Clinicopathological characteristics and eligibility for adjuvant olaparib of germline BRCA1/2 mutation carriers with HER2-negative early breast cancer.

Following the survival benefit demonstrated in the OlympiA trial, one year of adjuvant olaparib is now recommended for all patients with germline BRCA1/2 pathogenic/likely pathogenic variants (PV) and high-risk, HER2-negative early breast cancer after chemotherapy. However, optimal identification of high-risk patients who may derive benefit from this genomically-directed therapy is debated. In this study, we sought to characterize the real-world proportion of gBRCA1/2 PV carriers eligible for adjuvant olaparib according to the OlympiA criteria, and to compare clinicopathologic characteristics and outcomes between eligible and ineligible patients.

PARP Inhibitors for Breast Cancer Treatment: A Review.

Importance: Poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors have revolutionized the treatment of patients with germline BRCA1/2-associated breast cancer, representing the first targeted therapy capable of improving outcomes in patients with hereditary tumors. However, resistance to PARP inhibitors occurs in almost all patients. Observations: This narrative review summarizes the biological rationale behind the use of PARP inhibitors in breast cancer, as well as the available evidence, recent progress, and potential future applications of these agents. Recent studies have shown that the benefit of PARP inhibitors extends beyond patients with germline BRCA1/2-associated metastatic breast cancer to patients with somatic BRCA1/2 variants and to those with germline PALB2 alterations. Moreover, these agents proved to be effective both in the metastatic and adjuvant settings. However, patients with metastatic breast cancer usually do not achieve the long-term benefit from PARP inhibitors observed in other tumor types. Mechanisms of resistance have been identified, but how to effectively target them is largely unknown. Ongoing research is investigating both novel therapeutics and new combination strategies to overcome resistance. PARP1-selective inhibitors, by sparing the hematological toxic effects induced by the PARP2 blockade, are promising agents to be combined with chemotherapy, antibody-drug conjugates, and other targeted therapies. Conclusions and Relevance: Although the efficacy of PARP inhibitors is well established, many questions persist. Future research should focus on identifying predictive biomarkers and therapeutic strategies to overcome resistance. Integrating well-designed translational efforts into all clinical studies is thereby crucial to laying the groundwork for future insights from ongoing research.

Evolution of HER2 expression between pre-treatment biopsy and residual disease after neoadjuvant therapy for breast cancer.

INTRODUCTION: We have previously found that HER2 expression is dynamic, and can change from the primary breast tumor to matched recurrences. With this work, we aimed to assess the dynamics of HER2 during neoadjuvant treatment.(NAT). METHODS: We reviewed HER2 expression in pre- and post-treatment samples from consecutive patients with early-stage breast cancer that received NAT and underwent surgery at Dana-Farber Brigham Cancer Center between 01/2016-08/2022. The primary outcome was evolution of HER2 expression from pre- to post-NAT specimens in patients with residual disease. RESULTS: Among 1613 patients receiving NAT, 1080 had residual disease at surgery. A total of 319 patients (29.5%) experienced a change in HER2 expression (HER2 0 vs. HER2-low vs. HER2-positive) from the pre-treatment sample to residual disease, with roughly equal distribution between decreased (50.5%) and increased HER2 expression (49.5%). Similar rates of change in HER2 expression were observed with anthracycline-based (31.8%) or taxane/platinum-based regimens (32.4%). Patients with HER2-0 or HER2-low tumors at diagnosis were likelier to experience a change in HER2 expression post-NAT compared to HER2-positive (32.3% vs. 21.3%, p < 0.001). Changes in HER2 expression post-NAT were prognostic among patients with HER2-positive tumors at diagnosis (3-year recurrence-free survival for change vs. no change: 71.6% vs. 89.6%, p = 0.006) but not among those with HER2-negative tumors at diagnosis (3-year recurrence-free survival for change vs. no change: 79.3% vs. 81.1%, p = 0.31). CONCLUSIONS: Nearly 30% of patients with early-stage breast cancer showed a change in HER2 expression after NAT. Changes in HER2 expression post-NAT were only prognostic in the setting of HER2-positive tumors becoming HER2-negative at surgery.

Prevalence, Dynamics, and Prognostic Role of Clonal Hematopoiesis of Indeterminate Potential in Patients With Breast Cancer.

