Epidemiology

How do we translate complex molecular interactions into therapeutic benefit?

Signal transduction pathways involved in cancer

OmicsWederson Marcos Claudino et al., JCO 2007, mod.Targetomics

From omics to knowmics

All patients with same diagnosisCourtesy H. McLeod

Courtesy H. McLeod

Clinical Observation

(CPT-11/Cetuximab Chemotherapy Combination)Patient 1Patient 2

++++Mucositis+++++Diarrhea+++BM-Toxicity--Skin-Toxicity+++

+Tumor Response++++

Inter-individual Differences in Response to Treatment and Side Effects

Standard therapy Responders and Patients Not Predisposed to ToxicityAll patients with same diagnosisAlternate therapy non-respondersand toxic respondersCourtesy H. McLeod

One Size Doesn't Fit All!

Histologically they look like, butPt 47 yrs, pre-menopausal

T 2.4 cm, N (-), G1 ER ()/PR(+), HER-2 (-)

12/2003: QUARTFEC100 x 6 LHRH-Tam

Pt 39 yrs, pre-menopausal

T 2.2 cm, N (-), G1 ER ()/PR(+), HER-2 (-)

09/2000: QUART FEC100 x 6 LHRH-Tam

By courtesy of S. Iacobelli, 2006

Overview

A disease defined by negatives is not one disease! No single HER2 equivalent has been found A number of promising targets / driving pathways are emerging

DefinitionBiology

Basal-Like The Triple Negative Breast CancerEstrogen Receptor (ER) negativeProgesterone receptor (PR) negativeHer2neu (HER2) negativeER/PR/HER2 -

What is a triple-negative breast cancer?Triple-negative cancers account for 1017% of all breast carcinomas, depending on the thresholds used to define ER and PR positivity and the methods for HER2 assessment. The main characteristics of triple negative cancers that have emerged from the literature illustrate the similarities between basal-like and triple-negative tumours, including the fact thatthey more frequently affect younger patients (

Triple-negative and basal-like breastcancers: synonyms?Despite the great interest in basal-like cancers, there is still no internationally accepted definition of these tumours. From a scientific perspective, microarray based expression profiling analysis remains the gold standard for the identification of basal-like breast cancers.However, for the foreseeable future, this technology is unlikely to be introduced in the diagnostic armamentarium for breast cancer patients, and results of microarray-based expression profiling usingRNA extracted from formalin-fixed archival samples are suboptimal.Therefore, several attempts to define an immunohistochemical surrogate for basal-like cancers have been described. Although many immunohistochemical signatures have been described, little information about their specificity and sensitivity for the identification of basal-like cancers as defined by microarray analysis has been provided. The best example to date is the panel proposed by Nielsen et al., where basal-like cancers are defined as those lacking both ER and HER2 expression and expressing CK5 6 and EGFR.

Basal-likeSubgroup= EHER2Subgroup= DNormalbreastlikeLuminalSubtypeCLuminalSubtypeBLuminalSubtypeAERGeneexpressionEDCBAO.S.monthsAdapted from Sorlie et al. PNAS, 2001Gene Expression Patterns of Breast Carcinomas Predict SurvivalERGeneexpression

Will the same type of treatment fit all types of tumor ?

Gene Expression\ICHLuminal-like AER+ and/or PgR+ HER2-Luminal-like BER+ and/or PgR+ HER2+Basal-likeER- PgR- HER2- CK5/6+ and/or HER1+HER2-likeER- PgR- HER2+

Turner et al. 2006Typical Histological Features of Triple Negative Breast CAGrade 3, IDC, with central fibrosisPositive Staining for EGFRPositive Staining for CK 5/6

Triple-Negative vs Basal-LikeTriple-Negative prevalence = 18% (150/823)Triple-Negative Basal-Like = 66% (95/150)Triple-negative non-Basal-Like = Luminal BConforti et al. SABCS 2007 (N=823)

Triple-Negative vs Basal-LikeLacks of ER, PgR and HER2Prevalence = 10-15%Mostly High-GradeTriple-NegativeNo standard DefinitionLacks of ER, PgR and HER2Stains for CK5/6/14, EGFR, p53, c-kitPrevalence = 10-15%Mostly High-GradeBasal-Like

How do we identify Basal-Like Breast Cancers in the clinical setting?

