Molecularly guided therapy versus chemotherapy after disease control in unfavourable cancer of unknown primary (CUPISCO): an open-label, randomised, phase 2 study.

BACKGROUND: Patients with unfavourable subset cancer of unknown primary (CUP) have a poor prognosis when treated with standard platinum-based chemotherapy. Whether first-line treatment guided by comprehensive genomic profiling (CGP) can improve outcomes is unknown. The CUPISCO trial was designed to inform a molecularly guided treatment strategy to improve outcomes over standard platinum-based chemotherapy in patients with newly diagnosed, unfavourable, non-squamous CUP. The aim of the trial was to compare the efficacy and safety of molecularly guided therapy (MGT) versus standard platinum-based chemotherapy in these patients. This was to determine whether the inclusion of CGP in the initial diagnostic work-up leads to improved outcomes over the current standard of care. We herein report the primary analysis. METHODS: CUPISCO was a phase 2, prospective, randomised, open-label, active-controlled, multicentre trial done at 159 sites in 34 countries outside the USA. Patients with central eligibility review-confirmed disease (acceptable histologies included adenocarcinoma and poorly differentiated carcinoma) and an Eastern Cooperative Oncology Group performance status of 0 or 1, evaluated by CGP, who reached disease control after three cycles of standard first-line platinum-based chemotherapy were randomly assigned 3:1 via a block-stratified randomisation procedure to MGT versus chemotherapy continuation for at least three further cycles. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT03498521, and follow-up is ongoing. FINDINGS: From July 10, 2018, to Dec 9, 2022, 636 (42%) of 1505 screened patients were enrolled. Median follow-up in the treatment period was 24·1 months (IQR 11·6-35·6). Of 438 patients who reached disease control after induction chemotherapy, 436 were randomly assigned: 326 (75%) to the MGT group and 110 (25%) to the chemotherapy group. Median progression-free survival in the intention-to-treat population was 6·1 months (95% CI 4·7-6·5) in the MGT group versus 4·4 months (4·1-5·6) in the chemotherapy group (hazard ratio 0·72 [95% CI 0·56-0·92]; p=0·0079). Related adverse event rates per 100-patient-years at risk were generally similar or lower with MGT versus chemotherapy. INTERPRETATION: In patients with previously untreated, unfavourable, non-squamous CUP who reached disease control after induction chemotherapy, CGP with subsequent MGTs resulted in longer progression-free survival than standard platinum-based chemotherapy. On the basis of these results, we recommend that CGP is performed at initial diagnosis in patients with unfavourable CUP. FUNDING: F Hoffmann-La Roche.

Transcriptional profiling of breast cancer cells exposed to soy phytoestrogens after BRCA1 knockdown with a whole human genome microarray approach.

The estrogen-like properties of the soy phytoestrogens could modulate the estrogen-dependent expression of BRCA1 oncosuppressor, which is highly involved in hereditary and sporadic breast cancer. In order to better understand the importance of BRCA1 function and the role of other genes involved around BRCA1 in the phytoestrogen pathways, we have exploited the BRCA1-specific knockdown by RNA interference using double stranded small interfering RNA (siRNA) in breast tumor cell lines (MCF-7, MDA-MB-231) and a fibrokystic breast cell line (MCF-10a) and treated with 18.5 microM genistein or 78.5 microM daidzein for 72 h. We used pangenomic microarrays and subsequently TLDA analysis and demonstrated that cumulated BRCA1 knockdown with soy isoflavone supplementations in breast cell lines seems to modulate apoptosis, MAPK pathway, cell communication, xenobiotic metabolism, and sterol metabolism. Also, transient BRCA1 deficiency in breast cell lines significantly diminished or reversed gene expression after phytoestrogen supplementation. We observed that the significant decrease expression of apoptosis-related genes such as BAX, and the increase expression of BCL2, under BRCA1 knockdown condition, were completely reversed after phytoestrogen treatments. These results underlined the role of BRCA1 expression in breast carcinogenesis and suggested that soy phytoestrogen supplementation could play a role in cancer.

Evolution in the real-world therapeutic strategies in more than 20,000 women with breast cancer having received human epidermal growth factor receptor 2-targeted treatments: Results from the french personalized reimbursement model database (2011-2018).

