Alternating 17ß-Estradiol and Aromatase Inhibitor Therapies Is Efficacious in Postmenopausal Women with Advanced Endocrine-Resistant ER+ Breast Cancer.

PURPOSE: Strategies to implement estrogen therapy for advanced estrogen receptor-positive (ER+) breast cancer are underdeveloped. Preclinical data suggest that cycling treatment with 17ß-estradiol followed by estrogen deprivation can control tumor growth long-term. PATIENTS AND METHODS: Postmenopausal women with advanced ER+/HER2- breast cancer with recurrence or progression on ≥ 1 antiestrogen or aromatase inhibitor (AI)-based therapy were eligible. Patients received 17ß-estradiol (2 mg orally, three times a day) for 8 weeks followed by AI (physician's choice) for 16 weeks, alternating treatments on an 8-week/16-week schedule until disease progression. Patients then optionally received continuous single-agent treatment until a second instance of disease progression. Endpoints included 24-week clinical benefit and objective response per RECIST, and tumor genetic alterations. RESULTS: Of 19 evaluable patients, clinical benefit rate was 42.1% [95% confidence interval (CI), 23.1%-63.9%] and objective response rate (ORR) was 15.8% (95% CI, 5.7%-37.9%). One patient experienced a grade 3 adverse event related to 17ß-estradiol. Among patients who received continuous single-agent treatment until a second instance of disease progression, clinical benefit was observed in 5 of 12 (41.7%) cases. Tumor ER (ESR1) mutations were found by whole-exome profiling in 4 of 7 (57.1%) versus 2 of 9 (22.2%) patients who did versus did not experience clinical benefit from alternating 17ß-estradiol/AI therapy. The only two patients to experience objective responses to initial 17ß-estradiol had tumor ESR1 mutations. CONCLUSIONS: Alternating 17ß-estradiol/AI therapy may be a promising treatment for endocrine-refractory ER+ breast cancer, including following progression on CDK4/6 inhibitors or everolimus. Further study is warranted to determine whether the antitumor activity of 17ß-estradiol differs according to ESR1 mutation status.

Plasma DNA as a "liquid biopsy" incompletely complements tumor biopsy for identification of mutations in a case series of four patients with oligometastatic breast cancer.

PURPOSE: Circulating tumor DNA in plasma may present a minimally invasive opportunity to identify tumor-derived mutations to inform selection of targeted therapies for individual patients, particularly in cases of oligometastatic disease where biopsy of multiple tumors is impractical. To assess the utility of plasma DNA as a "liquid biopsy" for precision oncology, we tested whether sequencing of plasma DNA is a reliable surrogate for sequencing of tumor DNA to identify targetable genetic alterations. METHODS: Blood and biopsies of 1-3 tumors were obtained from 4 evaluable patients with advanced breast cancer. One patient provided samples from an additional 7 tumors post-mortem. DNA extracted from plasma, tumor tissues, and buffy coat of blood were used for probe-directed capture of all exons in 149 cancer-related genes and massively parallel sequencing. Somatic mutations in DNA from plasma and tumors were identified by comparison to buffy coat DNA. RESULTS: Sequencing of plasma DNA identified 27.94 ± 11.81% (mean ± SD) of mutations detected in a tumor(s) from the same patient; such mutations tended to be present at high allelic frequency. The majority of mutations found in plasma DNA were not found in tumor samples. Mutations were also found in plasma that matched clinically undetectable tumors found post-mortem. CONCLUSIONS: The incomplete overlap of genetic alteration profiles of plasma and tumors warrants caution in the sole reliance of plasma DNA to identify therapeutically targetable alterations in patients and indicates that analysis of plasma DNA complements, but does not replace, tumor DNA profiling. TRIAL REGISTRATION: Subjects were prospectively enrolled in trial NCT01836640 (registered April 22, 2013).

Visual Representations of Risk Enhance Long-Term Retention of Risk Information: A Randomized Trial.