Definition of Basal-Like Breast CancersMultiple immunohistochemical markers have been used to identify Basal-Like differentiationNo universally agreed upon criteria or precise set of basal markersNielsen et al.ER/PR/HER2 negativity in addition to either EGFR + and/or CK5/6 +Smith et al. high molecular weight cytokeratins CK5, 14 and 17Carey et al.ER/PR/HER2 negativity

80 to 90% of these will beBasal-Like Breast Cancers20-10% Adenoid cystic and Medullary Typical100 Patients with Triple Negative Breast CancerER/PR/HER2 -

Triple Negative Breast CancersComprise approximately 15% of all invasive cancersMore common in:Younger patientsAfrican AmericansBRCA1 mutation carriersUnique Morphologic AttributesPushing borderhigh gradecentral scarring/acellular zoneStromal/peritumoral lymphocytic infiltrate

BRCA1 and BLC phenotypeBRCA1 is a tumor suppressor gene that functions in DNA repairThese tumors are often ER-, HER2- (up to 80% of BRCA1 associated tumors have been shown to be basal-like)Thoughmost basal-like tumors have normal BRCA1

Hereditary BRCA1 breast tumors and basal-like sporadic tumors have a similar phenotype and gene expression signatureSuggesting involvement of BRCA1 in the pathogenesis of sporadic basal-like cancer

BRCA1/BLCBRCA1 mutations are rarely found in sporadic breast cancer, but BRCA1 expression is often reduced, especially in basal-like breast cancersWhy?BRCA1 promotor methylation has been demonstrated in 7 to 31% of sporadic cancers (Catteau et al)LOH of the BRCA1 locus which occurs in 15 to 45% of sporadic breast cancers (Rio et al)However, studies looking at the relationship between BRCA1 methylation, BRCA1 LOH and clinical features of breast tumors have been inconsistentID4, a negative regulator of BRCA1, was found to be expressed at a 9-10 times higher in BLC (Turner et al)

Shared Features with BRCA-1 Cancers

BRCA1 associated breast cancerBasal-Like Breast CancerEstrogen receptor NegativeHER2 negativeExpress Cytokeratin 5/6EGFR overexpression and mutationHigh gradep53 mutationCytogenic abnormalities

Immunohistochemical Features:Livasy et al, Sorlie et al, Foulkes et al, Nielsen et al

Other Breast CAn (%)Basal-liken (%)p valueER expression517/665 (78%)3/21 (14%)HER223/87 (26%)0/21 (0)Cytokeratin 5/6105/761 (14%)13/21 (62%)EGFR14/521 (8%)12/21(57%)< 0.001C-KIT67/605 (11%)6/21(30%)< 0.001P53 mutation13%9/11 (82%)< 0.001P53 protein27/124 (22%)32/63 (51%)< 0.006Vimentin2/28 (7%)17/18 (94%)0.0001

Phenotype changes during breast developmentLaakso, Clin Canc Res, 2006

Clinical features

Triple-Negative Breast Cancer: Clinical Features and Patterns of RecurrenceHBBC database (1987-1997)1601 (80%) of patients had details on hormone receptors/HER2 and were eligible for the study180 (12%) of the 1601 patients were defined as triple negative breast cancers Mean follow up was 8.1 yearsDent, R. et al. Clin Cancer Res 2007

Characteristics of Triple Negative vs. Other Breast Cancers* p values were calculated with the use of the chi-square testDent, R. et al. Clin Cancer Res 2007

CharacteristicOther(N=1421)number (percent)Triple Negative(N=180)number (percent)Significancep value *Mean Age at Diagnosis (yrs)57.753p < 0.0001Mean Tumor Size2.1 cm3.0 cmp < 0.0001Tumor Size T1 ( 2 cm)880(62.7)65(36.5)p < 0.0001 T2 (>2cm to 5cm)461(32.8)99(55.6) T3 (>5cm)64(4.6)14(7.9) Missing162Lymph Node Status Positive510(45.6)87(54.4)p = 0.02 Negative609(54.4)70(44.6) Missing or Not Tested30223Tumor Grade I237(19.9)15(9.8)p < 0.0001 II616(51.8)37(24.2) III336(28.3)101(66.0) Missing

