1. Epidemiology

3. Definition Biology

4. “Basal-Like” The “Triple Negative” Breast Cancer Estrogen Receptor (ER) negative Progesterone receptor (PR) negative Her2neu (HER2) negative ER/PR/HER2 -

5. Basal-like Subgroup = E HER2 Subgroup = D Normal breast like Luminal Subtype C Luminal Subtype B Luminal Subtype A ER Gene expression E D C B A O.S. months Adapted from Sorlie et al. PNAS, 2001 Gene Expression Patterns of Breast Carcinomas Predict Survival ER Gene expression

6. Will the same type of treatment fit all types of tumor ? Gene Expression\ICH Luminal-like AER+ and/or PgR+ HER2- Luminal-like BER+ and/or PgR+ HER2+ Basal-likeER- PgR- HER2- CK5/6+ and/or HER1+ HER2-likeER- PgR- HER2+

7. Turner et al. 2006 Typical Histological Features of “Triple Negative” Breast CA Grade 3, IDC, with central fibrosis Positive Staining for EGFR Positive Staining for CK 5/6

8. Triple-Negative vs Basal-Like Triple-Negative prevalence = 18% (150/823) Triple-Negative Basal-Like = 66% (95/150) Triple-negative non-Basal-Like = Luminal B Conforti et al. SABCS 2007 (N=823)

9. Triple-Negative vs Basal-Like Lacks of ER, PgR and HER2 Prevalence = 10-15% Mostly High-Grade Triple-Negative No standard Definition Lacks of ER, PgR and HER2 Stains for CK5/6/14, EGFR, p53, c-kit Prevalence = 10-15% Mostly High-Grade Basal-Like

10. How do we identify “Basal-Like” Breast Cancers in the clinical setting?

11. Definition of “Basal-Like” Breast Cancers Multiple immunohistochemical markers have been used to identify Basal-Like differentiation No universally agreed upon criteria or precise set of basal markers Nielsen et al.  ER/PR/HER2 negativity in addition to either EGFR + and/or CK5/6 + Smith et al.  high molecular weight cytokeratins CK5, 14 and 17 Carey et al.  ER/PR/HER2 negativity

12. 80 to 90 % of these will be “Basal-Like” Breast Cancers 20-10% Adenoid cystic and Medullary Typical 100 Patients with “Triple Negative” Breast Cancer ER/PR/HER2 -

13. “Triple Negative” Breast Cancers Comprise approximately 15% of all invasive cancers More common in: Younger patients African Americans BRCA1 mutation carriers Unique Morphologic Attributes Pushing border high grade central scarring/acellular zone Stromal/peritumoral lymphocytic infiltrate

14. BRCA1 and BLC phenotype BRCA1 is a tumor suppressor gene that functions in DNA repair These tumors are often ER-, HER2- (up to 80% of BRCA1 associated tumors have been shown to be “basal-like”) Though…most “basal-like” tumors have normal BRCA1 Hereditary BRCA1 breast tumors and “basal-like” sporadic tumors have a similar phenotype and gene expression signature Suggesting involvement of BRCA1 in the pathogenesis of sporadic “basal-like” cancer

15. BRCA1/BLC BRCA1 mutations are rarely found in sporadic breast cancer, but BRCA1 expression is often reduced, especially in “basal-like” breast cancers Why? BRCA1 promotor methylation has been demonstrated in 7 to 31% of sporadic cancers (Catteau et al) LOH of the BRCA1 locus which occurs in 15 to 45% of sporadic breast cancers (Rio et al) However, studies looking at the relationship between BRCA1 methylation, BRCA1 LOH and clinical features of breast tumors have been inconsistent ID4, a negative regulator of BRCA1, was found to be expressed at a 9-10 times higher in BLC (Turner et al)

16. Shared Features with BRCA-1 Cancers BRCA1 associated breast cancer “Basal-Like” Breast Cancer Estrogen receptor Negative HER2 negative Express Cytokeratin 5/6 EGFR overexpression and mutation High grade p53 mutation Cytogenic abnormalities

