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Improved relapse-free survival on aromatase inhibitors in breast cancer is associated with interaction between oestrogen receptor-α and progesterone receptor-b

British Journal of Cancervolume 119pages13161325 (2018) | Download Citation

Abstract

Background

Recent pre-clinical studies indicate that activated progesterone receptor (PR) (particularly the PR-B isoform) binds to oestrogen receptor-α (ER) and reprogrammes transcription toward better breast cancer outcomes. We investigated whether ER and PR-B interactions were present in breast tumours and associated with clinical parameters including response to aromatase inhibitors.

Methods

We developed a proximity ligation assay to detect ER and PR-B (ER:PR-B) interactions in formalin-fixed paraffin-embedded tissues. The assay was validated in a cell line and patient-derived breast cancer explants and applied to a cohort of 229 patients with ER-positive and HER2-negative breast cancer with axillary nodal disease.

Results

Higher frequency of ER:PR-B interaction correlated with increasing patient age, lower tumour grade and mitotic index. A low frequency of ER:PR-B interaction was associated with higher risk of relapse. In multivariate analysis, ER:PR-B interaction frequency was an independent predictive factor for relapse, whereas PR expression was not. In subset analysis, low frequency of ER:PR-B interaction was predictive of relapse on adjuvant aromatase inhibitor (HR 4.831, p = 0.001), but not on tamoxifen (HR 1.043, p = 0.939).

Conclusions

This study demonstrates that ER:PR-B interactions have utility in predicting patient response to adjuvant AI therapy.

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Additional information

Ethics approval and consent to participate: for patient-derived explant studies, tumour samples were obtained following informed consent from women undergoing surgery for breast cancer at the Burnside War Memorial Hospital, Adelaide. This study was approved by the University of Adelaide Human Research Ethics Committee (approval numbers: H-065-2005; H-169-2011). For the retrospective cohort, the use of clinical information and tumour blocks was approved by the Mater Health Services Human Research Ethics Committee with a waiver of consent (approval number: HREC/15/MHS/123). The study was performed in accordance with the Declaration of Helsinki.

References

  1. 1.

    Kohler, B. A. et al. Annual report to the nation on the status of cancer, 1975–2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. J. Natl Cancer Inst. 107, djv048 (2015). E-pub ahead of print 2015/04/01.

  2. 2.

    Howlader, N., Cronin, K. A., Kurian, A. W. & Andridge, R. Differences in breast cancer survival by molecular subtypes in the United States. Cancer Epidemiol. Biomark. & Prev. a Publ. Am. Assoc. Cancer Res. cosponsored Am. Soc. Prev. Oncol. 27, 619–626 (2018). E-pub ahead of print 2018/03/30.

  3. 3.

    Horwitz, K. B. & McGuire, W. L. Estrogen control of progesterone receptor in human breast cancer. Correlation with nuclear processing of estrogen receptor. J. Biol. Chem. 253, 2223–2228 (1978). E-pub ahead of print 1978/04/10.

  4. 4.

    Snell C. E., et al. Absent progesterone receptor expression in the lymph node metastases of ER-positive, HER2-negative breast cancer is associated with relapse on tamoxifen. J. Clin. Pathol. 70, 954–960 (2017). E-pub ahead of print 2017/04/19.

  5. 5.

    Stendahl, M. et al. High progesterone receptor expression correlates to the effect of adjuvant tamoxifen in premenopausal breast cancer patients. Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res. 12, 4614–4618 (2006). E-pub ahead of print 2006/08/11.

  6. 6.

    Dowsett, M. et al. Relationship between quantitative estrogen and progesterone receptor expression and human epidermal growth factor receptor 2 (HER-2) status with recurrence in the arimidex, tamoxifen, alone or in combination trial. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 26, 1059–1065 (2008). E-pub ahead of print 2008/01/30.

  7. 7.

    Thurlimann, B. et al. A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N. Engl. J. Med. 353, 2747–2757 (2005). E-pub ahead of print 2005/12/31.

  8. 8.