PURPOSE: Clonal hematopoiesis of indeterminate potential (CHIP) is frequent in patients with solid tumors. Prospective data about CHIP prevalence at breast cancer diagnosis and its dynamic evolution under treatment selective pressure are limited. PATIENTS AND METHODS: We performed targeted error-corrected sequencing on 614 samples from 380 patients with breast cancer. We investigated the dynamics of CHIP on prospectively collected paired samples from patients with early breast cancer (eBC) receiving chemotherapy (CT) or endocrine therapy (ET). We assessed the correlation of CHIP with survival in patients with metastatic triple-negative breast cancer (mTNBC). We estimated the risk of progression to treatment-related myeloid neoplasms (t-MN) according to the clonal hematopoiesis risk score (CHRS). In exploratory analyses, we considered clonal hematopoiesis (CH) with variant allele fraction (VAF) ≥0.005. RESULTS: CHIP was identified in 15% of patients before treatment. Few CHIP emerged after treatment, and the risk of developing new mutations was similar for patients receiving CT versus ET (odds ratio [OR], 1.16; P = .820). However, CT increased the risk of developing new CH with VAF ≥0.005 (OR, 3.45; P = .002). Five TP53-mutant CH with VAF ≥0.005 emerged among patients receiving CT. Most patients had low risk of t-MN according to the CHRS score. CHIP did not correlate with survival in mTNBC. CONCLUSION: CHIP is frequent in patients with breast cancer. In this study, CT did not lead to emergence of new CHIP, and most patients had low risk of developing t-MN. This finding is reassuring, given long life expectancy of patients with eBC and the association of CHIP with morbidity and mortality. However, TP53-mutant CH with VAF ≥0.005 emerged with CT, which carries high risk of t-MN. Evolution of these small clones and their clinical significance warrant further investigation.

Baseline Tumor Size as Prognostic Index in Patients With Advanced Solid Tumors Receiving Experimental Targeted Agents.

BACKGROUND: Baseline tumor size (BTS) has been associated with outcomes in patients with cancer treated with immunotherapy. However, the prognostic impact of BTS on patients receiving targeted therapies (TTs) remains undetermined. METHODS: We reviewed data of patients with advanced solid tumors consecutively treated within early-phase clinical trials at our institution from 01/2014 to 04/2021. Treatments were categorized as immunotherapy-based or TT-based (biomarker-matched or not). BTS was calculated as the sum of RECIST1.1 baseline target lesions. RESULTS: A total of 444 patients were eligible; the median BTS was 69 mm (IQR 40-100). OS was significantly longer for patients with BTS lower versus higher than the median (16.6 vs. 8.2 months, P < .001), including among those receiving immunotherapy (12 vs. 7.5 months, P = .005). Among patients receiving TT, lower BTS was associated with longer PFS (4.7 vs. 3.1 months, P = .002) and OS (20.5 vs. 9.9 months, P < .001) as compared to high BTS. However, such association was only significant among patients receiving biomarker-matched TT, with longer PFS (6.2 vs. 3.3 months, P < .001) and OS (21.2 vs. 6.7 months, P < .001) in the low-BTS subgroup, despite a similar ORR (28% vs. 22%, P = .57). BTS was not prognostic among patients receiving unmatched TT, with similar PFS (3.7 vs. 4.4 months, P = .30), OS (19.3 vs. 11.8 months, P = .20), and ORR (33% vs. 28%, P = .78) in the 2 BTS groups. Multivariate analysis confirmed that BTS was independently associated with PFS (P = .03) and OS (P < .001) but not with ORR (P = .11). CONCLUSIONS: Higher BTS is associated with worse survival outcomes among patients receiving biomarker-matched, but not biomarker-unmatched TT.

Clinicopathological features and survival outcomes of luminal-like breast tumors with estrogen receptor loss at metastatic recurrence: A case-control study.

