Search

Purpose: Epidemiologic studies indicate that dietary factors, such as coffee, may influence breast cancer and modulate hormone receptor status. The purpose of this translational study was to investigate how coffee may affect breast cancer growth in relation to estrogen receptor-α (ER) status.Experimental Design: The influence of coffee consumption on patient and tumor characteristics and disease-free survival was assessed in a population-based cohort of 1,090 patients with invasive primary breast cancer in Sweden. Cellular and molecular effects by the coffee constituents caffeine and caffeic acid were evaluated in ER+ (MCF-7) and ER− (MDA-MB-231) breast cancer cells.Results: Moderate (2–4 cups/day) to high (≥5 cups/day) coffee intake was associated with smaller invasive primary tumors (Ptrend = 0.013) and lower proportion of ER+ tumors (Ptrend = 0.018), compared with patients with low consumption (≤1 cup/day). Moderate to high consumption was associated with lower risk for breast cancer events in tamoxifen-treated patients with ER+ tumors (adjusted HR, 0.51; 95% confidence interval, 0.26–0.97). Caffeine and caffeic acid suppressed the growth of ER+ (P ≤ 0.01) and ER− (P ≤ 0.03) cells. Caffeine significantly reduced ER and cyclin D1 abundance in ER+ cells. Caffeine also reduced the insulin-like growth factor-I receptor (IGFIR) and pAkt levels in both ER+ and ER− cells. Together, these effects resulted in impaired cell-cycle progression and enhanced cell death.Conclusions: The clinical and experimental findings demonstrate various anticancer properties of caffeine and caffeic acid against both ER+ and ER− breast cancer that may sensitize tumor cells to tamoxifen and reduce breast cancer growth. Clin Cancer Res; 21(8); 1877–87. ©2015 AACR.

Patient characteristics by AR status for ages

Purpose: To evaluate whether tumor androgen receptor (AR) expression was prognostic and/or predictive for endocrine treatment alone or in combination with estrogen receptor (ER). The AR has been hypothesized to have differential prognostic roles in breast cancer depending on tumor ER status, and to influence endocrine treatment response.Experimental Design: A population-based prospective cohort of 1,026 patients diagnosed with primary invasive breast cancer in Lund, Sweden, between 2002 and 2012 was followed until June 2014. Associations between immunohistochemical AR expression in tumor tissue microarrays, patient and tumor characteristics, and AR genotypes were analyzed. Disease-free survival (DFS) by AR status, and combined ER/AR status was assessed in various treatment groups.Results: AR expression was assessable in 913 tumors. AR+ tumors (85.0%) were associated with higher age (P = 0.036) and favorable tumor characteristics. The AR+ status was a prognostic marker for DFS (LogRank P = 0.025). There was an interaction between AR and ER expression with respect to prognosis (adjusted Pinteraction ≤ 0.024). Tumors with discordant hormone receptor expressions (ER+AR− or ER−AR+) demonstrated worse prognosis compared with concordant tumor expressions (ER+AR+ or ER−AR−) in multivariable models [adjusted HRs (95% confidence intervals); ≥1.99 (1.28–3.10), P ≤ 0.002]. ER+AR− indicated early treatment failure with aromatase inhibitors (AI) among chemonaïve patients aged 50 or older.Conclusions: Prediction of breast cancer prognosis and treatment response was improved by combining AR and ER status. AR negativity predicted early treatment failure with AI but not tamoxifen, a finding that warrants confirmation in a randomized setting. Patients may benefit from anti-androgens or selective AR modulators. Clin Cancer Res; 21(16); 3640–50. ©2015 AACR.

Supplementary Fig. S1. Effect by caffeine or caffeic acid on apoptotic mediators

Background: Pre-clinical and epidemiological data strongly link high cholesterol with breast cancer progression and poor prognosis. It was recently uncovered that the pathogenicity of cholesterol in breast cancer is directly propagated by 27-hydroxycholesterol (27HC), an oxysterol produced when cholesterol is hydroxylated by cytochrome P450, family 27, subfamily A, polypeptide 1 (CYP27A1) during bile acid synthesis. 27HC promotes breast tumor growth and metastasis via interactions with the estrogen receptor (ER) and liver x receptors respectively. Consequently, pharmaceutical approaches that directly interfere with CYP27A1 activity have been proposed to mitigate the adverse impact of 27HC in breast cancer. However, CYP27A1 expression or deregulation in clinical breast cancer is not well characterised. The aim of this study was to comprehensively describe the impact of tumor-specific expression of CYP27A1 protein on clinical breast cancer pathobiology and prognosis. Methods: CYP27A1 expression in tumor cells was evaluated by immunohistochemistry in two independent population based cohorts including female patients with primary invasive breast cancer diagnosed between 1991 and 2010 (cohort 1) and between 2002 and 2012 (cohort 2). Staining was evaluable in 645 and 813 cases in cohort 1 and cohort 2, respectively. Associations between CYP27A1 expression with tumor pathological factors and survival were assessed by using logistic and Cox regression models respectively. Multivariable models adjusted for age at diagnosis, nodal status, histological grade, tumor size, ER and BMI. Results: CYP27A1 was overexpressed in 21% and 28% in cohort 1 and cohort 2 respectively. High CYP27A1 expression was significantly associated with adverse tumor pathological features including negative hormone receptor (ER and PgR) status and histological grade 3 in both cohorts and with larger tumors (>20 mm) in cohort two only (p Conclusions: Collectively, these results indicate that intratumoral CYP27A1 expression supports the notion that 27HC plays an important pathological role in breast cancer progression but tumor cell-specific CYP27A1 expression is not sufficient to independently predict overall survival in postmenopausal patients. Further sufficiently sized studies are needed to clarify the prognostic significance of CYP27A1 in younger and presumably premenopausal patients and evaluate its role as a treatment predictive factor. Citation Format: Kimbung S, Stålhammar T, Inasu M, Nodin B, Elebro K, Tryggvadottir H, Jirström K, Rose C, Ingvar C, Jernström H, Borgquist S. High expression of CYP27A1 in breast cancer is associated with poor tumor pathological features and may differentially predict prognosis depending on menopausal status [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-26.

BACKGROUND: Fast-track referral is an increasingly used method for diagnostic evaluation of patients suspected of having cancer. This approach is challenging and not used as often for patients with only nonspecific symptoms. In order to expedite the diagnostics for these patients, we established Sweden's first Diagnostic Center (DC) focusing on outcomes related to diagnoses and diagnostic time intervals.MATERIAL AND METHODS: The study was designed as a prospective cohort study. Patients aged ≥18 years who presented in primary care with nonspecific symptoms of a serious disease were eligible for referral to the DC after having completed an initial investigation. Acceptable diagnostic time intervals were defined to be a maximum of 15 days in primary care and 22 days at the DC. Diagnostic outcome, length of diagnostic time intervals and patient satisfaction were evaluated.RESULTS: A total of 290 patients were included in the study. Cancer was diagnosed in 22.1%, other diseases in 64.1%, and no diagnosis was identified in 13.8% of these patients. Patients diagnosed with cancer were older, had shorter patient interval (time from first symptom to help-seeking), shorter DC-interval (time from referral decision in primary care to diagnosis) and showed a greater number of symptoms compared to patients with no diagnosis. The median primary care interval was 21 days and the median DC interval was 11 days. Few symptoms, no diagnosis, female sex, longer patient interval, and incomplete investigations were associated with prolonged diagnostic time intervals. Patient satisfaction was high; 86% of patients reported a positive degree of satisfaction with the diagnostic procedures.CONCLUSIONS: We demonstrated that the DC concept is feasible with a diagnosis reached in 86.2% of the patients in addition to favorable diagnostic time intervals at the DC and a high degree of patient satisfaction.

The association between tumor cyclooxygenase 2 (COX-2) expression and breast cancer prognosis has been inconsistent. The purpose of this study was to evaluate the prognostic significance of COX-2 tumor expression according to adjuvant treatment, and potential effect modifications of non-steroid anti-inflammatory drug (NSAID) use, and other tumor and lifestyle factors. A prospective cohort of 1,116 patients with primary breast cancer in Lund, Sweden, included 2002-2012 was followed until June 2014 (median 5 years). Tumor-specific COX-2 expression was evaluated on tissue microarrays using immunohistochemistry. Associations between COX-2 intensity (negative, weak-moderate, high) and patient and tumor characteristics as well as prognosis were analyzed. Tumor-specific COX-2 expression was available for 911 patients and was significantly associated with higher age at diagnosis and less aggressive tumor characteristics. Higher COX-2 expression was associated with lower risk for breast cancer events during the first five years of follow-up, adjHR 0.60 (95%CI: 0.37-0.97), per category. The association between COX-2 expression and prognosis was significantly modified by oral contraceptive (OC) use (Pinteraction=0.048), preoperative NSAID use (Pinteraction=0.009), and tumor size (Pinteraction=0.039). COX-2 negativity was associated with increased risk for events during the first five years in ever OC users, adjHR 1.94 (1.01-3.72) and during the 11-year follow-up in preoperative NSAID users, adjHR 4.51 (1.18-11.44) as well as in patients with large tumors, adjHR 2.57 (1.28-5.15). In conclusion, this study, one of the largest evaluating COX-2 expression in breast cancer, indicates that the prognostic impact of COX-2 expression depends on host factors and tumor characteristics.

