A population-based comparison of treatment, resource utilization, and costs by cancer stage for Ontario patients with HER2-positive breast cancer

PURPOSE

We sought to expand the currently limited, Canadian, population-based data on the characteristics, treatment pathways, and health care costs according to stage in patients with human epidermal growth factor receptor-2 positive (HER2+) breast cancer (BC).

METHODS

We extracted data from the publicly funded health care system in Ontario. Baseline characteristics, treatment patterns, and health care costs were descriptively compared by cancer stage (I-III vs. IV) for adult women diagnosed with invasive HER2+ BC between 2012 and 2016. Resource use was multiplied by unit costs for publicly funded health care services to calculate costs.

RESULTS

Overall, 4535 patients with stage I-III and 354 with stage IV HER2+ BC were identified. Most patients with stage I-III disease were treated with surgery (4372, 96.4%), with the majority having a lumpectomy, and 3521 (77.6%) received radiation. Neoadjuvant (NAT) and adjuvant (AT) systemic treatment rates were 20.1% (n = 920) and 88.8% (n = 3065), respectively. Systemic treatment was received by 311 patients (87.9%) with metastatic HER2+ BC, 264 of whom (84.9%) received trastuzumab. Annual health care costs per patient were nearly 3 times higher for stage IV vs. stage I-III HER2+ BC.

CONCLUSION

Per-patient annual costs were substantially higher for women with metastatic HER2+ BC, despite less frequent exposure to surgery and radiation compared to those with early stage disease. Increasing NAT rates in early stage disease represent a critical opportunity to prevent recurrence and reduce the costs associated with treating metastatic HER2+ BC.

A population-based comparison of treatment patterns, resource utilization, and costs by cancer stage for Ontario patients with hormone receptor-positive/HER2-negative breast cancer

PURPOSE

To update and expand on data related to treatment, resource utilization, and costs by cancer stage in Canadian patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer (BC).

METHODS

We analyzed data for adult women diagnosed with invasive HR+/HER2- BC between 2012 and 2016 utilizing the publicly funded health care system in Ontario. Baseline characteristics, treatment received, and health care use were descriptively compared by cancer stage (I-III vs. IV). Resource use was multiplied by unit costs for publicly funded health care services to calculate costs.

RESULTS

Our study included 21,360 patients with stage I-III plus 813 with stage IV HR+/HER2- BC. Surgery was performed on 20,510 patients with stage I-III disease (96.0%), with the majority having a lumpectomy, and radiation was received by 15,934 (74.6%). Few (n = 1601, 7.8%) received neoadjuvant and most (n = 15,655, 76.3%) received adjuvant systemic treatment. Seven hundred and fifty eight patients with metastatic disease (93.2%) received systemic therapy; 542 (66.7%) received endocrine therapy. Annual per patient health care costs were three times higher in the stage IV vs. stage I-III cohort with inpatient hospital services representing nearly 40% of total costs.

CONCLUSION

The costs associated with metastatic HR+/HER2- BC reflect a significant disease burden. Low endocrine treatment rates captured by the publicly funded system suggest guideline non-adherence or that a fair portion of Ontarian patients may be incurring out-of-pocket drug costs.

A population-based comparison of treatment patterns, resource utilization, and costs by cancer stage for Ontario patients with triple-negative breast cancer

BACKGROUND

There have been few publications exploring the characteristics, treatment pathways, and health-care costs by stage in patients with a triple-negative breast cancer (TNBC) phenotype.

METHODS

Data from a publicly funded health-care system in Ontario were assessed. Baseline characteristics, treatment patterns, and health-care costs were descriptively compared by cancer stage (I-III vs IV) for adult women diagnosed with invasive TNBC between 2012 and 2016. Resource use was multiplied by unit costs for publicly funded health-care services to calculate health system-related costs.

RESULTS

A total of 3271 cases were identified, 3081 with stage I-III and 190 with stage IV TNBC. Baseline characteristics were aligned with previous reports. Surgery was the most common treatment among patients with stage I-III disease (n = 2979, 96.7%); 557 (18.7%) received neoadjuvant therapy (NAT) and 1974 (66.3%) received adjuvant therapy (AT), the latter at a median of 44 days postsurgery, and 2446 (79.4%) in the stage I-III cohort received radiation. Treatment for metastatic TNBC included surgery in 48 (25.3%), systemic therapy in 138 (72.6%), and radiotherapy in 112 (58.9%) patients. Top drug regimens included anthracyclines/taxanes. Annual per-patient health care costs were four times higher for stage IV vs. stage I-III TNBC.