BACKGROUND: There is a growing need for real-world data on cancer treatments usage, especially to assess compliance with recommendations. We developed a French project using hospital data to analyse evolution in the therapeutic strategies implemented in patients with human epidermal growth factor receptor 2 (HER2)-overexpressed (HER2+) breast cancer (BC) and exposed to injectable HER2-targeted therapies, i.e. trastuzumab, pertuzumab or trastuzumab emtansine (T-DM1). PATIENTS AND METHODS: Data from 26,350 women with BC were extracted in September 2018 from the Electronic Pharmacy Record systems of 120 French randomly recruited hospitals. Evolution in the treatments used, and combination regimens were described from 2011, in accordance with the BC stage and treatment line. RESULTS: Overall, 21,119 patients treated since 2011 were analysed: 16,398 patients with early BC (eBC) and 6030 patients with metastatic BC (mBC) including patients treated at both stages. In eBC, 89.2% of patients received trastuzumab combined with at least taxanes (trastuzumab-taxane-anthracycline: 62.6%). Patients with mBC were treated in the first line (80.3%) and/or the second line (40.1%) and/or ≥ the third line (28.3%). After its approval in 2014, pertuzumab was first used in first-line therapy combinations in 67.4% of the total cases, while trastuzumab-taxane decreased from 47.2% to 9.2%. Similarly, T-DM1 was used as the second-line treatment in 53.8% of cases. CONCLUSIONS: Given recent changes in available treatments for patients with HER2+ BC, this large French project provides robust information on real-world evolution in therapeutic strategies. Our data suggest there is room for significant improvement in optimal drug utilisation. Such data will be useful to build drug-related indicators for future value-based pricing solutions.

Safety profile of subcutaneous trastuzumab in patients with HER2-positive early breast cancer: The French HERmione non-interventional prospective study.

OBJECTIVES: HERmione study was conducted to assess, in human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (eBC), the safety profile of subcutaneous (SC) formulation of trastuzumab in real-life in France. MATERIALS AND METHODS: This prospective, non-interventional study included 511 patients planned to be treated in both neoadjuvant and adjuvant settings with a follow-up of 12 months maximum in 101 sites. The safety analyses concerned 505 patients. Primary endpoint was the description of systemic safety and local tolerability of the SC trastuzumab. RESULTS: The median age of patients was 58 years. Over the study, 2449 adverse events (AEs) occurred in 422 (83.6%) patients (asthenia, arthralgia, radiation skin injury, myalgia, hot flush and diarrhea in ≥10% of patients): 92 AEs (3.8%) were grade ≥3 (radiation skin injury in 1.8% of patients and febrile neutropenia in 1.4% of patients), 76 (3.1%) were serious (mainly febrile neutropenia in 1.4% of patients) and 336 (13.7%) were treatment-related (mainly injection site pain in 9.1% of patients). Congestive Heart Failure occurred in 58 (11.5%) patients and was related to treatment in 4.6% of patients. Only 34 AEs (1.4%) in 27 (5.4%) patients led to permanent treatment discontinuation. One death was assessed as not treatment-related. Quality of life (QoL) analyses showed no deterioration of global health status. CONCLUSION: The HERmione study showed that, in a real-life setting, the safety of SC trastuzumab administered in HER2-positive eBC patients is consistent with data reported from previous clinical trials, without new safety concerns or QoL deterioration.

Expression profiling by whole-genome microarray hybridization reveals differential gene expression in breast cancer cell lines after lycopene exposure.

The correlation between diet and variation in gene-expression is an important field which could be considered to approach cancer pathways comprehension. We examined the effects of lycopene on breast cancer cell lines using pangenomic arrays. Lycopene is derived predominantly from tomatoes and tomato products and there is some epidemiologic evidence for a preventive role in breast cancer. Previously, we investigated lycopene in breast cancer using a dedicated breast cancer microarray. To confirm these results and explore pathways other than those implicated in breast cancer, for this study we used pangenomic arrays containing 25,000 oligonucleotides. This in vitro study assayed two human mammary cancer cell lines (MCF-7 and MDA-MB-231), and a fibrocystic breast cell line (MCF-10a) treated or not with 10 microM lycopene for 48 h. A competitive hybridization was performed between Cy3-labeled lycopene treated RNA and Cy5-labeled untreated RNA to define differentially expressed genes. Using t-test analysis, a subset of 391 genes was found to be differentially modulated by lycopene between estrogen-positive cells (MCF-7) and estrogen-negative cells (MDA-MB-231, MCF-10a). Hierarchical clustering revealed 726 discriminatory genes between breast cancer cell lines (MCF-7, MDA-MB-231) and the fibrocystic breast cell line (MCF-10a). Modified gene expression was observed in various molecular pathways, such as apoptosis, cell communication, MAPK and cell cycle as well as xenobiotic metabolism, fatty acid biosynthesis and gap junctional intercellular communication.