INTRODUCTION: Estrogen receptor (ER) loss at metastatic relapse occurs in up to 20% of luminal-like primary breast tumors. Data about clinicopathological features associated with ER loss and its prognostic significance are limited. METHODS: In a nested-case-control study, we compared clinicopathological characteristics and clinical outcomes between a cohort of 51 patients with primary ER+ /HER2- and paired triple-negative metastasis (LUM-TN) and two control cohorts of paired early-metastatic ER+ /HER2- (LUM-LUM, n = 50) and triple-negative (TN-TN, n = 49) breast cancers. Stromal tumor-infiltrating lymphocytes (TILs) were assessed according to the TILs Working Group recommendations as continuous and discrete variables with cutoffs (20%, 40%). RESULTS: LUM-TN tumors had lower ER expression than LUM-LUM tumors, but lower grade and Ki67 than TN-TN cases. Median distant-metastasis free survival was similar for LUM-TN and LUM-LUM cohorts, but significantly longer than in TN-TN cases (log-rank P < 0.001). LUM-TN and TN-TN cohorts had a comparable survival from the time of metastatic recurrence, which was significantly shorter than in patients with LUM-LUM tumors (log-rank P < 0.001). High TILs were associated with worse outcomes in patients with ER loss (P < 0.001). CONCLUSIONS: Breast tumors with ER loss at metastatic relapse have intermediate features and outcomes compared with metastatic luminal-like and ab initio triple-negative tumors. Further investigation on the biological mechanisms underpinning the loss of ER expression is ongoing.

Next-generation antibody-drug conjugates for breast cancer: Moving beyond HER2 and TROP2.

Antibody-drug conjugates (ADCs) have reshaped the treatment of several malignancies, including breast cancer. Two ADCs are currently approved for the treatment of each breast cancer subtype, including the HER2 targeted ADCs trastuzumab emtansine (T-DM1) and trastuzumab deruxtecan (T-DXd), and the TROP2-targeted ADC sacituzumab govitecan. Each of the ADC components (antibody, linker, and payload) plays a key role in determining the efficacy and toxicity profile of an individual ADC, and their modification can lead to major changes in the clinical profile of these agents. Leveraging the knowledge from three decades of development in the field, several novel ADCs are currently being investigated. Some approaches include targeting different antigens beyond the established HER2/TROP2, or evaluating innovative constructs, such as bispecific ADCs, ADCs with dual payload, immune-modulating ADCs, radionuclide drug conjugates, and masked ADCs, among others. In this review article we discuss the evolving landscape of novel ADCs, highlighting opportunities and challenges emerging in the field.

Liquid biopsy for brain metastases and leptomeningeal disease in patients with breast cancer.

A significant subset of patients with metastatic breast cancer develops brain metastasis. As efficacy of systemic therapies has improved and patients live longer with metastatic breast cancer, the incidence of breast cancer brain metastases has increased. Brain metastases pose a clinical challenge in diagnosis, treatment, and monitoring across all breast cancer subtypes, and better tools are needed. Liquid biopsy, which enables minimally invasive sampling of a patient's cancer, has the potential to shed light on intra-cranial tumor biology and to improve patient care by enabling therapy tailoring. Here we review current evidence for the clinical validity of liquid biopsy in patients with breast cancer brain metastases, with a focus on circulating tumor cells and circulating tumor DNA.

Adjuvant Olaparib for Germline BRCA Carriers With HER2-Negative Early Breast Cancer: Evidence and Controversies.

In the OlympiA study, 1 year of adjuvant olaparib significantly extended invasive disease-free survival and overall survival. The benefit was consistent across subgroups, and this regimen is now recommended after chemotherapy for germline BRCA1/2 mutation (gBRCA1/2m) carriers with high-risk, HER2-negative early breast cancer. However, the integration of olaparib in the landscape of agents currently available in the post(neo)adjuvant setting-ie, pembrolizumab, abemaciclib, and capecitabine-is challenging, as there are no data suggesting how to select, sequence, and/or combine these therapeutic approaches. Furthermore, it is unclear how to best identify additional patients who could benefit from adjuvant olaparib beyond the original OlympiA criteria. Since it is unlikely that new clinical trials will answer these questions, recommendations for clinical practice can be made through indirect evidence. In this article, we review available data that could help guide treatment decisions for gBRCA1/2m carriers with high-risk, early-stage breast cancer.

Role of Immunotherapy in Early- and Late-Stage Triple-Negative Breast Cancer.

For women with triple-negative breast cancer, the addition of pembrolizumab to chemotherapy has become a standard of care in the early-stage and first-line metastatic setting. However, many questions persist. Different chemotherapy backbones and sequencing strategies have been evaluated, but evidence supporting the superiority of one over the other is weak. Although many have been investigated, programmed cell death ligand 1 (PDL1) is the only approved biomarker. Since immunotherapy has been associated with potentially severe and permanent toxicities, the identification of better predictive biomarkers is essential. New strategies are needed to increase the proportion of patients who might benefit from immunotherapy.

