCs. In this study, we have attempted to identify previously unrecognized CSC survival factors that can be used as druggable targets for bCSCs apoptosis regulators isolated from the TNBC line, MDA MB 468. After a thorough literature review, Oct-4 was identified as the most promising marker for its unique abundance in cancer and absence in normal cells and the contribution of Oct-4 to the sustenance of cancer cells. We then validated a very high expression of Oct-4 in the MDA MB 468 bCSCs population using flow-cytometry. The loss of Oct-4 was carried out using small interfering RNA (siRNA)-mediated knockdown in the bCSCs, followed by assessing for cellular apoptosis. Our results indicated that Oct-4 knockdown induced cell death, changes in cellular morphology, inhibited mammosphere formation, and positive for Annexin-V expression, thereby indicating the role of Oct-4 in bCSC survival. Moreover, our findings also suggest the direct interaction between Oct-4 and Vitamin C using in silico docking. This data, hence, contributes towards novel information about Oct-4 highlighting this molecule as a novel survival factor in bCSCs.

The Association between Early-Onset Diagnosis and Clinical Outcomes in Triple-Negative Breast Cancer: A Systematic Review and Meta-Analysis

Early-onset diagnosis, defined by age <40 years, has historically been associated with inferior outcomes in breast cancer. Recent evidence suggests that this association is modified by molecular subtype. We performed a systematic review and meta-analysis of the literature to synthesize evidence on the association between early-onset diagnosis and clinical outcomes in triple-negative breast cancer (TNBC). Studies comparing the risk of clinical outcomes in non-metastatic TNBC between early-onset patients and later-onset patients (≥40 years) were queried in Medline and EMBASE from inception to February 2023. Separate meta-analyses were performed for breast cancer specific survival (BCSS), overall survival (OS), and disease-free survival (DFS), locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and pathological complete response (pCR). In total, 7581 unique records were identified, and 36 studies satisfied inclusion criteria. The pooled risk of any recurrence was significantly greater in early-onset patients compared to later-onset patients. Better BCSS and OS were observed in early-onset patients relative to later-onset patients aged >60 years. The pooled odds of achieving pCR were significantly higher in early-onset patients. Future studies should evaluate the role of locoregional management of TNBC and the implementation of novel therapies such as PARP inhibitors in real-world settings, and whether they improve outcomes.

Risk of developing a second primary cancer in male breast cancer survivors: a systematic review and meta-analysis

BACKGROUND

With increasing survival after cancer diagnoses, second primary cancers (SPCs) are becoming more prevalent. We investigated the incidence and site of non-breast SPC risks following male breast cancer (BC).

METHODS

PubMed, Embase and Web of Science were systematically searched for studies reporting standardised incidence ratios (SIRs) for SPCs published by March 2022. Meta-analyses used the generic inverse-variance method, assuming a random-effects model. We evaluated SIRs for overall SPCs, site-specific risks, by age at BC onset, time since BC onset and geographic region. We assessed study quality using routine techniques.

RESULTS

Eight population-based retrospective cohort studies were identified. SIRs ranged from 1.05 to 2.17. The summary SIR estimate was 1.27 (95% CI: 1.03-1.56, I2: 86%), and there were increased colorectal (SIR: 1.29, 95% CI: 1.03-1.61), pancreatic (SIR: 1.64, 95% CI: 1.05-2.55) and thyroid (SIR: 5.58, 95% CI: 1.04-30.05) SPC risks. When an outlying study was excluded, the summary SIR for men diagnosed with BC before age 50 was 1.50 (95% CI: 1.21-1.85), significantly higher than men diagnosed at older ages (SIR: 1.14, 95% CI: 0.98-1.33).

CONCLUSIONS

Male BC survivors are at elevated risks of developing second primary colorectal, pancreatic and thyroid cancers. The estimates may assist their clinical management and guide decisions on genetic testing.

A synchronized dual drug delivery molecule targeting cancer stem cells in tumor heterogeneity and metastasis

Cancer stem-like cells (CSCs) represent a key barrier to successful therapy for triple-negative breast cancer (TNBC). CSCs promote the emergence of chemoresistance, triggering relapse and resulting in a poor prognosis. We herein present CDF-TM, a new small molecule-based binary prodrug conjugated with SN-38 and 3,4-difluorobenzylidene curcumin (CDF) that is specifically activated in hypoxic conditions. CDF-TM treatment significantly induced apoptosis in TNBC-derived 3D spheroids, accompanied with caspase-3 activation as well as the attenuation of tumor stemness with evidence of reduction in aldehyde dehydrogenase 1 (ALDH1) activity and the CD44^high/CD24^low phenotype. An in vivo orthotopic allograft model was used to investigate its effects on tumor growth and metastasis. The dissemination of CSCs from primary allografts was impaired by CDF-TM, along with inhibition of tumor growth via eradication of CSCs and downregulation of multidrug resistance 1 (MDR1). This new small molecule-based binary prodrug offers a novel therapeutic option for metastatic TNBC.

