Systematic review and meta-analysis

Breast cancer patients with the same stage of disease can have markedly different treatment responses and overall outcome. The strongest predictors for metastases (for example, lymph node status and histological grade) fail to classify accurately breast tumours according to their clinical behaviour. Chemotherapy or hormonal therapy reduces the risk of distant metastases by approximately one-third; however, 70-80% of patients receiving this treatment would have survived without it. None of the signatures of breast cancer gene expression reported to date allow for patient-tailored therapy strategies. Here we used DNA microarray analysis on primary breast tumours of 117 young patients, and applied supervised classification to identify a gene expression signature strongly predictive of a short interval to distant metastases ('poor prognosis' signature) in patients without tumour cells in local lymph nodes at diagnosis (lymph node negative). In addition, we established a signature that identifies tumours of BRCA1 carriers. The poor prognosis signature consists of genes regulating cell cycle, invasion, metastasis and angiogenesis. This gene expression profile will outperform all currently used clinical parameters in predicting disease outcome. Our findings provide a strategy to select patients who would benefit from adjuvant therapy.

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Gene expression profiling predicts clinical outcome of breast cancer

Background A more accurate means of prognostication in breast cancer will improve the selection of patients for adjuvant systemic therapy. Methods Using microarray analysis to evaluate our previously established 70-gene prognosis profile, we classified a series of 295 consecutive patients with primary breast carcinomas as having a gene-expression signature associated with either a poor prognosis or a good prognosis. All patients had stage I or II breast cancer and were younger than 53 years old; 151 had lymph-node–negative disease, and 144 had lymph-node–positive disease. We evaluated the predictive power of the prognosis profile using univariable and multivariable statistical analyses. Results Among the 295 patients, 180 had a poor-prognosis signature and 115 had a good-prognosis signature, and the mean (±SE) overall 10-year survival rates were 54.6±4.4 percent and 94.5±2.6 percent, respectively. At 10 years, the probability of remaining free of distant metastases was 50.6±4.5 percent in the group with a...

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A Gene-Expression Signature as a Predictor of Survival in Breast Cancer

Background: The finding of a decrease in contralateral breast cancer incidence following tamoxifen administration for adjuvant therapy led to the concept that the drug might play a role in breast cancer prevention. To test this hypothesis, the National Surgical Adjuvant Breast and Bowel Project initiated the Breast Cancer Prevention Trial (P-1) in 1992. Methods: Women (N = 13 388) at increased risk for breast cancer because they 1) were 60 years of age or older, 2) were 35‐59 years of age with a 5-year predicted risk for breast cancer of at least 1.66%, or 3) had a history of lobular carcinoma in situ were randomly assigned to receive placebo (n = 6707) or 20 mg/day tamoxifen (n = 6681) for 5 years. Gail’s algorithm, based on a multivariate logistic regression model using combinations of risk factors, was used to estimate the probability (risk) of occurrence of breast cancer over time. Results: Tamoxifen reduced the risk of invasive breast cancer by 49% (two-sided P<.00001), with cumulative incidence through 69 months of follow-up of 43.4 versus 22.0 per 1000 women in the placebo and tamoxifen groups, respectively. The decreased risk occurred in women aged 49 years or younger (44%), 50‐59 years (51%), and 60 years or older (55%); risk was also reduced in women with a history of lobular carcinoma in situ (56%) or atypical hyperplasia (86%) and in those with any category of predicted 5-year risk. Tamoxifen reduced the risk of noninvasive breast cancer by 50% (two-sided P<.002). Tamoxifen reduced the occurrence of estrogen receptor-positive tumors by 69%, but no difference in the occurrence of estrogen receptor-negative tumors was seen. Tamoxifen administration did not alter the average annual rate of ischemic heart disease; however, a reduction in hip, radius (Colles’), and spine fractures was observed. The rate of endometrial cancer was increased in the tamoxifen group (risk ratio = 2.53; 95% confidence interval = 1.35‐4.97); this increased risk occurred predominantly in women aged 50 years or older. All endometrial cancers in the tamoxifen group were stage I (localized disease); no endometrial cancer deaths have occurred in this group. No liver cancers or increase in colon, rectal, ovarian, or other tumors was observed in the tamoxifen group. The rates of stroke, pulmonary embolism, and deep-vein thrombosis were elevated in the tamoxifen group; these events occurred more frequently in women aged 50 years or older. Conclusions: Tamoxifen decreases the incidence of invasive and noninvasive breast cancer. Despite side effects resulting from administration of tamoxifen, its use as a breast cancer preventive agent is appropriate in many women at increased risk for the disease. [J Natl Cancer Inst 1998;90:1371‐88]

