ER+/PR− phenotype exhibits more aggressive biological features and worse outcome compared with ER+/PR+ phenotype in HER2-negative inflammatory breast cancer

The loss of progesterone receptor (PR) often predicts worse biological behavior and prognosis in estrogen receptor-positive (ER +) breast cancer. However, the impact of PR status on inflammatory breast cancer (IBC) has not been studied. Therefore, the purpose of our study was to investigate the influence of PR on IBC. Patients with ER+ and HER2-negative IBC were selected from the Surveillance, Epidemiology and End Results database. Pearson’s χ2 test was used to compare the clinicopathological characteristics between patients with estrogen receptor-positive/progesterone receptor-positive (ER+/PR +) and patients with estrogen receptor-positive/progesterone receptor-negative (ER+/PR−). Univariate and multivariate analyses were performed to investigate the effects of PR status on the breast cancer-specific survival (BCSS) and overall survival (OS) in IBC. Overall, 1553 patients including 1157 (74.5%) patients with ER+/PR+ and 396 (25.5%) patients with ER+/PR− were analyzed in our study. The patients with ER+/PR− were more likely to be high histological grade (p < 0.001) and liver metastasis (p = 0.045) compared to patients with ER+/PR+. Despite higher chance of receiving chemotherapy (83.6% vs 77.3%, P = 0.008), patients with ER+/PR− showed worse BCSS (5-year BCSS rate, 34.3% vs 51.3%, P < 0.001) and OS (5-year OS rate, 31.3% vs 46.1%, P < 0.001) compared with ER+/PR+ phenotype. Multivariate survival analysis showed that patients with ER+/PR− still had worse BCSS (hazard ratios [HR]: 1.764, 95% confidence intervals [CI] 1.476–2.109, P < 0.001) and OS (HR: 1.675, 95% CI 1.411–1.975, P < 0.001) than ER+/PR+ phenotype. Furthermore, patients with ER+/PR− showed worse outcomes than ER+/PR+ phenotype in most subgroups, especially in patients with younger age (≤ 60 years), lower histological grade, lymph node involved and distant metastasis. Patients with ER+/PR− had more aggressive biological behaviors and worse outcomes than patients with ER+/PR+ in IBC. Stronger treatments maybe needed for IBC patients with ER+/PR−.

Inflammatory breast cancer (IBC) is a rare subtype and accounts for 2-4% of all breast malignant tumors 1 , but it is characterized by aggressive biological behaviors and accounts for 7% of all breast cancer-related death 2 .Patients with IBC often present rapid progressive pain, erythema, and edema in the involved breast because lymphovascular spaces were embolized by tumor cells.Due to its aggressive behaviors, 85% of the patients already have lymph node involved and 30% of the patients show distant metastasis at the initial diagnosis of IBC 3 .Trimodality treatment including chemotherapy, surgery and radiation therapy has become a widely accepted approach and significantly improved the survival for IBC, but the overall survival (OS) rates remain very low (5-year and 10-year OS rates, 55.4% and 37.3%, respectively) 4 .
As non-IBC, IBC can also be divided into different molecular subtypes according to the status of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2).Endocrine therapy is recommended for IBC patients with estrogen receptor-positive (ER +) and/or progesterone receptorpositive (PR +) by the National Comprehensive Cancer Network (NCCN) guidelines.Many researches have revealed that the status of PR has great prognostic effect on breast cancer and patients with estrogen receptorpositive/progesterone receptor-positive (ER+/PR +) have better outcomes than patients with estrogen receptorpositive/progesterone receptor-negative (ER+/PR−) [5][6][7] .However, the role of PR status on IBC has not been illuminated because of the lower incidence of IBC.Actually, IBC is a special subtype and its biologic characteristics are distinct from that of non-IBC.IBC is more likely to be estrogen receptor-negative and HER2-positive compared with non-IBC 8,9 .Besides, some researches have demonstrated that patients with IBC exhibited higher percentage of progesterone receptor-negative status compared with that of patients with non-IBC (55-56.7%versus 32-46.8%) 9,10.While, it is still unknown whether the absence of PR expression will lead to worse prognosis of IBC or not.Thus, the purpose of this study was to estimate the differences of clinicopathologic features and prognosis between ER+/PR− phenotype and ER+/PR+ phenotype in IBC by analyzing the patients from Surveillance, Epidemiology and End Results (SEER) database.