CONCLUSION

Per-patient costs were higher in metastatic TNBC, despite a less frequent use of all treatment modalities compared to early TNBC. Treatment patterns were aligned with the options available at the time; however, neoadjuvant treatment rates were low.

A population-based analysis of breast cancer incidence and survival by subtype in Ontario women

Background

Breast cancer (bca) is the type of cancer most frequently diagnosed among women in Canada. Breast cancer is categorized into various molecular subtypes by the expression of estrogen receptor (er), progesterone receptor (pgr), and her2 (human epidermal growth factor receptor 2). Currently, Canada has no national cancer registry with epidemiology data by subtype. Thus, we conducted a study to determine incidence, survival, and clinicopathologic characteristics by bca subtype [triple negative breast cancer (tnbc); her2+; and hormone receptor-positive (hr+), her2-] in Canadian women newly diagnosed with bca.

Methods

Female patients diagnosed between 1 April 2012 and 31 March 2016 (fiscal 2012-2015) were identified in the Ontario Cancer Registry, and individual patient data were linked to data in provincial health administrative databases. Descriptive statistics and Kaplan-Meier curves were generated.

Results

In this cohort, 3277 women (9.5%) had tnbc, 4902 (14.3%) had her2+ bca, and 22,247 (64.8%) had hr+, her2-breast cancer. The annual incidence was 15 per 100,000 for the tnbc group, 21-23 per 100,000 for the her2+ group, and 97-105 per 100,000 for the hr+, her2- group. The lowest median overall survival (mos) of 8.9 months was observed in women with clinical stage iv tnbc. In comparison, the mos was 37.3 months in those with her2+ disease and 35.2 months in those with and hr+, her2- metastatic bca.

Conclusions

In the present study, the most recent and largest administrative database analysis of a Canadian population to date, we observed a subtype distribution consistent with previously reported data, together with comparable annual incidence and overall survival patterns.

A Metastatic Mouse Model Identifies Genes That Regulate Neuroblastoma Metastasis

Metastatic relapse is the major cause of death in pediatric neuroblastoma, where there remains a lack of therapies to target this stage of disease. To understand the molecular mechanisms mediating neuroblastoma metastasis, we developed a mouse model using intracardiac injection and in vivo selection to isolate malignant cell subpopulations with a higher propensity for metastasis to bone and the central nervous system. Gene expression profiling revealed primary and metastatic cells as two distinct cell populations defined by differential expression of 412 genes and of multiple pathways, including CADM1, SPHK1, and YAP/TAZ, whose expression independently predicted survival. In the metastatic subpopulations, a gene signature was defined (MET-75) that predicted survival of neuroblastoma patients with metastatic disease. Mechanistic investigations demonstrated causal roles for CADM1, SPHK1, and YAP/TAZ in mediating metastatic phenotypes in vitro and in vivo Notably, pharmacologic targeting of SPHK1 or YAP/TAZ was sufficient to inhibit neuroblastoma metastasis in vivo Overall, we identify gene expression signatures and candidate therapeutics that could improve the treatment of metastatic neuroblastoma. Cancer Res; 77(3); 696-706. ©2017 AACR.

A phosphoproteomics approach to identify candidate kinase inhibitor pathway targets in lymphoma-like primary cell lines

Mass spectrometry-based technologies are increasingly utilized in drug discovery. Phosphoproteomics in particular has allowed for the efficient surveying of phosphotyrosine signaling pathways involved in various diseases states, most prominently in cancer. We describe a phosphotyrosine-based proteomics screening approach to identify signaling pathways and tyrosine kinase inhibitor targets in highly tumorigenic human lymphoma-like primary cells. We identified several receptor tyrosine kinase pathways and validated SRC family kinases (SFKs) as potential drug targets for targeted selection of small molecule inhibitors. BMS-354825 (dasatinib) and SKI-606 (bosutinib), second and third generation clinical SFK/ABL inhibitors, were found to be potent cytotoxic agents against tumorigenic cells with low toxicity to normal pediatric stem cells. Both SFK inhibitors reduced ERK1/2 and AKT phosphorylation and induced apoptosis. This study supports the adaptation of high-end mass spectrometry techniques for the efficient identification of candidate tyrosine kinases as novel therapeutic targets in primary cancer cell lines.

