Tumor markers in breast cancer

Tumor markers in breast cancer •

Updated 2013 May 30 11:24:00 AM: human epidermal growth factor receptor 3 overexpression associated with increased mortality in patients with gastric and breast cancer but not in patients with colorectal cancer (J Natl Cancer Inst 2013 Feb 20) view updateShow more updates

Related Summaries: • •

Breast cancer (list of topics) Breast cancer in women

•

Chemotherapy for early and locally advanced breast cancer

•

BRCA mutation testing and management

Overview: •

tumor tissue tests recommended for every primary invasive breast cancer o estrogen receptors and progesterone receptors (NACB Grade A, Level I)

o

•



primary role is to identify patients likely to benefit from endocrine therapy; no benefit if estrogen receptor-negative (NACB Grade A, Level I)



hormone receptor status is an independent risk factor for survival (level 1 [likely reliable] evidence)

human epidermal growth factor receptor type 2 (HER2) expression (NACB Grade A, Level I) 

used to predict response to anti-HER2 therapy (trastuzumab) (NACB Grade A, Level I)



testing for HER2-positive breast cancer uses immunohistochemistry or fluorescent in situ hybridization (FISH)



HER2 amplification associated with decreased overall and relapsefree survival (level 1 [likely reliable] evidence)

tumor tissue tests to consider in some patients o

Oncotype DX assay (21-gene expression profile)





o

•

•

can be used in newly diagnosed node-negative estrogen receptorpositive breast cancer to predict recurrence risk with use of adjuvant tamoxifen therapy (NACB Grade A, Level I/II) 

low score identifies patients who may be able to avoid chemotherapy (NACB Grade A, Level I/II)



high score predicts likelihood of greater benefit with addition of chemotherapy to tamoxifen (NACB Grade B, Level II/III)

for women with node-positive, hormone receptor-positive breast cancer 

limited data found to determine whether Oncotope DXguided practice improves clinical outcomes



Oncotype DX may predict disease-free and overall survival in postmenopausal women treated with tamoxifen, and may predict whether addition of chemotherapy will increase disease-free and overall survival (level 2 [mid-level] evidence)

urokinase plasminogen activator (uPA) and plasminogen activator inhibitor (PAI)-1 

may be used to identify patients with lymph node-negative breast cancer unlikely to benefit from adjuvant chemotherapy (NACB Grade A, Level I), but not uniformly recommended across guidelines



should be measured with enzyme-linked immunosorbent assay (ELISA) using fresh tumor extracts > 200-300 mg (NACB Grade A, Level I)

serum cancer antigens may be used to monitor advanced breast cancer o

low sensitivity limits clinical utility of tumor markers for detecting distant relapse in patients with breast cancer (level 2 [mid-level] evidence)

o

primary use is in addition to history, physical exam, and diagnostic imaging in patients with advanced breast cancer and otherwise nonassessable disease (NACB Grade B, Level III)

o

rising levels may suggest progressive disease, except during first 4-6 weeks of new therapy (NACB Grade B, Level III)

o

most commonly used cancer antigens are (CA) 15-3, CA 27.29 and carcinoembryonic antigen (CEA)

tumor cell assays under investigation

•

o

presence of circulating tumor cells (CTCs) in peripheral blood associated with decreased overall and recurrence-free survival (level 2 [mid-level] evidence)

o

cytokeratin-positive (CK+) cells in bone marrow (as marker for bone marrow micrometastases) associated with decreased survival in patients with stage I-III breast cancer (level 1 [likely reliable] evidence)

tests with limited evidence for clinical use include o

serum HER2 extracellular domain levels

o

gene expression profiles other than Oncotype DX, such as MammaPrint

o

DNA flow cytometry-based parameters

o

markers of proliferation

o

tumor protein 53 (p53) tests

o

cathepsin D levels

o

glycoprotein expression

Hormone Receptors Recommendations: •

estrogen receptor (ER) and progesterone receptor (PR) tumor tissue assays(5) o consistently recommended by all guidelines for predicting response to endocrine therapy o

•

recommended by most guidelines for prognosis

American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) 2010 guideline recommendations on immunohistochemical testing of ER and PR in breast cancer(2) o

immunohistochemical test to determine ER and PR status used to identify patients likely to benefit from endocrine therapy

o

absence of benefit from endocrine therapy for women with ER-negative invasive breast cancers has been confirmed

o

testing recommended for 

all invasive breast cancers



all breast cancer recurrences

o

o



to ensure that prior results were not falsely negative



to evaluate specimen for biologic changes since previous testing

no formal recommendation made for patients with ductal carcinoma in situ 

testing of ER and PR commonly done and usefulness suggested by retrospective study published only in abstract form



validation studies appear unlikely to be done

interpretation of test results 

positive test defined as immunoreactivity (staining) in ≥ 1% of tumor nuclei



negative test defined as staining in < 1% of tumor cells in presence of appropriately-stained extrinsic and intrinsic (normal breast epithelium) controls



percentage of stained tumor cells may be helpful with treatment decisions 



•

increased percentage of ER staining associated with improved 

survival (overall, disease-free, recurrence-free and 5year)



response to endocrine therapy



time to treatment failure



time to recurrence

increased PR staining associated with improved 

overall survival



response to endocrine therapy



time to treatment failure/progression



time to recurrence

National Academy of Clinical Biochemistry (NACB) recommends ER and PR testing in all patients with breast cancer (NACB Grade A, Level I)(5) o

primary role is to identify patients who can be treated with endocrine therapy (NACB Grade A, Level I)

o

may be used with tumor stage, tumor grade and lymph node status to determine short-term prognosis in patients with newly diagnosed breast cancer (NACB Grade B, Level III)

Hormone receptors for prognosis: •

hormone receptor status is an independent risk factor for survival (level 1 [likely reliable] evidence) o based on 155,175 women > 30 years old with invasive breast carcinoma and known hormone receptor status from 11 cancer registries o

women entered cohort 1990-2001, results reflect mortality data in 2001

o

overall mortality

o



19.7% with estrogen receptor (ER)-negative/progesterone receptor (PR)-negative tumors



17.3% with ER-negative/PR-positive tumors

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12.2% with ER-positive/PR-negative tumors

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7.4% with ER-positive/PR-positive tumors

Reference - Breast Cancer Res 2007;9(1):R6 full-text

HER2-related Tests • human epidermal growth factor receptor type 2 (HER2) also called HER2/neu, ERBB2 or erbB2 Recommendations: •

•

recommendations regarding HER2 tumor tissue assays from multiple guidelines(5) o consistently recommended by all guidelines for predicting response to trastuzumab in early and advanced disease o

recommended by most guidelines (except American Society of Clinical Oncology [ASCO]) for prognosis

o

recommended by most guidelines for predicting response to adjuvant anthracycline-based therapy

o

not recommended for predicting response to endocrine therapy or to cyclophosphamide, methotrexate, fluorouracil chemotherapy

ASCO 2007 recommendations(1) o

HER2 testing for gene amplification (increased number of gene copies) and/or overexpression (increase in gene product which is HER2 protein)

o •



recommended for every primary invasive tumor to determine likelihood of benefit from trastuzumab in adjuvant or metastatic disease settings (high levels indicate patient may benefit)



if not receiving trastuzumab, HER2 positivity should prompt strong consideration of anthracycline use in patients who will receive adjuvant chemotherapy



not recommended for guiding use of adjuvant taxane chemotherapy



withholding endocrine therapy in hormone receptor-positive breast cancer



selecting which type of endocrine therapy to use



use as prognostic indicator

circulating extracellular domain of HER2 has insufficient evidence for use in breast cancer management

National Academy of Clinical Biochemistry (NACB) recommends HER2 testing in all patients with invasive breast cancer (NACB Grade A, Level I)(5) o

primary role is to identify patients who may be treated with trastuzumab (NACB Grade A, Level I)

o

may also identify patients that preferentially benefit from anthracyclinebased adjuvant chemotherapy (NACB Grade B, Level II/III) 

•



DynaMed commentary -- NACB recommendation of preferential benefit from anthracycline-based regimen in HER2-positive patients supported by MA 5 trial (in which trastuzumab was not used) but not supported by BCIRG-006 trial (in patients receiving trastuzumab) published in 2011

HER2 positivity(1, 3) o

occurs in 18%-20% of breast cancers

o

may be associated with 

increased response to anthracyclines and test should prompt strong consideration of anthracycline-based adjuvant therapy if chemotherapy indicated



poorer prognosis (increased mortality and recurrence) in absence of systemic therapy, but test not recommended for determining prognosis in early breast cancer



decreased benefit from non-anthracycline and non-taxane-containing chemotherapy, but test not recommended to guide use of taxanes in adjuvant setting



increased resistance to endocrine therapy, but test should not be used to withhold or determine type of endocrine therapy in patients with hormone receptor-positive disease

Tumor testing techniques: •

recommended methods include immunohistochemistry (IHC) or fluorescent in situ hybridization (FISH), which have similar ability to predict benefit from anti-human epidermal growth factor receptor type 2 (HER2) treatment(3) o positive HER2 status defined as any of

o

o •



3+ IHC staining (> 30% of invasive tumor cells with uniform, intense membrane staining)



> 6 HER2 gene copies per nucleus by FISH



FISH ratio (HER2 gene signals:chromosome 17 signals) > 2.2

negative HER2 status defined as any of 

0 or 1+ IHC staining



< 4 HER2 gene copies per nucleus by FISH



FISH ratio < 1.8

intermediate results require additional testing

IHC assays o

advantages - fast, inexpensive, slides stable and can be reassessed after longterm storage, allows determination of cell morphology

o

disadvantages - variation in testing protocol, interobserver variability in interpretation of results

o

Reference - Am J Clin Pathol 2009 Oct;132(4):539 full-text

o

commercially available FDA-approved tests include 

HercepTest



PATHWAY



Reference - Am J Clin Pathol 2008 Feb;129(2):263 PDF, commentary can be found in Am J Clin Pathol 2009 Jun;131(6):897

•

in situ hybridization (ISH) assays o

advantages and disadvantages 





 o

•

FISH 

less affected by handling and more objective interpretation than IHC, identifies HER2 positivity in tumors with 2+ (indeterminate) IHC results



expensive, signal decay disallows long-term storage and reassessment, may be difficult to identify areas of invasive carcinoma

silver-enhanced in situ hybridization (SISH) 

fast, fully automated, can assess chromosome 17 centromere in addition to HER2, long-term stability, easy to interpret



less experience with use due to newness of technology

chromogenic in situ hybridization (CISH) 

fast, less costly than FISH, stability allows long-term storage and reassessment, enables simultaneous assessment of tissue morphology and histology



no detection of chromosome 17 polysomy, less experience with use due to newness of technology

Reference - Am J Clin Pathol 2009 Oct;132(4):539 full-text

commercially available FDA-approved tests include 

PathVysion (FISH) (Am J Clin Pathol 2008 Feb;129(2):263 PDF)



INFORM (SISH) (Am J Clin Pathol 2008 Feb;129(2):263 PDF)



Inform dual ISH test (FDA Press Release 2011 Jun 14)



SPOT-Light HER2 (CISH) (FDA Press Release 2008 Jul 8)