Background: The association between smoking and breast cancer prognosis remains unclear. The purpose of this study was to investigate whether preoperative smoking was associated with prognosis in different treatment groups. Methods: This population-based cohort consisted of 1065 breast cancer patients without preoperative treatment included between 2002 and 2012 in Lund, Sweden. Smoking status was examined in relation to patient and tumour characteristics, and prognosis in different treatment groups. Results: At the preoperative visit, 21.0% smoked. Median follow-up time was 5.1 years. Overall, in the 1016 patients included in the survival analyses, there was no significant association between smoking and risk of breast cancer events (adjusted hazard ratio (adjHR): 1.45; 95% confidence interval (CI): 0.95–2.20). For the 309 aromatase inhibitor (AI)-treated patients ⩾50 years with oestrogen receptor-positive (ER+) tumours, smoking was associated with risk of breast cancer events (adjHR: 2.97; 95% CI: 1.44–6.13), distant metastasis (adjHR: 4.19; 95% CI: 1.81–9.72), and death (adjHR: 3.52; 95% CI: 1.59–7.81). Smoking was not associated with breast cancer events or distant metastasis in other treatment groups. Conclusions: Preoperative smoking was only associated with an increased risk for breast cancer events and distant metastasis in AI-treated patients. If confirmed, smoking status should be taken into consideration when selecting an endocrine therapy.

Background: Endocrine resistance is a major obstacle for optimal endocrine treatment in breast cancer (BC). Several genetic markers for tamoxifen response have been proposed. Although some genetic markers have been proposed for response to aromatase inhibitors (AI), data is insufficient. The aim of this study was 1) to perform an exploratory analysis of genes involved in Absorption, Distribution, Metabolism, and Elimination (ADME) to find new predictive markers in a subset of the cohort and 2) examine these potential markers in relation to risk for events in the extended cohort. Materials and methods: In Lund, Sweden, 190 AI-treated primary breast cancer patients with estrogen receptor positive tumors, who underwent breast cancer surgery between 2002 and 2008, were followed until December 31st 2012. Clinical data were obtained from medical records and population registries. The impact of single nucleotide polymorphisms (SNPs) on risk for breast cancer events was conducted on a subset of the cohort followed until December 31st 2011 (13 cases, 11 controls) and analyzed with data from a DMET (TM) chip including 1931 SNPs in 225 ADME-related genes. Secondly, four SNPs in CYP19A1 and the significant SNPs from the first analysis were reanalyzed concerning disease-free survival in the extended cohort of 190 patients. Results: A CYP1A2 SNP was significantly associated with risk for early events among the 24 AI-treated BC patients both in the subset of the cohort, (P=0.0007) and in the extended cohort, adjusted HR 3.83 (95% CI 1.40-10.42). SNPs in CYP19A1 alone were not significantly associated with disease-free survival in any of the analyses. The impact of the CYP1A2 SNP was modified by a SNP in CYP19A1, where patients with both SNPs had increased risk for early events, adjusted HR 5.21 (95% CI 2.05-13.23) compared to other patients. Conclusion: This study identified a potential and new predictive marker in BC patients: CYP1A2 alone and CYP1A2 in combination with CYP19A1. If confirmed, these results may provide a way to more personalized medicine. Citation Format: Simonsson M, Veerla S, Markkula A, Rose C, Ingvar C, Jernström H. CYP1A2– A novel genetic marker for aromatase inhibitor response in the treatment of breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-26.

Introduction: The association between smoking and breast cancer prognosis has been investigated in several studies but remains unclear. To our knowledge, no study has investigated whether the response to different endocrine treatments differs between smokers and non-smokers. Smoking can suppress aromatase activity, but also increase inflammation, which may lead to higher activity. The aim was to investigate whether preoperative smoking was associated with risk of breast cancer events in endocrine-treated patients. Patients and methods: This population based cohort consisted of 1026 female breast cancer patients with invasive tumors and no preoperative treatment who were enrolled in an ongoing prospective cohort study at Skåne University Hospital in Lund between October 2002 and June 2012. Pre- and postoperative questionnaires regarding lifestyle factors, including smoking status, and treatments were completed. Information on tumor characteristics, treatments, and dates for new breast cancer events or deaths was obtained from pathology reports, patients' charts and population registers. A breast cancer event was defined as local or regional recurrence, contralateral breast cancer, or distant metastasis. Results: For the survival analyses, two patients were excluded due to missing information on smoking and eight patients were excluded due to metastatic spread within 0.3 years of inclusion, leaving 1016 patients of which 206 (20.3%) reported preoperative smoking. Less than 1% of the 810 preoperative non-smokers reported smoking at either the 3-6-months or 1-year postoperative visits, while about 10% of the patients who smoked preoperatively reported not to smoke during the follow-up visits. Thus, the majority of the patients did not switch smoking status. Patients were followed for up to 11 years (median 5.1 years for patients still at risk). Overall, there was no significant association between smoking and risk of breast cancer events (adjusted hazard ratio (HR) 1.45: 95% CI 0.95-2.20; P=0.08) adjusted for patient and tumor characteristics. For the 408 tamoxifen-treated patients aged 50 years or older with estrogen receptor positive tumors, smoking was not significantly associated with risk for early events (adjusted HR 1.58: 95% CI 0.76-3.30; P=0.22). However, for the 309 aromatase inhibitor-treated patients aged 50 years or older with estrogen receptor positive tumors, smoking was significantly associated with a 3-fold increased risk of breast cancer events (adjusted HR 2.97: 95% CI 1.44-6.12; P=0.003). Some patients had been treated with sequential tamoxifen and aromatase inhibitor therapy. Conclusions: Preoperative smoking was associated with a significantly increased risk for breast cancer events among patients treated with aromatase inhibitors, but not among tamoxifen-treated patients. If confirmed, smoking status should be taken into consideration when selecting endocrine therapy. Citation Format: Jernström H, Persson M, Simonsson M, Markkula A, Rose C, Ingvar C. Tamoxifen or aromatase inhibitors: Should smoking status impact on selection of endocrine therapy in breast cancer patients?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-29.

Background and aim Estrogen receptor beta (ERβ) expression has been suggested to hold prognostic and predictive information, especially for endocrine treatment. The role of ERβ may depend on the expression of estrogen receptor alpha (ERα). The aim of this study was to evaluate ERβ expression in relation to tumor characteristics and risk for early events (disease-free survival, DFS) – overall and in different treatment groups, in a population-based cohort of primary breast cancer patients. Materials and methods Patients with primary breast cancer were invited at the preoperative visit between October 2002 and June 2012. After exclusion of patients who received preoperative treatment and patients with in situ carcinoma, the study population consisted of 1026 patients. Tumor specimens mounted in tissue microarrays were analyzed for ERβ expression using immunohistochemistry (antibody PPG5/10, Dako, dilution 1:20). Two cut-offs for positivity were evaluated (>10% and >75% of stained nuclei, respectively). Cox regression analyses yielding hazard ratios (HRs) with 95% confidence intervals (CIs) were adjusted for ERα status, tumor size, axillary lymph node involvement, histological grade, age at inclusion and body mass index. Events were defined as ipsi- or contralateral recurrences, regional or distant metastases. DFS was calculated from inclusion to event, non-breast cancer related death or last follow-up by June 30 2014, whichever came first. Patients were followed for up to 11 years (median follow-up 5.0 years for patients still at risk). Results ERβ expression was available for 911 patients (89%). ERβ positivity defined as >10% (ERβ10+, 92.1%) was positively associated with ERα (P75% (ERβ75+, 72.7%) was associated with ERα and PR positivity, lower histological grade, smaller invasive tumor size and no involvement of axillary nodes (all Ps≤0.03). In survival analyses among all patients, ERβ75+ was inversely associated with risk of early events (LogRank P=0.0005, adjHR 0.62: 95% CI 0.42-0.90; P=0.013). The magnitude of the association was larger in patients with ERα negative tumors (LogRankERα- P=0.011, adjHRERα- 0.42: 95% CI 0.17-1.02; P=0.05) compared to patients with ERα positive tumors (LogRankERα+ P=0.069, adjHRERα+ 0.74: 95% CI 0.48-1.14; P=0.18). In analyses stratified for chemotherapy, ERβ75+ expression was significantly associated with lower risk of early events among the 232 patients who had received chemotherapy (Log Rank P=0.0005, adjHR 0.31: 95% CI 0.15-0.63; P=0.001), but not among the 670 patients without chemotherapy (Log Rank P=0.14, adjHR 0.81: 95% CI 0.50-1.31; P=0.38). ERβ75+ was not associated with early events in patients with ERα+ tumors who received tamoxifen and/or aromatase inhibitors. Conclusion This study provides support for high tumor ERβ expression as a prognostic marker in breast cancer, for patients who received chemotherapy. Previous reports of ERβ as a predictor of endocrine therapy response could not be confirmed. Citation Format: Elebro K, Borgquist S, Rosendahl A, Markkula A, Simonsson M, Jirström K, Rose C, Ingvar C, Jernström H. Estrogen receptor beta expression is prognostic among chemotherapy-treated patients – Results from a population-based breast cancer cohort. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-27.