BACKGROUND: People often overestimate their risk of developing cancer, which can cause undue worry and unwarranted risk-reducing actions. Standard counseling has a limited and short-lived effect on correcting these misperceptions. We conducted a randomized study to evaluate whether incorporation of visual depictions of risk improves the efficacy and durability of cancer risk counseling. METHODS: Sixty-six individuals seen in the Familial Cancer Program were randomized to receive standard counseling or counseling supplemented with 2 interactive visual representations of their 10-year risk of developing the cancer type of greatest concern (enhanced counseling). The primary outcome was accuracy of self-perceived risk (ratio of perceived to objective risk) 2 weeks and 6 months after counseling. RESULTS: Prior to counseling, 80% of participants overestimated their risk. Improvement in self-perception of risk was greater among those individuals randomized to receive enhanced counseling. At the 2-week follow-up, the percentage of participants who continued to overestimate their risk by 5-fold or more was 3 to 4 times lower in those who received enhanced counseling, compared to the standard counseling group. At the 6-month follow-up, sustained improvement in risk perception was most evident among those exposed to visual depictions of their risk. Statistical significance was achieved in chi-square analysis at P < 0.05, grouping participants' risk estimate as approximately accurate (<2-fold) or different from objective risk to varying degrees. CONCLUSIONS: Overestimation of cancer risk among people with a family history of cancer is common. Counseling can improve risk perception, but individuals tend to revert back to their prior misperception 6 months after counseling. By including visual representations of risk during counseling, correction of risk perception was of greater magnitude and more durable.

Transactivation of the estrogen receptor promoter by BRCA1.

BACKGROUND: Absence of the estrogen receptor-α (ER) is perhaps the most distinctive pathological feature of breast cancers arising in women who inherit a mutation in BRCA1. Two hypotheses, not necessarily mutually exclusive, exist in the literature that describe mechanisms of ER transcriptional repression in breast cancer. One hypothesis suggests that methylation of cytosine-guanine dinucleotides (CpGs) primarily mediates repression, while the other maintains that transcriptional control is mediated by certain positive and negative promoter elements. METHODS: To determine if wild type BRCA1 could induce activity of the ER promoter, we performed a series of transient transfections with ER promoter segments linked to a luciferase reporter. The effect of BRCA1 on endogenous ER expression was evaluated by RNA analysis. RESULTS: Following cotransfection with a BRCA1 expression plasmid, we observed that ER promoter-driven luciferase activity was significantly increased in both MCF10A and IMEC cells (p < 0.005 and 0.0005 respectively, two-tailed t test). Specifically, the full length ER promoter construct showed approximately 5.6-fold (MCF10A) and tenfold (IMEC) increases in luciferase activity following BRCA1 transfection, compared with transfection with an empty expression plasmid (i.e. lacking BRCA1 sequence). We localized the ER promoter segment responsible for transactivation by BRCA1 to a 109 bp region containing an AP2γ homologous site. CONCLUSIONS: The work described here, along with previously published work, indicates that activity of certain transcriptional regulatory elements and CpG methylation both represent important mechanisms by which the ER gene is typically inactive in breast cancers associated with BRCA1 mutations. The absence of ER in these breast cancers has significant implications for pathogenesis, prevention, and treatment.

BRCA1 splice variants exhibit overlapping and distinct transcriptional transactivation activities.