Emerging Targeted Therapies for Early Breast Cancer.

Breast cancer is the most common malignancy and the second leading cause of cancer-related mortality in the United States (US). Most patients are diagnosed with early-stage disease; however, there is still a need to prevent recurrences that often present as incurable metastatic disease. The treatment landscape of early-stage breast cancer is evolving rapidly. The immune checkpoint inhibitor pembrolizumab is approved in combination with neoadjuvant chemotherapy for the treatment of high-risk triple-negative breast cancer (TNBC). The cyclin-dependent kinase (CDK) 4 and 6 inhibitor abemaciclib is approved for adjuvant treatment of patients with high-risk hormone receptor (HR)-positive disease. While adjuvant olaparib has shown significant improvement in outcomes for patients with pathogenic/likely pathogenic BRCA1/2 mutations and high-risk human epidermal growth factor receptor 2 (HER2)-negative breast cancer, and is approved in this setting. For the HER2-positive subtype, the post-neoadjuvant therapy can be tailored based on the response to neoadjuvant chemotherapy and HER2-targeted agents. In this narrative review, we summarize the most recent approvals for early-stage breast cancer as well as frequently encountered clinical challenges utilizing these medications.

Refining risk stratification in HR-positive/HER2-negative early breast cancer: how to select patients for treatment escalation?

PURPOSE: Despite advances in adjuvant therapeutic strategies, many patients with hormone receptor (HR)-positive/HER2-negative early breast cancer (EBC) experience disease recurrence, even many years after primary surgery. The aim of this review is: (i) to point out the current clinical, pathological, and genomic features that contribute to define the risk of recurrence in HR-positive EBC, (ii) to explore the potential role of liquid biopsy-based assays for refining risk assessment, and (iii) to discuss future perspectives and innovative strategies to optimize risk stratification and select patients for treatment escalation. METHODS: We searched PubMed, EMBASE and Scopus to review the current evidence about risk stratification in patients with HR-positive EBC, and to identify studies deemed to have the highest scientific value. RESULTS: Risk stratification of HR-positive/HER2-negative relies on traditional clinicopathological features (age, menopausal status, tumor size, nodal status, tumor grading, HR expression level, and proliferation markers), along with newly developed genomic scores, which accurately predict risk of recurrence and survival. Multiparametric scores including both clinicopathological and genomic variables have the highest prognostication power, even if comparative studies have not defined which one should be preferred. In parallel, liquid biopsy-based showed to be a valuable tool to identify high risk patients. CONCLUSION: The most appropriate definition of "high" and "low" risk HR-positive EBC is still unclear. Accordingly, treatment escalation/de-escalation depending on recurrence risk remains challenging. Implementation of new tools for risk stratification, such as liquid biopsy-based assays, as well as development of novel treatment strategies are strongly warranted.

Loss of HER2 in breast cancer: biological mechanisms and technical pitfalls.

Loss of HER2 in previously HER2-positive breast tumors is not rare, occurring in up to 50% of breast cancers; however, clinical research and practice underestimate this issue. Many studies have reported the loss of HER2 after neoadjuvant therapy and at metastatic relapse and identified clinicopathological variables more frequently associated with this event. Nevertheless, the biological mechanisms underlying HER2 loss are still poorly understood. HER2 downregulation, intratumoral heterogeneity, clonal selection, and true subtype switch have been suggested as potential causes of HER2 loss, but translational studies specifically investigating the biology behind HER2 loss are virtually absent. On the other side, technical pitfalls may justify HER2 loss in some of these samples. The best treatment strategy for patients with HER2 loss is currently unknown. Considering the prevalence of this phenomenon and its apparent correlation with worse outcomes, we believe that correlative studies specifically addressing HER2 loss are warranted.

Systemic Treatment of Ductal Carcinoma In Situ of the Breast.