    Viale, G. et al. Prognostic and predictive value of centrally reviewed expression of estrogen and progesterone receptors in a randomized trial comparing letrozole and tamoxifen adjuvant therapy for postmenopausal early breast cancer: BIG 1-98. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 25, 3846–3852 (2007). E-pub ahead of print 2007/08/08.

  9. 9.

    Early Breast Cancer Trialists' Collaborative Group (EBCTCG) Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials. Lancet (London, England) 2015; 386: 1341–1352; e-pub ahead of print 2015/07/28.

  10. 10.

    Ballare, C. et al. Two domains of the progesterone receptor interact with the estrogen receptor and are required for progesterone activation of the c-Src/Erk pathway in mammalian cells. Mol. Cell. Biol. 23, 1994–2008 (2003). E-pub ahead of print 2003/03/04.

  11. 11.

    Daniel, A. R. et al. Progesterone receptor-B enhances estrogen responsiveness of breast cancer cells via scaffolding PELP1- and estrogen receptor-containing transcription complexes. Oncogene 34, 506–515 (2015). E-pub ahead of print 2014/01/29.

  12. 12.

    Mohammed, H. et al. Progesterone receptor modulates ERalpha action in breast cancer. Nature 523, 313–317 (2015). E-pub ahead of print 2015/07/15.

  13. 13.

    Singhal, H. et al. Genomic agonism and phenotypic antagonism between estrogen and progesterone receptors in breast cancer. Sci. Adv. 2, e1501924 (2016). E-pub ahead of print 2016/07/08.

  14. 14.

    Finlay-Schultz, J. et al. Breast cancer suppression by progesterone receptors is mediated by their modulation of estrogen receptors and RNA polymerase III. Cancer Res. 77, 4934–4946 (2017). E-pub ahead of print 2017/07/22.

  15. 15.

    Giangrande, P. H. & McDonnell, D. P. The A and B isoforms of the human progesterone receptor: two functionally different transcription factors encoded by a single gene. Recent Prog. Horm. Res. 54, 291–313 (1999). Discussion 313–294; e-pub ahead of print 1999/11/05.

  16. 16.

    Voduc, K. D. et al. Breast cancer subtypes and the risk of local and regional relapse. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 28, 1684–1691 (2010). E-pub ahead of print 2010/03/03.

  17. 17.

    Graham, J. D. et al. Characterization of progesterone receptor A and B expression in human breast cancer. Cancer Res. 55, 5063–5068 (1995). E-pub ahead of print 1995/11/01.

  18. 18.

    Hopp, T. A. et al. Breast cancer patients with progesterone receptor PR-A-rich tumors have poorer disease-free survival rates. Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res. 10, 2751–2760 (2004). E-pub ahead of print 2004/04/23.

  19. 19.

    Rojas P. A., et al. Progesterone receptor isoform ratio: a breast cancer prognostic and predictive factor for antiprogestin responsiveness. J. Natl Cancer Inst. 7, djw317, 2017. E-pub ahead of print 2017/04/05.

  20. 20.

    Bamberger, A. M., Milde-Langosch, K., Schulte, H. M. & Loning, T. Progesterone receptor isoforms, PR-B and PR-A, in breast cancer: correlations with clinicopathologic tumor parameters and expression of AP-1 factors. Horm. Res. 54, 32–37 (2000). E-pub ahead of print 2001/02/22.

  21. 21.

    Singhal, H. et al. Progesterone receptor isoforms, agonists and antagonists differentially reprogram estrogen signaling. Oncotarget 9, 4282–4300 (2018). E-pub ahead of print 2018/02/13.

  22. 22.

    Simpson, E. R. Sources of estrogen and their importance. J. Steroid Biochem. Mol. Biol. 86, 225–230 (2003). E-pub ahead of print 2003/11/19.

  23. 23.

    Missmer, S. A., Eliassen, A. H., Barbieri, R. L. & Hankinson, S. E. Endogenous estrogen, androgen, and progesterone concentrations and breast cancer risk among postmenopausal women. J. Natl Cancer Inst. 96, 1856–1865 (2004). E-pub ahead of print 2004/12/17.

  24. 24.