Coffee is associated with decreased breast cancer risk, but the impact of body mass index (BMI) in combination with coffee consumption on prognosis is unclear. The suppressive effect of coffee constituents on the insulin-like growth factor receptor 1 (IGF1R) levels in breast cancer cells may play a role. The aim was to investigate the prognostic impact of coffee consumption and possible associations with tumor-specific IGF1R protein expression and BMI in a population-based cohort in Sweden, comprising 1,014 primary breast cancer patients without pretreatment enrolled 2002-2012 and followed for up to 13 years. Patients with higher coffee consumption had lower tumor IGF1R levels (P = 0.025), but only among the normal-weight patients (P = 0.005). Coffee did not impact the recurrence-risk overall. However, tamoxifen-treated patients with ER+ tumors drinking ≥ 2 cups of coffee/day had lower recurrence-risk [adjusted HR (HRadj) 0.57, 95% CI, 0.34-0.97] compared with patients with lower intake, although only among normal-weight patients (HRadj 0.37, 95% CI: 0.17-0.78; Pinteraction = 0.039). Similarly, coffee consumption ≥ 2 cups/day was associated with significantly lower recurrence-risk among the 640 radiotherapy-treated patients irrespective of BMI (HRadj 0.59, 95% CI 0.36-0.98) and in the 296 normal-weight patients (HRadj 0.36, 95% CI 0.17-0.76) but not in the 329 overweight or obese patients (HRadj 0.88, 95% CI 0.42-1.82) although the interaction was not significant (Pinteraction = 0.093). In conclusion, coffee consumption was negatively associated with tumor-specific IGF1R levels only among normal-weight patients. Though, IGF1R did not explain the association between coffee intake and improved prognosis among normal-weight tamoxifen- or radiotherapy-treated patients. Studies of IGF1R-targeting therapies may benefit from taking BMI and coffee consumption into account.

Purpose: Epidemiologic studies indicate that dietary factors, such as coffee, may influence breast cancer and modulate hormone receptor status. The purpose of this translational study was to investigate how coffee may affect breast cancer growth in relation to estrogen receptor-α (ER) status. Experimental Design: The influence of coffee consumption on patient and tumor characteristics and disease-free survival was assessed in a population-based cohort of 1,090 patients with invasive primary breast cancer in Sweden. Cellular and molecular effects by the coffee constituents caffeine and caffeic acid were evaluated in ER+ (MCF-7) and ER− (MDA-MB-231) breast cancer cells. Results: Moderate (2–4 cups/day) to high (≥5 cups/day) coffee intake was associated with smaller invasive primary tumors (Ptrend = 0.013) and lower proportion of ER+ tumors (Ptrend = 0.018), compared with patients with low consumption (≤1 cup/day). Moderate to high consumption was associated with lower risk for breast cancer events in tamoxifen-treated patients with ER+ tumors (adjusted HR, 0.51; 95% confidence interval, 0.26–0.97). Caffeine and caffeic acid suppressed the growth of ER+ (P ≤ 0.01) and ER− (P ≤ 0.03) cells. Caffeine significantly reduced ER and cyclin D1 abundance in ER+ cells. Caffeine also reduced the insulin-like growth factor-I receptor (IGFIR) and pAkt levels in both ER+ and ER− cells. Together, these effects resulted in impaired cell-cycle progression and enhanced cell death. Conclusions: The clinical and experimental findings demonstrate various anticancer properties of caffeine and caffeic acid against both ER+ and ER− breast cancer that may sensitize tumor cells to tamoxifen and reduce breast cancer growth. Clin Cancer Res; 21(8); 1877–87. ©2015 AACR.

The COX2 rs5277 (306G>C) polymorphism has been associated with inflammation-associated cancers. In breast cancer, tumor COX-2 expression has been associated with increased estrogen levels in estrogen receptor (ER)-positive and activated Akt-pathway in ER-negative tumors. Our study investigated the impact of COX2 genotypes on early breast cancer events and treatment response in relation to tumor ER status and body constitution. In Sweden, between 2002 and 2008, 634 primary breast cancer patients, aged 25–99 years, were included. Disease-free survival was assessed for 570 rs5277-genotyped patients. Body measurements and questionnaires were obtained preoperatively. Clinical data, patient- and tumor-characteristics were obtained from questionnaires, patients' charts, population registries and pathology reports. Minor allele(C) frequency was 16.1%. Genotype was not linked to COX-2 tumor expression. Median follow-up was 5.1 years. G/G genotype was not associated with early events in patients with ER-positive tumors, adjusted HR 0.77 (0.46–1.29), but conferred an over 4-fold increased risk in patients with ER-negative tumors, adjusted HR 4.41 (1.21–16.02)(pinteraction = 0.015). Chemotherapy-treated G/G-carriers with a breast volume ≥850 ml had an increased risk of early events irrespective of ER status, adjusted HR 8.99 (1.14–70.89). Endocrine-treated C-allele carriers with ER-positive tumors and a breast volume ≥850 ml had increased risk of early events, adjusted HR 2.30 (1.12–4.75). COX2 genotype, body constitution and ER status had a combined effect on the risk of early events and treatment response. The high risk for early events in certain subgroups of patients suggests that COX2 genotype in combination with body measurements may identify patients in need of more personalized treatment.

// Sofie Bjorner 1,* , Ann H. Rosendahl 1,* , Maria Simonsson 1 , Andrea Markkula 1 , Karin Jirstrom 1 , Signe Borgquist 1,2 , Carsten Rose 3 , Christian Ingvar 4 and Helena Jernstrom 1 1 Department of Clinical Sciences Lund, Lund University Faculty of Medicine, Oncology and Pathology, Lund, Sweden 2 Department of Oncology and Haematology, Skane University Hospital, Sweden 3 CREATE Health and Department of Immunotechnology, Lund University, Medicon Village, Lund, Sweden 4 Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Surgery, Lund, Sweden * These authors have contributed equally to this work Correspondence to: Helena Jernstrom, email: // Keywords : insulin-like growth factor-I receptor, insulin receptor, phospho-insulin-like growth factor-I receptor/insulin receptor, breast cancer, prognosis Received : December 06, 2016 Accepted : December 15, 2016 Published : December 21, 2016 Abstract Clinical trials examining insulin-like growth factor-I receptor (IGF1R)-targeting strategies have emphasized that better predictive biomarkers are required to improve patient selection. Immunohistochemical tumor-specific protein expression of IGF1R, insulin receptor (InsR), and phosphorylated IGF1R/InsR (pIGF1R/InsR) individually and combined in relation to breast cancer prognosis was evaluated in a population-based cohort of 1,026 primary invasive breast cancer patients without preoperative treatment diagnosed in Sweden. IGF1R ( n = 923), InsR ( n = 900), and pIGF1R/InsR ( n = 904) combined cytoplasmic and membrane staining was dichotomized. IGF1R strong /InsR mod/strong /pIGF1R/InsR pos tumors were borderline associated with 2-fold risk for events, HR adj (2.00; 95%CI 0.96-4.18). Combined IGF1R and pIGF1R/InsR status only impacted prognosis in patients with InsR mod/strong expressing tumors ( P interaction = 0.041). IGF1R strong expression impacted endocrine treatment response differently depending on patients’ age and type of endocrine therapy. Phospho-IGF1R/InsR pos was associated with lower risk for events among non-endocrine-treated patients irrespective of ER status, HR adj (0.32; 95%CI 0.16-0.63), but not among endocrine-treated patients ( P interaction = 0.024). In non-endocrine-treated patients, pIGF1R/InsR pos was associated with lower risk for events after radiotherapy, HR adj (0.31; 95%CI 0.12-0.80), and chemotherapy, HR adj (0.29; 95%CI 0.09-0.99). This study highlights the complexity of IGF hetero-and homodimer signaling network and its interplay with endocrine treatment, suggesting that combinations of involved factors may improve patient selection for IGF1R-targeted therapy.

Lipophilic statins purportedly exert anti-tumoral effects on breast cancer by decreasing proliferation and increasing apoptosis. HMG-CoA reductase (HMGCR), the rate-limiting enzyme of the mevalonate pathway, is the target of statins. However, data on statin-induced effects on HMGCR activity in cancer are limited. Thus, this pre-operative study investigated statin-induced effects on tumor proliferation and HMGCR expression while analyzing HMGCR as a predictive marker for statin response in breast cancer treatment. The study was designed as a window-of-opportunity trial and included 50 patients with primary invasive breast cancer. High-dose atorvastatin (i.e., 80 mg/day) was prescribed to patients for 2 weeks before surgery. Pre- and post-statin paired tumor samples were analyzed for Ki67 and HMGCR immunohistochemical expression. Changes in the Ki67 expression and HMGCR activity following statin treatment were the primary and secondary endpoints, respectively. Up-regulation of HMGCR following atorvastatin treatment was observed in 68 % of the paired samples with evaluable HMGCR expression (P = 0.0005). The average relative decrease in Ki67 expression following atorvastatin treatment was 7.6 % (P = 0.39) in all paired samples, whereas the corresponding decrease in Ki67 expression in tumors expressing HMGCR in the pre-treatment sample was 24 % (P = 0.02). Furthermore, post-treatment Ki67 expression was inversely correlated to post-treatment HMGCR expression (rs = -0.42; P = 0.03). Findings from this study suggest that HMGCR is targeted by statins in breast cancer cells in vivo, and that statins may have an anti-proliferative effect in HMGCR-positive tumors. Future studies are needed to evaluate HMGCR as a predictive marker for the selection of breast cancer patients who may benefit from statin treatment.

