Individuals who have mutations in the breast-cancer-susceptibility gene BRCA1 (hereafter referred to as BRCA1-mutation carriers) frequently undergo prophylactic mastectomy to minimize their risk of breast cancer. The identification of an effective prevention therapy therefore remains a 'holy grail' for the field. Precancerous BRCA1mut/+ tissue harbors an aberrant population of luminal progenitor cells1, and deregulated progesterone signaling has been implicated in BRCA1-associated oncogenesis2,3,4,5. Coupled with the findings that tumor necrosis factor superfamily member 11 (TNFSF11; also known as RANKL) is a key paracrine effector of progesterone signaling6,7,8,9,10 and that RANKL and its receptor TNFRSF11A (also known as RANK) contribute to mammary tumorigenesis11,12,13, we investigated a role for this pathway in the pre-neoplastic phase of BRCA1-mutation carriers. We identified two subsets of luminal progenitors (RANK+ and RANK) in histologically normal tissue of BRCA1-mutation carriers and showed that RANK+ cells are highly proliferative, have grossly aberrant DNA repair and bear a molecular signature similar to that of basal-like breast cancer. These data suggest that RANK+ and not RANK progenitors are a key target population in these women. Inhibition of RANKL signaling by treatment with denosumab in three-dimensional breast organoids derived from pre-neoplastic BRCA1mut/+ tissue attenuated progesterone-induced proliferation. Notably, proliferation was markedly reduced in breast biopsies from BRCA1-mutation carriers who were treated with denosumab. Furthermore, inhibition of RANKL in a Brca1-deficient mouse model substantially curtailed mammary tumorigenesis. Taken together, these findings identify a targetable pathway in a putative cell-of-origin population in BRCA1-mutation carriers and implicate RANKL blockade as a promising strategy in the prevention of breast cancer.

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We are grateful to the women who generously donated breast tissue for our studies and to the surgical, pathology and tissue bank colleagues for their substantial assistance and support. We thank L. Taylor, K. Shackleton, S. Nightingale and H. Liu for expert assistance; the Animal, FACS, Imaging and Histology facilities at WEHI; C. Perou and K. Hoadley for kind provision of the PAM50 subtypes; and A.Y. Rhee (Amgen Inc.) for assistance with the manuscript submission. We are grateful to H. Thorne and all kConFab staff, members and families for their contributions to this resource and to the Victorian Cancer Biobank (supported by the Victorian Government), which also provided coded breast tissue and data. We thank H. Yasuda for advice on the antibody to mouse RANKL and K.U. Wagner (Eppley Institute, Nebraska) for MMTV-Cre A mice. This work was supported by the Australian National Health and Medical Research Council (NHMRC) (grant numbers 1016701 (J.E.V. and G.J.L.), 1040978 (G.B.M., J.E.V. and G.J.L.) and 1054618 (G.K.S.)), NHMRC Independent Research Institute Infrastructure Support Scheme (IRIISS) (to WEHI; E.N., F.V., B.P., G.G., L.W., S.W.L., G.K.S., J.E.V. and G.J.L.), the Victorian State Government through the Victorian Cancer Agency and Operational Infrastructure Support, the National Breast Cancer Foundation (Australia) (grant numbers NC-13-32 and PS-15-042; to J.E.V. and G.J.L.); Amgen Inc. (J.E.V. and G.J.L.), the Qualtrough Cancer Research Fund (J.E.V. and G.J.L.), the Joan Marshall Breast Cancer Research Fund (J.E.V. and G.J.L.) and the Australian Cancer Research Foundation (to WEHI; E.N., F.V., B.P., G.G., L.W., S.W.L., G.K.S., J.E.V. and G.J.L.). E.N. is supported by a Cancer Council Victoria Scholarship and a Cancer Therapeutics CRC Top-Up Scholarship; B.P. is supported by a VCA Early Career Seed Grant 13035; G.K.S. and G.J.L. are supported by NHMRC Fellowships 1058892 (G.K.S.), 637307 (G.J.L.) and 1078730 (G.J.L.); and J.E.V. is supported by NHMRC Australia Fellowship 1037230.

Author information

Author notes

    • Daniel Branstetter
    •  & William C Dougall

    Present addresses: Cynosure Clinical Research LLC, North Bend, Washington, USA (D.B.); Queensland Institute of Medical Research (QIMR) Berghofer Medical Research Institute, Herston, Queensland, Australia (W.C.D.).

    • Jane E Visvader
    •  & Geoffrey J Lindeman

    These authors jointly directed this work.


  1. ACRF Stem Cells and Cancer Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Parkville, Victoria, Australia.

    • Emma Nolan
    • , François Vaillant
    • , Bhupinder Pal
    • , Sheau W Lok
    • , Jane E Visvader
    •  & Geoffrey J Lindeman
  2. Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.

    • Emma Nolan
    • , François Vaillant
    • , Bhupinder Pal
    • , Göknur Giner
    •  & Jane E Visvader
  3. Department of Pathology, Amgen Inc., Seattle, Washington, USA.

    • Daniel Branstetter
    • , Kathy Rohrbach
    • , Li-Ya Huang
    •  & Rosalia Soriano
  4. Bioinformatics Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.

    • Göknur Giner
    •  & Gordon K Smyth
  5. Imaging Laboratory, Systems Biology and Personalized Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.

    • Lachlan Whitehead
  6. Familial Cancer Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia.

    • Sheau W Lok
    •  & Geoffrey J Lindeman
  7. Department of Medical Oncology, Royal Melbourne Hospital, Parkville, Victoria, Australia.

    • Sheau W Lok
    •  & Geoffrey J Lindeman
  8. The Breast Service, Royal Melbourne Hospital and Royal Women's Hospital, Parkville, Victoria, Australia.

    • Gregory B Mann
  9. Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.

    • Gregory B Mann
  10. Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.

  11. Department of Mathematics and Statistics, University of Melbourne, Parkville, Victoria, Australia.

    • Gordon K Smyth
  12. Therapeutic Innovation Unit, Amgen Inc., Seattle, Washington, USA.

    • William C Dougall
  13. Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.

    • Geoffrey J Lindeman
  14. Familial Cancer Centre, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.

    • Geoffrey J Lindeman


  1. Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer (kConFab)


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E.N. designed and performed experiments, carried out data analysis and contributed to manuscript writing; B.P. performed RNA-seq and mRNA studies; D.B. performed pathology scoring and analysis of tumor and normal tissue samples; F.V. performed in vivo studies and analysis; G.G. and G.K.S. carried out bioinformatics analysis; L.W. developed a new scoring assay; and G.J.L. and S.W.L. developed and implemented the investigator-sponsored (ISS) BRCA-D study protocol. No Amgen authors were directly or indirectly involved in the ISS design, implementation, analysis or ISS-derived reported results (Fig. 3d and Supplementary Fig. 4b); G.B.M. provided material and discussions; kConFab provided annotated samples; K.R., L.-Y.H. and R.S. assisted with histological analysis of tumor and normal tissue samples; and J.E.V. and G.J.L. conceived the study, designed experiments and wrote the paper in collaboration with W.C.D.

Competing interests

D.B., K.R., L.-Y.H., R.S. and W.C.D. were former Amgen employees. D.B., K.R. and L.-Y.H. currently hold Amgen stock. Amgen Inc. contributed reagents and some financial support for this study, including financial support for the investigator-sponsored study, BRCA-D.

Corresponding authors

Correspondence to Jane E Visvader or Geoffrey J Lindeman.

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