    Carroll, J. S., Hickey, T. E., Tarulli, G. A., Williams, M. & Tilley, W. D. Deciphering the divergent roles of progestogens in breast cancer. Nat. Rev. Cancer 17, 54–64 (2017). E-pub ahead of print 2016/11/26.

  25. 25.

    Bines, J. et al. Activity of megestrol acetate in postmenopausal women with advanced breast cancer after nonsteroidal aromatase inhibitor failure: a phase II trial. Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. / ESMO 25, 831–836 (2014). E-pub ahead of print 2014/03/13.

  26. 26.

    Espie, M. Megestrol acetate in advanced breast carcinoma. Oncology 51(Suppl 1), 8–12 (1994). E-pub ahead of print 1994/10/01.

  27. 27.

    Birrell, S. N., Roder, D. M., Horsfall, D. J., Bentel, J. M. & Tilley, W. D. Medroxyprogesterone acetate therapy in advanced breast cancer: the predictive value of androgen receptor expression. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 13, 1572–1577 (1995). E-pub ahead of print 1995/07/01.

  28. 28.

    A pre-operative window study of Letrozole Plus PR agonist (megestrol acetate) versus letrozole alone in post-menopausal patients with ER-positive breast cancer. https://ClinicalTrials.gov/show/NCT03306472.

  29. 29.

    Centenera M. M., et al. A patient-derived explant (PDE) model of hormone-dependent cancer. Mol. Oncol. 12, 1608–1622. 2018; e-pub ahead of print 2018/08/18.

  30. 30.

    Soderberg, O. et al. Direct observation of individual endogenous protein complexes in situ by proximity ligation. Nat. Methods 3, 995–1000 (2006). E-pub ahead of print 2006/10/31.

  31. 31.

    Zieba, A., Ponten, F., Uhlen, M. & Landegren, U. In situ protein detection with enhanced specificity using DNA-conjugated antibodies and proximity ligation. Mod. Pathol. Off. J. US Can. Acad. Pathol. Inc. 31, 253–263 (2018). E-pub ahead of print 2017/09/25.

  32. 32.

    Kornaga, E. N. et al. Evaluation of three commercial progesterone receptor assays in a single tamoxifen-treated breast cancer cohort. Mod. Pathol. Off. J. US Can. Acad. Pathol. Inc. 29, 1492–1500 (2016). E-pub ahead of print 2016/08/27.

  33. 33.

    Mohsin, S. K. et al. Progesterone receptor by immunohistochemistry and clinical outcome in breast cancer: a validation study. Mod. Pathol. Off. J. US Can. Acad. Pathol. Inc. 17, 1545–1554 (2004). E-pub ahead of print 2004/07/24.

  34. 34.

    Hammond, M. E. et al. American society of clinical oncology/college of American pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer (unabridged version). Arch. Pathol. Lab. Med. 134, e48–e72 (2010). E-pub ahead of print 2010/07/01.

  35. 35.

    Edge S. B., American Joint Committee on Cancer. AJCC cancer staging manual, 7th ed. Springer: New York; London, 2010.

  36. 36.

    Torhorst, J. et al. Tissue microarrays for rapid linking of molecular changes to clinical endpoints. Am. J. Pathol. 159, 2249–2256 (2001). E-pub ahead of print 2001/12/06.

  37. 37.

    Allott, E. H. et al. Intratumoral heterogeneity as a source of discordance in breast cancer biomarker classification. Breast Cancer Res.: BCR 18, 68 (2016). E-pub ahead of print 2016/06/29.

  38. 38.

    McShane, L. M. et al. REporting recommendations for tumor MARKer prognostic studies (REMARK). Breast Cancer Res. Treat. 100, 229–235 (2006). E-pub ahead of print 2006/08/26.

  39. 39.

    Mote, P. A. et al. Progesterone receptor A predominance is a discriminator of benefit from endocrine therapy in the ATAC trial. Breast Cancer Res. Treat. 151, 309–318 (2015). E-pub ahead of print 2015/04/29.

  40. 40.

    Privalsky, M. L. The role of corepressors in transcriptional regulation by nuclear hormone receptors. Annu. Rev. Physiol. 66, 315–360 (2004). E-pub ahead of print 2004/02/24.