The role of estrogen receptor beta (ERβ) in breast cancer has been investigated since its identification in 1996. Studies based on protein expression have indicated that ERβ is a favorable prognostic marker. Further, ERβ expression is lower in obese breast cancer patients. Fewer studies have focused on the prognostic impact of ERβ polymorphisms. Therefore, we analyzed the associations between four previously identified haplotype tagging single nucleotide polymorphisms (htSNPs), associated haplo- and diplotypes, and breast cancer-free survival according to body constitution. The patient cohort included 634 women from the prospective breast cancer and blood study (BC Blood study, Sweden) with a median follow-up of 4.92 years. Four htSNPs (i.e., rs4986938, rs1256049, rs1256031, rs3020450) in the ESR2 gene and the correlating haplo- and diplotypes were analyzed and correlated to selected patient and tumor characteristics and to disease-free survival, including stratification for BMI. Based on the four htSNPs, seven haplotypes and eight diplotypes were identified. The patient and tumor characteristics were well-balanced across all geno- and haplotypes. Disease-free survival differed according to rs4986938 and rs1256031 (Log-Rank P = 0.045 and P = 0.041, respectively) and the number of haplotype copies of the wildtype CCGC and TCAC (Log-Rank P = 0.027 and P = 0.038, respectively). In the survival analyses stratified for BMI, significant survival differences between alleles were observed among overweight women (rs4986938 and rs1256031 with Log-Rank P = 0.001 and P = 0.001, respectively). The BMI-stratified survival analyses based on haplotypes showed shorter disease-free survival for overweight women with null copies of CCGC (Log-Rank P = 0.001) and for overweight women with any TCAC copy (Log-Rank P < 0.0001). Markedly impaired disease-free survival was found for genotypes in two out of four ESR2 htSNPs and for two haplotypes. ESR2 polymorphisms seem to divide patients into good and poor survivors based on BMI, stressing the need of taking host factors into consideration in the evaluation of prognostic markers.

Background: Lipophilic statins proposedly harbour anti-tumoral effects in breast cancer by decreasing proliferation and increasing apoptosis. Although the biological mechanisms are not fully elucidated, HMG-CoA reductase (HMGCR) is the well-recognized target of statins. HMGCR is the rate-limiting enzyme of the mevalonate pathway, which produces cholesterol, steroid-based hormones and non-sterol isoprenoids. Previous studies demonstrated an inter-tumoral variation of HMGCR expression, suggesting HMGCR as a prognostic marker. HMGCR activity, in response to statin treatment as evaluated in MCF7 breast cancer cells, showed an adaptive induction of HMGCR activity. To our knowledge, no in vivo statin-induced effects on HMGCR activity have been reported. Furthermore, the potential of HMGCR as a predictive marker for statin treatment needs to be addressed. Aim: To validate the statin-induced anti-proliferative effects while investigating the HMGCR response and the impact of HMGCR as a statin-predictive marker in invasive breast cancer. Design and Methods: The study was designed as a single-center window-of-opportunity trial including patients with primary invasive breast cancer and a minimum tumor size of 15 mm. The trial was powered to include 50 patients. Following core needle biopsies, patients were prescribed high-dose atorvastatin (80 mg/day) during two weeks prior to surgery. Pre- and post treatment tumor samples were stored as paraffin imbedded tissue blocks. Proliferation was investigated by Ki67 expression using the MIB-1 antibody, counting 400 tumor cells per sample. The cytoplasmic intensity of HMGCR expression (negative, weak, moderate, strong) was determined using the monoclonal antibody HPA-8338. Change in Ki67 expression following statin treatment was the primary end-point and HMGCR activity alterations a secondary end-point. Results: Fifty patients entered the study with forty-three patients completing all study parts. No serious adverse events were reported. A significant up-regulation of HMGCR following atorvastatin treatment was observed in 27 of 30 patients with discordant HMGCR expression in paired samples (p = 0.0002, McNemar-Bowker test). A non-significant average decrease in proliferation (Ki67) was observed in 15 of 26 evaluable samples (relative reduction 7.6%, p = 0.39), irrespective of HMGCR expression. However, tumors with any positive HMGCR expression in pre-treatment samples had a significant decrease in Ki67 of 24% (p = 0.02). The odds of Ki67 decrease was 7.3 times higher in tumors with any HMGCR compared to tumors with absent HMGCR expression (p = 0.04, Fisher's exact test). Also the linear trend in Ki67 decreased over the four HMGCR categories (4.0% per category) and Spearman's Rho (= −0.44) were significant (p = 0.04 and p = 0.02, respectively). Conclusions: HMGCR, the target of statin treatment, was up-regulated in breast cancer samples after atorvastatin treatment. This indicates HMGCR targeting within the tumor, which resulted in increased enzymatic activity. This study supports previous reports of statin-induced anti-proliferative effects in breast cancer, and suggests that HMGCR could be used as a predictive marker for selection of breast cancer patients with beneficial anti-tumoral effects from statin treatment. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD03-07.

The association between tumor cyclooxygenase 2 (COX-2) expression and breast cancer prognosis has been inconsistent. The purpose of this study was to evaluate the prognostic significance of COX-2 tumor expression according to adjuvant treatment, and potential effect modifications of non-steroid anti-inflammatory drug (NSAID) use, and other tumor and lifestyle factors. A prospective cohort of 1,116 patients with primary breast cancer in Lund, Sweden, included 2002-2012 was followed until June 2014 (median 5 years). Tumor-specific COX-2 expression was evaluated on tissue microarrays using immunohistochemistry. Associations between COX-2 intensity (negative, weak-moderate, high) and patient and tumor characteristics as well as prognosis were analyzed. Tumor-specific COX-2 expression was available for 911 patients and was significantly associated with higher age at diagnosis and less aggressive tumor characteristics. Higher COX-2 expression was associated with lower risk for breast cancer events during the first five years of follow-up

Purpose: Isoform-specific tumor estrogen receptor β (ERβ) expression may hold prognostic information in breast cancer, especially among endocrine-treated breast cancer patients. The study's purpose was to evaluate ERβ isoform 1 (ERβ1) expression in relation to tumor characteristics, ESR2 genotypes, and prognosis in different treatment groups. Experimental Design: A population-based prospective cohort of 1,026 patients diagnosed with primary invasive breast cancer in Lund, Sweden, between October 2002 and June 2012 was followed until June 2014 (median 5 years). Associations between immunohistochemical ERβ1 expression, patient and tumor characteristics, as well as outcome within treatment groups were analyzed. Results: Tumor ERβ1 expression was available for 911 patients (89%) and was not associated with ESR2 genotypes. ERβ1 positivity, defined as >75% (ERβ175+, 72.7%), was positively associated with established favorable tumor characteristics. Overall, ERβ175+ was associated with lower risk of breast cancer events [HRadj = 0.60; 95% confidence interval (CI), 0.41–0.89]. The magnitude of the association was larger in patients with ERα− tumors (HRadj = 0.30; 95% CI, 0.12–0.76), compared with ERα+ tumors (HRadj = 0.66; 95% CI, 0.42–1.03). Among the 232 chemotherapy-treated patients, ERβ175+ tumors were associated with lower risk of breast cancer events compared with ERβ175− tumors (HRadj = 0.31; 95% CI, 0.15–0.64). Among the 671 chemonaïve patients, ERβ175 status was not associated with the outcome. Conclusions: High ERβ1 expression was a favorable prognostic marker in this breast cancer cohort, especially in chemotherapy-treated patients, but not in endocrine therapy–treated patients. These results warrant confirmation, preferably via a biomarker study in a previously conducted randomized trial. Clin Cancer Res; 23(3); 766–77. ©2016 AACR.

Background Endocrine resistance is a major obstacle to optimal treatment effect in breast cancer. Some genetic markers have been proposed to predict response to aromatase inhibitors (AIs) but the data is insufficient. The aim of the study was to find new genetic treatment predictive markers of AIs. Methods The ongoing population-based BC-blood study in Lund, Sweden includes women with primary breast cancer. This paper is based on AI-treated patients with estrogen receptor positive tumors who underwent breast cancer surgery in 2002–2008. First, an exploratory analysis of 1931 SNPs in 227 genes involved in absorption, distribution, metabolism, and elimination of multiple medications, using DMET™ chips, was conducted in a subset of the cohort with last follow-up in December 31st 2011 (13 cases, 11 controls). Second, selected SNPs from the first analysis were re-analyzed concerning risk for early breast cancer events in the extended cohort of 201 AI-treated with last follow-up in June 30th 2014. Clinical data were obtained from medical records and population registries. Results Only CYP1A2 rs762551 C-allele was significantly associated with increased risk for early events in the 24 patients (P = 0.0007) and in the extended cohort, adjusted Hazard ratio (HR) 2.22 (95 % CI 1.03–4.80). However, the main prognostic impact was found within five years, adjusted HR 7.88 (95 % CI 2.13–29.19). The impact of the CYP1A2 rs762551 C-allele was modified by a functional polymorphism in the regulator gene AhR Arg554Lys (G > A). Compared to patients who were homozygous for the major allele in both genes (CYP1A2 A/A and AhR G/G), a 9-fold risk for early events was found in patients who had at least one minor allele in both genes, adjusted HR 8.95 (95 % CI 2.55–31.35), whereas patients with at least one minor allele in either but not both genes had a 3-fold risk for early events, adjusted HR 2.81 (95 % CI 1.07–7.33). The impact of CYP1A2 rs762551 C-allele was also modified by the CYP19A1 rs4646 C/C, adjusted HR 3.39 (95 % CI 1.60–7.16) for this combination. This association was strongest within the first five years, adjusted HR 10.42 (95 % CI 3.45–31.51). Conclusion CYP1A2 rs762551 was identified as a new potential predictive marker for early breast cancer events in AI-treated breast cancer patients. Moreover, combined genotypes of CYP1A2 rs762551 and CYP19A1 rs4646 or AhR Arg554Lys could further improve prediction of early AI-treatment response. If confirmed, these results may provide a way to more personalized medicine.