Age disparities in triple-negative breast cancer treatment and outcomes: An NCDB analysis

BACKGROUND

Race, access to care, and molecular features result in outcome disparities in triple-negative breast cancer (TNBC). We sought to determine the role of age in TNBC disparity by hypothesizing that younger patients receive more comprehensive treatment, resulting in survival differences.

METHODS

The National Cancer Database was used to identify women with unilateral TNBC treated from 2005 through 2017. Patients were stratified by age (≤40, 41-70, >70); demographics, clinical characteristics, and treatment factors were compared. Logistic regression determined factors associated with treatment received. Survival outcomes were analyzed using a stratified log-rank test.

RESULTS

Of the 168,715 patients, 16,287 (9.6%) were ≤40 years. Patients ≤40 were significantly more likely to present at higher clinical stage (P < .001) and receive neoadjuvant chemotherapy (NAC, P < .001). Bilateral mastectomy was the most common surgery for patients ≤40 (37%), whereas partial mastectomy was most often used in patients 41 to 70 years old (48%) and those >70 (49%) (P < .001). Patients ≤40 years were significantly more likely to undergo both NAC and mastectomy than those >40 (odds ratio 1.5, both P < .05) despite a greater in-breast tumor response in the youngest patients. Patients treated with mastectomy and axillary lymph node dissection had inferior survival outcomes compared to those treated with partial mastectomy and sentinel lymph node biopsy across all 3 age groups (P < .001).

CONCLUSION

The clinical characteristics of TNBC differ significantly at the extremes of age, likely driving treatment decisions. Although patients ≤40 present with a more advanced disease and appropriately receive NAC, they also undergo more extensive surgery that does not yield a survival benefit. Further research is needed to determine if age disparity is due to oncologic factors or patient and provider preferences.

Repurposing Tranexamic Acid as an Anticancer Agent

Tranexamic Acid (TA) is a clinically used antifibrinolytic agent that acts as a Lys mimetic to block binding of Plasminogen with Plasminogen activators, preventing conversion of Plasminogen to its proteolytically activated form, Plasmin. Previous studies suggested that TA may exhibit anticancer activity by blockade of extracellular Plasmin formation. Plasmin-mediated cleavage of the CDCP1 protein may increase its oncogenic functions through several downstream pathways. Results presented herein demonstrate that TA blocks Plasmin-mediated excision of the extracellular domain of the oncoprotein CDCP1. In vitro studies indicate that TA reduces the viability of a broad array of human and murine cancer cell lines, and breast tumor growth studies demonstrate that TA reduces cancer growth in vivo. Based on the ability of TA to mimic Lys and Arg, we hypothesized that TA may perturb multiple processes that involve Lys/Arg-rich protein sequences, and that TA may alter intracellular signaling pathways in addition to blocking extracellular Plasmin production. Indeed, TA-mediated suppression of tumor cell viability is associated with multiple biochemical actions, including inhibition of protein synthesis, reduced activating phosphorylation of STAT3 and S6K1, decreased expression of the MYC oncoprotein, and suppression of Lys acetylation. Further, TA inhibited uptake of Lys and Arg by cancer cells. These findings suggest that TA or TA analogs may serve as lead compounds and inspire the production of new classes of anticancer agents that function by mimicking Lys and Arg.

Varying outcomes of triple-negative breast cancer in different age groups-prognostic value of clinical features and proliferation

PURPOSE

Triple-negative breast cancer (TNBC) is an aggressive disease lacking specific biomarkers to guide treatment decisions. We evaluated the combined prognostic impact of clinical features and novel biomarkers of cell cycle-progression in age-dependent subgroups of TNBC patients.

METHODS

One hundred forty seven TNBC patients with complete clinical data and up to 18 year follow-up were collected from Turku University Hospital, Finland. Eight biomarkers for cell division were immunohistochemically detected to evaluate their clinical applicability in relation to patient and tumor characteristics.