0 and 1+ IHC results may identify HER2-negative tumors, but 2+ and 3+ readings appear less reliable indicators of HER2 status (level 2 [mid-level] evidence) o

based on 1 systematic review with subgroup analysis and 2 diagnostic cohort studies without blinding

o

FISH test result was reference standard

o

systematic review of 17 studies published since 2005 evaluating IHC and FISH concordance in > 6,400 patients with breast cancer 

subgroup analysis included 6 studies with sufficient data and IHC scoring by manual systems in 2,736 patients



estimated IHC concordance with FISH was

 o

o



96.5% for IHC 0



94% for IHC 1+ (assuming 1+ reading indicates HER2 negativity)



18% for IHC 2+ (82% of HER2-negative tumors produced a 2+ positive IHC result)



83% for IHC 3+ (17% of HER2-negative tumors were identified as positive by IHC)

Reference - Appl Immunohistochem Mol Morphol 2009 Jan;17(1):1

2,913 patients with breast cancer had tumor specimens tested by both FISH and IHC for HER2 status 

542 patients (18.6%) had HER2-positive tumors by FISH



positive IHC result (3+) had 98.8% specificity and 91.6% positive predictive value



indeterminate (2+) or positive (3+) results combined had 91.6% sensitivity, so negative result (0 or 1+) had 97.2% negative predictive value



Reference - JAMA 2004 Apr 28;291(16):1972 full-text, editorial can be found in JAMA 2004 Apr 28;291(16):2019, commentary can be found in JAMA 2004 Jul 21;292(3):328, JAMA 2004 Oct 20;292(15):1817

1,575 breast cancer tumor specimens were assessed for HER2 status by IHC (HercepTest), and subgroup of weakly positive tumors (IHC 2+) were also assessed by FISH (PathVysion) 

216 tumors (14%) were weakly positive, of which 12% (26 tumors) were HER2-positive by FISH



595 IHC 0 tumors (38%), 549 IHC 1+ tumors (35%) and 215 IHC 3+ tumors (13%) did not have HER2 status confirmed by FISH



Reference - Mayo Clin Proc 2002 Feb;77(2):148 PDF

•

•

testing for HER2-positive breast cancer using IHC and confirming scores of 2+ or 3+ with FISH appears cost-effective o

based on review of 17 studies

o

Reference - CMAJ 2007 May 8;176(10):1429 full-text

FISH analysis of central nervous system metastases accurately reflected HER2/neu status of primary lesions in 10 patients with breast cancer in small cohort study (Arch Pathol Lab Med 2003 Nov;127(11):1451 PDF)

HER2 in determining prognosis: •

human epidermal growth factor receptor type 2 (HER2) amplification associated with decreased overall and relapse-free survival in premenopausal women with node-positive breast cancer (level 1 [likely reliable] evidence) o based on post-hoc analysis of randomized trials o

HER2 amplification tested in 639 tissue samples from 710 premenopausal women with node-positive breast cancer who were randomized to anthracycline-containing regimen (cyclophosphamide, epirubicin, and fluorouracil [CEF]) vs. non-anthracycline-containing regimen (cyclophosphamide, methotrexate, and fluorouracil [CMF])

o

628 tumors tested for HER2 amplification by fluorescent in situ hybridization (FISH) were included in analysis, of which 26% had HER2 amplification

o

HER2 amplification associated with

o

o



decreased overall survival (hazard ratio [HR] for death 1.62, 95% CI 1.24-2.11)



decreased relapse-free survival (HR for relapse 1.31, 95% CI 1.031.67)

among tumors with HER2 amplification, CEF was superior to CMF in terms of 

increased relapse-free survival (HR for relapse 0.52, 95% CI 0.340.8)



nonsignificant trend toward increased overall survival (HR for death 0.65, 95% CI 0.42-1.02)

no significant differences in overall or relapse-free survival comparing CEF vs. CMF in women with tumors not showing HER2 amplification

o

•

•

Reference - N Engl J Med 2006 May 18;354(20):2103 full-text, editorial can be found in N Engl J Med 2006 May 18;354(20):2177, commentary can be found in N Engl J Med 2006 Aug 24;355(8):845

HER2 overexpression associated with reduced overall and disease-free survival o

506 women with invasive ductal breast carcinoma had tumor specimens assessed for HER2 overexpression

o

median follow-up 82 months

o

20.1% of tumors were positive for HER2

o

HER2 overexpression associated with decreased 

overall survival (p = 0.005)



disease-free survival (p = 0.02)

o

Reference - Breast Cancer Res 2004;6(1):R24 full-text

o

DynaMed commentary -- study looked at women treated from 1981-1999 which was before treatment with trastuzumab was widely available limiting applicability to women who are treated with trastuzumab

HER2 overexpression associated with reduced post-relapse survival and might predict resistance to endocrine therapy in women with hormone-receptor positive metastatic breast cancer o

73 women with estrogen or progesterone receptor-positive metastatic breast cancer had primary tumor specimens assessed for HER2 overexpression

o

all patients had previously had mastectomy or lumpectomy for primary breast cancer (with or without adjuvant systemic therapy) and received endocrine therapy as first-line treatment upon relapse

o

median follow-up after relapse 77 months

o

12.3% of tumors were positive for HER2

o

HER2 associated with

o



decreased post-relapse survival (p = 0.001)



nonsignificant trend toward resistance to endocrine therapy (p = 0.054)

Reference - Breast Cancer Res 2006 Jul 25;8(4):R48 full-text

o

•

•

•

DynaMed commentary -- study looked at women treated from 1982-2002 which was before treatment with trastuzumab was widely available limiting applicability to women who are treated with trastuzumab

HER2-positive disease associated with reduced disease-free survival in women with small, node-negative breast tumors o

based on pooled analysis of observational studies

o

pooled analysis of 1 cohort study and 1 case-control study reporting prognosis by HER status in 1,344 women with node-negative breast cancer (pT1a/b N0) with tumor ≤ 1 cm

o

compared to HER2-negative disease, HER2-positive disease associated with reduced disease-free survival (hazard ratio 2.6, 95% CI 1.53-4.41)

o

no significant differences in 5-year distant recurrence

o

Reference - Breast Cancer Res Treat 2012 Nov;136(1):289

HER2-positive disease associated with reduced 5-year relapse-free survival in women with small, node-negative breast tumors o

based on prospective cohort study

o

454 women with pT1 N0 breast cancer not treated with adjuvant trastuzumab were analyzed

o

17.2% were positive for HER2

o

18 recurrences occurred at median follow-up 46.3 months

o

5-year relapse-free survival 97.2% in HER2-negative patients vs. 88% in HER2-positive patients (p < 0.001)

o

Reference - Br J Surg 2011 Nov;98(11):1561

HER2-positive disease associated with reduced disease-free survival, especially in women with hormone receptor-positive disease o

based on matched cohort study

o

150 women with pT1a-b, pN0 and HER2-positive disease who had surgery were matched with controls and followed for median 4.6 years 

79 HER2-positive, hormone receptor-positive patients matched to 158 HER2-negative, hormone receptor-positive patients



71 HER2-positive, hormone receptor-negative patients matched to 71 HER2-negative, hormone receptor-negative patients

o

•

HER2-positive disease associated with 

decreased 5-year disease-free survival in patients with hormone receptor-positive disease (HR 5.2, 95% CI 1-25.9)



trend toward decreased 5-year disease-free survival 

overall (HR 2.4, 95% CI 0.9-6.5)



in patients with hormone receptor-negative disease (HR 1.2, 95% CI 0.3-4.7)

o

Reference - J Clin Oncol 2009 Dec 1;27(34):5693 full-text , editorial can be found in J Clin Oncol 2009 Dec 1;27(34):5671

o

DynaMed commentary -- no women in this study were treated with trastuzumab limiting applicability to women who are treated with trastuzumab

except for predicting benefit with trastuzumab for women with HER2-positive tumors, limited evidence to determine if HER2 status predicts overall treatment response in patients with breast cancer o

based on systematic review of low-to-moderate quality studies

o

systematic review of 70 studies evaluating outcomes associated with serum or tumor HER2 status in patients with breast and other cancers

o

44 studies included patients with breast cancer

o

in patients with breast cancer, limited evidence for association between HER2 status and

o



benefit with addition of trastuzumab to chemotherapy in patients with equivocal, discordant (defined as disagreement between immunohistochemistry and FISH results) or negative HER2 status



benefit from chemotherapy -- evidence for benefit from anthracycline in HER2-positive but not HER2-negative patients was statistically significant in only 1 of 4 randomized trials



complete pathologic response to neoadjuvant chemotherapy



response to hormonal therapy in hormone-receptor positive patients



disease progression or response to treatment using serum HER2

Reference - AHRQ Evidence Report on Breast Tumors and HER2 Testing 2008 Nov:172 PDF

HER2 extracellular domain levels:

•

conflicting evidence for utility of serum HER2 extracellular domain testing in diagnosis and management of patients with HER2-positive breast cancer (level 2 [mid-level] evidence) o based on systematic review without assessment of study quality o

systematic review of 63 studies evaluating serum HER2 extracellular domain (ECD) testing in patients with HER2-positive breast cancer

o

increased serum ECD level

o



associated with HER2-positive tumor tissue in 16 studies with 1,974 patients



not associated with tumor HER2 status in 10 studies with 836 patients

pretreatment ECD levels in patients receiving chemotherapy or hormonal therapy assessed in 23 studies 



o



decreased time to progression in 8 studies



decreased duration of response in 9 studies



no significant differences in response rate, disease-free survival, progression-free survival and overall survival

decrease from baseline ECD during or after chemotherapy or hormonal therapy significantly associated with response to treatment in only 1 of 7 studies

serum ECD levels before and during treatment with trastuzumab assessed in 12 studies with 1,576 patients 



o

increased pretreatment ECD level associated with

pretreatment ECD level 

associated with outcome (such as treatment response, time to progression, survival) in 2 studies with 88 patients



not associated with outcome in 10 studies with 1,488 patients

change in ECD level during treatment 

associated with outcome in 8 studies with 741 patients



not associated with outcome in 4 studies with 835 patients

Reference - Lancet Oncol 2011 Mar;12(3):286

•

baseline HER2 extracellular domain level does not appear to predict response to lapatinib in patients with HER2-negative metastatic breast cancer (level 2 [mid-level] evidence) o

based on post-hoc analysis of randomized trial

o

579 women with newly diagnosed HER2-negative or HER2-unknown metastatic breast cancer randomized to paclitaxel plus lapatinib vs. paclitaxel plus placebo

o

baseline HER2 ECD levels quantified (low or elevated) in 472 women with available samples

o

baseline HER2 ECD not associated with overall tumor response rates or progression-free survival with vs. without lapatinib in subgroup of 391 HER2-negative women

o

HER2 amplification identified in 86 patients with previously unknown HER2 status showed benefit with lapatinib, regardless of baseline ECD level

o

Reference - J Clin Oncol 2009 Nov 20;27(33):5552 full-text

Plasminogen Activator-related Tests • assesses tumor urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor 1 (PAI-1) levels to determine prognosis, especially in patients with node-negative disease(1, 5) Recommendations: •

urokinase plasminogen activator (uPA) and plasminogen activator inhibitor (PAI)-1 recommended for determining prognosis by(5) o American Society of Clinical Oncology (ASCO) 2007 o

