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O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Arriagada, r. breast cancer
1. Predictive factors of the effect of adjuvant
systemic treatments in breast cancer
R. Arriagada 1-3
, S. Michiels 2
1
Karolinska Institutet and University
Hospital, Stockholm, Sweden
2
Institut Gustave-Roussy
3
Université de Paris-Sud, France
2. Predictive factors of the effect of
adjuvant systemic treatments
• Why only systemic treatments ?
• Hormonal receptors
• HER2
• Molecular classifications
• Genomics signatures
• Methodological considerations
3. Radiotherapy in invasive breast cancer
Isolated loco-regional recurrences in the trials of
any type of radiotherapy (RT) versus no RT
Isolated local recurrence
Absolute difference in risk of
isolated local recurrence: 20%,
mostly within the first 5 years.
EBCTCG, Lancet 366: 2087-2106,
2005
4. Prognostic and predictive factors
• Prognostic factors: those that in multivariate
analysis show an independent effect on the
studied event
• May be studied in large retrospective series
• Predictive factors: those that are shown to be
significantly related to treatment effect
• They should be studied in large randomised
series testing the treatment (subgroup analysis),
or taking tumour response as event (advanced
disease or neo-adjuvant setting)
5. Hormonal receptors and hormonoresistance
• ER: good predictors but not enough
• Still about 50% of patients with ER+ are non-
responders
• About 10% of patients with ER- are responders
• ER and PR are not enough
• Others markers, pathways and cross-talks
6. Variations of treatment effects
according to covariates
Intrinsic resistance to hormonal treatments
HR N Rate 95% CI
ER+ PR+ 102 / 319 32 % 27 - 37
( ER - PR + 15 / 26 58 % 37 – 77 )
ER + PR - 151 / 223 68 % 61 - 74
ER - PR - 179 / 197 91 % 86 - 94
* Osborne K. Breast, 1991
7. Hormonoresistance breast cancer
Rationale
• Two-thirds of tumours have positive ER and/or PR
• ER good predictor of tumour response (50%), but
only a part of the puzzle
- ERα
- ERβ (Gustafsson et al)
- Other factors (EGFR / HER2 receptors)
- Crosstalk ER and GFR pathways
8. Hormonoresistance breast cancer
Rationale
• EGFR / HER2 pathway may play a role in
resistance to SERMs (e.g. tamoxifen)
• ER complex with other transcription factors (Fos
and Jun proteins), alter gene transcription (cyclyn
D, ILGF-1,…)
• P53 mutation: poor response to tamoxifen
9. Hormonoresistance
Tamoxifen: largely used for 30 years
Hormonoresistance
• Loss of ER expression
• Modification of expression oestrogen-related
genes such as those coding GF or GF receptors
• Altered expression of transcriptional cofactors
associated with ER α
• Deterioration of ER α circulation
• Implication of ER β
• Alterations of tamoxifen metabolism
• ……
10. Hormonoresistance
Tamoxifen: gold standard for 30 years
• Agonistic and antagonistic effects
• Prevents the binding of oestrogen to its receptor
• Intrinsic (50% of ER+) and acquired resistance
• Agonistic effect: increase some side effects
• Adjuvant use for 5 years (however, some patients
could benefit from a longer treatment)
• More accurate and selective predictive factors are
needed.
11. Hormonoresistance
Anti-aromatase inhibitors (AIs)
• Exemestane, anastrazole, letrozole
• More effective than TAM in postmenopausal pts
• Optimal treatment and sequencing to be defined
• Adverse effects: joint disorders
• ER+, HER2+ : AIs ?
• ER+, PR+ : sequence of TAM and AIs ?
12. Hormonoresistance
Fulvestrant
• Steroidal ER antagonist with no agonist effect
• It binds, blocks and accelerates degradation of
ER protein
• As effective as anastrazole and tamoxifen in
advanced ER+ breast cancer
• Well tolerated
• Lacks cross-resistance with TAM and AIs
• Sequential regimens ?