  41. 41.

    Bulun, S. E. & Simpson, E. R. Competitive reverse transcription-polymerase chain reaction analysis indicates that levels of aromatase cytochrome P450 transcripts in adipose tissue of buttocks, thighs, and abdomen of women increase with advancing age. J. Clin. Endocrinol. Metab. 78, 428–432 (1994). E-pub ahead of print 1994/02/01.

  42. 42.

    Brown, K. A. et al. Menopause Is a Determinant of Breast Aromatase Expression and Its Associations With BMI, Inflammation, and Systemic Markers. J. Clin. Endocrinol. Metab. 102, 1692–1701 (2017). E-pub ahead of print 2017/03/23.

  43. 43.

    Geisler, J. et al. Letrozole is superior to anastrozole in suppressing breast cancer tissue and plasma estrogen levels. Clin. Cancer Res.: Off. J. Am. Assoc. Cancer Res. 14, 6330–6335 (2008). E-pub ahead of print 2008/10/03.

  44. 44.

    Weiler, P. J. & Wiebe, J. P. Plasma membrane receptors for the cancer-regulating progesterone metabolites, 5alpha-pregnane-3,20-dione and 3alpha-hydroxy-4-pregnen-20-one in MCF-7 breast cancer cells. Biochem. Biophys. Res. Commun. 272, 731–737 (2000). E-pub ahead of print 2000/06/22.

  45. 45.

    Randomized Controlled Trial of Neo-adjuvant Progesterone and Vitamin D3 in Women With Large Operable Breast Cancer and Locally Advanced Breast Cancer. https://ClinicalTrials.gov/show/NCT01608451.

  46. 46.

    Primary Progesterone Therapy for Operable Breast Cancer. https://ClinicalTrials.gov/show/NCT00123669.

  47. 47.

    Cui, X., Schiff, R., Arpino, G., Osborne, C. K. & Lee, A. V. Biology of progesterone receptor loss in breast cancer and its implications for endocrine therapy. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 23, 7721–7735 (2005). E-pub ahead of print 2005/10/20.

  48. 48.

    Winqvist, R. et al. Loss of heterozygosity for chromosome 11 in primary human breast tumors is associated with poor survival after metastasis. Cancer Res. 55, 2660–2664 (1995). E-pub ahead of print 1995/06/15.

  49. 49.

    Tomlinson, I. P., Nicolai, H., Solomon, E. & Bodmer, W. F. The frequency and mechanism of loss of heterozygosity on chromosome 11q in breast cancer. J. Pathol. 180, 38–43 (1996). E-pub ahead of print 1996/09/01.

  50. 50.

    Stone, A. et al. DNA methylation of oestrogen-regulated enhancers defines endocrine sensitivity in breast cancer. Nat. Commun. 6, 7758 (2015). E-pub ahead of print 2015/07/15.

  51. 51.

    Purdie, C. A. et al. Progesterone receptor expression is an independent prognostic variable in early breast cancer: a population-based study. Br. J. Cancer 110, 565–572 (2014). E-pub ahead of print 2013/12/05.

  52. 52.

    Hershman, D. L. et al. Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res. Treat. 126, 529–537 (2011). E-pub ahead of print 2010/08/31.

  53. 53.

    Endocrine therapy with or without abemaciclib (LY2835219) following surgery in participants with breast cancer. https://ClinicalTrials.gov/show/NCT03155997.

  54. 54.

    Adjuvant ribociclib with endocrine therapy in hormone receptor+ /HER2- high risk early breast cancer. https://ClinicalTrials.gov/show/NCT03078751.

  55. 55.

    PALbociclib CoLlaborative Adjuvant Study: a randomized phase III trial of palbociclib with standard adjuvant endocrine therapy versus standard adjuvant endocrine therapy alone for hormone receptor positive (HR+) human epidermal growth factor receptor 2 (HER2)-negative early breast cancer. https://ClinicalTrials.gov/show/NCT02513394.

  56. 56.

    Morgan, L. R. Megestrol acetate v tamoxifen in advanced breast cancer in postmenopausal patients. Semin. Oncol. 12(1Suppl 1), 43–47 (1985). E-pub ahead of print 1985/03/01.