European Group on Tumor Markers (EGTM) 2005

o

National Academy of Clinical Biochemistry (NACB) 2008

•

uPA/PAI-1 testing not recommended (for or against) by 4 other guidelines(5)

•

ASCO recommends uPA and PAI-1 as prognostic tool in patients with newly diagnosed, node-negative breast cancer(1) o

low levels associated with sufficiently low recurrence risk (especially in hormone receptor-positive cancer treated with adjuvant endocrine therapy) that chemotherapy adds minimal additional benefit.

o

high levels indicate high risk of recurrence that may benefit substantially from cyclophosphamide, methotrexate and 5-fluorouracil (CMF)-based adjuvant chemotherapy

•

o

use enzyme-linked immunosorbent assay (ELISA) on ≥ 300 mg fresh or frozen cancer tissue

o

immunohistochemistry testing not accurate for uPA and PAI-1

NACB recommendations for uPA and PAI-1(5) o

may be used to identify patients with lymph node-negative disease who do not need or are unlikely to benefit from adjuvant chemotherapy (NACB Grade A, Level I)

o

should be measured by validated ELISA using extracts of fresh or freshly frozen tumor (> 200-300 mg) (NACB Grade A, Level I)

Plasminogen activator testing in determining prognosis: •

tumor urokinase plasminogen activator (uPA) and plasminogen activator inhibitor (PAI)-1 levels may predict recurrence risk and benefit of chemotherapy in patients with node-negative breast cancer (level 2 [mid-level] evidence) o based on prognostic cohort from randomized trial with high crossover rate o

556 patients aged 28-71 years with node-negative breast cancer were assessed for tumor uPA and PAI-1 levels and were treated with observation only vs. 6 28-day cycles of cyclophosphamide 500 mg/m2, methotrexate 40 mg/m2 and 5-fluorouracil 600 mg/m2 on days 1 and 8 (CMF) based on risk level, randomization or patient preference 

241 low-risk patients (defined as uPA level ≤ 3 ng/mg of protein and PAI-1 levels ≤ 14 ng/mg of protein) were treated with observation only



182 high-risk patients (defined as uPA level > 3 ng/mg of protein and/or PAI-1 levels > 14 ng/mg of protein) were randomized to observation vs. CMF



133 high-risk patients who refused randomization were treated with observation (82%) or CMF (18%)

o

20% of patients randomized to CMF refused chemotherapy, 15% of patients randomized to observation chose to receive CMF

o

disease recurrence (primary outcome measure) in 10.8% (60 patients) at median follow-up 32 months

o

3-year recurrence rate with observation only was 6.7% in low-risk patients vs. 14.7% in high-risk patients (p = 0.006)

o

estimated 3-year disease recurrence risk in high-risk patients comparing CMF vs. observation in analysis of randomized patients only

o •



12% vs. 18.1% in intention-to-treat analysis (not significant)



9.3% vs. 19.4% in per-protocol analysis (relative risk 0.27, 95% CI 0.09-0.78, NNT 10)

Reference - Clin Breast Cancer 2008 Apr;8(2):168 PDF

tumor uPA and PAI-1 each may predict risk of distant metastases in patients with node-negative early breast cancer o

based on prognostic cohort study

o

169 patients with node-negative early breast cancer who did not receive chemotherapy had frozen tumor samples assessed for uPA and PAI-1

o

median follow-up 73 months

o

56.8% had high levels (defined as uPA > 3 ng/mg of protein and/or PAI-1 levels > 14 ng/mg of protein)

o

uPA, PAI-1 and uPA plus PAI-1 each associated with distant relapse (p = 0.002)

o

uPA associated with disease-free survival (p = 0.01)

o

uPA and PAI-1 not associated with locoregional recurrence

o

Reference - Anticancer Res 2009 May;29(5):1475

Multigene Expression Assays • gene profiles are groups of genes associated with differences in tumor behavior o also called gene signatures o

o

testing can help individualize treatment decisions based on a patient's specific tumor characteristics 

prognostic gene profiles provide information on tumor natural history irrespective of treatment



predictive gene profiles provide information on likelihood of response to particular treatments

Reference - Mol Diagn Ther 2009;13(2):73

Recommendations: •

Oncotype DX text(5) o recommended by American Society of Clinical Oncology (ASCO) 2007, National Comprehensive Cancer Network (NCCN) 2008 and National

Academy of Clinical Biochemistry (NACB) 2008 for determining prognosis in patients treated with adjuvant tamoxifen o •

ASCO 2007 recommendations on multiparameter gene expression analysis(1) o

o •

not recommended by European Group on Tumor Markers (EGTM) 2005 or St. Gallen conference

Oncotype DX assay can be used in newly diagnosed node-negative estrogen receptor-positive breast cancer to predict recurrence risk with tamoxifen use 

low scores can identify patients who may benefit from tamoxifen and not require chemotherapy



high scores may indicate greater benefit from addition of adjuvant chemotherapy (specifically cyclophosphamide, methotrexate and fluorouracil) to tamoxifen

clinical utility of other tests including MammaPrint, Rotterdam Signature and Breast Cancer Gene Expression Ratio is under investigation

NACB 2008 recommendations for gene expression profiling(5) o

o

Oncotype DX assay may be used to predict recurrence in patients with lymph node-negative, estrogen receptor-positive disease 

to identify low-risk patients receiving tamoxifen who may be able to avoid chemotherapy (NACB Grade A, Level I/II)



to identify high-risk patients who may benefit from adjuvant cyclophosphamide-methotrexate-5-fluorouracil or methotrexate-5fluorouracil chemotherapy (NACB Grade B, Level III)

microarray-based gene signature analysis should not routinely be used to predict outcome (NACB Grade B, Level III)

Available assays: •

Oncotype DX - 21-gene reverse transcriptase-polymerase chain reaction assay(4) o prognostic and predictive profile o

test result is a recurrence score from 0 to 100

o

used in estrogen receptor-positive breast cancer to evaluate recurrence risk and to predict benefit of adjuvant chemotherapy 

low risk is score < 18



intermediate risk is score 18-30



high risk is score > 30



•

MammaPrint - 70-gene DNA microarray assay(4) o

•

•

in low-risk patients, addition of chemotherapy not associated with improvement in distant metastases or survival compared to hormone therapy alone

test result is a correlation coefficient predictive of recurrence-free survival 

> 0.4 predicts good prognosis



≤ 0.4 predicts poor prognosis

HOXB13/IL17BR ratio (H/I) - 6-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay(4) o

used to predict recurrence in estrogen receptor-positive breast cancer with positive or negative lymph nodes

o

measures expression of homeobox (HOXB13) gene and interleukin 17B receptor gene (IL17BR)

o

test result is a hazard ratio based on a normalized HOXB13-to-IL17BR gene expression ratio

o

higher ratio predicts increased recurrence risk

less commonly used gene profiles include(4) o

ProEx Br - immunohistochemical (IHC) assay to predict relapse

o

Mammostrat - IHC assay to identify high, medium and low risk among tamoxifen-treated patients with estrogen receptor-positive, lymph nodenegative breast cancer

o

eXagenBC - 3-gene fluorescent in situ hybridization (FISH) assay to assess recurrence risk, uses different 3-gene sets for estrogen receptor-positive and estrogen receptor-negative tumors

o

Celera metastasis score - 14-gene RT-PCR assay predictive of 3.5-fold increased metastasis risk in patients in highest compared to lowest risk quintiles

o

Breast bioclassifier - 55 gene RT-PCR assay to predict benefit from chemotherapy independent of hormone receptor status

o

Rotterdam signature - 76-gene DNA microarray assay used for prognosis independent of hormone receptor status in lymph node-negative breast cancer

o

invasiveness gene signature - 186-gene DNA microarray assay used for prognosis independent of node or hormone receptor status

o

Nuvoselect - 30-gene DNA microarray assay to predict response to chemotherapy with paclitaxel, 5-fluorouracil, doxorubicin and cyclophosphamide; 200-gene assay to predict response to hormone therapy

o

Cytochrome P450 CYP2D6 - 1-gene DNA microarray assay to predict benefit of adding aromatase inhibitor to tamoxifen in estrogen receptorpositive breast cancer

o

Gene expression grade index - 97-gene DNA microarray assay that correlates with histologic breast cancer grade and can classify intermediategrade tumors as having high or low risk for recurrence

•

Wound Response Indicator - 512-gene signature associated with overall and distant metastasis-free survival (Mol Diagn Ther 2009;13(2):73)

•

stroma-derived prognostic predictor, a stromal gene expression profile, reported to predict disease outcome in study of 53 primary breast tumors (Nat Med 2008 May;14(5):518 full-text)

•

genomic predictor reported to predict response to and survival after neoadjuvant chemotherapy in patients with newly diagnosed invasive breast cancer, with 92% disease-free survival at median 3 years in patients with tumors predicted to be sensitive to taxane and anthracycline-based regimens (JAMA 2011 May 11;305(18):1873)

•

high hypoxia response score on gene expression profile of HIF1A gene associated with poor overall survival and increased rate of metastases in 295 early breast cancers and 72 ovarian cancers (PLoS Med 2006 Mar;3(3):e47 full-text), commentary can be found in PLoS Med 2006 Aug;3(8):e370 full-text

Evidence for gene profiles: •

gene expression profiling may predict prognosis in patients with stage I or stage II lymph node-negative breast cancer (level 2 [mid-level] evidence) but limited evidence for clinical utility o based on Evaluation of Genomic Applications in Practice and Prevention evidence review o

evidence included systematic review without explicit inclusion criteria of 26 studies evaluating 3 gene profiling tests, key primary publications, comments from test developers and peer reviewers and other sources of information

o

tests for genetic profiling of stage I or II lymph node-negative breast cancer reviewed for validity and clinical application included 

MammaPrint for use in estrogen receptors (ER)-positive or negative patients

o



Oncotype DX for use in ER-positive patients taking tamoxifen



Breast Cancer Gene Expression Ratio (Quest H:I Test) for use in ERpositive women taking tamoxifen and considering additional therapy

MammaPrint associated with future metastases, but insufficient evidence to determine value added to standard risk stratification 

o

recurrence scores associated with future metastases 

at 5 years (odds ratio [OR] 8.8, 95% CI 3.9-19) in analysis of 1 case-control and 2 cohort studies with 447 patients



at 10 years (OR 5.2, 95% CI 2.4-12) in analysis of 2 cohort studies with 453 patients

Oncotype DX Recurrence Score associated with disease recurrence and response to chemotherapy, but inadequate evidence for clinical utility 

recurrence score (RS) associated with 







distant metastases by 10 years in 1 cohort study with 668 patients 

OR 4.1 (95% CI 2.4-6.9) for RS ≥ 18 (intermediate or high risk)



OR 4.4 (95% CI 2.8-7) for RS ≥ 31 (high risk)

recurrence by 10 years in 1 cohort study with 227 patients 

OR 11 (95% CI 3.4-39) for RS ≥ 18



OR 15 (95% CI 5.4-41) for RS ≥ 31

benefit from chemotherapy (p = 0.038, RS ≥ 31 associated with benefit, RS < 18 associated with little benefit) in 1 study with 651 patients (evidence limited to cyclophosphamide, methotrexate, fluorouracil [CMF]/methotrexate-5fluorouracil [MF] regimens)

all of these studies were in node-negative, estrogen receptor-positive breast cancer

o

insufficient evidence for clinical validity or utility of Quest H:I Test

o

Reference - Genet Med 2009 Jan;11(1):66 full-text

o

systematic review included in above report can be found at AHRQ on Gene Expression Profiling Tests and Breast Cancer Outcomes 2008 Jan:160, also

published in Ann Intern Med 2008 Mar 4;148(5):358, commentary can be found in Ann Intern Med 2008 Sep 2;149(5):357 •

