1 Division of Gynecologic Oncology in Department of Obstetrics and Gynecology, Levven University Hospital, Levven, Belgium; 2 Division of Gynecologic Oncology in Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 3 Multidisciplinary Breast Centre, 4 Department of Pathology, 5 Department of Medical Oncology, 6 Department of Radiooncology and 7 Department of Surgery, Leuven University Hospital, Leuven, Belgium
* Correspondence to: Dr P. Neven, Leuven University Hospital, Herestraat 49, Leuven, Belgium. Tel: +32-16-344634; Fax: +32-16-344629; E-mail: Patrick.Neven{at}uz.kuleuven.ac.be
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Abstract |
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Patients and methods: Our study population consisted of 1362 consecutive women receiving primary surgery for non-metastatic invasive breast cancer. We compared the relationship between both hormone receptors and HER2/neu overexpression in different age groups taking other tumour characteristics into account.
Results: In a multivariate model, considering the overall group, a negative ER, a negative PR and a high tumour grade were predictive for HER2/neu overexpression (P <0.001). Considering 246 women aged 45 years, the only predictor for HER2/neu overexpression in this age category was a high tumour grade (P = 0.003). Considering the 1116 women aged >45 years, ER (P = 0.001), PR (P = 0.001) and tumour grade (P <0.001) were associated with HER2/neu (P <0.001).
Conclusion: Our findings indicate that the association between ER, PR and HER2/neu overexpression varies with age. The hormone receptors are not an independent predictor for the HER2/neu status in young women while they are in elder patients.
Key words: estrogen receptor, progesterone receptor, HER2/neu, breast tumours
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Introduction |
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The HER2/neu membrane receptor can be analysed by semi-quantitative measurement using immunohistochemistry (IHC) that accurately predicts gene amplification [18]. Testing of HER2/neu is currently standard practice because it estimates the response to the anti-HER2/neu antibody, trastuzumab, which in monotherapy or combination with chemotherapy improves the disease outcome of HER2/neu over-expressors with metastatic breast cancer [19
].
The inverse association between HER2/neu and hormone receptors has been linked with the fact that estrogens suppress HER2/neu through the ER [20]. It is unclear whether this inverse association differs in different age groups. Tumour grade as an important predictor for HER2/neu overexpression, shows an association with hormone receptor expression that differs between young and older women and this maybe reflected with an age-related association between hormone receptors and HER2/neu [21
23
]. Another observation is that premenopausal hormone responsive breast cancers remain sensitive to anti-estrogens, whereas a lower response to tamoxifen has been suggested in postmenopausal women if HER2/neu is also expressed [16
, 24
]. We therefore believe that the inverse association between the HER2/neu and hormone receptors status may differ by age. We have previously shown that the negative association between progesterone receptors (PR) and HER2/neu in women with an ER-positive breast cancer is age-related [25
]. As of today, no such data have been reported for ER or PR considering ER-positive and ER-negative breast cancers together.
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Patients and methods |
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Assessments
The following factors were included for evaluation: patient's age at diagnosis, maximal microscopic tumour size, worse tumour grade, axillary lymph node status, ER, PR and HER2/neu status. ER, PR and HER2/neu IHC stains according to the Envision method were performed. Immunocytochemical stains were performed on 4 µm paraffin sections, using a water bath for heat-induced epitope retrieval and Envision-HRP with DAB (Dakocytomation, Glostrup, Denmark) for visualization of the antibody complexes. Primary antibodies (Novocastra, Newcastle upon Tyne, UK) directed against estrogen receptor alfa (NCL-ER-6F11), progesterone receptor A (NCL-PgR-312, clone 16) and c-erbB-2 oncoprotein internal domain (CB11) were applied in a dilution of 1/30, 1/40 and 1/40, respectively.
ER, PR and HER2/neu IHC stains were semi-quantitatively evaluated. Using the H score for ER or PR, a negative result was defined when staining showed 50 or less, and positive between 51 and 300. The DAKO scoring system for HER2/neu was defined as negative for a DAKO score of 0, 1+ or 2+ and positive when a DAKO score of 3+ was given. Tumour grading was performed according to the Ellis and Elston grading system [26].
Analysis of the results
To justify which age is the best cut-off for an inverse association between HER2/neu and both of the hormone receptors, we compared the proportion of tumours being HER2/neu positive by receptor status for ER or PR in each of the seven age plots, with a range of 5 years starting at age 45 years and ending at age >70 years. We identified in the age group
45 years that in the univariate model a positive ER was only of borderline significance and a positive PR was not significant in predicting HER2/neu overexpression. In the group age >45 years, there was in all of the six remaining age plots a negative relationship between the hormone receptors and HER2/neu, both for ER and PR. The statistical analysis was therefore done for the two age groups
45 years and >45 years.