DNA repair gene ERCC2 polymorphisms and associations with breast and ovarian cancer risk.

Breast and ovarian cancers increased in the last decades. Except rare cases with a genetic predisposition and high penetrance, these pathologies are viewed as a polygenic disease. In this concept, association studies look for genetic variations such as polymorphisms in low penetrance genes, i.e. genes in interaction with environmental factors. DNA repair systems that protect the genome from deleterious endogenous and exogenous damages have been shown to have significantly reduced. In particular, enzymes of the nucleotide excision repair pathway are suspected to be implicated in cancer. In this study, 2 functional polymorphisms in a DNA repair gene ERCC2 were analyzed. The population included 911 breast cancer cases, 51 ovarian cancer cases and 1000 controls. The genotyping of 2 SNP (Single Nucleotide Polymorphism) was carried out on the population with the MGB (Minor Groove Binder) probe technique which consists of the use of the allelic discrimination with the Taqman method. This study enabled us to show an increase in risk of breast cancer with no oral contraceptive users and with women exhibiting a waist-to-hip ratio (WHR) > 0.85 for Asn homozygous for ERCC2 312.

Association between genetic polymorphisms and ovarian cancer risk.

BACKGROUND: The etiology of ovarian cancer is not fully understood. Polymorphisms in low penetrance genes involved in carcinogen and estrogen metabolism are hypothesized to play a role in the initiation of carcinogenesis. PATIENTS AND METHODS: A case-control study was conducted to investigate the role of these polymorphisms in ovarian cancer risk. The participants were genotyped for eleven polymorphisms in seven genes involved in estrogen and xenobiotic metabolism (CYP1A1, CYP1B1, COMT, GSTP1, NAT2, estrogen receptor ESR, and progesterone receptor PGR). RESULTS AND CONCLUSION: The odds ratios for ovarian cancer risk were 2.02 (95% confidence interval [CI] = 1.14-3.56) in the NAT2 intermediate acetylators and 4.07 (95% CI = 1.30-12.70) in the slow acetylators. At least three cumulative high-risk genotypes increased ovarian cancer risk, but not significantly. More studies are needed in order to define genetic ovarian risk factors.

DNA repair gene ERCC2, XPC, XRCC1, XRCC3 polymorphisms and associations with bladder cancer risk in a French cohort.

In polygenic diseases, association studies look for genetic variation such as polymorphisms in low penetrance genes, i.e. genes in interaction with environmental factors. DNA repair systems that protect the genome from deleterious endogenous and exogenous damage have been shown to significantly reduce activity. In particular, enzymes of the nucleotide excision repair pathway are suspected to be implicated in cancer. In this study bladder cancer which is viewed as a polygenic disease was investigated. The functional polymorphisms of four DNA repair genes, excision repair cross-complementing group 2 (ERCC2), Xeroderma Pigmentosum group C (XPC), and Xray repair cross-complementing groups 1 and 3 (XRCC1 and XRCC3) were analyzed. The studied population included 51 bladder cancer cases and 45 controls. The genotyping of six SNP (single nucleotide polymorphism) was carried out on these populations with the MGB (Minor Groove Binder) probe technique which uses allelic discrimination with the Taqman method. The Gln allele of the XPC 939 polymorphism was found to be associated with an increase in bladder cancer risk.

Immunohistochemical expression of RARalpha, RARbeta, and Cx43 in breast tumor cell lines after treatment with lycopene and correlation with RT-QPCR.