21-gene expression profile (Oncotype DX) o

for women with node-negative, estrogen receptor-positive breast cancer, recurrence score associated with distant metastases, 10-year recurrence risk, and benefit from chemotherapy, based on systematic review above

o

for women with node-positive, hormone receptor-positive breast cancer 



limited data found to determine whether Oncotope DX-guided practice improves clinical outcomes in women with node-positive breast cancer 

based on review of evidence and guidelines



2 studies identified for clinical validity are summarized below



Reference - PLoS Curr 2011 Jul 21;3:RRN1249 full-text

Oncotype DX may predict disease-free and overall survival in postmenopausal women with node-positive, estrogen receptorpositive breast cancer treated with tamoxifen, and may predict whether addition of chemotherapy will increase disease-free and overall survival (level 2 [mid-level] evidence) 

based on subgroup analysis of randomized trial (SWOG8814)



1,477 postmenopausal women with axillary node-positive, hormone receptor-positive breast cancer were randomized to 1 of 3 treatments 

tamoxifen alone for 5 years



6 cycles of cyclophosphamide, doxorubicin, and fluorouracil (CAF) then tamoxifen



concurrent CAF plus tamoxifen



subgroup analysis limited to 367 women in tamoxifen alone or sequential CAF/tamoxifen arms who had sufficient RNA available in pretreatment tumor samples for Oncotype DX assay



recurrence score predicted survival in women treated with tamoxifen alone

Results: 10-Year Disease- 10-Year Overall Recurrence Score Free Survival Survival < 18 (low risk) 60% 77% 18-31 (intermediate 49% 68% risk) ≥ 31 (high risk) 43% 51%  in analyses comparing CAF plus tamoxifen vs. tamoxifen alone





•



no significant differences in disease-free survival or overall survival in women with low risk or intermediate risk based on Oncotype DX



estimated 10-year disease-free survival in high risk women 55% vs. 43% (p = 0.003, NNT 9)



estimated 10-year overall survival in high risk women 68% vs. 51% (p = 0.027, NNT 6)

Reference - Lancet Oncol 2010 Jan;11(1):55, full-text, editorial can be found in Lancet Oncol 2010 Jan;11(1):6

21-gene recurrence score (Oncotype DX) predicted distant recurrence risk in node-negative and node-positive patients in cohort of 1,231 postmenopausal women with hormone receptor-positive breast cancer treated with endocrine therapy in ATAC trial (J Clin Oncol 2010 Apr 10;28(11):1829)

76-gene expression profile (Rotterdam signature) may predict metastatic risk in node-negative breast cancer (level 2 [mid-level] evidence) o

based on derivation cohort study without independent validation

o

76-gene prognosis profile derived from derivation cohort of 115 patients and validated in cohort of 171 patients with lymph node-negative breast cancer, including estrogen receptor-positive and -negative tumors

o

all tumor samples were selected from tumor bank in Netherlands

o

distant metastases within 5 years in 33% of patients in validation cohort

o

in validation cohort, 76-gene profile had 

47% positive predictive value



93% negative predictive value

o

•

•

Reference - Lancet 2005 Feb 19;365(9460):671, editorial can be found in Lancet 2005 Feb 19-25;365(9460):634, commentary can be found in Lancet 2005 May 14-20;365(9472):1685

186-gene "invasiveness gene signature" might predict 10-year metastasis-free survival in node-negative breast cancer (level 2 [mid-level] evidence) o

based on derivation cohort study with inadequate validation

o

295 patients with early breast cancer (derivation cohort) and 286 patients with node-negative breast cancer (validation cohort) from 2 databases were assessed for gene expression and 10-year survival

o

only 109 of 186 genes in derivation cohort-generated profile were tested in validation cohort and disease-free but not overall survival assessed in validation cohort

o

in derivation cohort, 186-gene signature associated with increased 

death (hazard ratio [HR] 1.4, 95% CI 1-1.4)



metastasis (HR 1.3, 95% CI 1.2-1.5)

o

in validation cohort, 109 of 186 genes significantly correlated with risk of metastases (no p value reported)

o

prognostic power increased when combined with wound-response signature

o

Reference - N Engl J Med 2007 Jan 18;356(3):217 full-text, editorial can be found in N Engl J Med 2007 Jan 18;356(3):294, commentary can be found in N Engl J Med 2007 May 3;356(18):1887

165-gene SET (sensitivity to endocrine therapy) index may predict distant relapse-free survival in patients with estrogen receptor (ER)-positive breast cancer treated with adjuvant endocrine therapy (level 1 [likely reliable] evidence) o

based on derivation and validation cohort study

o

165-gene expression profile derived from 437 patients with newly diagnosed breast cancer

o

SET index validated in 

2 cohorts with 225 (cohort 1) and 298 (cohort 2) patients with ERpositive breast cancer who received 5 years of tamoxifen alone as adjuvant therapy

•



122 patients with ER-positive breast cancer who received neoadjuvant chemotherapy followed by tamoxifen and/or aromatase inhibition



2 cohorts with 208 and 133 patients with ER-positive breast cancer who received no adjuvant systemic therapy

o

distant relapse-free survival defined as interval from breast surgery until diagnosis of distant metastasis or death from any cause

o

SET index associated with risk for distant relapse-free survival in patients treated with adjuvant endocrine therapy 

HR 0.7 (95% CI 0.56-0.88) for tamoxifen treated cohort 1



HR 0.76 (95% CI 0.56-0.88) for tamoxifen treated cohort 2



HR 0.19 (95% CI 0.05-0.69) for neoadjuvant chemotherapy/endocrine therapy treated cohort

o

no significant association between SET index and distant relapse-free survival in untreated patients

o

Reference - J Clin Oncol 2010 Sep 20;28(27):4111, editorial can be found in J Clin Oncol 2010 Sep 20;28(27):4101

Mammostrat immunohistochemical 5-gene assay predicts relapse-free survival in women with hormone receptor-positive early breast cancer treated with exemestane or exemestane and tamoxifen (level 1 [likely reliable] evidence) o

based on validation cohort study

o

tissue samples from 4,598 postmenopausal women with hormone receptorpositive early breast cancer were assessed for p53, HTF9C, CEACAM5, NDRG1, and SLC7A5 using Mammostrat test and women were stratified by Mammostrat risk score

o

all women were from TEAM randomized trial comparing exemestane monotherapy vs. sequential therapy with tamoxifen followed by exemestane

o



47% of women were node-positive and 36% were treated with adjuvant chemotherapy



median follow-up was 5.1 years

3,837 women who had Mammostrat score successfully calculated were stratified by risk of relapse 

low risk in 43%



medium risk in 25%

 o

o

•

high risk in 32%

5-year distant relapse-free survival by risk category 

92.7% for low risk



87.8% for medium risk



82.8% for high risk

5-year recurrence-free survival by risk category 

86% for low risk



81.7% for medium risk



76.8% for high risk

o

risk stratification by Mammostrat score was similar to overall analysis in subgroups of all women did not have adjuvant chemotherapy and women with node-negative cancer did not have chemotherapy

o

no significant differences in risk stratification comparing exemestane monotherapy vs. sequential therapy

o

Reference - J Clin Oncol 2012 Dec 20;30(36):4477

wound-response gene expression signature may predict local recurrence risk after breast-conserving therapy o

based on derivation cohort study without independent validation cohort

o

161 women who had breast-conserving therapy were selected from cohort of 295 women with stage I or II breast cancer and assessed for gene expression and recurrence within derivation and validation cohorts

o

17 patients (10.6%) had local recurrence

o

3 gene expression profiles (wound-response, 70-gene prognosis, hypoxia) were tested for predicting local recurrence

o

wound-response signature was only profile with statistically significant results (p = 0.04)

o

in validation subset, wound-response signature predicting 10-year recurrence risk as 5% in low-risk group and 29% in high-risk group

o

Reference - Breast Cancer Res 2006;8(5):R62 full-text

•

•

addition of gene expression profiling to clinicopathological risk stratification may identify subcategories of relapse risk in patients with early breast cancer (level 2 [mid-level] evidence) o

based on derivation and validation cohort studies using different clusters for gene expression profiles

o

964 patients with early breast cancer were evaluated for relapse risk and had tumor samples assessed for gene expression signatures 

573 patients included in derivation cohort



391 patients in validation cohort

o

patients were assigned a clinicopathologic risk category (low, intermediate, or high risk of relapse) based on age, comorbidities, estrogen receptor status, tumor grade, tumor size and lymph node status

o

patients were also given a cluster assignment based on dominant gene expression pattern

o

outcome measure was relapse-free survival at mean follow-up 11 years

o

validation cohort used clusters based on different gene expression patterns than the derivation cohort (related but not identical)

o

in validation cohort, genomic profiles identified 2 subcategories within each clinicopathologic risk category that were associated with significant differences in relapse-free survival (all p ≤ 0.03)

o

Reference - JAMA 2008 Apr 2;299(13):1574 full-text, editorial can be found in JAMA 2008 Apr 2;299(13):1605, commentary can be found in JAMA 2008 Aug 13;300(6):650

genomic instability in tumor stroma associated with tumor grade and regional lymph node metastasis (level 2 [mid-level] evidence) o

based on retrospective cross-sectional study

o

tumor samples from 220 women with primary sporadic invasive breast carcinomas were evaluated for loss of heterozygosity/allelic imbalance (genomic instability) with 386 microsatellite markers

o

genomic instability in stroma associated with 

tumor grade (p = 0.0013 for chromosome 11)



regional lymph node metastasis (p = 0.0002-0.0016 for chromosomes 1, 2, 5, 18, 20 and 22)

o

genomic instability in epithelium associated with progesterone receptor status (p = 0.002 for chromosome 14)

o

Reference - JAMA 2007 May 16;297(19):2103 full-text

Cancer Antigens • common tumor markers for breast cancer include(1, 5) o cancer antigen (CA) 15-3

•

o

CA 27.29 (also called BR 27.29)

o

carcinoembryonic antigen (CEA)

other serum markers o

tissue polypeptide antigen (TPA) and tissue polypeptide specific antigen (TPS)(5) 

o

used in some countries for 

postoperative surveillance in patients without evidence of disease



monitoring therapy in advanced disease (may be useful if CA 15-3, CA 27.29 and CEA not elevated)

angiogenic serum factors, including 

nitric oxide



tumor necrosis factor-alpha (TNF-alpha)



basic fibroblast growth factor (bFGF)



copper



Reference - Br J Biomed Sci 2010;67(4):167

Recommendations: •

cancer antigen (CA) 15-3 and CA 27.29 (also called BR 27.29)(5) o recommended by most groups for monitoring advanced disease, especially in absence of measurable disease o