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Tamoxifen for Prevention of Breast Cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study

Background We present the combined results of two trials that compared adjuvant chemotherapy with or without concurrent trastuzumab in women with surgically removed HER2-positive breast cancer. Methods The National Surgical Adjuvant Breast and Bowel Project trial B-31 compared doxorubicin and cyclophosphamide followed by paclitaxel every 3 weeks (group 1) with the same regimen plus 52 weeks of trastuzumab beginning with the first dose of paclitaxel (group 2). The North Central Cancer Treatment Group trial N9831 compared three regimens: doxorubicin and cyclophosphamide followed by weekly paclitaxel (group A), the same regimen followed by 52 weeks of trastuzumab after paclitaxel (group B), and the same regimen plus 52 weeks of trastuzumab initiated concomitantly with paclitaxel (group C). The studies were amended to include a joint analysis comparing groups 1 and A (the control group) with groups 2 and C (the trastuzumab group). Group B was excluded because trastuzumab was not given concurrently with paclit...

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Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer

The mating-induced preovulatory surge of luteinizing hormone (LH) lasts for at least 12 h in the female ferret. This prolonged increase in circulating LH is presumably accompanied by a corresponding elevation in the activity and output of luteinizing hormone-releasing hormone (LHRH) neurons projecting to the hypothalamic-hypophyseal portal blood vessels and adenohypophysis. We used the protein products of the immediate early genes (IEGs) c-fos, and c-jun as markers of neural activation in order to determine whether a sub-population of LHRH neurons is differentially activated by mating and whether non-LHRH neurons in specific forebrain regions are selectively activated at different times during the mating-induced preovulatory LH surge. In Experiment 1, estrous female ferrets were perfused 0.5, 1.5, 3.0, 6.0 or 12.0 h after receiving one 5-min intromission from a male or after being placed alone in a testing cage for 20 min. Fos-like immunoreactivity (Fos-IR; Oncogene Ab-2 antiserum) and LHRH-like immunoreactivity (LHRH-IR; LR-1 antiserum) were visualized. The percentage of Fos-IR LHRH neurons was significantly augmented 1.5 h after mating but had returned to basal levels by 3.0 h. The double-labeled LHRH neurons were concentrated in the caudal medio-basal hypothalamus. In non-LHRH neurons the number of Fos-IR neural nuclei was significantly increased by mating in the medial preoptic area (MPOA), bed nucleus of the stria terminalis (BNST), medial amygdala (MA), ventrolateral hypothalamus (VLH), and midbrain central tegmental field (CTF) 1.5 h after mating but, as in LHRH neurons, had returned to basal levels by 3.0 h. In Experiment 2, estrous females were perfused 1.5 h or 8.0 h after either receiving one 5-min intromission or being placed alone in a testing cage, and the brains were processed for LHRH and c-Fos-like (DCH-1, Dr Gerard Evan), c-Jun-like (Jun-IR; Oncogene Ab-2) or Egr-1-like (Egr-IR; Santa Cruz) immunoreactivity. The percentage of LHRH neurons colabeled with both Fos-IR and Jun-IR was significantly greater in the 1.5 h group than in the unpaired group. Again, the induction of these IEG products occurred in LHRH neurons in the caudal medio-basal hypothalamus. Mating significantly increased the number of Fos-IR non-LHRH neural nuclei in the MPOA, BNST, MA, VMH and CTF, as well as the number of Egr-IR nuclei in the MPOA, BNST and MA in the 1.5 h group. By contrast, the number of Jun-IR non-LHRH neurons was unaffected by mating. In these Experiments we have identified a sub-population of LHRH neurons which, using Fos and Jun as markers of neural activation, is activated by mating and may be differentially involved in the generation of the preovulatory LH surge. Although the LHRH system is presumably activated throughout the duration of the 12 h preovulatory LH surge, c-Fos and c-Jun immunoreactivity in LHRH neurons is augmented only transiently. Fos-IR and Egr-IR in non-LHRH neurons show a similar time-course. Together, these results suggest that the presence of augmented levels of these proteins is not required for the maintenance or termination of the preovulatory output of LHRH.