RESULTS

Age at diagnosis was the decisive factor predicting disease-specific mortality in TNBC (p = 0.002). The established prognostic features, nodal status and Ki-67, predicted survival only when combined with age. The outcome and prognostic features differed significantly between age groups, middle-aged patients showing the most favorable outcome. Among young patients, only lack of basal differentiation predicted disease outcome, indicating 4.5-fold mortality risk (p = 0.03). Among patients aged > 57, the established prognostic features predicted disease outcome with up to 3.0-fold mortality risk for tumor size ≥ 2 cm (p = 0.001). Concerning cell proliferation, Ki-67 alone was a significant prognosticator among patients aged > 57 years (p = 0.009). Among the studied cell cycle-specific biomarkers, only geminin predicted disease outcome, indicating up to 6.2-fold increased risk of mortality for tumor size < 2 cm (p = 0.03).

CONCLUSION

Traditional clinical features do not provide optimal prognostic characterization for all TNBC patients. Young age should be considered as an additional adverse prognostic feature in therapeutic considerations. Increased proliferation, as evaluated using Ki-67 or geminin immunohistochemistry, showed potential in detecting survival differences in subgroups of TNBC.

Real-World Data from a Refractory Triple-Negative Breast Cancer Cohort Selected Using a Clinical Data Warehouse Approach

Simple Summary

Patients with metastatic triple-negative breast cancer (mTNBC) have a very poor prognosis. We assume that some mTNBC patients have worse treatment outcomes and defined them as cases of refractory TNBC. We tried to investigate the characteristics and treatment outcomes of our refractory mTNBC cohort selected using a clinical data warehouse (CDW) approach. Between January 1997 and December 2019, TNBC patients were searched for in the breast cancer registry and, among them, pathologically confirmed mTNBC patients were selected as the study cohort (n = 451). Refractory TNBC was defined as cases of TNBC with confirmed distant metastasis within one year after adjuvant treatment. The refractory mTNBC group was younger and had a higher proportion of Ki-67 ≥ 3+ than the nonrefractory group. In addition, a much poorer prognosis existed among mTNBC patients, with an overall survival (OS) of 14.3 months and progression-free survival (PFS) of 4.2 months after first-line palliative chemotherapy compared to an OS of 24.8 months and PFS of 6.2 months in the nonrefractory TNBC group (p < 0.001).

Abstract

Purpose: Triple-negative breast cancer (TNBC) is well known for its aggressive course and poor prognosis. In this study, we sought to investigate clinical, demographic, and pathologic characteristics and treatment outcomes of patients with refractory, metastatic TNBC selected by a clinical data warehouse (CDW) approach. Patients and methods: Data were extracted from the real-time breast cancer registry integrated into the Data Analytics and Research Window for Integrated Knowledge C (DARWIN-C), the CDW of Samsung Medical Center. Between January 1997 and December 2019, a TNBC cohort was searched for in the breast cancer registry, which includes records from more than 40,000 patients. Among them, cases of pathologically confirmed metastatic TNBC (mTNBC) were selected as the cohort group (n = 451). The extracted data from the registry via the CDW platform included clinical, pathological, laboratory, and chemotherapy information. Refractory TNBC was defined as confirmed distant metastasis within one year after adjuvant treatment. Results: This study comprised a total of 451 patients with mTNBC, including 69 patients with de novo mTNBC, 131 patients in the nonrefractory TNBC group with confirmed stage IV disease after one year of adjuvant treatment, and 251 patients with refractory mTNBC, whose disease recurred as stage IV within one year after completing adjuvant treatment. The refractory mTNBC cohort was composed of patients with disease that recurred at stage IV after surgery (refractory mTNBC after surgery) (n = 207) and patients in whom metastasis was confirmed during neoadjuvant chemotherapy (unresectable TNBC due to progression during neoadjuvant chemotherapy) (n = 44). Patients in the refractory mTNBC group were younger than those in the nonrefractory group (median age 46 vs. 51 years; p < 0.001). Considering the pathological findings, the refractory group had a greater proportion of cases with Ki-67 ≥ 3+ than did the nonrefractory group (71% vs. 47%; p = 0.004). During a median 8.4 years of follow-up, the overall survival was 24.8 months in the nonrefractory mTNBC group and 14.3 months in the refractory mTNBC group (p < 0.001), and the median progression-free survival periods were 6.2 months and 4.2 months, respectively (p < 0.001). The median disease-free survival period was 30.1 months in the nonrefractory mTNBC group and only 7.6 months in the refractory mTNBC group. Factors related to metastatic sites affecting overall survival were liver metastasis at diagnosis (p < 0.001) and leptomeningeal involvement (p = 0.001). Conclusions: We revealed that patients with refractory mTNBC had a much poorer prognosis among all mTNBC cases and described the characteristics of this patient group.