•

recommended by European Group on Tumor Markers (EGTM) 2005 but not other groups for surveillance following surgery

carcinoembryonic antigen (CEA)(5) o

recommended for monitoring advanced disease by American Society of Clinical Oncology (ASCO) 2007, EGTM and National Academy of Clinical

Biochemistry (NACB) 2008 (but not European Society of Medical Oncology [ESMO] 2005) o •

•

recommended by EGTM but not other groups for surveillance following surgery

ASCO 2007 recommendations regarding tumor markers for monitoring response during active treatment of metastatic disease(1) o

tumor markers include CA 15-3, CA 27.29 and CEA

o

can be used in addition to diagnostic imaging, history and physical exam 

insufficient evidence for use as sole monitoring tool, but increasing levels can indicate treatment failure if disease is difficult to measure otherwise



rising levels during first 4-6 weeks of new therapy may not be sign of treatment failure

o

insufficient evidence for use in screening, diagnosis or staging

o

not recommended for monitoring for recurrence after primary breast cancer treatment

NACB 2008 recommendations regarding CA 15-3, BR 27.29 and CEA(5) o

should not routinely be used in asymptomatic patients for early detection of recurrence or metastases after surgery (NACB Grade B, Level III)

o

may be used in conjunction with radiology and clinical exam to monitor chemotherapy in patients with advanced breast cancer; for patients with otherwise non-assessable disease, sustained increases in concentration suggest progressive disease (NACB Grade B, Level III)

Clinical utility: •

•

elevated serum cancer antigen (CA) 15-3 levels associated with poor response to chemotherapy in retrospective cohort of 73 patients with locally advanced breast cancer (BMC Cancer 2006 Sep 5;6:220 full-text) serum carcinoembryonic antigen (CEA) and CA 15-3 levels do not appear to be useful indicators of progression during fulvestrant therapy for metastatic breast cancer (level 2 [mid-level] evidence) o

based on prognostic cohort study without validation

o

67 postmenopausal women with hormone receptor-positive metastatic breast cancer and failure of prior endocrine therapy were assessed for CEA and CA 15-3 levels and tumor progression during treatment with fulvestrant

o

•



7 patients (10.5%) had partial response (≥ 25% reduction decrease in sum of products of diameters of all measurable lesions, no increase in lesion size and no new lesions)



28 patients (41.8%) had stable disease (< 25% increase or decrease in sum of products of diameters of all measurable lesions without appearance of new lesions for ≥ 6 months)



32 patients (47.8%) had de novo disease progression (> 25% increase in lesion size or appearance of new lesions)



28 patients (41.8%) had secondary progression (disease progression after partial response or stable disease)

both CA 15-3 and CEA marker levels significantly increased 

after 6 months of treatment in patients with stable disease



after 4 months in patients with de novo disease progression



in 3 months prior to progression in patients with secondary progression

o

CEA significantly decreased in first 6 months of treatment in patients with partial response (p = 0.0165)

o

Reference - BMC Cancer 2006 Mar 26;6:81 full-text

low sensitivity limits clinical utility of serum tumor markers for detecting distant relapse in patients with breast cancer (level 2 [mid-level] evidence) o

based on diagnostic cohort study with reference standard result not blinded from diagnostic test result

o

268 patients with breast cancer who were disease-free after surgery were assessed for tumor markers during mean 16-month follow-up

o

reference standard was radiologic exam (bone scan, liver ultrasound and chest x-ray) for metastases

o

tumor markers tested included CEA, CA 15-3, mucin-like carcinomaassociated antigen and tissue polypeptide

o

19 distant metastases occurred in 18 (6.7%) women

o

sensitivities for tumor markers ranged from 53%-74%, specificities ranged from 84%-96%

o

Reference - BMC Cancer 2006 Nov 20;6:269 full-text

•

increased serum TNF-alpha, CA 15-3 and copper each may predict decreased overall survival in premenopausal women with breast cancer (level 2 [midlevel] evidence) o

based on small cohort study

o

30 premenopausal women with breast cancer assessed for preoperative serum nitric oxide (NO), TNF-alpha, bFGF, copper and CA 15-3 levels and compared with 15 controls

o

patients with breast cancer were followed for 36 months

o

breast cancer associated with increased

o

o •



NO (p = 0.011)



TNF-alpha (p = 0.004)



bFGF (p = 0.039)



copper (p < 0.001)



CA 15-3 (p = 0.001)

decreased overall survival among breast cancer patients associated with increased 

TNF-alpha (p = 0.035)



CA 15-3 (p = 0.04)



copper (p = 0.0339)

Reference - Br J Biomed Sci 2010;67(4):167

serum levels of bFGF may differentiate women with and without breast cancer (level 2 [mid-level] evidence) o

based on case-control study

o

65 healthy women and 73 breast cancer patients had bFGF levels measured

o

bFGF > 1 pg/mL had 85% sensitivity and 63% specificity for breast cancer

o

Reference - Breast Cancer Res 2004;6(1):R38 full-text

o

DynaMed commentary -- study in patients with suspected breast cancer necessary before clinically applicable

Tumor Cell Assays • circulating tumor cell assays, including FDA-cleared test (CellSearch Assay), have insufficient evidence for use in breast cancer management(1)

Circulating tumor cells: •

presence of circulating tumor cells (CTCs) in peripheral blood associated with decreased overall and recurrence-free survival (level 2 [mid-level] evidence) o based on systematic review with assessment of study quality not reported o

systematic review of 24 studies evaluating detection of CTCs in peripheral blood as prognostic indicator in 4,013 patients with breast cancer and 1,333 controls (early breast cancer included in 23 studies, metastatic cancer included in 5 studies)

o

studies used reverse transcriptase polymerase chain reaction testing to detect CTCs using various molecular markers such as cytokeratin 19 (CK19), mammaglobin (hMAM), HER2, carcinoembryonic antigen and others

o

detection of CTCs associated with

o

o •

•



decreased overall survival (hazard ratio [HR] 3, 95% CI 2.29-3.94) in analysis of 11 studies with 2,305 cases and 471 controls



decreased recurrence-free survival (HR 2.67, 95% CI 2.09-3.42) in analysis of 13 studies with 2,646 cases and 487 controls



certain clinicopathological features overall, including 

high histologic grade (HR 1.21, 95% CI 1.09-1.35)



tumor > 2 cm (HR 1.12, 95% CI 1.02-1.22)



≥ 1 positive lymph node (HR 1.1, 95% CI 1-1.21)

in subgroup analysis of markers 

CTCs positive for CK19 not associated with clinicopathologic features



CTCs positive for hMAM not associated with high histologic grade

Reference - Breast Cancer Res Treat 2011 Dec;130(3):809

response of circulating epithelial (tumor) cells (MAINTRAC analysis) during first 3-4 cycles of neoadjuvant chemotherapy reported to predict final tumor reduction at surgery (level 3 [lacking direct] evidence) o

based on prospective cohort study without clinical outcomes in 30 patients with breast cancer

o

Reference - Breast Cancer Res 2005;7(6):R975 full-text

circulating tumor DNA might be a useful marker for metastatic breast cancer

o

based on prospective cohort study

o

52 women with metastatic breast cancer were assessed for circulating cellfree tumor DNA, circulating tumor cells, and CA15-3

o

targeted or whole-genome sequencing was used to identify somatic genomic alterations in each patient and personalized assays were designed to quantify circulating tumor DNA in serially collected plasma specimens

o

in analysis of 30 women in whom somatic genomic alterations were identified

o

•



circulating tumor DNA detected in 29 women (97%)



circulating tumor cells detected in 26 women (87%)

Reference - N Engl J Med 2013 Mar 28;368(13):1199, editorial can be found in N Engl J Med 2013 Mar 28;368(13):1249

review of use of circulating tumor cells as prognostic marker in metastatic breast cancer can be found in Expert Rev Anticancer Ther 2010 Feb;10(2):171

Bone marrow tumor cells: •

cytokeratin-positive (CK+) cells in bone marrow (as marker for bone marrow micrometastases) associated with decreased survival in patients with stage I-III breast cancer (level 1 [likely reliable] evidence) o based on 3 cohort studies o

621 patients with stage I-III breast cancer had bone marrow aspirate assessed for CK+ cells and cell morphology 

disseminated tumor cell (DTC) defined as having CK positivity plus morphologic features specific to tumor cells



CK+ cells detected in 302 patients (49%), identified as DTCs in 94 patients (15%) and non-DTCs in 208 patients (34%)



median follow-up for survival 56 months



5-year survival in multivariate analysis comparing bone marrow DTCs vs. no DTCs (non-DTC CK+ patients and CK- patients) 

overall survival 77% vs. 89% (hazard ratio [HR] 1.92, 95% CI 1.12-3.48)



distant metastasis-free survival 79% vs. 83% (HR 1.96, 95% CI 1.21-3.17)



o



no significant differences in overall survival between non-DTC CK+ patients and CK- patients



Reference - Clin Cancer Res 2008 Jun 1;14(11):3306 full-text

552 patients with completely resected stage I-III breast cancer and 191 patients with benign breast disease had bone marrow aspirate tested for CK+ cells and were assessed for survival at median 38-month follow-up 

CK+ cells in 36% (199 patients) with vs. 1% (2 patients) without breast cancer



in patients with breast cancer, CK+ cells associated with 

decreased overall survival 75% vs. 94% (HR 4.17, 95% CI 2.51-6.94) in multivariate analysis



decreased distant disease-free survival 60% vs. 92% (HR 6.07, 95% CI 3.91-9.42) in multivariate analysis



increased cancer-related death





o

local relapse-free survival 79% vs. 82% (HR 3.73, 95% CI 1.71-8.13)



relative risk (RR) 13.26 (95% CI 3.01-58.46) in patients with lymph node-negative breast cancer



RR 13.26 (95% CI 3.01-58.46) in patients with lymph node-positive breast cancer

no significant differences in locoregional breast cancer relapse

Reference - N Engl J Med 2000 Feb 24;342(8):525 full-text, editorial can be found in N Engl J Med 2000 Feb 24;342(8):580, correction can be found in N Engl J Med 2000 Jul 27;343(4):308, commentary can be found in N Engl J Med 2000 Aug 24;343(8):577

89 patients with stage I-III breast cancer and no evidence of recurrence at median 19 months after surgery had pre- and post-treatment bone marrow aspirates tested for CK+ cells and were assessed for survival at median follow-up 41 months after initial aspiration 



bone marrow positive for CK+ cells 

pre- and post-treatment in 10 patients (persistently positive)



pre- but not post-treatment in 14 patients

bone marrow negative for CK+ cells







pre- and post-treatment in 50 patients (persistently negative)



pre- but not post-treatment in 15 patients

median survival comparing persistently negative vs. positive bone marrow 

overall survival 66 months vs. 61 months in patients with bone marrow persistently positive or positive post-treatment only (p = 0.045)



distant disease-free survival 65 months vs. 57 months in patients with persistently positive bone marrow (p = 0.04)

Reference - Cancer 2001 Jul 1;92(1):46 full-text

Other Tumor Markers • tumor markers with insufficient evidence for use in assigning patients to prognostic groups(1) o DNA flow cytometry-based parameters (such as DNA content, S phase) o •

immunohistochemically based markers of proliferation, including Ki67, cyclin D, cyclin E, p27, p21, thymidine kinase, topoisomerase II

tumor markers with insufficient evidence for use in breast cancer management include(1) o

circulating extracellular domain of HER2

o

p53 (tissue levels, gene mutations or deletions)

o

cathepsin D

o

cyclin E

o

proteomic patterns (analysis of protein patterns)

o

micrometastases in bone marrow aspirate

o

circulating tumor cell assays, including FDA-cleared test (CellSearch Assay)