BACKGROUND: CYP2C8/9 polymorphisms may influence breast cancer-free survival after diagnosis due to their role in the metabolism of tamoxifen, paclitaxel, and other chemotherapy. cytochrome P450 (CYP)2C8/9 metabolise arachidonic acid to epoxyeicosatrienoic acids, which enhance migration and invasion in vitro and promote angiogenesis in vivo. We aimed to investigate the frequency of CYP2C8/9 polymorphisms in relation to breast tumour characteristics and disease-free survival. METHODS: A prospective series of 652 breast cancer patients from southern Sweden was genotyped for CYP2C8*3, CYP2C8*4, CYP2C9*2, and CYP2C9*3. Blood samples and questionnaires were obtained pre- and postoperatively. Clinical information and tumour characteristics were obtained from patients' charts and pathology reports. RESULTS: Frequencies of CYP2C8/9 polymorphisms were similar to healthy European populations. Significantly less node involvement (P=0.002) and fewer PR+ tumours (P=0.012) were associated with CYP2C8*4. Median follow-up was 25 months and 52 breast cancer-related events were reported. In a multivariate model, CYP2C8/9*3/*1*/*2/*1 was the only factor associated with increased risk for early events in 297 tamoxifen-treated, ER-positive patients, adjusted HR 2.54 (95%CI 1.11-5.79). The effect appeared to be driven by CYP2C8*3, adjusted HR 8.56 (95%CI 1.53-51.1). CONCLUSION: Polymorphic variants of CYP2C8/9 may influence breast tumour characteristics and disease-free survival in tamoxifen-treated patients. (Less)

Flow cytometric DNA analysis was performed on fine-needle aspirates from frozen tumour biopsies from 421 node-negative, non-adjuvantly-treated breast-cancer patients with a median observation time of 6.75 years. Among premenopausal patients (n = 175), those having at least one DNA "hypoploid" subpopulation defined as DNA index (DI) < 0.96 or 1.44 < or = 1.92 (n = 81) were characterized by early recurrences (log-rank p = 0.05), Wilcoxon p = 0.007), poor overall survival (OS) (p < 0.001) and poor survival after recurrence (p < 0.001). In the postmenopausal group (n = 246), there were no significant difference among 7 different DI classes regarding either recurrence-free survival (RFS) or OS. S-phase fraction (SPF), divided into quartiles, predicted OS in premenopausal patients only (p = 0.02). Conventional multivariate Cox analysis of OS in the premenopausal group revealed hypoploidy to be the only independent prognostic factor involving a relative risk (RR) of 22.8. Age < or = 40 years was of marginal significance, whereas SPF, histological grade (WHO), oestrogen and progesterone receptor (PgR) content, tumour size and number of lymph nodes removed were excluded from the model. Application of the conventional Cox model to the premenopausal group regarding RFS was found inappropriate due to lack of proportionality of the hazards of hypoploidy due to lack of proportionately of the hazards of hypoploidy, SPF and histological grade. However, introduction of time-dependent co-variates using 2 years as cut-off level showed hypoploidy with a RR of 3.52 and age < or = 40 years with a RR of 3.28 to be independent prognostic factors. In the postmenopausal group, the conventional Cox model identified the number of lymph nodes removed to be the only independent prognostic factor regarding RFS as well as OS, whereas SPF < 9% (lowest quartile) was of marginal significance in RFS analysis. Hypoploidy was correlated to high SPF, low PgR content and low differentiation, indicating that hypoploid tumours proliferate rapidly and hormone-independently. These patients may therefore benefit from adjuvant chemotherapy administered while tumour burden and risk of drug resistance are still low.

Background The mevalonate pathway synthetizes cholesterol, steroid hormones, and non-steriod isoprenoids necessary for cell survival. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) is the rate-limiting enzyme of the mevalonate pathway and the target for statin treatment. HMGCR expression in breast tumors has recently been proposed to hold prognostic and treatment-predictive information. This study aimed to investigate whether HMGCR expression in breast cancer patients was associated with patient and tumor characteristics and disease-free survival (DFS). Methods A population-based cohort of primary breast cancer patients in Lund, Sweden was assembled between October 2002 and June 2012 enrolling 1,116 patients. Tumor tissue microarrays were constructed and stained with a polyclonal HMGCR antibody (Cat. No HPA008338, Atlas Antibodies AB, Stockholm, Sweden, diluted 1:100) to assess the HMGCR expression in tumor tissue from 885 patients. HMGCR expression was analyzed in relation to patient- and tumor characteristics and disease-free survival (DFS) with last follow-up June 30th 2014. Results Moderate/strong HMGCR expression was associated with less axillary lymph node involvement, lower histological grade, estrogen and progesterone receptor positivity, HER2 negativity, and older patient age at diagnosis compared to weak or no HMGCR expression. Patients were followed for up to 11 years. The median follow-up time was 5.0 years for the 739 patients who were alive and still at risk at the last follow-up. HMGCR expression was not associated with DFS. Conclusion In this study, HMGCR expression was associated with less aggressive tumor characteristics. However, no association between HMGCR expression and DFS was observed. Longer follow-up may be needed to evaluate HMGCR as prognostic or predictive marker in breast cancer.

Most, but not all, studies have found that women with a high urinary 2-hydroxyestrogen (2OHE) to 16 alpha-hydroxyestrone (16 alpha OHE1) ratio are at reduced risk for breast cancer and have a better prognosis. The aim was to identify factors associated with the pre-operative 2OHE to 16 alpha OHE1 ratio and factors that predicted the change in the ratio between the pre-operative visit and first follow-up visit three to six months post-o.peratively among 59 women with primary ER positive breast cancer tumors. Body measurements, questionnaires and blood samples for measurements of the 2OHE and 16 alpha OHE1 plasma levels and CYP1A2*1F genotyping were collected at both visits. Post-operatively, 15 women received tamoxifen, 30 women tamoxifen and radiotherapy concomitantly, and 14 women radiotherapy. The pre-operative ratio was not correlated with tumor characteristics, but was significantly higher in women who consumed three or more cups of coffee daily (p = 0.009). The number of CYP1A2*1F Galleles was correlated with a lower ratio at both visits (p = 0.13 and p = 0.02, respectively). The ratio increased between the two visits in 69.5% of the women, The factors associated with a significant increase in the ratio were concomitant tamoxifen and radiotherapy (p = 0.006), increasing alcohol consumption (p = 0.006), and a high coffee consumption (p = 0.03), but not age or CYP1A2*1F genotype. In this pilot study, breast cancer patients who started tarnoxifen during radiotherapy and who had a moderate coffee and alcohol consumption demonstrated a significant improvement in their estrogen metabolite profile between the pre- and post-operative visits. (c) 2006 Elsevier Inc. All rights reserved. (Less)

We compared the power of gene expression measurements with that of conventional prognostic markers, i.e., clinical, histopathological, and cell biological parameters, for predicting distant metastases in breast cancer patients using both established prognostic indices (e.g., the Nottingham Prognostic Index (NPI)) and novel combinations of conventional markers. We used publicly available data on 97 patients, and the performance of metastasis prediction was represented by receiver operating characteristic (ROC) areas and Kaplan-Meier plots. The gene expression profiler did not perform noticeably better than indices constructed from the clinical variables, e.g., the well established NPI. When analysing separately subgroups, according to the oestrogen receptor (ER) status both approaches could predict clinical outcome more easily for the ER-positive than for the ER-negative cohort. Given the time it may take before microarray processing is used worldwide, particularly due to the costs and the lack of standards, it is important to pursue research using conventional markers. Our analysis suggests that it might be possible to improve the combination of different conventional prognostic markers into one prognostic index.