The chi-square test was used to examine the categorical variables and the association between HER2/neu overexpression and other clinicopathological factors in univariate analysis. Multivariate analysis with logistic regression was used to find out the independent factors predicting HER2/neu overexpression. All statistical tests were two-sided and P <0.05 was considered significant. All statistical analyses were performed with Statistical Package for the Social Sciences (SPSS) software version 11.0.1 for Windows (SPSS Inc, Chicago, IL, USA).
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Results |
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Discussion |
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The lower frequency of HER2/neu overexpression in hormone receptor positive tumours compared with hormone receptor negative breast cancers has been explained by a cross linkage between the two pathways for tumour growth. Apart from steroids and the hormone receptors, breast cancer growth is also regulated by peptide growth factors and both pathways are associated, or cross-talk [20, 29
]. ER and HER2/neu signalling are inversely related through a transcriptional repression of HER2/neu by estradiol binding to ER [20
]. Our results suggested that the inverse association between the hormone receptor and HER2/neu status does not appear in women aged
45 with a high-grade tumour. We have no plausible explanation for this new observation. High-grade ER-positive breast cancers may appear earlier in life if they are HER2/neu positive than if they are HER2/neu negative. This would suggest a growth advantage of high-grade ER-positive tumours through higher levels of circulating estrogens if they are HER2/neu positive. This age-related association between HER2/neu and hormone receptors has to be considered when using HER2/neu as a prognostic factor and probably also when using HER2/neu for treatment-related decisions. Under the age of 45 years, most HER2/neu positive tumours are PR positive whereas this is not the case in any of the older age groups.
The prognostic value of the hormone receptor status in grade 3 tumours may, therefore, be less important in younger than in older women, because high-grade ER-positive cases are as likely to be HER2/neu positive as ER-negative cases. Some have already pointed towards the fact that the prognostic role of a positive ER or PR is restricted to postmenopausal women because a high tumour grade overrules any other prognostic tumour characteristic in premenopausal women [30]. In this perspective we believe we can add yet another reason for this observation.
The absence of a negative association between hormone receptors and HER2/neu overexpression in a subgroup of women under the age of 45 also has therapeutic implications. Because PR is a predictive marker for response to anti-estrogens [31], our data imply that women aged
45 with a HER2/neu positive breast cancer may be more likely to be responsive to anti-estrogens than postmenopausal women with such a tumour. A lower likelihood of response to anti-estrogens such as tamoxifen in postmenopausal HER2/neu overexpressors has been reported [15
, 16
], whereas Love et al. [24
] reported that premenopausal women with an ER-positive HER2/neu positive breast cancer remain sensitive to castration and tamoxifen.
In multivariate analysis HER2/neu overexpression was not associated with a positive lymph node status, with age 45 years or with larger tumours (size >20 mm), although others have made this observation [10
, 11
]. We, however, did not differentiate between the very young age group, i.e. 35 or 40 years, where HER2/neu seems more likely to be over-expressed [10
]. We agree with other authors that lymph node status and tumour size do not predict for HER2/neu status in women with breast cancer [7
, 8
].
To our knowledge, this study is the first to assess the association between HER2/neu and tumour characteristics such as the hormone receptor status and tumour grade by age 45 or >45 years. Other studies have shown that hormone receptor negative breast cancers or high-grade tumours are more likely to be HER2/neu positive than hormone receptor positive breast cancers or low-grade tumours [5
11
]. These studies, however, did not stratify for age and their analysis were only based on a univariate model. Because over 75% of all women with breast cancer appear beyond age 45, an age effect may not become apparent when only considering the overall population.
One shortcoming of our study is that we did not use fluorescence in situ hybridisation (FISH) to measure HER2/neu. Instead, we used IHC staining to analyse ER, PR and HER2/neu, which is easier and less expensive than ligand binding assays for measuring steroid hormone receptors and FISH for measuring HER2/neu. IHC for HER2/neu has an equivalent ability as FISH to predict response to anti-HER2/neu therapy and IHC for measuring steroid hormone receptors is better in predicting response to adjuvant endocrine therapy than ligand binding assays [18]. Furthermore, our data are robust in that one single pathologist did the readings for the established prognostic factors. Another important issue is that the large number of patients we included in our analyses is larger than most of the other studies evaluating the association between established tumour characteristics and HER2/neu status.
In conclusion, in women with an operable breast cancer, the hormone receptor status and tumour grade were independently associated with HER2/neu in women aged >45 years. In women aged 45 years, ER or PR did not predict for the HER2/neu status in high-grade tumours whereas an absent hormone receptor did predict for HER2/neu overexpression in low-grade tumours. Our findings indicated that the association between hormone receptors (ER or PR) and HER2/neu vary with the age of patients. This association has to be considered when using HER2/neu as a prognostic factor and probably also when using it for treatment-related decisions.
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Acknowledgements |
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Received for publication April 8, 2005. Revision received June 26, 2005. Accepted for publication June 27, 2005.
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References |
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