Markers of proliferation: • •

assays to detect degree of cell proliferation, which may be associated with recurrence risk in patients with human epidermal growth factor receptor type 2 (HER2)-negative, estrogen receptor-positive disease o

high proliferation may indicate increased risk which, when added to other risk factors, may suggest value of adding chemotherapy to endocrine therapy

•

•

o

low proliferation together with other indicators of low risk may identify patients who can be treated with endocrine therapy alone

o

Reference - Ann Oncol 2009 Aug;20(8):1319 full-text

markers include o

DNA flow cytometry-based markers (such as S phase determination)

o

Ki67

o

cyclin D

o

cyclin E

o

p27

o

p21

o

thymidine kinase

o

topoisomerase II

o

mitotic index

o

proliferating cell nuclear antigen

o

thymidine or bromodeoxyuridine labelling index

o

Reference - J Clin Oncol 2007 Nov 20;25(33):5287 full-text(1), Breast 2008 Aug;17(4):323

in women < 55 years old with lymph node-negative breast cancer and Adjuvant!-predicted 10-year breast cancer-specific survival ≥ 95%, mitotic activity index may further stratify high-risk and low-risk patients (level 2 [midlevel] evidence) o

based on derivation cohort study without validation

o

516 women < 55 years old with lymph node-negative breast cancer were assessed using mitotic activity index (MAI) and Adjuvant! prognostic tool

o

median follow-up 118 months

o

122 women had Adjuvant!-predicted 10-year breast cancer-specific survival ≥ 95% 

observed breast cancer-specific survival 91%



breast cancer-specific survival stratified by MAI (p < 0.001) 

99% in 74 women with MAI < 3

 o

o •

394 women had Adjuvant!-predicted 10-year breast cancer-specific survival < 95% 

observed breast cancer-specific survival 74%



breast cancer-specific survival stratified by MAI (p < 0.001) 

92% in 86 women with MAI < 3



70% in 308 women with MAI ≥ 3

Reference - J Clin Oncol 2011 Mar 1;29(7):852

topoisomerase II alpha (TOP2A) o

•

79% in 48 women with MAI ≥ 3

TOP2A FISH pharmDx FDA approved to test for TOP2A gene for assessing risk of recurrence and long-term survival in patients with relatively high-risk breast cancer (FDA Press Release 2008 Jan 14)

increased Ki67, mitotic index, proliferating cell nuclear antigen and thymidine or bromodeoxyuridine labelling index each associated with decreased survival in patients with early breast cancer (level 2 [mid-level] evidence) o

based on systematic review without assessment of study quality

o

systematic review of 85 studies evaluating tumor Ki67 overexpression, mitotic index, proliferating cell nuclear antigen overexpression or thymidine or bromodeoxyuridine labelling index and survival in early breast cancer in 32,825 patients

o

median follow-up range 37-162 months

o

meta-analyses limited to studies providing a hazard ratio (HR) for effect of marker on overall or disease-free survival

o

decreased survival associated with (based on pooled estimates of multivariate analyses) 



Ki67 overexpression 

HR 1.73 (95% CI 1.37-2.17) for overall survival in analysis of 13 studies with 3,709 patients, results limited by significant heterogeneity (p = 0.0001)



HR 1.84 (95% CI 1.62-2.1) for disease-free survival in analysis of 14 studies with 4,983 patients

higher mitotic index





 •



HR 2.32 (95% CI 1.76-3.06) for overall survival in analysis of 6 studies with 1,185 patients



HR 2.39 (95% CI 1.73-3.28) for disease-free survival in analysis of 14 studies with 2,366 patients

proliferating cell nuclear antigen overexpression 

HR 2.38 (95% CI 1.22-4.66) for overall survival in analysis of 4 studies with 1,004 patients, results limited by significant heterogeneity (p = 0.001)



no data on disease-free survival suitable for meta-analysis, but disease-free survival significantly reduced in 3 studies with 837 patients

higher labelling index 

HR 1.99 (95% CI 1.34-2.96) for overall survival in analysis of 4 studies with 5,834 patients



HR 1.77 (95% CI 1.33-2.35) for disease-free survival in analysis of 6 studies with 6,080 patients

Reference - Breast 2008 Aug;17(4):323

limited evidence for prognostic and predictive value of most markers of proliferation o

based on systematic review of low-to-moderate quality studies

o

systematic review of 132 studies evaluating prognostic and predictive utility of 9 markers of proliferation in early breast cancer in 159,516 patients 

prognostic outcomes were death or recurrence



predictive outcomes were response to therapy

o

most studies were retrospective or assessed tumor marker utility as secondary outcome

o

only studies with multivariate analyses and > 100 evaluable patients included

o

Ki67 

prognostic value in 15 of 15 studies with 5,137 patients (high level associated with worse prognosis)



o

o

o

o

o

o

predictive value in 2 of 5 studies with 945 patients (benefit from chemotherapy in patients with high Ki67 or whose levels drop during therapy)

p27 

prognostic value in 8 of 12 studies with 3,224 patients (low levels associated with worse outcomes)



predictive value in 2 of 2 studies with 973 patients (increased benefit from tamoxifen in patients with low p27)

p21 

prognostic value in 4 of 11 studies with 3,034 patients (low levels associated with worse outcomes)



predictive value in 1 of 1 study with 107 patients (increased benefit from tamoxifen and decreased benefit from chemotherapy in patients with high p21)

cyclin E 

prognostic value in 7 of 10 studies with 2,368 patients (high levels associated with worse prognosis)



predictive value in 1 of 1 study with 108 patients (decreased benefit from tamoxifen in patients with high cyclin E)

cyclin D1 

prognostic value in 2 of 7 studies with 1,509 patients (overexpression associated with increased relapse-free survival in 2 studies, increased overall survival in 1 study)



predictive value in 1 of 1 study with 167 patients (no benefit from tamoxifen in patients with high levels of cyclin D1)

thymidine labeling index 

high index associated with decreased survival reported in several studies, study sizes not reported



predictive value in 3 of 3 studies (high index associated with benefit from chemotherapy in 2 multicenter trials, benefit from sequential vs. alternating courses of doxorubicin and CMF in 1 study with 285 women)

flow cytometry

o

o

o •



prognostic value in 41 of 49 studies (high S-phase fraction associated with worse prognosis)



no predictive value in 1 of 1 study of adjuvant tamoxifen in progesterone receptor-positive stage I-III breast cancer

thymidine kinase 

prognostic value in 1 of 1 study with 290 patients (high activity associated with decreased relapse-free survival in pre/perimenopausal women, and decreased overall survival in postmenopausal women)



predictive value in 2 of 2 studies (high thymidine associated benefit from anthracycline-based chemotherapy [vs. no chemotherapy] in 1 study, and poorer response to cyclophosphamide, methotrexate, 5fluorouracil or cyclophosphamide, doxorubicin, 5-fluorouracil chemotherapy [vs. patients with low thymidine kinase levels] in 1 study with 1,692 patients)

topoisomerase II alpha 

prognostic value in 2 of 3 studies with 1,403 patients (high level associated with worse prognosis)



predictive value in 1 of 1 study (high topoisomerase II alpha level associated with benefit from chemotherapy in patients with estrogen receptor-negative disease and tumor size < 40 mm)

Reference - Ann Oncol 2005 Nov;16(11):1723 full-text

Ki67 expression might predict resistance to endocrine therapy in women with hormone-receptor positive metastatic breast cancer (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

73 women with estrogen or progesterone receptor-positive metastatic breast cancer had primary tumor specimens assessed for Ki67 expression

o

all patients had previously had mastectomy or lumpectomy for primary breast cancer (with or without adjuvant systemic therapy) and received endocrine therapy as first-line treatment upon relapse

o

median follow-up after relapse 77 months

o

35.6% of tumors were positive for Ki67

o

Ki67 associated with resistance to endocrine therapy (p = 0.024)

o

Ki67 not associated with post-relapse survival

o

Reference - Breast Cancer Res 2006 Jul 25;8(4):R48 full-text

Tumor protein 53 (p53): • •

also called TP53 high tissue p53 levels or p53 mutations or deletions may be associated with reduced disease-free and overall survival, but not clinically useful for breast cancer management because immunohistochemical tissue testing detects both mutated and stabilized wild-type p53 and misses p53 deletions(1)

•

p53 accumulation associated with decreased overall and disease-free survival (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

506 women with invasive ductal breast carcinoma had tumor specimens assessed for HER2 overexpression, p53 accumulation and Ki67 expression

o

median follow-up 82 months

o

29% of tumors were p53-positive

o

p53 associated with decreased

o •



overall survival (p = 0.01)



disease-free survival (p = 0.01)

Reference - Breast Cancer Res 2004;6(1):R24 full-text

TP53 mutation associated with increased mortality risk (level 2 [mid-level] evidence) o

based on retrospective cohort study

o

212 patients with primary breast cancer had DNA analysis of white blood cells for TP53 mutation and were followed for 12-16 years

o

80 patients with sufficient specimen size also had gene expression analysis of tumor tissue

o

TP53 mutation independently associated with increased breast cancer death

o



relative risk 5.24 (95% CI 3.03-9.07) overall



relative risk 4.43 (95% CI 2.04-9.64) in subgroup with gene expression analysis

mutation associated with characteristic gene expression pattern including higher expression of CCNB2, CDCA5, CENPA and UBE2C

o •

Reference - Breast Cancer Res 2007;9(3):R30 full-text

p53 accumulation associated with reduced post-relapse survival and might predict resistance to endocrine therapy in women with hormone-receptor positive metastatic breast cancer (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

73 women with estrogen or progesterone receptor-positive metastatic breast cancer had primary tumor specimens assessed for p53 accumulation

o

all patients had previously had mastectomy or lumpectomy for primary breast cancer (with or without adjuvant systemic therapy) and received endocrine therapy as first-line treatment upon relapse

o

median follow-up after relapse 77 months

o

21.9% of tumors were positive for p53

o

p53 associated with

o



decreased post-relapse survival (p < 0.0001)



resistance to endocrine therapy (p = 0.0049)

Reference - Breast Cancer Res 2006 Jul 25;8(4):R48 full-text

Glycoprotein expression: •

high CD24 glycoprotein expression associated with lymph node metastases in patients with breast cancer (level 2 [mid-level] evidence) o based on systematic review without assessment of study quality o

systematic review of 28 studies evaluating CD24 expression and clinicopathologic features of breast, ovarian, colorectal, renal and other cancers in 2,925 patients

o

breast cancer assessed in 7 studies with 683 patients

o

CD24 expressed in 71% of patients, with cytoplasmic staining of CD24 in 62%

o

cytoplasmic staining of CD24 associated with malignancy (78% of 110 malignant lesions vs. 2% of 25 benign lesions, odds ratio [OR] 35.8, 95% CI 8.91-143.92) in analysis of 3 studies with 112 patients

o

high total CD24 expression associated with lymph node metastases (OR 3.55, 95% CI 1.66-7.55) in analysis of 3 studies with 330 patients

o

CD24 expression not associated with tumor size, grade, clinical stage or estrogen receptor or HER2 status in analysis of 3 studies with 330 patients

o •

Reference - Oncol Rep 2009 Nov;22(5):1149

epithelial glycoprotein Ep-CAM o

Ep-CAM RNA expression on microarray analysis may predict metastatic risk in node-negative breast cancer not treated with adjuvant systemic therapy (level 2 [mid-level] evidence) 

based on derivation and validation cohort study with mixed results in 2 validation cohorts