Molecular analyses of triple-negative breast cancer in the young and elderly

Background

Breast cancer in young adults has been implicated with a worse outcome. Analyses of genomic traits associated with age have been heterogenous, likely because of an incomplete accounting for underlying molecular subtypes. We aimed to resolve whether triple-negative breast cancer (TNBC) in younger versus older patients represent similar or different molecular diseases in the context of genetic and transcriptional subtypes and immune cell infiltration.

Patients and methods

In total, 237 patients from a reported population-based south Swedish TNBC cohort profiled by RNA sequencing and whole-genome sequencing (WGS) were included. Patients were binned in 10-year intervals. Complimentary PD-L1 and CD20 immunohistochemistry and estimation of tumor-infiltrating lymphocytes (TILs) were performed. Cases were analyzed for differences in patient outcome, genomic, transcriptional, and immune landscape features versus age at diagnosis. Additionally, 560 public WGS breast cancer profiles were used for validation.

Results

Median age at diagnosis was 62 years (range 26–91). Age was not associated with invasive disease-free survival or overall survival after adjuvant chemotherapy. Among the BRCA1-deficient cases (82/237), 90% were diagnosed before the age of 70 and were predominantly of the basal-like subtype. In the full TNBC cohort, reported associations of patient age with changes in Ki67 expression, PIK3CA mutations, and a luminal androgen receptor subtype were confirmed. Within DNA repair deficiency or gene expression defined molecular subgroups, age-related alterations in, e.g., overall gene expression, immune cell marker gene expression, genetic mutational and rearrangement signatures, amount of copy number alterations, and tumor mutational burden did, however, not appear distinct. Similar non-significant associations for genetic alterations with age were obtained for other breast cancer subgroups in public WGS data. Consistent with age-related immunosenescence, TIL counts decreased linearly with patient age across different genetic TNBC subtypes.

Conclusions

Age-related alterations in TNBC, as well as breast cancer in general, need to be viewed in the context of underlying genomic phenotypes. Based on this notion, age at diagnosis alone does not appear to provide an additional layer of biological complexity above that of proposed genetic and transcriptional phenotypes of TNBC. Consequently, treatment decisions should be less influenced by age and more driven by tumor biology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01392-0.

Clinicopathologic features and prognosis of triple-negative breast cancer in China: a retrospective cohort study of patients under 35 years old

AIM

To analyze factors that affect the prognosis of triple-negative breast cancer patients under 35 years old.

MATERIAL AND METHODS

We retrospectively analyzed confirmed triple-negative breast cancer cases from 2000 to 2016 in multiple institutions. A total of 105 patients were included in the study, Nineteen of them were diagnosed with age ≤ 25, and 86 of them were aged between 26 to 35.

RESULT

There were no statistically significant differences in clinicopathologic features and treatment choices between patients aged ≤ 25 years and those aged 26-35 years (P > 0.05). Survival analysis showed no statistically significant differences in DFS and OS between the two groups (P > 0.05). Multiple factor analysis showed that age of menarche (HR 0.697, 95% CI [0.5634, 0.8631]), pregnancy correlation (HR 2.673, 95% CI [1.1581, 6.1741]), and lymph node positivity (HR 4.915, 95% CI [2.3774, 10.1627]) were independent prognostic factors that affected patients' DFS. Independent prognostic factors that influenced OS were age of menarche (HR 0.598, 95% CI [0.462 6, 0.775]) and lymph node positivity (HR 7.751, 95% CI [2.923, 20.559]).

CONCLUSION

There was no difference in the clinicopathological features and prognosis between women ≤ 25 and women aged 26-35 years with triple-negative breast cancer. Age of menarche, pregnancy correlation, and positive lymph nodes were independent factors affecting prognosis. The relationship between reproductive factors and prognosis in young patients with triple-negative breast cancer needs further discussion.

Receptor conversion in metastatic breast cancer: analysis of 390 cases from a single institution

Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status provide clinical utility in guiding therapeutic decision-making in metastatic breast cancer (BC). Increasing data have shown substantial differences between the receptor profiles of primary BCs and their paired metastases. In this study, we provide a large single center cohort to assess the frequency of receptor conversion in metastatic BC. The overall discordant rates were 18.3%, 40.3%, and 13.7% for ER, PR, and HER2, respectively. The discordance was significantly higher for PR when compared with ER and HER2. The conversion occurred significantly as a switch from positive to negative receptor status when compared with that from negative to positive for all three receptors. Semiquantitative analyses revealed a significantly decreased expression of both ER (25%) and PR (57%) in the metastases. There was a higher rate of PR discordance in bone metastases when comparing to other common organs of relapse. Furthermore, in the subset of patients with a single primary and multiple distant metastases, the discordant rates among the distant sites were 27.5%, 39.4%, and 14.3% for ER, PR, and HER2, respectively. A positive ER status, be it in primary or metastatic BC, was associated with a prolonged metastasis-free survival when compared with ER-negative primary tumors without conversion. Furthermore, a positive ER status in metastatic BC regardless of primary was associated with a superior overall survival when compared with an ER-negative tumor without conversion. Thus, receptor conversion is a frequent event in the course of BC progression, and can also be seen between different metastatic sites. Moreover, some conversions are of prognostic significance. The findings may reflect tumor heterogeneity, sampling or treatment effect, but may also indicate alteration in tumor biology. Repeat biomarker testing is warranted in making appropriate treatment plans in the pursuit of precision medicine.