Patient selection
SEER database provides cancer statistics about patients' demographics, tumor characteristics, methods of treatment and follow-up information, which covers approximately 28% of the United States population.Because the status of HER2 was collected into SEER database since 2010, we used the SEER*Stat version 8.4.0 to identify eligible patients based on the following inclusion criteria: breast cancer, female sex, T4d (cT4d/pT4d), estrogen receptor-positive status, HER2-negtative status and being diagnosed from 2010 to 2018.The excluded criteria were patients with multiple primary tumors, less than 1 month of follow-up, or patients with unknown information about PR status, marital status, lymph node status, distant metastasis and surgery (Fig. 1, flow-chart).Finally, 1553 patients met the criteria and their clinicopathologic data including age, race, marital status, histological grade, lymph node stage, status of PR, sites of distant metastasis, therapeutic regimens and follow-up information were acquired and analyzed.The eligible patients were allocated to two groups (ER+/PR+ phenotype or ER+/ PR− phenotype) according the status of PR.After 2010, the status of PR was detected by immunohistochemistry, and negativity was defined as < 1% of malignant cells positively staining for PR 11 .

Statistical analysis
Pearson's χ 2 test was used to estimate the difference of clinicopathologic factors between ER+/PR− phenotype and ER+/PR+ phenotype in IBC.The endpoints were breast cancer-specific survival (BCSS) and overall survival (OS) in our study.BCSS was defined as the interval from the diagnosis of breast cancer to mortality caused by breast cancer or the final follow-up in censored cases.OS was defined as the interval from the diagnosis of breast cancer to mortality from all causes or the final follow-up in censored cases.Survival curves of the patients with ER+/PR− phenotype or ER+/PR+ phenotype were constructed by the Kaplan-Meier method, and the log-rank test was applied to determine the effect of PR status on BCSS and OS.A Cox proportional hazards model was used for the multivariate analysis and to estimate hazard ratios with 95% confidence intervals (CIs).STATA software (Version 13; Stata Corporation) was applied for all statistical analyses.The forest plot was generated by Microsoft Office Excel (Version 2021; Microsoft Corporation).All tests were two sided and p-value < 0.05 were considered statistically significant.

Ethical approval
This study used previously collected de-identified data, and the need for informed consent had been waived due to the retrospective nature of the study, and was deemed exempt from review by the Ethics Committee of the Affiliated Hospital of North Sichuan Medical College.