194 patients (derivation cohort) with node-negative breast cancer not treated with adjuvant systemic therapy had resected tumor tissue assessed for Ep-CAM expression and were followed for mean 10 years (Mainz cohort)



validation in 588 patients from 2 microarray datasets of nodenegative breast cancer not treated in the adjuvant setting





286 patients (Rotterdam cohort, 180 relapse-free, 106 with distant metastases)



302 patients (Transbig cohort)

in derivation cohort 







high Ep-CAM levels by microarray analysis associated with 

decreased breast cancer-specific disease-free survival (hazard ratio [HR] 1.99, 95% CI 1.13-3.52)



decreased metastasis-free survival (HR 1.94, 95% CI 1.003-3.74)



decreased overall survival (HR 2.26, 95% CI 1.034.94)

immunologic Ep-CAM status not associated with significant differences in disease-free survival, overall survival or metastasis-free interval

in validation cohorts, high Ep-CAM levels associated with 

decreased metastasis-free survival (HR 1.73, 95% CI 1.042.9) in 1 cohort with 302 patients



trend toward decreased metastasis-free survival (p = 0.089, HR not reported) in 1 cohort with 286 patients

Reference - Breast Cancer Res Treat 2011 Feb;125(3):637

o

epithelial glycoprotein Ep-CAM overexpression associated with decreased overall and disease-free survival (level 2 [mid-level] evidence) 

based on prognostic cohort study without validation



205 patients with localized breast cancer were assessed for tumor EpCAM overexpression by immunohistochemical staining and followed for median 10.8 years



Ep-CAM overexpression associated with (independent of tumor size, nodal status, histologic grade and hormone receptor expression)





decreased disease-free survival (relative risk [RR] 2.35, 95% CI 1.46-3.78)



decreased overall survival (RR 1.87, 95% CI 1.17-2.98)

Reference - Lancet 2000 Dec 9;356(9246):1981

•

pretreatment p-glycoprotein expression associated with poor clinical response to neoadjuvant chemotherapy in 50 cases of locally advanced breast cancer (World J Surg Oncol 2005 Sep 14;3:61 full-text)

•

COX-2 expression and MDR1/P-glycoprotein expression associated with higher grade and shorter survival in 104 cases of primary invasive breast cancer (Breast Cancer Res 2005;7(5):R862 full-text)

Lymphocyte cell surface markers: •

fewer CD1a and CD4 lymphocytes in axillary lymph node associated with decreased 5-year disease-free survival in stage II-III breast cancer o based on derivation cohort study without independent validation o

77 patients with stage II-III breast cancer had 47 sentinel and 104 axillary nodes assessed for CD4, CD8 and CD1a lymphocytes and were followed for 5 years

o

patients arbitrarily assigned to derivation cohort (29 patients) or validation cohort (48 patients) and outcome analysis used entire patient sample

o

disease recurrence in 43% (33 patients)

o

decreased disease-free survival associated with 

axillary lymph node CD1a cell population < 0.6% (hazard ratio [HR] 0.42, 95% CI 0.239-0.738)



axillary lymph node CD4 cell population < 7% (HR 0.93, 95% CI 0.877-0.99)

o

disease-free survival not associated with sentinel lymph node immune profile

o

Reference - PLoS Med 2005 Sep;2(9):e284 full-text

Other gene expression markers: •

mammaglobin may be useful in identifying breast cancer in metastatic or recurrent tumors from unknown primary site (level 2 [mid-level] evidence) o based on 2 case-control studies o

o

115 recurrent breast cancer tumors (43 local, 72 distant) and 38 metastatic lesions of non-breast cancers were assessed with antibodies to mammaglobin and gross cystic disease fluid protein-15 (GCDFP-15, also called BRST-2) 

breast cancer tumors expressed mammaglobin in 47.8% and GCDFP-15 in 11.3%



all non-breast cancer tumors were negative for both markers



Reference - Breast 2010 Oct;19(5):355

tissue samples from 70 breast cancers and 140 other carcinomas were assessed with antibodies to mammoglobin, BRST-1 and BRST-2 

mammaglobin expressed in 84% breast cancers and 15% non-breast cancers



BRST-1 expressed in 76% breast cancers and 26% non-breast cancers



BRST-2 expressed in 44% breast cancers and 2% non-breast cancers



diagnostic performance comparing mammaglobin vs. BRST-1 vs.

BRST-2 (p values not reported)

 •



sensitivity 84.3% vs. 75.7% vs. 44.3%



specificity 85% vs. 73.6% vs. 97.9%

Reference - Arch Pathol Lab Med 2003 Oct;127(10):1330 full-text

8p12 and 17q12 gene amplifications associated with decreased metastasis-free survival in patients with breast cancer (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

547 women with breast cancer had tumor samples assessed for amplification of genes in 6 different chromosomal regions

o

o

o •

gene amplification at region 

8p12 in 22.8% and 8q24 in 6.1%



11q13 in 19.6%



17q12 in 9.9%



20q13Z in 9.9% and 20q13Co in 8.5%



12p13 in 4.1%

decreased 5-year metastasis-free survival associated with 

8p12 amplification (69% vs. 82% without amplification, hazard ratio [HR] 2.25, 95% CI 1.28-3.93)



17q12 amplification (65% vs. 84% without amplification, HR 2.09, 95% CI 1.02-4.26)

Reference - BMC Cancer 2006 Oct 13;6:245 full-text

tumor cytokeratin 14 (CK14) expression associated with increased survival unless metastatic disease (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

443 patients with grade III invasive ductal carcinoma had immunohistochemical testing of tumors for CK14 and were followed for mean 116 months

o

88 tumors (20%) showed CK14 expression

o

CK14 positivity associated with 

increased disease-free survival (HR 0.72, 95% CI 0.52-0.99) but not overall survival



increased long-term survival (p = 0.02)



increased disease-free survival in patients without metastatic disease but decreased in patients with metastatic disease



trend toward increased brain metastases (p = 0.051)



estrogen-receptor negativity (p < 0.0001)



decreased 

axillary node metastases (p = 0.001)



bone metastases (p = 0.01)

 o •

•

liver metastases (p = 0.035)

Reference - Breast Cancer Res 2007;9(1):R4 full-text

human epidermal growth factor receptor 3 overexpression associated with increased mortality in patients with gastric and breast cancer but not in patients with colorectal cancer (level 2 [mid-level] evidence) o

based on systematic review of observational studies

o

systematic review of 12 observational studies evaluating human epidermal growth factor receptor 3 (HER3) expression in patients with solid tumors (mostly colorectal cancer, gastric cancer, or breast cancer)

o

HER3 overexpression associated with increased mortality compared to normal expression in analysis of 12 studies 

mortality at 3 years (odds ratio [OR] 2.24, 95% CI 1.77-2.83)



mortality at 5 years (OR 2.2, 95% CI 1.75-2.76)



significant increase for gastric and breast cancers but no significant difference for colorectal cancer in stratified analysis of studies by tumor type

o

analysis restricted to tumors that commonly overexpress HER2 reported stronger association between HER3 overexpression and increased risk of mortality

o

Reference - J Natl Cancer Inst 2013 Feb 20;105(4):266

G/G and A/G genotypes at mu-opioid receptor gene A118G polymorphism associated with reduced breast cancer-specific mortality compared to A/A genotype o

based on cohort study

o

2,039 women aged 23-74 years with breast cancer were genotyped at muopioid receptor gene A118G single nucleotide polymorphism and followed for median 9 years

o

> 1 copy of G allele at A118G associated with reduced risk of breast cancerspecific mortality (p < 0.001) 

hazard ratio 0.57 (95% CI 0.38-0.85) comparing G/G genotype vs.

A/A genotype



hazard ratio 0.32 (95% CI 0.22-0.49) comparing A/G genotype vs.

A/A genotype

o

Reference - Anesthesiology 2012 Apr;116(4):896

•

high levels of angiomotin expression associated with shorter overall survival (120 months vs. 136.5 months, p < 0.05) in study of 120 women with breast cancer (BMC Cancer 2006 Jan 23;6:16 full-text)

•

YKL-40 expression associated with poorer disease-free survival at mean 3.2-year follow-up in 109 patients with breast cancer (World J Surg Oncol 2007 Feb 7;5:17 full-text)

•

decreased levels of activated leukocyte cell adhesion molecule in frozen tissue specimens correlated with poorer prognosis (metastasis, recurrence, death) among 120 patients with breast cancer followed for 6 years (Breast Cancer Res 2004;6(5):R478 full-text)

Combinations of Tumor Markers • immunohistochemical subtypes o immunohistochemical subtype may predict short- and long-term survival in patients with breast cancer (level 2 [mid-level] evidence) 

based on pooled analysis of 10,159 women with breast cancer from 12 studies



tumors classified into 6 subtypes based on expression of 5 immunohistochemical markers, including basal markers cytokeratin5/6 (CK 5/6) and epidermal growth factor receptor (EGFR, also called HER1) 

71% were luminal (hormone receptor-positive), human epidermal growth factor receptor type 2 (HER2)-positive, basal marker-positive or negative



6% were luminal, HER2-negative, basal marker-positive or negative



6% were nonluminal (hormone receptor-negative) HER2positive tumors, basal marker-positive or negative



9% were nonluminal, HER2-negative, basal marker-positive



7% were nonluminal, HER2-negative, basal marker-negative



mortality 31% in 85,799 person-years follow-up (62% of deaths due to breast cancer)



luminal, HER2-negative subtypes associated with constant mortality rates over time

o



luminal, HER2-positive and nonluminal subtypes associated with peak mortality within 5 years of diagnosis then decline in mortality over time



nonluminal subtypes associated with poorer prognosis in first 5 years after diagnosis



luminal HER2-positive tumor associated with worst prognosis at 15 years



Reference - PLoS Med 2010 May 25;7(5):e1000279 full-text, editorial can be found in PLoS Med 2010 May 25;7(5):e1000281

breast cancer-specific survival appears to differ by immunohistochemical subtype (level 2 [mid-level] evidence) 

based on 2 retrospective cohort studies



934 women median age 59 years with newly diagnosed invasive breast cancer were assessed for tumor estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor type 2 (HER2) status and followed for median 13.3 years 





subtype prevalence and breast cancer-specific survival 

luminal A subtype (ER+ and/or PR+, HER2-) in 66%, survival 79%



luminal B subtype (ER+ and/or PR+, HER2+) in 4.5%, survival 64%



basal-like subtype (ER-, PR-, HER-) in 22.5%, survival 75%



HER2-enriched subtype (HER2+, ER-, PR-) in 7%, survival 61%

Reference - Cancer Epidemiol Biomarkers Prev 2012 Oct;21(10):1848

496 women with invasive breast cancer had adequate data for assessment of ER, PR, HER2, cytokeratin 5/6 (CK 5/6) and HER1 status and were followed for 8.1-11.2 years 

subtype prevalence and breast cancer-specific survival 

luminal A subtype (ER+ and/or PR+, HER2-) in 51%, survival 84%



luminal B subtype (ER+ and/or PR+, HER2+) in 16%, survival 87%

 •

•



basal-like subtype (ER-, PR-, HER2-, cytokine 5/6 positive and/or HER1+) in 20%, survival 75%