Breast cancer in the young patient: review of therapy and treatment considerations

In 2019, 13,050 young women were diagnosed with pre-invasive or invasive breast cancer in the USA and 1070 women died of their disease. Young women are underrepresented in clinical trials, and treatment for these women less than 40 years old is extrapolated from studies of older women. Young women face unique challenges such as decreased fertility, psychosocial issues and an extended survivorship period that impacts quality of life. Herein, we review breast cancer treatment options in the young patient (women <40 years old). We explore the biologic differences between breast cancer in young versus older patients, review surgical and systemic therapy options and highlight special considerations that are unique in these young patients.

Integrated molecular profiling of young and elderly patients with triple-negative breast cancer indicates different biological bases and clinical management strategies

BACKGROUND

Age at the time of breast cancer diagnosis not only predicts clinical outcome but also indicates distinct molecular characteristics that provide the rationale for appropriate treatment strategies. However, to the authors' knowledge, little is known regarding the molecular profile and biological basis of triple-negative breast cancers (TNBCs) occurring in young and elderly patients.

METHODS

Using the study institution's largest, single-center, multiomics TNBC data set, the authors analyzed the clinical and genomic features of young (aged ≤39 years) and elderly (aged ≥65 years) patients with TNBC.

RESULTS

In the current study, a total of 50 patients, 354 patients, and 69 patients, respectively, were grouped as young, intermediate, and elderly patients with TNBC. Young patients with TNBC had worse short-term survival, upregulation of DNA repair, cell cycle and RNA metabolism gene sets, frequent pathogenic germline variants, and predominant homologous recombination deficiency-related mutational signatures. Several copy number alterations also were found to be enriched in young patients with TNBC. Nearly one-half of the TNBC cases in elderly patients were of the luminal androgen receptor subtype. TNBC in elderly patients was identified as being associated with severe fibrosis; a lower Ki-67 index; and somatic mutations in PIK3CA, KMT2D, ERBB2, ERBB3, and their corresponding pathways. Elderly patients with TNBC also were more likely to harbor targetable mutations.

CONCLUSIONS

The findings of the current study indicated that young patients with TNBC had an enhanced cell cycle, which may have helped to explain their inferior short-term survival, whereas the homologous recombination deficiency and enriched pathogenic germline variants observed among young patients with TNBC suggested the need for genetic counseling and testing, as well as the potential use of DNA damage agents and poly(adenosine diphosphate ribose) polymerase (PARP) inhibitors. Molecular characteristics of elderly patients with TNBC, although suggesting less response to chemotherapy, provided a rationale for the routine detection of actionable somatic mutations.

Breast and colorectal cancer recurrence and progression captured by five U.S. population-based registries: Findings from National Program of Cancer Registries patient-centered outcome research

OBJECTIVES

Cancer recurrence is a meaningful patient outcome that is not captured in population-based cancer surveillance. This project supported National Program of Cancer Registries central cancer registries in five U.S. states to determine the disease course of all breast and colorectal cancer cases. The aims were to assess the feasibility of capturing disease-free (DF) status and subsequent cancer outcomes and to explore analytic approaches for future studies.

METHODS

Data were obtained on 11,769 breast and 6033 colorectal cancer cancers diagnosed in 2011. Registry-trained abstractors reviewed medical records from multiple sources for up to 60 months to determine documented DF status, recurrence, progression and residual disease. We described the occurrence of these patient-centered outcomes along with analytic considerations when determining time-to-event outcomes and recurrence-free survival.

RESULTS

Disease-free status was determined on all but 3.8 % of cancer cases. Among 14,458 cases that became DF, 6.1 % of breast and 13.0 % of colorectal cancer cases had a documented recurrence. Recurrence-free survival varied by stage; for stage II-III cancers at 48 months, 83.2 % of female breast and 69.2 % of colorectal cancer patients were alive without recurrence. The ability to distinguish between progression and residual disease among never disease-free patients limited our ability to examine progression as an outcome.