Ductal carcinoma in situ (DCIS) is a noninvasive breast cancer (BC), whose diagnosis significatively increased with the diffusion of BC screening programs. DCIS actually represents roughly 20% of new BC diagnoses (1). About 70% of DCIS shows positivity for hormone receptor (HR), while HER2 is overexpressed in 25-30% of the cases (2,3). Concerning the systemic approach, the only one that should be considered for HR-positive DCIS is adjuvant endocrine therapy (ET), according to NCCN guidelines (4). In fact, the excellent prognosis of this neoplasm does not justify the utilization of more aggressive treatment strategies, such as HER2- directed therapies or chemotherapy. Here we discuss the results of the most important clinical trials enrolling DCIS patients in the adjuvant and in the preoperative setting; in addition, we report the chemoprevention studies utilizing ET which demonstrated a reduction of the risk of DCIS development. On balance, the choice to undertake or not an adjuvant ET, which is often burdened by adverse events that could impact on the quality of life of the patients and on their adherence to the therapy, should be discussed with the patient, taking into account that no survival advantage has been demonstrated so far.

Safety of COVID-19 mRNA Vaccines in Patients with Cancer Enrolled in Early-Phase Clinical Trials.

Pivotal trials of COVID-19 vaccines did not include cancer patients, with questions remaining about their safety and efficacy in this population. Patients enrolled in early-phase clinical trials receive novel treatments with unknown efficacy and safety profiles. Studies on the safety of COVID-19 vaccines in these patients are urgently required. This is a retrospective, real-world, cohort study of patients receiving anticancer treatments and COVID-19 vaccines between 1 February and 25 June 2021 at the Division of New Drugs Development for Innovative Therapies of the European Institute of Oncology. One hundred thirteen patients were enrolled, 40 in early-phase clinical trials, and 20 under novel immunotherapy agents. Nearly three-quarters of the patients experienced at least one adverse event (AE) after the first dose (1D) (74.3%) and second dose (2D) (72.6%). Most of the AEs were local (67.3% 1D and 61.9% after 2D), while 31.8% (1D) and 38.1% (2D) of the patients had systemic AEs. No AEs above grade 2 were observed. Therefore, COVID-19 vaccines appear to be safe in patients enrolled in early-phase clinical trials, including patients receiving novel immunotherapy compounds. All cancer patients should be prioritized for COVID-19 vaccination, regardless of ongoing treatments or enrollment in early-phase trials.

Assessment of estrogen receptor low positive status in breast cancer: Implications for pathologists and oncologists.

Estrogen receptor (ER) status assessment by immunohistochemistry (IHC) is the gold standard test for the identification of patients with breast cancer who may benefit from endocrine therapy (ET). Whilst most ER+ breast cancers have a high IHC score, about 3% of cases display a low positivity, with 1% to 10% of cells being weakly stained. These tumors are generally classified within the luminal-like category; however, their risk profile seems to be more similar to that of ER-negative breast cancers. The decision on ET for patients with a diagnosis of ER-low breast cancer should be carefully considered in light of the risks and possible benefits of the treatment. Potential pitfalls hinder pathologists and oncologists from establishing an appropriate threshold for "low positivity". Furthermore, several pre-analytical and analytical variables might trouble the pathological identification of these clinically challenging cases. In this review, we sought to discuss the adversities that can be accounted for the pathological identification of ER-low breast cancers in real-world clinical practice, and to provide practical suggestions for the perfect ER testing in light of the most updated recommendations and guidelines.

Selective FGFR/FGF pathway inhibitors: inhibition strategies, clinical activities, resistance mutations, and future directions.

Introduction: Fibroblast growth factor receptor (FGFR)/fibroblast growth factor (FGF) is a pathway characterized by recurring alterations in cancer. Its dysregulations enhance cancer cell proliferation, survival, migration and invasion, as well as angiogenesis and immune evasion.Areas covered: FGFR/FGF selective inhibitors belong to a broad class of drugs with some being approved for specific indications and others under investigation in ongoing phase I and II clinical trials. In this review, all available clinical data from trials on selective FGFR/FGF inhibitors as well as described resistance mutations and mechanisms are presented. FGFR/FGF pathway inhibitors are classified according to the mechanism they employ to dampen/suppress signaling and to the preferred FGFR binding mode when X-ray crystal structure is available.Expert opinion: Data presented suggests the general actionability of FGFR1,2,3 mutations and fusions across histologies, whereas FGFR1,2,3 amplifications alone are poor predictors of response to tyrosine kinase inhibitors. Overexpression on immunohistochemistry (IHC) of FGF19, the stimulatory ligand of FGFR4, can predict response to FGFR selective inhibitors in hepatocellular carcinoma. Whereas IHC overexpression of FGFR1,2,3 is not sufficient to predict benefit from FGFR inhibitors across solid tumors. FGFR1,2,3 mRNA overexpression can predict response even in absence of structural alteration. Data on resistance mutations suggests the need for new inhibitors to overcome gatekeeper mutations.