HER2+/ER- subtype in 7%, survival 52%



unclassified subtype (negative for ER, PR, HER2, HER1 and cytokine 5/6) in 6%, survival 77%

Reference - JAMA 2006 Jun 7;295(21):2492 full-text

combination of HER2 overexpression and protein 53 (p53) accumulation associated with decreased survival compared to either marker alone (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

506 women with invasive ductal breast carcinoma had tumor specimens assessed for HER2 overexpression and p53 accumulation

o

median follow-up 82 months

o

9.7% of tumors were positive for both HER2 and p53

o

compared to neither or single-marker positivity, combination of HER2 and p53 associated with decreased overall and disease-free survival (both p = 0.0001)

o

Reference - Breast Cancer Res 2004;6(1):R24 full-text

combination of HER2 and topoisomerase II alpha (TOP2A) overexpression associated with decreased survival compared to either marker alone (level 2 [mid-level] evidence) o

based on non-inception prognostic cohort study

o

225 patients with stage I-IV breast cancer had tumor samples assessed by immunohistochemistry for HER2 and TOP2A overexpression

o

mean follow-up 67 months

o

HER2 overexpressed in 9.8%, TOP2A overexpressed in 24.9%, both overexpressed in 9.3% Median and 5-Year Survival: Test Result Median Survival 5-Year Survival HER2 plus TOP2A overexpression 45 months 33% HER2 overexpression 68 months* 57.7%* TOP2A overexpression 104 months* 63.7%* No overexpression Not reached* 84.4%* Abbreviations: HER2, human epidermal growth factor receptor type 2;

Median and 5-Year Survival: Test Result Median Survival 5-Year Survival TOP2A, topoisomerase II alpha.

o

* p < 0.0001 compared to HER2 plus TOP2A overexpression Reference - Breast Cancer Res 2005;7(3):R374 full-text

Quality Improvement Physician Quality Reporting System Quality Measures: •

251. Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients o measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 (HER2) by Immunohistochemistry (IHC) uses the system recommended in the American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines for HER2 testing in breast cancer

•

see Physician Quality Reporting System Quality Measures for additional information

Guidelines and Resources Guidelines: International guidelines: •

international expert consensus recommendations on use of standard markers and incorporation of molecular markers into breast cancer therapy can be found in Cancer 2011 Apr 15;117(8):1575

United States guidelines: •

American Society of Clinical Oncology (ASCO) 2007 update of recommendations for the use of tumor markers in breast cancer can be found in J Clin Oncol 2007 Nov 20;25(33):5287 full-text or at National Guideline Clearinghouse 2007 Oct:11741, commentary can be found in J Clin Oncol 2008 Apr 20;26(12):2057

•

American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines on o

immunohistochemical testing of estrogen and progesterone receptors in breast cancer can be found in J Clin Oncol 2010 Jun 1;28(16):2784 full-text or at National Guideline Clearinghouse 2010 Nov 15:16041, also published in Arch Pathol Lab Med 2010 Jul;134(7):e48

o

human epidermal growth factor receptor 2 (HER2) testing in breast cancer can be found in J Clin Oncol 2007 Jan 1;25(1):118 full-text 

ASCO/CAP 2009 update can be found in Arch Pathol Lab Med 2009 Apr;133(4):611 full-text

•

Evaluation of Genomic Applications in Practice and Prevention (EGAPP) recommendations on tumor gene expression profiling in breast cancer can be found in Genet Med 2009 Jan;11(1):66 full-text

•

National Academy of Clinical Biochemistry (NACB) guidelines on o

use of tumor markers in testicular, prostate, colorectal, breast and ovarian cancers can be found in Clin Chem 2008 Dec;54(12):e11 full-text or at National Guideline Clearinghouse 2010 Sep 17:15553

o

quality requirements for use of tumor markers in clinical practice can be found at NACB 2009 PDF or at National Guideline Clearinghouse 2010 Mar 3:14283

•

National Comprehensive Cancer Network (NCCN) guideline on breast cancer can be found at NCCN website (free registration required)

•

expert recommendations on array-based technology and recommendations for utilization in medical genetics practice for detection of chromosomal abnormalities can be found in Genet Med 2010 Nov;12(11):742

United Kingdom guidelines: •

•

Endocrine Cancer Group guideline on HER2 testing in the UK: recommendations for breast and gastric in-situ hybridisation methods can be found in J Clin Pathol 2011 Aug;64(8):649 full-text United Kingdom National External Quality Assessment Service (UKNEQAS) guideline on HER2 gene amplification in breast cancer can be found in Am J Clin Pathol 2012 Apr;137(4):595 full-text

European guidelines: •

European Society of Medical Oncology (ESMO) clinical practice guidelines on o primary breast cancer (diagnosis, treatment, and follow-up) can be found in Ann Oncol 2011 Sep;22 Suppl 6:vi12 full-text o

locally recurrent or metastatic breast cancer (diagnosis, treatment, and follow-up) can be found in Ann Oncol 2011 Sep;22 Suppl 6:vi25 full-text

o

BRCA in breast cancer can be found in Ann Oncol 2011 Sep;22 Suppl 6:vi31 full-text

•

Spanish Society of Medical Oncology (SEOM) clinical guideline on using molecular markers in clinical practice can be found in Clin Transl Oncol 2011 Aug;13(8):587

•

Spanish Society for Medical Oncology (SEOM) guideline on hereditary cancer can be found in Clin Transl Oncol 2011 Aug;13(8):580

•

Spanish Society of Pathology/Spanish Society of Medical Oncology guideline on HER2 testing in breast cancer can be found in Clin Transl Oncol 2009 Jun;11(6):363

•

St. Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2009 guideline on thresholds for therapies can be found in Ann Oncol 2009 Aug;20(8):1319 full-text

•

European Group on Tumor Markers (EGTM) guideline on clinical use of tumor markers in breast cancer can be found in Tumour Biol 2005 Nov-Dec;26(6):281

•

Groupe d'Etude des Facteurs Pronostiques par Immunohistochimie dans le Cancer du Sein (GEFPICS) recommendations on HER2 status determination in breast cancers in France can be found in Ann Pathol 2010 Oct;30(5):357 [French]

Asian guidelines: •

Japanese Breast Cancer Society recommendations on adequate evaluation of hormone receptors can be found in Oncol Rep 2010 Aug;24(2):299

•

Chinese Anti-Cancer Association consensus statement on diagnosis and treatment of HER2-positive breast cancer can be found in Zhonghua Zhong Liu Za Zhi 2010 Feb;32(2):158 [Chinese]

•

expert guideline on HER2 detection in breast cancer can be found in Zhonghua Bing Li Xue Za Zhi 2009 Dec;38(12):836 [Chinese]

Review articles: • •

review of molecular testing of solid tumors can be found in Arch Pathol Lab Med 2011 Jan;135(1):67 full-text review of management of breast cancer in the genome era can be found in Annu Rev Med 2009;60:153

•

review of genomic predictors of outcome and treatment response in breast cancer can be found in Mol Diagn Ther 2009;13(2):73

•

review of clinical application of gene expression profiling in breast cancer can be found in Surg Oncol Clin N Am 2010 Jul;19(3):581

•

review of early breast cancer can be found in Breast Cancer Res 2009;11(2):205 full-text

•

review of gene expression profiling in breast cancer: classification, prognostication, and prediction can be found in Lancet 2011 Nov 19;378(9805):1812, editorial can be found in Lancet 2011 Nov 19;378(9805):1758

•

review of gene expression signatures in breast cancer can be found in N Engl J Med 2009 Feb 19;360(8):790

•

review of gene expression-based prognostic and predictive markers for breast cancer (for practicing pathologists) can be found in Arch Pathol Lab Med 2009 Jun;133(6):855 PDF

•

review of consensus conference III on image-detected breast cancer and state-ofthe-art diagnosis and treatment can be found in J Am Coll Surg 2009 Oct;209(4):504

•

review of serum tumor markers in breast cancer can be found in Clin Chem 2006 Mar;52(3):345 full-text

•

review of node-negative breast cancer can be found in Oncologist 2011;16 Suppl 1:51 full-text

•

review of prognostic and predictive utility of markers of proliferation in early breast cancer can be found in Ann Oncol 2005 Nov;16(11):1723 full-text

References General references used: •

•

•

1. Harris L, Fritsche H, Mennel R, et al. American Society of Clinical Oncology.

American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. J Clin Oncol. 2007 Nov 20;25(33):5287312. full-text or at National Guideline Clearinghouse 2008 Feb 18:11741, commentary can be found in J Clin Oncol 2008 Apr 20;26(12):2057 2. Hammond ME, Hayes DF, Dowsett M, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol. 2010 Jun 1;28(16):2784-95. full-text or at National Guideline Clearinghouse 2010 Nov 15:16041, also published in Arch Pathol Lab Med 2010 Jul;134(7):e48 3. Wolff AC, Hammond ME, Schwartz JN, et al. American Society of Clinical Oncology, College of American Pathologists. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007 Jan 1;25(1):118-45. full-text

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4. Turaga K, Acs G, Laronga C. Gene expression profiling in breast cancer. Cancer Control. 2010 Jul;17(3):177-82. PDF

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5. Sturgeon CM, Duffy MJ, Stenman UH, et al. National Academy of Clinical Biochemistry laboratory medicine practice guidelines for use of tumor markers in testicular, prostate, colorectal, breast and ovarian cancers. Clin Chem. 2008 Dec;54(12):e11-79. full-text or at National Guideline Clearinghouse 2010 Sep 17:15553

Guideline grading system used: •

National Academy of Clinical Biochemistry (NACB) grading system o strength of recommendations

o

o



Grade A - high - further research very unlikely to change Panel’s confidence in estimate of effect



Grade B - moderate - further research likely to have important impact on Panel's confidence in estimate of effect and likely to change estimate



Grade C - low - further research very likely to have important effect on Panel's confidence in estimate of effect and likely to change estimate



Grade D - very low - any estimate of effect very uncertain

levels of evidence 

Level I - evidence from single, high-powered, prospective, controlled study specifically designed to test marker, or evidence from metaanalysis, pooled analysis, or overview of level II or III studies



Level II - evidence from study in which marker data are determined in relationship to prospective therapeutic trial performed to test therapeutic hypothesis but not specifically designed to test marker utility



Level III - evidence from large prospective studies



Level IV - evidence from small retrospective studies



Level V - evidence from small pilot studies



Expert opinion

Reference - NACB guideline on use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancers (Clin Chem 2008 Dec;54(12):e11 full-text or at National Guideline Clearinghouse 2010 Sep 17:15553)

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Special acknowledgements: •

Ranjna Sharma, MD (Instructor in Surgery, Harvard Medical School; Beth Israel Deaconess Medical Center – Breast Cancer Center; Massachusetts, United States) provides peer review.

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