It was previously shown that letrozole (Femara) was significantly more potent than anastrozole (Arimidex) in inhibiting aromatase activity in vitro and in inhibiting total body aromatisation in patients with breast cancer. The objective of this study was to compare letrozole (2.5 mg per day) and anastrozole (1 mg per day) as endocrine therapy in postmenopausal women with advanced breast cancer previously treated with an anti-oestrogen. This randomised, multicentre and multinational open-label phase IIIb/IV study enrolled 713 patients. Treatment was for advanced breast cancer that had progressed either during anti-oestrogen therapy or within 12 months of completing that therapy. Patients had tumours that were either positive for oestrogen and/or progesterone receptors (48%) or of unknown receptor status (52%). The primary efficacy endpoint was time to progression (TTP). Secondary endpoints included objective response, duration of response, rate and duration of overall clinical benefit (responses and long-term stable disease), time to treatment failure, and overall survival, as well as general safety. There was no difference between the treatment arms in TTP; median times were the same for both treatments. Letrozole was significantly superior to anastrozole in the overall response rate (ORR) (19.1% versus 12.3%, P=0.013), including in predefined subgroups (receptor status-unknown, and soft-tissue- and viscera-dominant site of disease). There were no significant differences between the treatment arms in the rate of clinical benefit, median duration of response, duration of clinical benefit, time to treatment failure or overall survival. Both agents were well tolerated and there were no significant differences in safety. These results support previous data documenting the greater aromatase-inhibiting activity of letrozole and indicate that advanced breast cancer is more responsive to letrozole than to anastrozole as second-line endocrine therapy.

Randomized clinical trials have established the role of third-generation aromatase inhibitors (AIs) (letrozole, anastrozole, and exemestane) as standard treatment for patients with hormone-sensitive metastatic breast cancer who have experienced disease progression with antiestrogen therapy. Significant gains in clinical efficacy and improved tolerability over progestins (megestrol acetate) and the first-generation AI aminoglutethimide have positioned these agents above previous therapies. Estrogen receptor (ER) status remains the best predictive determinant of endocrine response, and further randomized trials with properly selected patient populations may distinguish individual AIs within this class. A recently completed, randomized, head-to-head phase III trial of letrozole versus anastrozole as second-line endocrine therapy demonstrated a significant difference in objective response rate for letrozole compared with anastrozole (19% versus 12%, respectively; P = 0.014), with similar time to progression. The improved efficacy and safety of AIs as second-line endocrine therapies has spawned trials of their use as first-line endocrine therapy versus tamoxifen for patients with metastatic breast cancer. Based on favorable results from these trials, letrozole and anastrozole have also been approved for use as first-line treatment of postmenopausal women with hormone receptor-positive metastatic breast cancer.

The goal of endocrine therapy in breast cancer is to block the action of estrogen on the tumor cells either by inhibiting estrogen from binding to the specific estrogen receptor or by inhibiting its synthesis. Tamoxifen, a selective estrogen receptor modulator, is the standard endocrine treatment for hormone receptor-positive breast cancer, both in the adjuvant and metastatic settings. Tamoxifen inhibits the binding of estrogen to the receptor, resulting in inhibition of hormone action. However, as tamoxifen is also weakly estrogenic, it may not be optimally effective and increases the risk of endometrial cancer and stroke. Furthermore, patients may be refractory or may become resistant to tamoxifen treatment. Since aromatase inhibitors (AI) block the synthesis of estrogen and have no intrinsic estrogenic activity, they have the potential to be more effective than tamoxifen. Their different mechanism of action and chemical structures may also circumvent tamoxifen resistance. Consequently, AIs are currently being evaluated as an alternative to tamoxifen treatment. A preclinical model has recently been developed to compare the efficacy of AIs and antiestrogens in different treatment schemes and to assist in the design of clinical trials. Current studies with the MCF-7Ca xenograft model are exploring the effects of combination and sequential therapy on tumor growth. The efficacy of AIs in the treatment of hormone receptor-positive breast cancer was first demonstrated in five multicenter second-line trials enrolling several hundreds of postmenopausal patients with metastatic breast cancer who had failed tamoxifen treatment. More recently, anastrozole demonstrated efficacy at least equivalent to that of tamoxifen in first-line randomized, phase III clinical trials in postmenopausal women with hormone receptor-positive or unknown metastatic breast cancer, whereas letrozole demonstrated superiority. The steroidal AI exemestane is currently under evaluation. Letrozole is the only AI to have been studied in a randomized, phase III trial in the neoadjuvant setting. In this trial, more patients underwent breast-conserving surgery with letrozole than with tamoxifen. Smaller phase II studies also suggest that both anastrozole and exemestane are active in the neoadjuvant setting. Because neoadjuvant trials permit temporal sampling of breast tissue, substudies in the phase III trial with letrozole have examined the impact of such biomarkers as estrogen receptor, progesterone receptor and epidermal growth factor receptor family members, HER-1 and HER-2, on patient response. AIs are currently under evaluation in the adjuvant setting, and preliminary results of the Arimidex, Tamoxifen Alone or in Combination (ATAC) trial have been reported. AIs have proven as safe as tamoxifen in trials in patients with metastatic breast cancer. Ongoing clinical trials in the adjuvant setting include companion studies of end-organ effects, particularly bone metabolism and lipid metabolism evaluations. Quality-of-life assessments are also parts of major clinical trials. A head-to-head quality-of-life assessment of anastrozole compared with letrozole demonstrated patient preference for letrozole. These assessments also clearly indicated the eagerness of patients to participate actively in treatment decisions

Tumour angiogenesis and the levels of plasminogen activator inhibitor type 1 (PAI-1) are both informative prognostic markers in breast cancer. In cell cultures and in animal model systems, PAI-1 has a proangiogenic effect. To evaluate the interrelationship of angiogenesis and the PAI-1 level in breast cancer, we have evaluated the prognostic value of those factors in a total of 228 patients with primary, unilateral, invasive breast cancer, evaluated at a median follow-up time of 12 years. Microvessels were immunohistochemically stained by antibodies against CD34 and quantitated by the Chalkley counting technique. The levels of PAI-1 and its target proteinase uPA in tumour extracts were analysed by ELISA. The Chalkley count was not correlated with the levels of uPA or PAI-1. High values of uPA, PAI-1, and Chalkley count were all significantly correlated with a shorter recurrence-free survival and overall survival. In the multivariate analysis, the uPA level did not show independent prognostic impact for any of the analysed end points. In contrast, the risk of recurrence was independently and significantly predicted by both the PAI-1 level and the Chalkley count, with a hazard ratio (95% CI) of 1.6 (1.01-2.69) and 1.4 (1.02-1.81), respectively. For overall survival, the Chalkley count, but not PAI-1, was of significant independent prognostic value. The risk of death was 1.7 (1.30-2.15) for Chalkley counts in the upper tertile compared to the lower one. We conclude that the PAI-1 level and the Chalkley count are independent prognostic markers for recurrence-free survival in patients with primary breast cancer, suggesting that the prognostic impact of PAI-1 is not only based on its involvement in angiogenesis.

A total of 266 recurrence-free breast cancer patients from the randomized DBCG-82TM breast conservation trial were called in for a follow-up investigation to study the impact of surgical and radiation treatment factors on the cosmetic and functional outcome after breast conservation. The patients were interviewed and examined after a median follow-up time of 6.6 years, and 194 of them (73%) regarded the cosmetic result as excellent or good. Morbidity assessments showed that breast fibrosis, skin telangiectasia, and breast retraction were significantly associated with a less satisfactory cosmetic result. On univariate analysis, it was found that treatment with a direct anterior electron field produced more morbidity and inferior cosmetic outcomes compared with tangential photon treatment, while increasing breast size was associated with increased breast retraction and breast fibrosis. Treatment characteristics that emerged as independent prognostic factors of a poor cosmetic outcome on multivariate analysis were the use of a direct anterior electron field (OR = 2.15, CI 1.25-3.70) and adjuvant systemic therapy (OR = 2.13, 1.22-3.71). A significant but relatively low level of concordance was found between the patients' and the clinician's evaluations of cosmetic results but self-assessments of breast morbidity and psychological distress were significantly related to the observed treatment-induced side effects after breast-conserving treatment, indicating that subjective perceptions and observations as reported by the patients are relevant for the identification of treatment factors that impact on normal tissue reactions.

Aim and introduction The aim of this study was to elucidate the prognostic importance of nuclear expression of the insulin receptor (nucInsR) in primary breast cancer. The InsR is important for the metabolism, for the insulin-like growth factor (IGF) signaling network and is implicated in breast cancer. Insulin and InsR are interlinked with obesity and body mass index (BMI), which are also associated with breast cancer. The InsR is present both in the membrane and cytoplasm and can additionally translocate to the nucleus. The role of nucInsR is not well understood and the prognostic importance is unclear. Methods The tumor-specific expression of nucInsR was evaluated by immunohistochemistry on invasive breast cancer tissue microarrays from 984 primary breast cancer patients included in a population-based cohort in Sweden. Patients were followed for up to 11 years, the median follow-up for patients still at risk was five years. nucInsR in relation to prognosis was analyzed using Cox regression, adjusted for age, invasive tumor size, axillary lymph node involvement, histological grade, estrogen receptor (ER) status, BMI, tumor storage time, and treatment. Results Status for nucInsR was available for 900 patients (91.5%). nucInsRpos staining was present in 214 patients (23.8%) and was associated with lower age (P=0.004), and lower waist-to-hip ratio (P=0.006), but not with BMI, ER or PR status. During follow-up, 107 patients had a first breast cancer event. nucInsR had no prognostic significant impact among all patients. However, there was a significant effect modification of BMI on nucInsR regarding event-free survival (Pinteraction=0.006). Patients with nucInsRpos-expressing tumors and higher BMI (≥25 kg/m2) had lower risk for any breast cancer event, adjusted HR (0.49; 95% CI 0.26-0.93), while patients with nucInsRpos-expressing tumors and normal BMI ( Conclusions These results indicate that nucInsR status may add prognostic information in primary breast cancer depending on BMI. Citation Format: Sofie Björner, Ann H. Rosendahl, Maria Simonsson, Andrea Markkula, Karin Jirström, Signe Borgquist, Carsten Rose, Christian Ingvar, Helena Jernström. Nuclear expression of insulin receptor (InsR) adds prognostic information in primary breast cancer patients with high BMI [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 676. doi:10.1158/1538-7445.AM2017-676