Abstract C35: The development of metastatic mouse models of neuroblastoma to bone and brain to identify the molecular mechanisms governing metastasis

Metastasis is a key reason for the lack of success in treating children with neuroblastoma (NB). Over 50% of patients present with metastatic lesions in the bone, brain, liver and lymph nodes, with a high fatality rate for patients that relapse with those metastases. A better understanding of the molecular processes defining the complexity and multi-step nature of NB dissemination is required for the development of effective treatments. To date, there is no NB model that quantitatively and reproducibly metastasizes to bone and brain. Thus, we developed novel metastatic mouse models of neuroblastoma to bone and brain through in vivo selection to enhance metastatic capability. SK-N-AS, derived from a bone marrow metastasis, and IMR-32, a MYCN-amplified line derived from an abdominal mass, were tagged for in vivo monitoring using a triple reporter (TR) encoding TK, GFP and firefly luciferase, which allows for nuclear imaging, FACs analysis, and whole body bioluminescence. Reporter expression was confirmed by double sorting for GFP and testing for luciferase activity. Cells were introduced into the blood stream of NOD/SCID mice through intra-cardiac injection, and monitored bi-weekly using bioluminescence. SK-N-ASTR cells metastasized to the adrenal gland (87%, 13/15 animals) and bone (mandible, hindlimbs, 67%, 10/15 animals), whereas IMR-32TR cells metastasized to bone (100%, 10/10 animals) and brain (40%, 4/10 animals). Metastatic lesions were confirmed by ex-vivo bioluminescence, 3D bioluminescence, MRI or micro-CT. Cells from specific metastatic sites of individual mice were isolated, expanded in culture, GFP sorted and injected into a second cohort of mice. Several of the SK-N-ASTR re-injected cell lines derived from bone exhibited enhanced metastasis after one round of in vivo selection, with 100% metastasis to bone and the adrenal gland (a common location of primary NB tumours) and up to 60% metastasis to brain, as confirmed by MRI. Subsequently, these animals had a decreased overall survival rate of approximately 43 days relative to the parental cell line, of 69 days. The metastatic sub-populations do not proliferate at higher rates than the parental cell line, as assessed by BrdU labeling. Thus, the enhanced metastasis observed in vivo is not due to a faster growth rate, but rather selection of metastasis promoting functions. This is supported by the finding that the metastatic SK-N-ASTR sub-populations also exhibited enhanced migration and invasion toward serum, as assessed using boyden chambers, compared to the parental line. These sub-populations are being characterized to identify the molecular mechanisms governing metastasis. Metastasis to brain and bone is an often fatal event in children with newly diagnosed and recurrent NB. We have developed the first reproducible and efficient NB metastatic mouse model to identify novel genes and signalling proteins regulating metastasis, and to identify drug candidates that suppress metastatic growth.

Citation Format: Kelly E. Fathers, Samar Mouaaz, Constanza Rioseco, Anna Mourskaia, Ronald Blasberg, Meredith Irwin, Peter Siegel, David Kaplan. The development of metastatic mouse models of neuroblastoma to bone and brain to identify the molecular mechanisms governing metastasis. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Invasion and Metastasis; Jan 20-23, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;73(3 Suppl):Abstract nr C35.

Crk adaptor proteins act as key signaling integrators for breast tumorigenesis

Introduction

CT10 regulator of kinase (Crk) adaptor proteins (CrkI, CrkII and CrkL) play a role in integrating signals for migration and invasion of highly malignant breast cancer cell lines. This has important implications, as elevated CrkI/II protein levels were observed in a small cohort of breast cancer patients, which identified a potential role for Crk proteins in breast cancer progression. Numerous in vitro studies identified a role for Crk proteins in cell motility, but little is known about how Crk proteins contribute to breast cancer progression in vivo.

Methods

The clinical significance of Crk proteins in human breast cancer was assessed by analyzing published breast cancer datasets using a gene expression signature that was generated following CrkII over-expression and by examining Crk protein expression in tissue microarrays of breast tumors (n = 254). Stable knockdown of Crk (CrkI/CrkII/CrkL) proteins was accomplished using a short hairpin RNA (shRNA)-mediated approach in two basal breast cancer cell lines, MDA-231 1833TR and SUM1315, where the former have a high affinity to form bone metastases. Both in vitro assays (cell migration, invasion, soft agar growth) and in vivo experiments (intra-cardiac, tibial and mammary fat pad injections) were performed to assess the functional significance of Crk proteins in breast cancer.