CONCLUSIONS

This study demonstrated that population-based registries given intense support and resources can capture recurrence and offer a generalizable picture of cancer outcomes. Further work on refining definitions, sampling strategies, and novel approaches to capture recurrence could advance the ability of a national cancer surveillance system to contribute to patient-centered outcomes research.

Risk factors for distant metastasis of patients with primary triple-negative breast cancer

Objective: Triple-negative breast cancer (TNBC) involves higher rates of recurrence and distant metastasis. The present study sought to characterize the risk factors for distant metastasis of TNBC.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database was exploited to enroll patients diagnosed with TNBC from 2010 to 2015. The eligible patients were dichotomized into locoregional and distant metastasis at the time of diagnosis. Patients’ demographics and tumor features, and treatment were evaluated to identify the risk factors for distant metastasis of primary TNBC. The categorical variables were examined by chi-square tests. Univariate and multivariate logistic regression analyses were used to determine the risk factors for distant metastasis. Breast cancer-specific survival (BCSS) and overall survival (OS) were estimated by Kaplan–Meier plots with log-rank tests.

Results: We collected 26863 patients with primary TNBC, 1330 (5.0%) of them presented with distant metastasis. In the univariate analysis, all the variables indicated statistical significance. The significant variables were subsequently enlisted into the multivariate logistic regression analysis. Age > 50, higher clinical stage T and N, and tumor size > 5 cm were independent risk factors for distant metastasis of primary TNBC. Moreover, higher clinical stage T and stage N were independent risk factors for bone metastasis of the patients. TNBC patients with either bone or visceral metastasis have poor survival, with brain metastasis worst of all, though the OS difference was not statistically significant.

Conclusions: TNBC patients with larger age, higher clinical stage, larger tumor size were more predisposed to have distant metastasis. Great attention should be paid to the prognosis of these patients with distant metastasis.

Risk of loco-regional recurrence and distant metastases of patients with invasive breast cancer up to ten years after diagnosis - results from a registry-based study from Germany

BACKGROUND

Population-based estimates of the long-term risk of loco-regional recurrence and distant metastases of breast cancer (BRC) patients are scant, as most published studies used hospital-based cohorts or participants of clinical trials. This work aims to extend available knowledge by providing population-based long-term estimates of the cumulative risk of BRC recurrence up to 10 years after diagnosis.

METHODS

Data from the population-based Saarland Cancer Registry were used and included 9359 female patients with primary invasive BRC diagnosed between 1999 and 2009. Estimates of the cumulative incidence (CI) of BRC recurrence were derived for patients who had received local surgery with free resection margins by type of recurrence and stratified by age, tumor characteristics and major treatment options, taking into account mortality from any cause as a competing risk.

RESULTS

The 10-year CI of BRC recurrence was 16%. For loco-regional recurrence and distant metastases alone it was 8 and 11%, respectively. The estimates showed substantial variation and were particularly increased if tumors were advanced (T1/2N+ 23%, T3/4N0 24%, T3/4N+ 34%), of high grade (23%), or of 'HER2/neu positive' (28%) or 'triple negative' subtype (23%), respectively.

CONCLUSIONS

The derived estimates reflect the risk of 'real world' patients and may therefore extend available knowledge. These data are thus of great relevance for clinicians, their patients and researchers. The study likewise demonstrated the usefulness of cancer registries for a population-based monitoring of the effectiveness of cancer care in terms of disease recurrence as a major treatment related outcome measure.

Impact of age on pathological complete response and locoregional recurrence in locally advanced breast cancer after neoadjuvant chemotherapy

Background

Neoadjuvant chemotherapy (NAC) is the standard approach for downstaging of locally advanced breast cancer and can improve breast conservation rates. A pathological complete response (pCR) after NAC associated with favorable long-term outcomes has been described. There is still a high locoregional recurrence (LRR) rate after NAC and the influence of age on LRR after NAC is unclear. This study analyzed the relationship between age and LRR after NAC.

Methods

Two hundred and sixty-three patients with invasive breast cancer who received NAC followed by mastectomy or breast conserving surgery (BCS) were enrolled. Concurrent weekly epirubicin and docetaxel was the NAC regimen.

Results

Twenty-nine patients (11%) achieved a pCR after NAC. In univariate analysis, age <50 years, luminal B (HER2 positive) subtype, HER2 overexpression subtype, and triple-negative subtype were factors to predict a pCR. In multivariate analysis, age <50 years, luminal B (HER2 positive) type, HER2 overexpression, and triple-negative subtype were the independent factors to predict a pCR. No patients in the pCR group developed LRR compared with 31 patients in the non-pCR group. Eleven patients (6.9%) in the younger group (age <50 years) developed LRR compared with 20 patients (19.4%) in the older group (age ≥50 years). In multivariate analysis, younger age (<50 years) was the only independent prognostic factor for a LRR-free survival.