Purpose: To evaluate whether tumor androgen receptor (AR) expression was prognostic and/or predictive for endocrine treatment alone or in combination with estrogen receptor (ER). The AR has been hypothesized to have differential prognostic roles in breast cancer depending on tumor ER status, and to influence endocrine treatment response. Experimental Design: A population-based prospective cohort of 1,026 patients diagnosed with primary invasive breast cancer in Lund, Sweden, between 2002 and 2012 was followed until June 2014. Associations between immunohistochemical AR expression in tumor tissue microarrays, patient and tumor characteristics, and AR genotypes were analyzed. Disease-free survival (DFS) by AR status, and combined ER/AR status was assessed in various treatment groups. Results: AR expression was assessable in 913 tumors. AR+ tumors (85.0%) were associated with higher age (P = 0.036) and favorable tumor characteristics. The AR+ status was a prognostic marker for DFS (LogRank P = 0.025). There was an interaction between AR and ER expression with respect to prognosis (adjusted Pinteraction ≤ 0.024). Tumors with discordant hormone receptor expressions (ER+AR− or ER−AR+) demonstrated worse prognosis compared with concordant tumor expressions (ER+AR+ or ER−AR−) in multivariable models [adjusted HRs (95% confidence intervals); ≥1.99 (1.28–3.10), P ≤ 0.002]. ER+AR− indicated early treatment failure with aromatase inhibitors (AI) among chemonaïve patients aged 50 or older. Conclusions: Prediction of breast cancer prognosis and treatment response was improved by combining AR and ER status. AR negativity predicted early treatment failure with AI but not tamoxifen, a finding that warrants confirmation in a randomized setting. Patients may benefit from anti-androgens or selective AR modulators. Clin Cancer Res; 21(16); 3640–50. ©2015 AACR.

The purpose was to study oral contraceptive (OC) use in relation to breast cancer events and endocrine treatment response in a prospective population-based cohort, because it is unclear whether history of OC use impacts on prognosis in breast cancer patients. Between 2002 and 2011, 994 primary breast cancer patients without preoperative treatment were enrolled in Lund, Sweden and followed until December 2012. History of OC use was obtained from preoperative questionnaires. Tumor characteristics, clinical data, and date of death were obtained from pathology reports, patient charts, and population registries. Among the 948 patients with invasive cancer and no metastasis detected on the post-operative screen, 74 % had ever used OCs. Patients were followed for up to nine years (median follow-up 3 years), and 100 breast cancer events were recorded. Ever OC use was not associated with prognosis, irrespective of duration. However, any OC use before age 20 was associated with a threefold increased risk for breast cancer events in patients

Early detection of prostate cancer (PC) using prostate-specific antigen (PSA) in blood reduces PC-death among unscreened men. However, due to modest specificity of PSA at commonly used cut-offs, there are urgent needs for additional biomarkers contributing enhanced risk classification among men with modestly elevated PSA.Recombinant antibody microarrays were applied for protein expression profiling of 80 plasma samples from routine PSA-measurements, a priori divided into four risk groups, based on levels of total and %free PSA.The results demonstrated that plasma protein profiles could be identified that pin-pointed PC (a malignant biomarker signature) and most importantly that showed moderate to high correlation with biochemically defined PC risk groups. Notably, the data also implied that the risk group with midrange PSA and low %free PSA, a priori known to be heterogeneous, could be further stratified into two subgroups, more resembling the lowest and highest risk groups, respectively.In this pilot study, we have shown that plasma protein biomarker signatures, associated with risk groups of PC, could be identified from crude plasma samples using affinity proteomics. This approach could in the longer perspective provide novel opportunities for improved risk classification of PC patients.

Purpose To investigate the association between pre- and postoperative alcohol consumption and risk for early breast cancer events, since the association between alcohol consumption and prognosis in breast cancer patients is unclear. Methods Alcohol consumption was recorded for 934 primary breast cancer patients who underwent breast cancer surgery in Lund, Sweden, between 2002 and 2011 and were followed until December 31st 2012. Clinical data were obtained from medical records and population registries. Pre- and postoperative alcohol consumption was analyzed in relation to risk for early events. Results Median follow-up time was 3.03 years and 100 breast cancer events, 65 distant metastases, and 76 deaths occurred. Compared to no consumption, any preoperative alcohol consumption was weakly associated with lower risk for early events, adjusted HR 0.69 (0.45-1.04), distant metastases, 0.60 (0.36-1.00) and death, 0.62 (0.38-1.01). In the 572 patients without axillary lymph node involvement, any alcohol consumption was not associated with risk for early events. However, in the 360 patients with axillary lymph node involvement, preoperative alcohol consumption was associated with lower risk for early events (adjusted HR 0.43 0.24-0.77; P interaction = 0.01). Conclusion Pre- and postoperative alcohol consumption was weakly associated with lower risk for early breast cancer events. The data does not support recommending that all breast cancer patients abstain from low to moderate alcohol consumption.

Background In breast cancer, high levels of the inflammatory cytokine interleukin-6 (IL-6) have been associated with disease-free survival and treatment resistance. Increased serum levels of IL-6 have been correlated with increased levels of NF-κβ and aromatase expression in adipose tissue. Several IL6 single nucleotide polymorphisms have been associated with breast cancer prognosis, but the impact may differ depending on tumour oestrogen receptor (ER) status. This translational study investigated the association between IL6 genotypes, ER-status, and treatment on the risk of early events among breast cancer patients. Methods The study included 634 25- to 99-year-old primary breast cancer patients in Sweden from 2002–2008. Genotyped IL6 single nucleotide polymorphisms rs1800797, rs1800796, rs1800795, and rs2069849 were analysed separately and as diplotypes. Disease-free survival was assessed for 567 patients. Clinical data, patient-, and tumour-characteristics were obtained from questionnaires, patient charts, population registries, and pathology reports. Results The median follow-up time was 5.1 years. IL6 diplotype was not associated with early events for all 567 patients, but AGCC/AGCC diplotype-carriers with ER-negative tumours had an increased risk, (adjusted Hazard Ratio (HR) = 5.91, 95% CI: 1.28–27.42). Any C-carriers (rs1800795) with ER-negative tumours had a higher risk of early events than GG-carriers with ER-negative tumours, (adjusted HR = 3.76, 95% CI: 1.05–13.43), particularly after radiotherapy (adjusted HR = 7.17, 95% CI: 1.16–32.28). Irrespective of ER-status, chemotherapy-treated Any C-carriers had a higher risk of early events than GG-carriers (adjusted HR = 3.42, 95% CI: 1.01–11.54). Conclusions The main finding of the present study was that IL6 genotype was strongly associated with early events among patients with ER-negative tumours, particularly among radiotherapy-treated patients, and among chemotherapy-treated patients irrespective of ER-status. The high risk for early events observed in these subgroups of patients suggests that combined information on IL6 genotype, tumour ER-status, and breast cancer treatment may represent a tool for identifying patients who require more personalised treatment. Electronic supplementary material The online version of this article (doi:10.1186/1471-2407-14-759) contains supplementary material, which is available to authorized users.

Background. CYP2D6 is considered the key enzyme in tamoxifen metabolism. Several studies have investigated the relationship between the CYP2D6 genotype and tamoxifen treatment outcome, with discrepant results. CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy may account for some of the discrepancies. We examined the association between CYP2D6 genotype and early breast cancer events in tamoxifen-treated breast cancer patients, in relation to CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy. Material and methods. Pre- and postoperative questionnaires on lifestyle and concomitant medications were completed by 634 primary breast cancer patients between 2002 and 2008, among whom 333 patients had ER-positive tumors and received tamoxifen. CYP2D6*3, *4, *6, *10 and *41 were genotyped. Information on clinical data, breast cancer events, and tumor characteristics was obtained from patients' charts, population registries, the Regional Tumor Registry, and pathology reports. Results. Median follow-up was 4.9 years. Neither poor metabolizers (adjusted HR 0.50; 95% CI 0.07-3.82) nor intermediate metabolizers (adjusted HR 1.00; 95% CI 0.47-2.11) had an increased risk of early breast cancer events when compared with extensive metabolizers. CYP2D6 activity score (taking into account genotype and CYP2D6 inhibitor use) was not associated with early breast cancer events (LogRank, Ptrend = 0.44). Conclusions. CYP2D6 genotype was not associated with tamoxifen treatment outcome, even when CYP2D6 inhibitor use, aromatase inhibitor use, or chemotherapy was taken into account. CYP2D6 genotype may be of minor importance for tamoxifen-treated patients in Scandinavia.