  57. 57.

    Jonat, W. et al. A randomised trial comparing two doses of the new selective aromatase inhibitor anastrozole (Arimidex) with megestrol acetate in postmenopausal patients with advanced breast cancer. Eur. J. Cancer. 32a, 404–412 (1996). E-pub ahead of print 1996/03/01.

  58. 58.

    Buzdar, A. U. et al. A phase III trial comparing anastrozole (1 and 10 milligrams), a potent and selective aromatase inhibitor, with megestrol acetate in postmenopausal women with advanced breast carcinoma. Arimidex Study Group. Cancer 79, 730–739 (1997). E-pub ahead of print 1997/02/15.

  59. 59.

    Buzdar, A. et al. Phase III, multicenter, double-blind, randomized study of letrozole, an aromatase inhibitor, for advanced breast cancer versus megestrol acetate. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 19, 3357–3366 (2001). E-pub ahead of print 2001/07/17.

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Acknowledgements

The authors thank the following people for their contributions to this study: Yanlin Liu for assembly of the database used to collate patient information. Lauren Furnas for help with block retrieval. Brenton Seidl for help with retrieving patient information. Geraldine Lavin-Law for technical work involving the patient-derived explants. This work was supported by grants from the Royal College of Pathologists of Australasia Foundation (CS), National Health and Medical Research Council of Australia (NHMRC) (ID 1130077 WDT and TEH), and Cancer Australia/National Breast Cancer Foundation (ID 1043497; WDT, TEH). CS is supported by a Betty McGrath Fellowship from Mater Foundation. CL is a recipient of PhD scholarships from the Australian Government (Australian Postgraduate Award) and Royal College of Pathologists of Australasia (RCPA Foundation Postgraduate Research Fellowship). WDT is also supported by a grant from the National Breast Cancer Foundation (PS-15-041). TEH is supported by a Career Development Fellowship from the Royal Adelaide Hospital Research Foundation (Adelaide, Australia). The project also has received funding from the Mater Foundation (Queensland, Australia) and The Hospital Research Foundation (Adelaide, Australia). The Translational Research Institute is supported by a grant from the Australian Government.

Author information

Author notes

  1. These authors contributed equally: Jane E. Armes, Wayne D. Tilley.

Affiliations

  1. Cancer Pathology Research Group, Mater Research Institute—The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia

    • Cameron E. Snell
    •  & Madeline Gough
  2. Department of Anatomical Pathology, Mater Pathology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia

    • Cameron E. Snell
    • , Madeline Gough
    • , Cheng Liu
    •  & Jane E. Armes
  3. Department of Medical Oncology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia

    • Kathryn Middleton
    • , Catherine Shannon
    •  & Natasha Woodward
  4. Department of Breast and Endocrine Surgery, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia

    • Christopher Pyke
  5. Mater Research Institute—The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia

    • Kathryn Middleton
    • , Christopher Pyke
    • , Catherine Shannon
    •  & Natasha Woodward
  6. Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia

    • Theresa E. Hickey
    •  & Wayne D. Tilley

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Contributions

C.E.S, J.A, T.E.H. and W.D.T. conceived the study. C.E.S, M.G. and T.E.H. performed the experiments. C.E.S. and C.L. scored the slides. C.E.S. and M.G. performed statistical analyses. Patient data was collected by K.M, C.P, C.S. and N.W. C.E.S. wrote the paper with major editing from W.D.T, T.E.H. and J.E.A. and minor editing and final approval of the submitted version by all authors.

Competing interests

KM reports receiving travel expenses from Roche. CS reports receiving compensation for being on advisory boards for Roche and AstraZeneca. NW reports stock ownership (CSL), receiving travel/expenses from Roche and research funding from Medivation. The remaining authors declare that they have no conflict of interest.

Availability of data and materials

To protect patient privacy, all patient data have been de-identified and reported in aggregate. De-identified patient data are available from the authors on request by e-mail.

Note

This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).

Corresponding author

Correspondence to Cameron E. Snell.

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https://doi.org/10.1038/s41416-018-0331-3