The global changes in gene expression induced by transient increased expression of full length BRCA1 as well as the spliced variant BRCA1(S) were evaluated by cDNA expression array in a human non-tumorigenic mammary epithelial cell line, MCF10A. Over 30 genes were identified that displayed an altered expression pattern in response to the expression of BRCA1 splice variants. The expression of NFkappaB inducing kinase was markedly down-regulated in BRCA1(L) transfected cells. However, a NFkappaB-responsive promoter construct yielded increased basal activity in BRCA1(L) transfected cells, as well as following treatment with tumor necrosis factor-alpha or lymphotoxin. In addition, nuclear extracts from BRCA1(L) transfected cells displayed increased DNA binding to the kappaB consensus site. The transcriptional activity of a panel of promoter constructs was evaluated following expression of wild type or mutant BRCA1. Full length BRCA1 transactivated the estrogen receptor-alpha (ERalpha) and BCL2 promoters as well as AP-1, SRE, and CRE containing promoters. Transactivation activity of the exon 11-deleted BRCA1(S) was more limited and usually of lower magnitude. The ability of a pathogenic mutation, 5382insC, to abrogate the transcriptional transactivation by BRCA1(L) and BRCA1(S) was also investigated. Mutant BRCA1 retained wild type levels of transcriptional activity for the ERalpha promoter as well as for the NFkappaB, AP-1, and CRE-responsive promoters but had reduced or no activity with the BCL2 and SRE promoters. These results show that BRCA1 isoforms have both overlapping and distinct transcriptional transactivation activity, and that a mutant form of BRCA1 implicated in carcinogenesis is not devoid of all activity.

Increased CpG methylation of the estrogen receptor gene in BRCA1-linked estrogen receptor-negative breast cancers.

A distinctive feature of BRCA1-linked breast cancers is that they typically do not express estrogen receptor-alpha (ER(alpha)). Previous investigation suggests that methylation of CpGs within the ER(alpha) promoter mediates repression of gene expression in some ER(alpha)-negative breast cancers. To determine if methylation of CpGs within the ER(alpha) promoter is associated with BRCA1-linked breast cancers, we evaluated methylation in exon 1 of the ER(alpha) gene in 40 ER(alpha)-negative breast cancers, 20 of which were non BRCA1-linked and 20 BRCA1-linked. CpG methylation was evaluated by either methylation-sensitive restriction digest (HpaII), methylation-sensitive PCR (MSP), or direct sequencing of bisulfite-treated genomic DNA. Results from HpaII digests and MSP documented a high degree of methylation, the MSP data showing slightly higher methylation in the BRCA1-linked group. CpGs analysed by direct sequencing showed an overall average methylation of 25% among non BRCA1-linked cancers and 40% among BRCA1-linked cancers (P=0.0031). The most notable difference was found at five particular CpGs, each of which exhibited a greater than twofold increase in methylation in the BRCA1-linked group compared to the non BRCA1-linked group (P<0.03 for each CpG). Methylation of certain critical CpGs may represent an important factor in transcriptional repression of the ER(alpha) gene in BRCA1-linked breast cancers.

Consequences of altered TGF-beta expression and responsiveness in breast cancer: evidence for autocrine and paracrine effects.

To characterize the impact of increased production of TGF-beta in a xenograft model of human breast cancer, TGF-beta-responsive MDA-231 cells were genetically modified by stable transfection so as to increase their production of active TGF-beta1. Compared with control cells, cells that produced increased amounts of TGF-beta proliferated in vitro more slowly. In vivo, however, tumors derived from these cells exhibited increased proliferation and grew at an accelerated pace. To evaluate the role of autocrine TGF-beta signaling, cells were also transfected with a dominant-negative truncated type II TGF-beta receptor (TbetaRII). Disruption of autocrine TGF-beta signaling in the TGF-beta-overexpressing cells reduced their in vivo growth rate. Co-inoculation of Matrigel with the TGF-beta-overexpressing cells expressing the truncated TbetaRII compensated for their diminished in vivo growth capacity, compared with the TGF-beta-overexpressing cells with an intact autocrine loop. Tissue invasion by the tumor was a distinctive feature of the TGF-beta-overexpressing cells, whether or not the autocrine loop was intact. Furthermore, tumors derived from TGF-beta-overexpressing cells, irrespective of the status of the autocrine TGF-beta-signaling pathway, had a higher incidence of lung metastasis. Consistent with the suggestion that TGF-beta's enhancement of invasion and metastasis is paracrine-based, we observed no significant differences among the cell clones in an in vitro invasion assay. Thus, in this experimental model system in vitro assays of cell proliferation and invasion do not accurately reflect in vivo observations, perhaps due to autocrine and paracrine effects of TGF-beta that influence the important in vivo-based phenomena of tumor growth, invasion, and metastasis.