Discussion
Progesterone receptor (PR) is a downstream gene target of estrogen receptor (ER) and the loss of PR often indicates a poor prognosis in breast cancer 7,12,13 .Previous studies have shown that ER+/PR− phenotype accounts for 10.5-15% of ER-positive breast cancer 6,7,12,14 .However, it's worth noting that 25.5% of the patients were ER+/ PR− IBC in our study and this proportion is much higher than that of the whole breast cancer population, which may partly explain the worse outcome of IBC.Keeping with previous study 3 , 87.8% of the patients already had lymph node involved and 39.3% of the patients were distant metastasis at the initial diagnosis of breast cancer, which demonstrated the aggressive biological behavior of IBC.On accounting of higher proportion of patients with ER+/PR− phenotype and more aggressive biological characteristics, it is very necessary to figure out the effect of PR status on IBC.As previous studies 6,7,15 , the loss of PR also predicted unfavorable biological characteristics in IBC.In our study, the patients with ER+/PR− phenotype were prone to be poor histological grade (III-IV), which often predicts worse survival 16,17 .In addition, the tendency of distant metastasis for ER+/PR− phenotype differed from ER+/PR+ phenotype.Consistent with our previous study 15 , more liver metastasis happened to patients with ER+/PR− phenotype than patients with ER+/PR+ phenotype in IBC, which indicates greater propensity of visceral metastasis for ER+/PR− phenotype.However, more bone metastasis occurred to patients with ER+/ PR+ phenotype than patients with ER+/PR− phenotype, which demonstrated a pattern of bone metastatic spread typically attributed to hormone receptor-positive breast cancer 18 .
Although the prognosis of breast cancer has been greatly improved with the advent of various systemic treatments, the survival of IBC was still far from satisfaction.Consistent with previous studies 19,20 , the survival for IBC was very poor in our research (5-year BCSS and OS rates, 47.3% and 42.5%, respectively).Given the poor prognosis for IBC, previous researches tried to find the risk factors and demonstrated many independent predicted factors, such as race, lymph node ratio, AJCC stage, histological grade, ER status, PR status, HER2 status, surgery status, and radiotherapy status 16,19 .Although those researches have demonstrated that PR-negative status contributes to worse outcome for IBC, the difference of prognosis between ER+/PR− phenotype and ER+/ PR+ phenotype is still unknown and needed to be further verified because worse outcome of PR-negative cohort mainly resulted from patients with triple-negative IBC in their study.Therefore, we excluded triple-negative IBC and compared the prognosis between ER+/PR− phenotype and ER+/PR+ phenotype in IBC by those two cohorts.As shown in our study, the patients with ER+/PR− phenotype exhibited significant worse survival than patients with ER+/PR+ phenotype, especially in the patients with younger age, lower histological grade, lymph node involved and distant metastasis.Due to the worse clinicopathologic features and prognosis for patients with ER+/PR− phenotype, the loss of PR has aroused wide attention from scholars.The main researches focused on genomics changes, such as PR promoter hypermethylation or loss of heterozygosity at the PR gene locus 21,22 .A recent study illuminated that almost 20% of the patients with ER+/PR− and HER2-negative were non-luminallike and didn't benefit from sufficient endocrine therapy 12 , which partly explains the worse outcome for IBC with ER+/PR− phenotype.As mentioned above, higher percentage of patients presented PR loss in IBC and worse survival were seen in those patients.Therefore, the patients with ER+/PR− phenotype belonging to nonluminal-like IBC should also be identified and more effective treatments should be performed on them, such as cyclin-dependent kinase 4/6 inhibitors.In addition to PR status, older age and black race were also prognostic risk factors for patients with ER+ and HER2-negative IBC.Poor histological grade and visceral metastasis were recognized as poor prognostic factors for IBC 16,19 , which was also demonstrated by our study.As shown above, the patients with ER+/PR− IBC presented poor histological grade and more visceral metastasis, which may also explain the worse outcomes for patients with ER+/PR− phenotype in our study.Chemotherapy, surgery and radiation are the indispensable approaches of trimodality treatment 23 , and all of these could significantly improve the survival for IBC in our study.
The limitations of this study must be clarified.First, some bias can't be avoided for the nature of retrospective study.Thus, multivariable Cox proportional hazards model and subgroup analysis were performed to adjust for confounding effects as much as possible.Second, the information about endocrine therapy can't be acquired from the database, which impeded the further analysis about the effectiveness of endocrine therapy.Nevertheless, most of the patients should have received enough endocrine therapy for the widespread of standard treatment in the United States.Third, because the SEER database didn't collect the follow-up information about local recurrence and distant metastasis, we can't analyze the recurrence-free survival and distant disease-free survival.However, our study is the first one that used the relatively large cohort to estimate the influence of PR status on patients with IBC.It illuminated the significant discordance of clinicopathological features and prognosis between ER+/ PR− phenotype and ER+/PR+ phenotype in IBC, which indicated the necessity that stronger treatments should be applied to patients with ER+/PR− IBC.

Conclusions
More than 25% of the patients presented loss of PR expression among the ER-positive and HER2-negative IBC.Poor prognostic factors were prone to occur in IBC patients with ER+/PR− phenotype than ER+/PR+ phenotype, such as higher histological grade (III-IV) and liver metastasis.More effective treatments should be applied to IBC patients with ER+/PR− phenotype because significant worse outcomes were seen in those patients compared with ER+/PR+ phenotype. https://doi.org/10.1038/s41598-023-50755-4www.nature.com/scientificreports/

Figure 1 .
Figure 1.Flowchart for patient selection from the surveillance, epidemiology and end results (SEER) database.

Figure 2 .
Figure 2. Kaplan-Meier curves of breast cancer-specific survival (A) and overall survival (B) based on hormone receptor status for patients with ER-positive and HER2-negative inflammatory breast cancer.

Figure 3 .
Figure 3. Kaplan-Meier curves of breast cancer-specific survival based on hormone receptor status for patients with ER-positive and HER2-negative inflammatory breast cancer in stage III (A) and stage IV (B).

Figure 4 .
Figure 4. Kaplan-Meier curves of breast cancer-specific survival (A) and overall survival (B) based on hormone receptor status for stage III inflammatory breast cancer patients with ER-positive and HER2-negative after standard trimodality treatment.

Figure 5 .
Figure 5. Subgroup survival analysis of the multivariate Cox regression models.It shows the difference in breast cancer-specific survival and overall survival between ER+/PR− phenotype and ER+/PR+ phenotype in inflammatory breast cancer.

Table 1 .
The clinicopathological features of patients with ER-positive and HER2-negative IBC.# Grade IV refers to breast cancer with undifferentiated or anaplastic histological features.ER Estrogen receptor, PR Progesterone receptor, IBC Inflammatory breast cancer, BCS Breast-conserving surgery.