Tumor Size by Nodal Status according to Basal-Like Group* p values were calculated with the use of the chi-square testDent, R. et al. Clin Cancer Res 2007

Non Basal-like Group(N=1421) Basal-like Group(N=180)Tumour SizeLymph Node PositiveNumber (percent)Lymph Node PositiveNumber (percent)5.1 cm53(91.4)12(92.3)p

Distant RecurrenceDent, R. et al. Clin Cancer Res 2007;13:4429-4434Probability of being recurrence-free1.00.90.80.70.60.50.40.30.20.10.0Years after diagnosisp

Overall SurvivalDent, R. et al. Clin Cancer Res 2007;13:4429-4434Probability of survival1.00.90.80.70.60.50.40.30.20.10.0Years after diagnosisp

Non-random distributionSubtypeSmid et al, Cancer Res, in press

26 11 2 1 5 45

22 2 4 1 5 34

14 4 6 3 0 27

4 1 2 1 1 9

5 12 4 8 1 30

bone

lung

liver

brain

pleura

total

luminal B

luminal A

HER2

normal

basal

Patterns of Metastatic SpreadMore likely to spread to brain, lung and possibly liver and less likely to spread to bone and soft tissuesTsuda et al. 2000 Am J of Surgical PathologyRodriguez-Pinilla et al. Clinical Cancer Research 2006Fulford et al. Breast Cancer Research and Treatment 2007Hicks et al. 2006 Am J of Surgical Pathology

More likely to present with visceral metastases versus bone metastases as first site of metastases70% vs 37%, p < 0.001 (Dent et al. SABCS 2007)

Median Time from Distant Relapse to Death22 months9 monthsDent R, Trudeau M, Pritchard K, Hana W, Narod S. et al. Clinical Cancer Res 2007Triple Negative Breast CAOther Breast CA

Treatment

Current treatment for triple-negative breast cancersThere is currently no specific systemic regimen recommended for the treatment of triple-negative breast cancers, and little data on which to base treatment selection.

Current treatment for triple-negative breast cancersThere are several features inherent to basal-like cancers that have consistently been shown to be associated with clinical and pathological responsiveness to neoadjuvant chemotherapy in generalER negativityhigh expression of Ki-67In a prospective study to document the chemo sensitivity of breast-cancer subtypes, a complete pathological response rate to preoperative paclitaxel and doxo rubicin chemotherapy was seen in 45% of basal-like cancers, 45% of ERBB2-positive cancers, and only 6% of luminal cancers.

Current treatment for triple-negative breast cancersThe genetic instability of basal-like cancers is expected to lead to an increased potential for resistance to treatments.The use of combination and sequential regimens seems a sensible option for basal-like cancers, although there is no evidence to support this idea.

Triple-negative breast cancer: therapeutic optionsBecause of the absence of specific treatment guidelines for this subgroup, triple-negative breast cancers are managed with standard treatment.However, such treatment leaves them associated with a high rate of local and systemic relapse.S Cleator, W Heller, R C Coombes, The Lancet, 2007

Triple-negative breast cancer: therapeutic optionsS Cleator, W Heller, R C Coombes, The Lancet, 2007

Response of Brca1/p53 Mammary Tumors to Doxorubicin or Cisplatin/Carboplatin in vivo

Characteristics of retrieved studies - IGennari et al, JNCI 2008

Study ComparisonHER2 status determined (%)NSABP B11 Paik S et al, JNCI 1998PF vs PAF 638/682 (94%)NSABP B15Paik S et al, JNCI 2000CMF vs AC 2.034/2.295 (89%)GUN 3 De Laurentiis M et al, ASCO 2001CMF vs CMF/EV 123/220 (56%)BelgianDi Leo A et al, Clin Cancer Res 2002CMF vs HEC/EC 354/777 (46%)Milan Moliterni A et al, J Clin Oncol 2003CMF vs CMF A 506/552 (92%)DanishKnoop AS et al, J Clin Oncol 2005CMF vs FEC 805/980 (82%)NCIC MA5 Pritchard KI et al, NEJM 2006CMF vs CEF 628/710 (88%)