Results

A gene signature derived following CrkII over-expression correlated significantly with basal breast cancers and with high grade and poor outcome in general. Moreover, elevated Crk immunostaining on tissue microarrays revealed a significant association with highly proliferative tumors within the basal subtype. RNAi-mediated knockdown of all three Crk proteins in metastatic basal breast cancer cells established a continued requirement for Crk in cell migration and invasion in vitro and metastatic growth in vivo. Furthermore, Crk ablation suppressed anchorage independent growth and in vivo orthotopic tumor growth. This was associated with diminished cell proliferation and was rescued by expression of non-shRNA targeted CrkI/II. Perturbations in tumor progression correlated with altered integrin signaling, including decreased cell spreading, diminished p130Cas phosphorylation, and Cdc42 activation.

Conclusions

These data highlight the physiological importance of Crk proteins in regulating growth of aggressive basal breast cancer cells and identify Crk-dependent signaling networks as promising therapeutic targets.

Abstract 918: A key role for Crk adaptor proteins in basal breast cancer tumor growth in vivo

Elevated levels of Crk proteins are observed in human cancers, including breast cancer, identifying a potential role for Crk in tumor progression. However, little is known about how Crk contributes to breast cancer progression in vivo. Crk proteins (CrkI, CrkII, CrkL) can regulate cell signaling downstream of integrins and various receptor tyrosine kinases through the formation of protein-protein complexes. We tested the hypothesis that Crk proteins are key signaling nodes for breast cancer tumorigenesis using shRNA-mediated knockdown of all 3 Crk proteins in highly aggressive human basal breast cancer cell lines.

Crk knockdown cells show no differences in cell proliferation under 2D culture conditions, but show significantly decreased growth in soft agar under low serum conditions. This demonstrates that Crk loss imparts a renewed dependence on adhesion and growth factor signaling in highly aggressive breast tumor cell lines and highlights a requirement for Crk dependent signals for anchorage independent growth in vitro. Consistent with this, loss of Crk in basal breast cancer cells inhibited in vivo orthotopic tumor growth in nude mice. Using immunohistochemical staining of cells 3 days post-injection, Crk knockdown diminished proliferation in vivo, but did not alter cell apoptosis when compared to controls. This difference was reflected in the formation of smaller lesions by Crk knockdown cells by 8 days post-injection. Importantly, rescue of Crk protein expression restored in vivo tumor growth, demonstrating a specific requirement for Crk proteins in this process.

To evaluate the significance of Crk in human breast cancer, immunohistochemistry was performed on two independent tissue microarrays of human breast tumors (n=209, n=234). Crk protein levels and the proliferative index were assessed by staining with antibodies to Crk and Ki67. Both Crk and Ki67 antigen positivity correlated strongly with high tumor grade (p=0.001, p=2.27e-10). Within both TMA datasets, CrkI/II (R2=0.3855, p=0.0004) and CrkL (R2=0.3845, p=0.0002) protein levels showed a strong positive correlation with cell proliferation within basal tumors, demonstrating a strong link between elevated Crk protein and an aggressive tumor phenotype. In addition to assessing Crk protein levels, a gene expression signature consisting of 151 genes was derived following Crk overexpression in a breast cancer cell line that initially had low levels of Crk. Notably, when this signature was applied to 5 breast cancer gene expression datasets (n=1469 breast cancers) there was a strong correlation with both the basal molecular subtype (p<6.7e-14), and with high tumor grade (p<6.4e-12), both of which are associated with poor prognosis, providing support for the IHC data.

These findings demonstrate that Crk proteins are unexpectedly essential for growth of aggressive human breast cancer cell lines in vivo, and suggest a key role for Crk proteins in basal breast cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 918. doi:10.1158/1538-7445.AM2011-918

CrkII transgene induces atypical mammary gland development and tumorigenesis

The v-Crk protein was originally isolated as the oncogene fusion product of the CT10 chicken retrovirus. Cellular homologues of v-Crk include Crk, which encodes two alternatively spliced proteins (CrkI and CrkII), and CrkL. Though CrkI/II proteins are elevated in several types of cancer, including breast, the question of whether these Crk adaptor proteins can promote breast cancer has not been addressed. We created a transgenic mouse model that allows the expression of CrkII through the hormonally responsive mouse mammary tumor virus promoter. During puberty, transgenic mice were found to have delayed ductal outgrowth, characterized by increased collagen surrounding the terminal end buds. In post-pubertal mice, precocious ductal branching was observed and associated with increased proliferation. Focal mammary tumors appeared in a subset of animals, with a latency of approximately 15 months. Mouse mammary tumor virus/CrkII tumors showed high levels of Crk protein as well as various cytokeratin markers characteristic of their respective tumor pathologies. This study demonstrates that the precise expression of CrkII is critical for integrating signals for ductal outgrowth and branching morphogenesis during mammary gland development. Furthermore, this study provides evidence for a potential role of CrkII in integrating signals for breast cancer progression in vivo, which has important implications for elevated CrkII observed in human cancer.