Lycopene, the major carotenoid found in tomatoes, is a potent antioxidant associated with the prevention of degenerative diseases such as breast cancer. This effect could be due to the interaction between lycopene and retinoic acid receptors as well as the stimulation of gap junction communication and synthesis of connexin 43. The expression of the RARalpha, RARbeta, and Cx43 proteins was analyzed using immunohistochemistry in two breast cancer cell lines, MCF-7 and MDA-MB-231, and in a fibrocystic dystrophy cell line, MCF-10a, after a 48-hr exposure to 10 microM lycopene. A real-time quantitative PCR analysis was then performed to measure mRNA expression. RARalpha and Cx43 expression were increased at both mRNA and protein levels in two breast cell lines.

Risk factors for early age at breast cancer onset--the "COSA program" population-based study.

BACKGROUND: Breast cancer is the most frequent cancer in women in western countries. A number of risk factors are now known, but the etiology of the disease is not fully understood. The aim of this study was to determine the effects of reproductive, anthropometric and environmental factors on cancer onset. PATIENTS AND METHODS: 934 women who developed a non-hereditary breast cancer were recruited from different hospitals in the Auvergne region (France) and completed a questionnaire. RESULTS: The use of oral contraceptives (OC) increased the risk of early cancer development (odds ratio = 1.84, 95% confidence interval = 1.38-2.44). The age at first OC use appeared to be a major factor since the risk decreased when OC use was after the age of 23 years (odds ratio = 0.52, 95% confidence interval = 0.34-0.79). A duration of breast-feeding greater than 26 weeks decreased the risk of early cancer development (odds ratio = 0.62, 95% confidence interval = 0.39-0.97). No overall association was found with anthropometric or lifestyle factors and early age at breast cancer onset. CONCLUSION: OC use, age at first OC use and lactation were significantly associated with an early age at breast cancer onset. Thus, a number of "risk factors" could be considered as "early onset risk factors".

Gene signature of breast cancer cell lines treated with lycopene.

Among the micronutrients studied in relation between nutrition and cancer, lycopene appears to be a breast cancer preventive phytochemical candidate found in raw tomatoes and tomato-derived products. In order to investigate the responsiveness of breast cancer genes to lycopene and to better understand the molecular mechanisms underlying the effects of lycopene, we used an oligonucleotide microarray approach. Human breast cancer cell lines (MCF-7 and MDA-MB-231) and a fibrocystic breast cell line (MCF-10a) were either exposed or not exposed to 10 microM lycopene for 48 h. Microarrays comprising 202 genes were used to identify genes responsive to lycopene supplementation. Hierarchical clustering revealed a cell line-specific lycopene modulation of breast cells. Based on the observed results, lycopene seems to exert regulation on apoptosis, cell cycle and DNA repair mechanisms according to estrogen and retinoic acid receptor cell status.

Can pathologic complete response (pCR) be used as a surrogate marker of survival after neoadjuvant therapy for breast cancer?

Breast cancer is heterogeneous in clinical, morphological, immunohistochemical and biological features, as reflected by several different prognostic subgroups. Neoadjuvant approaches are currently used for the "in vivo" efficacy assessment of treatments. Pathological complete response (pCR) has been reported as a reliable predictive factor of survival in that setting. However, pCR remains a subject of controversy in terms of definition and its evaluation methods. In addition, its predictive value for patient outcome in various breast cancer biological subtypes has been under debate. In this review, we will present the existing definitions of pCR, the impact of its evaluation methods on its rate and the assessment of its predictive value for patient outcome in the molecular subtypes of breast cancer (luminal A and B, Triple Negative and HER2-positive).

Effects of resveratrol on the expression of a panel of genes interacting with the BRCA1 oncosuppressor in human breast cell lines.

BACKGROUND: trans-Resveratrol, or 3,5,4'trihydroxy-trans-stilbene, is a polyphenolic compound that seems to provide a protective effect against several types of cancer, notably breast cancer. Through its phytoestrogenic properties it regulates the expression of hormone-dependent genes, such as the oncosuppressor BRCA1, in breast cells. This gene is involved in the majority of hereditary breast cancer, as well as sporadic cancers. METHODS: We used three human breast tumor cell lines (HBL100, MCF7 and MBA-MB-231) and one breast cell line (MCF10a) derived from a fibrocystic disease to study in vitro the effect of resveratrol on the transcription of a group of genes whose proteins interact in different pathways with BRCA1. BRCA1, BRCA2, ER alpha, ER beta, p53, p21(waf1/cip1), CBP/P300, RAD51, pS2 and Ki67 mRNA were quantified using real-time quantitative RT-PCR with an ABI 7700 apparatus. RESULTS: Resveratrol modulated the expression of these genes in a pattern dependent on the status of alpha and beta estrogen receptors. These results show that resveratrol regulates gene expression via the estrogen receptor pathway and also an undetermined pathway. CONCLUSION: Thus, resveratrol seems to have an effect on breast tumor cell lines, on a fibrocystic cell line by affecting several factors regulating the function of BRCA1.