Total (determined/randomised)5.088/6.216 (82%)

Characteristics of studies - IIGennari et al, JNCI 2008

StudyMethodHER2 positive/screened%NSABP B11IHC239/63837%NSABP B15IHC599/2.03429%GUN 3IHC30/12324%BelgianFISH73/35421%MilanIHC95/50619%DanishIHC/FISH246/80533%NCIC MA5IHC/FISH/PCR 163/628 (FISH)26%

Total (positive/screened)1.445/5.08828%

Adjuvant Anthracyclines and HER2:Disease Free SurvivalAnthra betterStudyHER2 statusHR(95% CI)+0.60(0.44 to 0.82)-0.96(0.75 to 1.23)+0.84(0.65 to 1.08)-1.02(0.86 to 1.20)+0.65(0.34 to 1.26)-1.35(0.93 to 1.97)+0.83(0.46 to 1.49)-1.22(0.91 to 1.64)+0.75(0.53 to 1.06)-0.79(0.60 to 1.05)+0.52(0.34 to 0.80)-0.91(0.71 to 1.17)Overall0.90(0.82 to 0.98)+0.71(0.61 to 0.83)-1.00(0.90 to 1.11)NSABP B11NSABP B15BelgianMilanDBCG 89DNCIC MA5HER2 specific0.000.501.001.502.00Test for interaction: 2 13.7, p< .001Non anthra betterGennari A. et al. JNCI 2008

Adjuvant Anthracyclines and HER2 :Overall SurvivalStudyHER2 statusHR(95% CI)+0.66(0.42 to 1.01)-0.90(0.69 to 1.18)+0.82(0.63 to 1.06)-1.07(0.88 to 1.30)+0.85(0.27 to 2.69)-1.64(0.85 to 3.15)+0.61(0.32 to1.16)-1.26(0.89 to 1.79)+0.73(0.50 to 1.05)-0.82(0.59 to 1.13)+0.65(0.42 to 1.01)-1.06(0.80 to1.40)+0.71(0.32 to 1.55)-1.25(0.58 to 2.67)Overall0.91(0.79 to 1.04)+0.73(0.62 to 0.85)-1.03(0.92 to 1.16)NSABP B11NSABP B15GUNMilanDBCG 89DNCIC MA5HER2 specificGOIRC0.000.501.001.502.002.503.003.50Test for interaction: 2 12.6, p< .001Anthra betterNon anthra betterGennari A. et al. JNCI 2008

Efficacy summaryRisk of relapse 29% HR 0.71 (0.61-0.83)

Risk of death 27% HR 0.73 (0.62-0.85)

HER2 positiveRisk of relapse anthra non anthra HR 1.00 (0.90-1.11)

Risk of death anthra non anthra HR 1.03 (0.92-1.16) HER2 negativep

Highly hormon-sensitiveModerately hormon-sensitiveHER-2 amplifiedTriple negative

Pathological Complete Response to Chemotherapy Differs by Subtipes

AC TCarey CCR 07T FACRouzier CCR 05Luminal A/B4/62 (7%)2/30 (7%)Normal-likeNA0/10 (0)HER2+ and ER-4/11 (36%)9/20 (45%)Triple negative9/34 (27%)10/22 (45%)

Neoadjuvant Chemotherapy in Triple Negative Patients. MD Anderson ExperienceThe largest date set available (1118 pts) 23% TNBC, pCR 15%Liedtke, M. et al. J Clin Oncol; aheadof print on Febr 4, 2008

RegimensptsTNBCnon-TNBCFAC/FEC/AC30820%5%TFAC/TFEC58828%17%Taxanes5812%2%Other16414%7%Total111822%11%p 0.034

Neoadjuvant Chemotherapy in TNBCSurvival by Pathological ResponseLiedtke, M. et al. J Clin Oncol; aheadof print on Febr 4, 2008

Ixabepilone+Capecitabine a Phase III TrialPrevious AnthraTaxane ResistantVahdat LT et al: ASCO2007

Vahdat LT et al: ASCO2007Ixabepilone+Capecitabine a Phase III Trial

Ixabepilone+Capecitabine a Phase III TrialRugo et al: SABCS 2007

Perspectives

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