13. Hormonoresistance
Additional predictive factors
• ERα + and PR+ only used for practical indications
• Functional genomics: subgroups of gene profile
(e.g. Paik et al)
• Proteomics: study complex protein mixtures with
high resolution, SELDI-TOF-MS and antibody
array (Linderholm et al): 5 new potential
biomarkers
14. Hormonoresistance
Practical implications of prediction
• Tumours resistant to TAM could be sensitive to
AIs and viceversa
• The same for the indication of Fulvestrant
• Definition of optimal sequencing (BIG 01-98)
• Knowledge about mechanisms of resistance: new
drugs or treatment of hormonal resistance
16. Domain Function Homology
A/B The regulatory domain 18%
C The DNA-binding domain 97%
D The hinge 30%
E The ligand-binding domain 59%
F The F region 18%
Oestrogen receptor family
Human Estrogen Receptor α: 6q25.1
Human Estrogen Receptor β : 14q22-24
A/B C D E F -COOHNH2-
1 148 214 304 500 530
NH2- A/B C D E F -COOH
1 185 251 355 549 595
17. • In ductal cells of the mammary gland, ERα and
ERβ oppose each other on proliferation
• The proliferative response to oestrogens is
determined by the ratio of ERα / ERβ
• Functions of ERβ in the breast are probably
related to both its anti-proliferative and its
pro-differentiation functions
• Breast cancer in postmenopausal women:
high expression of ERα (cancer cells and
normal ducts)
indicate a normal elevation of ERα in the
absence of its ligand, estradiol
Oestrogen receptor family I
18. • ERα expression in normal postmenopausal
breast is not elevated
• ERβ expressed > 60% of breast epithelial cells
• In some women, ERβ is not detected but the
splice variant ERβ cx may be very abundant
• Breast cancer sections showed that ERβ is lost
and ERα is gained as we go from normal
tissue to cancer
• A decreased level of ERβ mRNA may be
associated with breast tumourigenesis
• DNA methylation: important mechanism for
ERβ gene silencing in breast cancer
Oestrogen receptor family II
19. Pharmacogenetic Tools (TAM)
Efficacy
• Polymorphism of TAM metabolising genes :
– CYP2D6 : TAM OH-Tam, N-desmethylTam⇨ ⇨
4 OH-N-desmethylTam (endoxifen)
• Antidepressant (selective serotonin re-uptake
inhibitors), currently used for hot flushes linked
to TAM, are CYP2D6 inhibitors.
• Plasma concentration of Endoxifen ⇩ if CYP2D6
*4/*4 genotype or paroxetin use.
Goetz et al, 2005,2007; Jin et al, 2005; Borges et al, 2006; Wegman et al, 2007
21. Variations of treatment effects according to
covariates
Intrinsic resistance to chemotherapy
IBCSG study: 1275 pts N- , periop CT
Factor N HR (CT vs no) P (Cox)
Grade 1 200 2.11 0.04
2 519 0.76
3 432 0.75
ER + 608 0.87 0.01
- 379 0.58
PR + 459 0.67 0.03
PR - 466 0.80
* Neville et al, JCO 10: 696-705, 1992
22. Variations of treatment effects according to
covariates
Adjuvant setting: Hormonal receptors
• In more recent randomised data, HR+ appears as a
marker of intrinsic chemoresistance:
♦ French studies *
♦ IBCSG IX study **
* Arriagada R et al. Ann Oncol, 13: 1378-86, 2002
Arriagada R et al. Acta Oncol, 44: 458-66, 2005
** IBCSG JNCI 94: 1054-1065, 2002
23. Variations of treatment effects
according to covariates
Chemotherapy
• Drug type: anthracycline vs CMF-like
regimens (EBCTCG)
• Anthracycline dose: Belgian and French trials*
• Hormonal receptors: French study**
• Age (EBCTCG)
* Piccart M et al, JCO 19: 3103-10, 2001; Bonneterre J et al,
JCO 19: 602-11, 2001
** Arriagada R et al. Acta Oncol 44: 458-66, 2005
24. DFS according to ER
ERPoor 27/79 41/76 -10.2 16.8
ER++ 47/157 63/159 -9.2 27.4
ER+++ 85/250 84/249 -0.2 42.2
Total 159/486 188/484 -19.6 86.4
Category CT NoCT O-E Variance (CT:NoCT) ( SD)
No.Events/No.Entered RelativeRisk RiskRedn
CTeffect2P=0.04
CTbetter|NoCTbetterTestforheterogeneity:2P=0.09
Testfortrend:2P=0.03
20 % 10
0.0 0.5 1.0 1.5 2.0
Trend
P = 0.03
Arriagada R et al. Acta Oncol 44: 458-66, 2005
25. DFS according to ER
Interaction
P = 0.005
Comforti R et al. Ann Oncol (in press)
26. DFS in ER- (CT vs no CT)
Interaction
P = 0.005
Comforti R et al. Ann Oncol (in press)
27. DFS according to HER2
Interaction
P = 0.34
Comforti R et al. Ann Oncol (in press)
28. DFS according to molecular
subclassification
Interaction
P = 0.076
Comforti R et al. Ann Oncol (in press)