The temporal pattern of mating-induced immediate-early gene product immunoreactivity in LHRH and non-LHRH neurons of the estrous ferret forebrain.

Male ferrets castrated on postnatal day 5 displayed significantly lower levels of neck gripping, mounting, and pelvic thrusting behavior than groups of males castrated on postnatal days 20 or 35 when tested in adulthood after treatment with testosterone (T). Administering a high dosage of T via sc Silastic capsules to ovariectomized female ferrets over postnatal days 5-20 caused a significant enhancement of all three parameters of masculine coital behavior and ossification of clitorides, in comparison with control females that received no exogenous hormone neonatally. A lower dosage of T given to other ovariectomized females over the same neonatal period caused only slight coital masculinization even though the plasma concentrations of T achieved in females with this particular implant were somewhat higher than the levels normally present in gonadally intact male ferrets at any time between postnatal days 5 and 40. Administration of high and low dosages of T to ovariectomized females over days 20-35 failed to cause any coital or genital masculinization. The results suggest that T acts in the male ferret brain between postnatal days 5 and 20 to cause coital masculinization. The sensitivity of the male brain to T during this period may, however, normally be enhanced by the action of T or some other hormone before day 5.

Effect of Neonatal Gonadectomy and Administration of Testosterone on Coital Masculinization in the Ferret

Estrogen receptors were visualized in adult ferret brains using the H222 estrogen receptor antibody and immunocytochemical techniques. H222 immunoreactive (H222ir) cell nuclei were present in many forebrain regions in gonadectomized ferrets of both sexes. In many instances, H222ir cells also had immunoreaction product in their processes. All cells with H222ir processes also contained H222ir nuclei. More H222ir processes were observed in females in the medial and lateral preoptic area/anterior hypothalamus, and at the level of the descending fornix and caudal anterior commissure. Quantitative image analysis confirmed that females had significantly more (approximately 50%) extranuclear H222 immunoreaction product than males in cells in the magnocellular or preoptic subnuclei of the bed nucleus of the stria terminalis. Cells in the principal subnucleus of the bed nucleus of the stria terminalis and ventrolateral septum were notable for the relative paucity of H222ir processes. Sex differences in the intracellular extranuclear distribution of estrogen receptor protein in particular brain regions might contribute to the differential regulation of estrogen-dependent functions in the two sexes.

Sex and regional differences in intracellular localization of estrogen receptor immunoreactivity in adult ferret forebrain

Administration of naloxone (SC 5 mg/kg) significantly reduced ejaculation and mounting in male rats in the weeks following castration. A similar effect was obtained by injecting morphine (SC 1 or 5 mg/kg). In contrast, the same dosages of naloxone or morphine did not affect the sexual performance of gonadally intact males. Opioid peptides may contribute to the temporary persistence of sexual behavior in testosterone-deficient male mammals, in which incentive qualities of the female partner are an important determinant of sexual arousal.

Inhibition of mating by naloxone or morphine in recently castrated, but not intact male rats.

The present studies examined the patterns of circulating testosterone (T) within 0–24 h after birth in male and female ferrets along with concomitant changes in neural aromatase activity and hypothalamic concentrations of estradiol (E2) Plasma and brain samples were obtained 0 and 2 h (cesarean delivery) or 0, 2, 12, and 24 h (natural delivery) after birth Plasma T levels were significantly higher in male neonates 2 h after birth than at 0 h in both cesarean-delivered (948 ± 125 vs 337 ± 060 ng/ml) and naturally delivered (1928 ± 294 vs 513 ± 193 ng/ml) ferrets, while female neonates showed no significant changes in T over these sampling times T levels had returned to 0 h levels by 12 h in naturally delivered males T was significantly lower in females than in males 0, 2, and 24 h after natural delivery, whereas T levels were equivalent in males and females immediately after cesarean delivery Male kits kept on a heating pad for 2 h after natural delivery had lower plasma T levels than males 

Michael J. Baum

Papers

The temporal pattern of mating-induced immediate-early gene product immunoreactivity in LHRH and non-LHRH neurons of the estrous ferret forebrain.

Effect of Neonatal Gonadectomy and Administration of Testosterone on Coital Masculinization in the Ferret

Sex and regional differences in intracellular localization of estrogen receptor immunoreactivity in adult ferret forebrain

Inhibition of mating by naloxone or morphine in recently castrated, but not intact male rats.

Effect of birth on plasma testosterone, brain aromatase activity, and hypothalamic estradiol in male and female ferrets.