Clinical outcomes of patients with metastatic breast cancer enrolled in phase I clinical trials.

BACKGROUND: Next-generation phase I clinical trials (Ph1s) investigating targeted therapy (TT) and immunotherapy (IO) led to consistent improvements in outcomes of patients with cancer . Ph1s are mainly designed to enrol patients with different tumour types; hence, scant information on characteristics and outcomes of specific tumours is available. The aim of our study is to evaluate the outcomes of patients with metastatic breast cancer (BC) enrolled in Phs1 testing TT, IO and combinations. MATERIAL AND METHODS: We retrospectively collected data on clinical characteristics and outcomes of all patients with metastatic BC treated in Ph1s from 2014 to 2019 at our Institution. The primary end-points were progression-free survival (PFS) and overall survival (OS). The secondary objectives were overall response rate (ORR), disease control rate (DCR) and 90-day mortality rate. Univariate and multivariate analyses were performed to assess the impact of different variables. RESULTS: One hundred fifty-one patients with metastatic BC were treated, including 70 (46%) with hormone receptor-positive (HR+), 18 (12%) with HER2+ and 63 (42%) with triple-negative (TN) BC. The median age was 52.4 years (26.9-77.9). Patients with TNBC were less pretreated than patients with HR+ and HER2+ subtypes. Patients with HR+ tumours were preferentially included in TT rather than IO trials (97% vs. 2.9%, P < 0.001). In 148 patients evaluable for tumour response, DCR and ORR were 51.4% and 18.9%, respectively. Higher response rates have been observed in patients treated with TT (TT vs. IO: 23.5% vs. 3.0%, P = 0.008) and in the HER2+ or TN subtypes (HER2+ vs. TN vs. HR+: 33.3% vs. 24.2% vs. 10.3%, P = 0.032). Improved median PFS was observed in patients treated with TT (P < 0.001), aged ≥ 65 years (P = 0.001) and having fewer than 3 metastatic sites (P = 0.026). Patients with HR+ and HER2+ subtypes presented a numerically higher median PFS than those with TNBC (3.65 vs. 3.58 vs. 2.28 months, P = 0.053). Median OS was longer in HR+ and HER2+ subtypes than that in TNBC (20 vs. 16 vs. 10 months, P = 0.007). Variables independently associated with improved OS were fewer than three metastatic sites (P = 0.014) and a baseline lactate dehydrogenase lower than upper limit of normal (P < 0.001). CONCLUSION: Our study provides novel insights on the landscape of metastatic breast cancer metasta treated in Ph1s. Patients with TNBC still have poor outcomes, reinforcing the need to better translate preclinical findings into the clinical context. TT-based trials-mainly biomarker-driven-are associated with improved outcomes, suggesting that future IO trials have to be guided by meaningful biomarkers. Finally, patients with low tumour burden can have significant benefit, underling the importance to enrol patients in earlier lines of treatment to maximise the benefit.

Breast Cancer with Bone Metastasis: Molecular Insights and Clinical Management.

Despite the remarkable advances in the diagnosis and treatment of breast cancer patients, the presence or development of metastasis remains an incurable condition. Bone is one of the most frequent sites of distant dissemination and negatively impacts on patient's survival and overall frailty. The interplay between tumor cells and the bone microenvironment induces bone destruction and tumor progression. To date, the clinical management of bone metastatic breast cancer encompasses anti-tumor systemic therapies along with bone-targeting agents, aimed at slowing bone resorption to reduce the risk of skeletal-related events. However, their effect on patients' survival remains controversial. Unraveling the biology that governs the interplay between breast neoplastic cells and bone tissue would provide means for the development of new therapeutic agents. This article outlines the state-of-the art in the characterization and targeting the bone metastasis in breast cancer, focusing on the major clinical and translational studies on this clinically relevant topic.