Since the few data exploring a possible association between Epstein–Barr virus (EBV) and breast cancer are conflicting, we investigated this association together with the influences of geographical areas. 509 breast cancers were sampled from areas with varying risks of nasopharynx carcinoma (NPC) such as North Africa (Algeria and Tunisia, high-risk area); southern France (Marseille, intermediate-risk area); and northern Europe (northern France, the Netherlands and Denmark; low-risk areas). Polymerase chain reaction (PCR) of a subregion of EBV BamHIC encoding the EBERs demonstrated that 31.8% of the tumours contained the viral genome. No significant differences were observed among the geographical areas. However, positive samples showed higher loads of the EBV genome in the NPC high- and intermediate-risk areas than in the low-risk areas. EBV type 1 was the dominant strain. In situ hybridization studies using a35S-labelled riboprobe for EBER1 and a laser capture microdissection, combined with quantitative PCR, showed that EBV localization was restricted to some tumour epithelial cell clusters. EBV could not be detected in the stroma. Considering the whole population covered, the presence of the EBV genome was not correlated with age, menopausal status, tumour, size, nodal status or histological grade. © 2001 Cancer Research Campaign http://www. bjcancer.com

The efficacy of combined endocrine therapy with tamoxifen (TAM), aminoglutethimide (AG), and hydrocortisone (H) or tamoxifen and fluoxymesterone (FLU) was evaluated against treatment with tamoxifen alone in 311 patients above 65 years of age with a first recurrence of a metastatic breast cancer. A total of 279 patients were eligible. The response rates were assessed for 258 fully evaluable patients and were the following for the TAM (N = 94), the TAM+AG+H (N = 83), and the TAM+FLU (N = 81) groups, respectively, PR: 14, 18, and 21%, and CR: 20, 11, and 23%. The overall response rates are not statistically different (p = 0.30). The 95% CL of difference in response rates for TAM vs. TAM+AG+H are -9-19% and for TAM vs. TAM+FLU -4-25%. Time to treatment failure was comparable with median values of 9.2, 7.7, and 9.2 months in the TAM, TAM+AG+H, and TAM + FLU group, respectively (p = 0.17). The corresponding figures for survival are median times of 22.0, 24.1, and 21.1 months with a p-value of 0.62. Toxicity was more pronounced in both the combined treatment groups, and could in most instances be attributed to treatment with either AG+H or FLU. Currently, new specific aromatase inhibitors with lesser toxicity than AG are being evaluated in combination with TAM for treatment of primary and metastatic breast cancer. In conclusion, the simultaneous use of TAM and AG +H or FLU does not seem to improve the therapeutic efficacy in elderly postmenopausal patients with metastatic disease. So far, combined endocrine therapy in this group of patients should only be used in the context of clinical trials.

The aim of the trial was to compare efficacy and safety of the aromatase inhibitor formestane (250 mg i.m. given every 2 weeks) with the progestin megestrol acetate (160 mg administered orally once daily), as second-line therapy in postmenopausal patients with advanced breast cancer previously treated with tamoxifen. A total of 547 patients were enrolled. Analyses revealed no statistically significant or clinically relevant difference between treatments with respect to time endpoints. In the intent-to-treat analysis, the median values for time to failure and overall survival for formestane were 169 and 561 days, respectively. The corresponding values for megestrol acetate were 169 days and 597 days, respectively. Overall response rates were comparable for formestane and megestrol acetate (16.3% vs 20.3%). Formestane was better tolerated than megestrol acetate. In the megestrol acetate group, cardiovascular events, weight increase, and vaginal haemorrhage were significantly more frequent than in the formestane group. Thus, formestane is a suitable alternative to progestins in patients previously treated with tamoxifen. (C) 2000 Harcourt Publishers Ltd.

Following modified radical mastectomy, pre- and perimenopausal (amenorrhoea for5 years) patients with stage II or III breast cancer received CMF (cyclophosphamide 600, methotrexate 40, 5-fluorouracil 600 mg/m2 intravenously (i.v.) every 4 weeks, 9 cycles). The effect on recurrence-free survival (RFS) and overall survival (OS) of the addition of adjuvant tamoxifen (TAM) to adjuvant chemotherapy was examined by randomisation either to no additional treatment (n = 314), or concurrently TAM 30 mg daily for 1 year (n = 320). 40% had positive, 12% negative and 48% unknown receptor status. One year after surgery 21% versus 35% (CMF + TAM versus CMF) were still menstruating (P0.01). With a median follow-up of 12.2 years there was no difference in RFS (10-year RFS 34% versus 35%, P = 0.81) or OS (45% versus 46%, P = 0.73). In a Cox proportional hazards model, tumour size, number of metastatic lymph nodes, frequency of metastatic nodes in relation to total number of nodes removed, degree of anaplasia, age, and menostasia within the first year after operation were significant independent prognostic factors for RFS, and the same factors except age for OS. No significant interactions with TAM were seen. Thus, in this group of pre- and perimenopausal high-risk early breast cancer patients with heterogeneous receptor status given CMF i.v., concurrent TAM for 1 year did not improve the outcome. These results do not exclude that receptor positive patients may benefit from adjuvant TAM for longer periods given sequentially to chemotherapy.

A woman's build and the risk of breast cancer seem to be related. While relative overweight, as described by the body mass index, seems to be associated with increased breast cancer risk in postmenopausal women, overweight in premenopausal women seems slightly protective. Papers from a MEDLINE search are reviewed regarding the association between build and the development of breast cancer. Different aspects of build, such as height, weight, body mass index and body shape, are discussed. The more prominent associations found through this search are a positive association between height and breast cancer risk both in pre- and postmenopausal women. Regarding body mass index, the association is negative in premenopausal women and positive in postmenopausal women. Body shape described as masculine versus feminine seems to have no impact on breast cancer risk in premenopausal women, but seems to be positively associated with breast cancer in postmenopausal women. Possible biological mechanisms responsible for the associations with breast cancer risk are discussed, including endogenous oestrogens, androgens and glucose metabolic substances. Avoiding or reducing postmenopausal overweight may modify breast cancer risk indicators in a more favourable direction.

Background and Objective Bubble formation, pressure wave generation, and cavitations constitute major factors influencing the outcome of clinical Excimer laser angioplasty. Thus, the rationale of this study was to determine the extent of pressure waves occurring during excimer laser ablation and to discuss possibilities that allow a less traumatic plaque removal in the coronary circulation. Study Design/Materials and Methods Conventional and experimental Xenon-Chlorid-Excimer lasers emitting light at a wave-length of 308nm and a pulse duration of 115ns were used for testing of signals. Whereas the conventional excimer laser light source transmits light through all fibres of a 1.7 mm laser catheter simultaneously, the prototype excimer laser divides the laser beam into several areas of uniform energy fluence by scanning the beam from one section to the other using the intermission between two laser discharges. Hydrophones consisting of piezoelectric films detected the acoustic signals, which were obtained on normal arterial wall and atherosclerotic plaque. Results Multiplexing decreases maximum pressures for both normal arterial wall and calcified plaque significantly, whereas pressure rise time remains comparable. During ablation of pure blood, a linear increase of peak pressures of 1 MPa at 10 mJ/mm2 to 7.5 MPa at 50 mJ/mm2 is found. Contrast media intensifies the extent of pressure wave formation. At 20 mJ/mm2, 60% contrast media added to blood results in an increase of maximum pressures from 1.5 MPa up to 5 MPa. Dilution with saline solution is effective; however, high concentrations of > 90% are required to achieve a significant pressure wave reduction. Conclusion Peak pressures of several thousand kPa occur during excimer laser ablation of contrast media, blood, calcified plaque, and normal arterial wall in a decreasing order. Multiplexing and saline flushing are capable of reducing the intensity of the generated acoustic signals during tissue ablation. It has to be taken into consideration, however, that high concentrations of saline solution are necessary to achieve a significant reduction of peak pressures. Lasers Surg. Med. 21:72–78, 1997. © 1997 Wiley-Liss, Inc.

The COX2 rs5277 (306GC) polymorphism has been associated with inflammation-associated cancers. In breast cancer, tumor COX-2 expression has been associated with increased estrogen levels in estrogen receptor (ER)-positive and activated Akt-pathway in ER-negative tumors. Our study investigated the impact of COX2 genotypes on early breast cancer events and treatment response in relation to tumor ER status and body constitution. In Sweden, between 2002 and 2008, 634 primary breast cancer patients, aged 25-99 years, were included. Disease-free survival was assessed for 570 rs5277-genotyped patients. Body measurements and questionnaires were obtained preoperatively. Clinical data, patient- and tumor-characteristics were obtained from questionnaires, patients' charts, population registries and pathology reports. Minor allele(C) frequency was 16.1%. Genotype was not linked to COX-2 tumor expression. Median follow-up was 5.1 years. G/G genotype was not associated with early events in patients with ER-positive tumors, adjusted HR 0.77 (0.46-1.29), but conferred an over 4-fold increased risk in patients with ER-negative tumors, adjusted HR 4.41 (1.21-16.02)(p(interaction) = 0.015). Chemotherapy-treated G/G-carriers with a breast volume ≥ 850 ml had an increased risk of early events irrespective of ER status, adjusted HR 8.99 (1.14-70.89). Endocrine-treated C-allele carriers with ER-positive tumors and a breast volume ≥ 850 ml had increased risk of early events, adjusted HR 2.30 (1.12-4.75). COX2 genotype, body constitution and ER status had a combined effect on the risk of early events and treatment response. The high risk for early events in certain subgroups of patients suggests that COX2 genotype in combination with body measurements may identify patients in need of more personalized treatment.