29. Overcoming drug resistance
Drug Doses
Lower doses of anthracyclines have a lower effect
than higher doses
1. CALGB *
2. Belgian trial **
3. French trial ***
4. Counterpart: AML ?
* Budman et al. JNCI 90: 1205-11, 1998
** Piccart et al. JCO 19: 3103-10, 2001
*** Bonneterre et al. JCO 19: 602-11, 2001
**** Ann Oncol 14: 663-5, 2003
32. Adjuvant trastuzumab
HER2
• HER2 +++ predictive of treatment effect
• 0 / 1 effect ? Determinism ?
• NSABP-31: HER++ FISH (–) also a similar effect
• New trial for these patients
• BETH trial: adding bevacizumab for N+, HER2+++
Piccart M et al. N Engl J Med 353: 1659-72,
HERA trial
33. Definition of new predictive factors
Genomics / Proteomics
1. Knowledge about the human genoma
2. Knowledge about functional genes
3. Investigation of gene expression: proteins
4. Technical facilities: Micro-arrays
1. Frozen tissues
2. Fresh tissues
These investigations will be introduced in
prospective randomised trials (e.g. MINDACT)
34. Definition of new predictive factors
Genomics / Micro-arrays
1. Determination of 25,000 genes
2. Selection of a genetic profile (or signature)
based on 70 genes
3. Used in limited database and evaluated as a
prognostic factor *
4. The introduction in randomised trials will allow
to evaluate their predictive value
* van’t der Veer L et al. Nature, 2002
Van der Vijver M et al. NEJM, 2003
35. NSABP 21-gene RS (Oncotype DX)
Tam versus TAM + CT (CMF or MF)
651 pts
DMF interval
A) Total
B) Low risk
C) Intermediate
D) High risk
(25 %)
Paik S et al.
J Clin Oncol
24: 2006
36. Definition of new predictive factors
BIG/TRANSBIG: Mindact
US Intergroup TAILORx trial
• Thousands of N- patients to be included
• Europe: Amsterdam signature
• US: Oncotype
• Randomising adjuvant CT and HT
• Expensive +++
• Feasibility ?
37. Prognostic signature challenges
C. Sotiriou (Brussels)
• 10 – 20% discordance between labs
• Molecular classification: suboptimal
reproducibility
• Fine-tuning needed
• Very small gene overlap
• Some validations
• Most prognostic genes are markers of
proliferation
38. Statistical challenges related to
micro-chips
Hopes and false positive results
S. Michiels, S. Koscielny,
T. Boulet, C. Hill
Biostatistics and Epidemiology Department
16 April 2007
39. Some issues
Molecular signature
• Limited number of genes defining patient groups
• Predictive signature for a defined metastatic risk
assumes the existence of an unique genetic
combination for this risk
The old story of numbers
• Analysed series with a small number of patients and
thousands of covariates
• Statistical power issues, interpretation and results
validation
40. Taille de l'échantillon d'apprentissage
Tauxdemauvaisesclassifications
20 40 60 80 100
0.20.30.40.50.6
Prediction quality
95% CI
Mean rate of
misclassification
• Proportion of misclassification according to the
number of number of patients in the learning sample
( van’t Veer, 2002)
41. Data of the validation 1 study
n=234 (55 with distant metastases)
Survival without distant metastasis, Cox model
(Dunkler, Michiels, Schemper. Eur J Cancer, 2007)
Explained variability of the pioneer study
R2
Model without factors 0%
Model with only conventional factors 16 % (±5%)
Model with only molecular signature 12% (±4%)
Model with conventional factors AND the
molecular signature
19 % (±5%)
Added value of the molecular signature 3 %
42. Predictive factors of the effect of systemic
treatments
Conclusions
• Useful predictive factors: HR, HER2
• However, they explain only a part of the
variability
• They give probabilities and are not
deterministic
• Biomics signatures: Hopes and a large field of
research
• Clinical application: only robust results
Editor's Notes
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Nous constatons à l’heure actuelle une augmentation exponentielle du nombre de publications étudiant les marqueurs biologiques, nombreuses étant celles affichant des résultats significatifs. Ce sont pour la plupart des études rétrospectives qui donnent lieu à des interprétations biologiques a posteriori.
Nous utiliserons les données publiées sur le cancer du sein pour illustration.
Il s’agit d’une hypothèse très forte.