Conclusion

Younger age can predict a pCR and is an independent prognostic factor for LRR in locally advanced breast cancer patients after NAC as concurrent epirubicin and docetaxel.

Can We Use Survival Data from Cancer Registries to Learn about Disease Recurrence? The Case of Breast Cancer

Background: Population-representative risks of metastatic recurrence are not generally available because cancer registries do not collect data on recurrence. This article presents a novel method that estimates the risk of recurrence using cancer registry disease-specific survival.Methods: The method is based on an illness-death process coupled with a mixture cure model for net cancer survival. The risk of recurrence is inferred from the estimated survival among the noncured fraction and published data on survival after recurrence. We apply the method to disease-specific survival curves from female breast cancer cases without a prior cancer diagnosis and with complete stage and hormone receptor (HR) status in Surveillance, Epidemiology and End Results registries (1992-2013).Results: The risk of recurrence is higher for women diagnosed with breast cancer at older age, earlier period, more advanced stage, and HR-negative tumors. For women diagnosed at ages 60-74 in 2000-2013, the projected percent recurring within 5 years is 2.5%, 9.6%, and 34.5% for stages I, II, and III HR-positive, and 6.5%, 20.2%, and 48.5% for stages I, II, and III HR-negative tumors. Although HR-positive cases have lower risk of recurrence soon after diagnosis, their risk persists longer than for HR-negative cases. Results show a high degree of robustness to model assumptions.Conclusions: The results show that it is possible to extract information about the risk of recurrence using disease-specific survival, and the methods can in principle be extended to other cancer sites.Impact: This study provides the first population-based summaries of the risk of breast cancer recurrence in U.S. women. Cancer Epidemiol Biomarkers Prev; 27(11); 1332-41. ©2018 AACR.

Prognostic value of Ki-67 according to age in patients with triple-negative breast cancer

PURPOSE

The prognostic value of Ki-67 in triple-negative breast cancer (TNBC) is yet unclear because the cut-off points employed differ widely and its predictive effect may vary according to age. The purpose of this study was to analyze the role of Ki-67 among patients with TNBC, and determine the optimal Ki-67 cut-off point to demonstrate its prognostic relevance associated with patient age and treatment strategy.

METHODS/PATIENTS

201 consecutive patients treated for primary TNBC from 1999 to 2014 were analyzed. Clinicopathological characteristics and outcomes were compared between patients treated with neoadjuvant or adjuvant chemotherapy. We used time-dependent receiver operating characteristic (ROC) curve and time-dependent area under the ROC curve (AUC) to evaluate the discriminative ability of Ki-67 at 3 and 5 years of follow-up. A Ki-67 cut-off point that maximized sensibility and specificity was established. Interaction effect between age and Ki-67 on disease-free survival (DFS) and overall survival (OS) was evaluated by stratified analysis.

RESULTS

According to the coordinates of the ROC curves, the best cut-off point for Ki-67 was 60% (high/low). In the whole group, there was not a statistically significant association between Ki-67 and OS and DFS, using a cut-off point of 60%. In multivariate analysis (COX proportional hazards regression), for DFS high Ki-67 (> 60%) was a poor prognostic factor in patients > 40 years old and a better prognostic factor among the patients < 40 years old.

CONCLUSION

Prognostic value of Ki-67 in TNBC, using a cut-off point of 60%, may vary depending on age.

How do age and molecular subtypes impact surgical decisions?

Tumor molecular subtype and patient age are the predominant drivers of recommendations for systemic therapy in patients with breast cancer. Yet, the impact of these factors on surgical decision-making remains controversial. Younger women often receive the most extensive surgical therapy despite a lack of evidence that bigger surgery translates into better outcomes. In contrast, among older women, there is a desire to minimize local therapy and its associated morbidity. Here, we review contemporary data highlighting the relationship between patient age and breast cancer molecular subtype, and local therapy outcomes. Our perspective is that tumor biology, rather than age, should be the driving factor in determining appropriate local therapy for breast cancer.