Heterogeneity of Tie2 expression in tumor microcirculation: influence of cancer type, implantation site, and response to therapy

To evaluate the expression of the Tie2/Tek tyrosine kinase receptor in tumor blood vessels, we examined Tie2lacZ(+)/RAG1(-) mice. There was considerable heterogeneity (Tie2-negative, Tie2-positive, or Tie2-composite blood vessels) in subcutaneous xenografts of human colorectal carcinoma (HCT116; 97.5% Tie2-positive vessels) versus human melanoma (WM115; 75.9% Tie2-positive vessels). Similar patterns of Tie2 expression occurred in abdominal metastases derived from the same cell lines. Immunostaining for endothelial markers and Tie2 revealed that endogenous protein levels corresponded with transgene activity. Endothelial cells were confirmed to be of mouse origin through triple immunofluorescence staining with mouse antiserum to human nuclei, isolectin GS-IB(4), and anti-Tie2. Similar Tie2 heterogeneity was observed in clinical specimens from a variety of human cancers, including malignant melanoma and colorectal carcinoma. We also examined the effect of Tek-Delta Fc anti-angiogenic therapy on tumor growth and Tie2 expression patterns in HCT116 and WM115 subcutaneous xenografts. Tek-Delta induced extensive tumor regression in HCT116 tumors and concomitant reductions in Tie2-expressing blood vessels. However, no significant responses were seen in Tek-Delta-treated WM115 tumors. Thus, vascular heterogeneity of Tie2 expression is cancer-type specific, suggesting that the tumor microenvironment and/or direct cancer cell interactions influence Tie2 endothelial expression.

CrkI and CrkII function as key signaling integrators for migration and invasion of cancer cells

Crk adaptor proteins play an important role during cellular signaling by mediating the formation of protein complexes. Increased levels of Crk proteins are observed in several human cancers and overexpression of Crk in epithelial cell cultures promotes enhanced cell dispersal and invasion, implicating Crk as a regulator of invasive responses. To determine the requirement of Crk for invasive signals, we targeted the CRKI/II gene by RNA interference. Consistent knockdown of CrkI/II was observed with two small interfering RNA targeting sequences in all human cancer cell lines tested. CrkI/II knockdown resulted in a significant decrease in migration and invasion of multiple malignant breast and other human cancer cell lines (MDA-231, MDA-435s, H1299, KB, and HeLa). Moreover, CrkI/II knockdown decreased cell spreading on extracellular matrix and led to a decrease in actin stress fibers and the formation of mature focal adhesions. Using immunohistochemistry, we show elevated CrkI/II protein levels in patients with breast adenocarcinoma. Together, these studies identify Crk adaptor proteins as critical integrators of upstream signals for cell invasion and migration in human cancer cell lines and support a role for Crk in metastatic spread.

Angiogenesis and the role of epigenetics in metastasis

The major obstacle to devising effective ways to treat cancer is its heterogeneity and genetic instability. It was originally postulated that targeting the process of tumor angiogenesis could circumvent this problem, as it involves genetically stable epigenetically controlled host stroma. Thus, anti-angiogenic approaches should be applicable across various tumor types and organ sites, including metastases. However, early clinical experience with this therapy revealed unexpectedly distinct responses between different tumors and organ sites. Here we propose that the heterogeneity of pre-clinical and clinical results obtained with anti-angiogenic agents stems from the deep functional linkage that may exist between genetic and epigenetic tumor progression. Thus, epigenetic processes regulating tumor associated host blood vessels (such as tumor microenvironment) display unstable, heterogeneous and progressive characteristics to an extent comparable with (and causally linked to) the instability of the cancer cell genome. As well, many known epigenetic factors (such as hypoxia, inflammation, expression of growth factors, etc.) may have genetic causes and consequences (e.g., oncogene expression, loss of tumor suppressor genes). This reciprocal interrelationship and heterogeneity may translate into site and stage specific changes in angiogenesis regulation, and angiogenesis dependence, ultimately to changes in the metastatic ability/efficiency of cancer cells, even in the same patient. A better understanding of the linkage between genetic and epigenetic events in growth and metastasis of various cancers may result in more effective use of anti-angiogenic therapy in future.