Differential expressions of BRCA1 and BRCA2 in infantile gynecomastia.

BRCA1 and BRCA2 breast cancer susceptibility genes are responsible for most of the hereditary breast cancers. No or very few sporadic breast tumors have been shown to harbor mutations in the coding sequence of BRCA1 or BRCA2. In contrast to normal breast epithelial cells, BRCA1 mRNA levels in tumors appeared to be down-regulated by methylation, while BRCA2 showed significant overexpression in sporadic breast cancers. We report herein an infantile gynecomastia in a two-year-old boy, studied by immunohistochemistry of anti-BRCA1 and anti-BRCA2 antibodies. We demonstrated that BRCA1 proteins, like BRCA2, are widely expressed in the nuclei of epithelial cells surrounding the lumen of the ducts in infantile gynecomastia. The intensive nuclear staining of both proteins in the mammary tissues means that BRCA1 and BRCA2 proteins are largely expressed in infantile gynecomastia.

Genistein and daidzein act on a panel of genes implicated in cell cycle and angiogenesis by polymerase chain reaction arrays in human prostate cancer cell lines.

BACKGROUND: The prostate cancer most frequently affects men. The ethnic origin and family antecedents of prostate cancer are established as risk factors. The genetic factors associated with environmental factors such as the nutrition also play a role in the development of the cancer. Epidemiological studies showed that the Asian populations exhibited an incidence of prostate cancer markedly subordinate by comparison with the Western populations. This would be explained partially by their important consumption of soy. Both main phytoestrogens of soy, the genistein and the daidzein, present anti-proliferative properties. METHODS: For that purpose, we used different prostate cancer cell lines (LNCaP, DU 145, PC-3) and, by flow cytometry, we determined the concentration of phytoestrogens inducing a cell cycle arrest and the required time of incubation. RESULTS: Then, the effects of 40microM genistein or 110microM daidzein for 48h were determined and studied on the expression of genes involved in the human cell cycle and angiogenesis and conducted by SYBR green quantitative PCR. CONCLUSION: We demonstrated modulations of cyclin-dependent kinase-related pathway genes, DNA damage-signaling pathway and a down-regulation of EGF and IGF.

Phytoestrogens regulate the expression of genes involved in different biological processes in BRCA2 knocked down MCF-7, MDA-MB-231 and MCF-10a cell lines.

Breast cancer is a public health problem in the Western countries. Several studies have shown that BRCA2, like BRCA1 oncosuppressors, are strongly involved in hereditary and sporadic mammary carcinogenesis. It has also been suggested that soy has a protective effect against breast cancer in Asia and, more particularly, phytoestrogens such as daidzein and genistein. Thus, phytoestrogens may have an impact on the expression of BRCA2 gene, and there is a possible link between BRCA2 and genes acting around the BRCA2. To focus on these processes, we set up the BRCA2 specific knockdown by RNA interference in two breast tumor cell lines (MCF-7 and MDA-MB-231) and also in a non-tumorigenic breast cell line (MCF-10a). After inhibition of BRCA2 expression, cells were maintained in different conditions and treated with either daidzein or genistein or left untreated. Microarray analysis of mRNAs isolated from the BRCA2 knocked down MCF-7, MDA-MB-231, and MCF-10a cell lines after being treated with phytoestrogens showed 35 differentially expressed genes between positive-ERbeta cells and negative-ERbeta cells. After genistein or daidzein treatments, BRCA1 was found to be up-regulated when knocked down with BRCA2-siRNA MCF-7 and BRCA2 was found to be up-regulated when knocked down with BRCA2-siRNA MDA-MB 231 cells. In MCF-10a, we observed a significant decrease in BAX and BCL2 expressions with a greater effect of daidzein. We also found an increase in BRIP expression between genistein and daidzein treatment knocked down with BRCA2-siRNA MCF-7 and MDA-MB-231 cell lines.