Modulation of SOX2 expression delineates an end-point for paclitaxel-effectiveness in breast cancer stem cells

Tumor relapse in triple negative breast cancer patients has been implicated to chemoresistant cancer stem cells (CSCs), which under favorable conditions culminate in tumor re-formation and metastasis. Hence, eradication of CSCs during systemic chemotherapy is imperative. CSCs were sorted using immuno-phenotyping and aldefluor assay. Gene expression profiling of normal breast stem cells and breast CSCs from chemo-treated patients were carried out. Silencing SOX2 was achieved by siRNA method. Mammosphere culture and wound healing assays were carried out to assess efficacy of CSCs. Microarray analysis revealed elevated expression of SOX2, ABCG2 and TWIST1, unraveling an intertwined pluripotency-chemoresistance-EMT axis. Although paclitaxel treatment led to temporary arrest of cell migration, invasiveness resumed after drug removal. The ‘twist in the tale’ was a consistently elevated expression of TWIST1, substantiating that TWIST1 can also promote stemness and chemoresistance in tumors; hence, its eradication was imperative. Silencing SOX2 increased chemo-sensitivity and diminished sphere formation, and led to TWIST1 down regulation. This study eventually established that SOX2 silencing of CSCs along with paclitaxel treatment reduced SOX2-ABCG2-TWIST1 expression, disrupted sphere forming capacity and also reduced invasiveness by retaining epithelial-like properties of the cells, thereby suggesting a more comprehensive therapy for TNBC patients in future.

Highlights from the 15th St Gallen International Breast Cancer Conference 15-18 March, 2017, Vienna: tailored treatments for patients with early breast cancer

The 15th St Gallen International Breast Cancer Conference was held in Vienna for the second time, from 15th–18th March 2017. 4000 people from 105 countries all over the world were invited to take part in the event. The real highlight of the conference was the last day with the International Consensus Session which was chaired by around 50 experts on breast cancer worldwide. With reference to data from scientific research, the consensus panel tried to offer guidelines for the management of breast cancer with the aim of providing patients with optimal treatment. The topics covered focused on the treatment of breast cancer, consideration of surgery, radiotherapy, neo-adjuvant, and adjuvant systemic therapy for breast cancer, as well as genetics and prevention of breast cancer.

In particular, in terms of precision medicine, an important topic of the conference was ‘is it possible to think that it could become routine in clinical practice to use immunotherapy and targeted therapy based on genetic signatures?’

In view of personalised therapy, it is important to take into consideration women’s treatment preferences. It is also important not only to offer guidelines which help breast cancer experts all over the world to choose the proper treatment for women with breast cancer but also to discuss the pros and cons of the therapy with the patient. This allows for a better understanding of the disease.

‘From the maximum tolerable to the minimum effective treatment: it is essential to escalate treatment when necessary and to de-escalate when unnecessary’. These few words could summarise the meaning of the 15th St Gallen International Breast Cancer Conference. Prof Martine Piccart-Gebhart was awarded with the St Gallen International Breast Cancer Award 2017 for her fundamental clinical research contribution and Prof Giuseppe Curigliano with the Umberto Veronesi Memorial Award which aims to recognise a physician’s leading role in advancing the science and care of breast cancer patients. Curigliano, in his lecture, spoke about the revolutionary immunotherapy in the clinical management of breast cancer (BC). For the development of these therapies, it is necessary to identify the genetic determinants of BC immune phenotypes in which The Cancer Genome Atlas (TCGA) has contributed towards this.

For example, the T helper (Th-1) phenotype (ICR4), which also exhibits upregulation of immune-regulatory transcripts (eg. PDL1, PD1, FOXP3, IDO1, and CTLA4), was associated with prolonged patients’ survival. Chromosome segment 4q21, which includes genes encoding the Th-1 chemokines CXCL9-11, was significantly amplified only in the immune favourable phenotype (ICR4). The mutation and neo-antigen load progressively decreased from ICR4 to ICR1 but could not explain immune phenotypic differences. Mutations of TP53 were enriched in the immune favourable phenotype (ICR4). Instead, the presence of MAP3K1 and MAP2K4 mutations were closely associated with an immune unfavourable phenotype (ICR1). Using both the TCGA and the validation dataset, the degree of MAPK deregulation segregates BC according to their immune disposition. These findings suggest that mutational-driven deregulation of MAPK pathways is linked to the negative regulation of intratumoural immune response in BC.

The main themes of this congress were: 1) Surgery of the primary tumour and margins; 2) Surgery of the axilla; 3) Radiotherapy: hypofractionated, ‘boost’ to tumour bed, partial breast, regional node, after mastectomy, advanced technology; 4) Pathology: subtypes, TILs; 5) Multi-gene signatures and therapy; 6) Endocrine therapy: pre- and post-menopausal and duration; 7) Chemotherapy: subtypes, stages; 8) Anti-HER-2 therapy; 9) Neo-adjuvant therapy; 10) Adjuvant bisphosponates; 11) Adjuvant diet and exercise.