Gene signature of rat mammary glands: Influence of lifelong soy isoflavones consumption.

Epidemiological studies have indicated that phytoestrogen has a preventive effect on breast cancer development. However, controversial results have been reported suggesting these compounds have ambivalent effects on breast tissue. Here, we report a transgenerational study conducted on female Wistar rats fed a diet enriched with phytoestrogen. Using a pangenomic microarray approach, a transcriptomic study was performed on mammary glands extracted from the animals. Gene expression was examined at 3 ages: 3, 18 and 24 months. The F1 generation did not express the same genes as the F0 control generation fed the same diet. This effect increased with animal age: in 3-, 18- and 24-month-old rats, 293, 441 and 2868 differentially expressed genes were respectively observed. These results suggest that long-term exposure to isoflavones may play a key role in gene regulation. Additionally, epigenetic patterns were found to be affected by DNA-methyltransferase and histone-deacetylase expression.

Gene expression profiling of breast cancer cell lines in response to soy isoflavones using a pangenomic microarray approach.

Although the rate of breast cancer differs between women in Asian and Western countries, molecular genetics/genomics basis of this epidemiological observation remains elusive. Moreover, the intake of phytoestrogens is associated with a lower incidence of breast cancer. Genistein and daidzein are the primary soy isoflavones with a chemical structure similar to estrogens. Conceivably, the actions of phytoestrogens on gene expression signatures might mediate their postulated effects on breast cancer pathogenesis. The present study evaluated the transcriptional responsiveness of breast cancer cells to soy phytoestrogens using a whole-genome microarray-based approach. Human breast cancer cell lines and a fibrocystic breast cell line were treated with genistein or daidzein. We identified 278 and 334 differentially expressed genes after genistein or daidzein treatment, respectively, in estrogen-positive (MCF-7) and estrogen-negative (MDA-MB-231, MCF-10a) cells. Hierarchical clustering of this finding revealed a significant modulation, respectively, of 246 or 169 genes after genistein or daidzein exposures. Importantly, the molecular pathways for the differentially expressed genes included those that relate to cell communication, biodegradation of xenobiotics, lipid metabolism, signal transduction, and cell growth/death. These molecular observations collectively contribute to a growing knowledgebase on the putative mechanism(s) of action of phytoestrogens in breast cancer pathogenesis and chemoprevention.

Central adiposity as a major risk factor of ovarian cancer.

The identification of risk factors for ovarian cancer is crucial in prevention of the disease. This pathology is the leading cause of death from gynecological malignancies. The aim of this study was to evaluate the role of factors influencing hormonal levels such as body mass index (BMI), BMI at age 20, waist-to-hip ratio (WHR), oral contraceptive (OC) use, and risk of ovarian cancer. A case-control study was conducted in women who developed ovarian cancer. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI). While no association was found between BMI, BMI at age 20 and risk of ovarian cancer, high WHR increased the risk with ORs of 2.93 and 8.58 (p<10(-6)) for the highest categories (WHR=0.801-0.85 and WHR>0.85) versus the lowest (WHR<0.8). Central adiposity is a key factor in ovarian cancer and suggests the involvement of androgen conversion in adipose tissue.

Nutrigenomics and antioxidants.

Since the complete sequencing of the human genome, the era of the 'omics' has appeared. Among them, a new discipline called 'nutrigenomics' emerged from the interface of nutrition research and genetics. Its aim is to understand how nutrients modulate gene expression. This powerful tool allows determinination of new biomarkers and the molecular pathways by which our diet may have a potential protective effect against degenerative diseases such as cancer. On one hand, cellular metabolism produces continuous oxidative stress and reactive oxygen species with mutagenic and oncogenic effects. On the other hand, diet provides natural antioxidants present in various fruits and vegetables that may prevent diseases. This review first reports the main antioxidants provided by diet and the main results from epidemiological studies of their role in health. Second, we describe how nutrigenomics could provide new insights into nutrition research and innovative developments through neutraceutical products and a personalized medicine.