17. Immunohistochemical Features: Other Breast CA n (%) “Basal-like” n (%) p value ER expression517/665 (78%)3/21 (14%) HER223/87 (26%)0/21 (0) Cytokeratin 5/6105/761 (14%)13/21 (62%) EGFR14/521 (8%)12/21(57%)< 0.001 C-KIT67/605 (11%)6/21(30%)< 0.001 P53 mutation13%9/11 (82%)< 0.001 P53 protein27/124 (22%)32/63 (51%)< 0.006 Vimentin2/28 (7%)17/18 (94%)0.0001 Livasy et al, Sorlie et al, Foulkes et al, Nielsen et al

18. Phenotype changes during breast development Laakso, Clin Canc Res, 2006

23. Clinical features

24. “Triple-Negative” Breast Cancer: Clinical Features and Patterns of Recurrence HBBC database (1987-1997) 1601 (80%) of patients had details on hormone receptors/HER2 and were eligible for the study 180 (12%) of the 1601 patients were defined as “triple negative” breast cancers Mean follow up was 8.1 years Dent, R. et al. Clin Cancer Res 2007

25. Characteristics of “Triple Negative” vs. Other Breast Cancers Characteristic Other (N=1421) number (percent) “Triple Negative” (N=180) number (percent) Significance p value * Mean Age at Diagnosis (yrs)57.753p < 0.0001 Mean Tumor Size2.1 cm3.0 cmp < 0.0001 Tumor Size T1 (≤ 2 cm)880(62.7)65(36.5)p < 0.0001 T2 (>2cm to ≤ 5cm)461(32.8)99(55.6) T3 (>5cm)64(4.6)14(7.9) Missing162 Lymph Node Status Positive510(45.6)87(54.4)p = 0.02 Negative609(54.4)70(44.6) Missing or Not Tested30223 Tumor Grade I237(19.9)15(9.8)p < 0.0001 II616(51.8)37(24.2) III336(28.3)101(66.0) Missing * p values were calculated with the use of the chi-square test Dent, R. et al. Clin Cancer Res 2007

26. Tumor Size by Nodal Status according to “Basal-Like” Group Non “Basal-like” Group (N=1421) “Basal-like” Group (N=180) Tumour Size Lymph Node Positive Number (percent) Lymph Node Positive Number (percent) <1.0 cm38(19.3)5(55.6) 1 - 2 cm180(39.3)25(55.6) 2.1- 5 cm238(59.5)43(48.9) >5.1 cm53(91.4)12(92.3) p<0.0001p=0.042 * p values were calculated with the use of the chi-square test Dent, R. et al. Clin Cancer Res 2007

27. Distant Recurrence Dent, R. et al. Clin Cancer Res 2007;13:4429-4434 Probability of being recurrence-free 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0123456789101112131415161718 Years after diagnosis p<0.0001 (log-Rank test) Other (290 of 1421)“Triple-negative” (61 of 180)

28. Overall Survival Dent, R. et al. Clin Cancer Res 2007;13:4429-4434 Probability of survival 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0123456789101112131415161718 Years after diagnosis p<0.0001 (log-Rank test) Other (261 of 1420)“Triple-negative” (62 of 180)

30. Non-random distribution X² statistic 42.78 p 0.0003 Subtype Smid et al, Cancer Res, in press

31. Patterns of Metastatic Spread More likely to spread to brain, lung and possibly liver and less likely to spread to bone and soft tissues – Tsuda et al. 2000 Am J of Surgical Pathology – Rodriguez-Pinilla et al. Clinical Cancer Research 2006 – Fulford et al. Breast Cancer Research and Treatment 2007 – Hicks et al. 2006 Am J of Surgical Pathology More likely to present with visceral metastases versus bone metastases as first site of metastases – 70% vs 37%, p < 0.001 (Dent et al. SABCS 2007)

32. Median Time from Distant Relapse to Death 22 months 9 months Dent R, Trudeau M, Pritchard K, Hana W, Narod S. et al. Clinical Cancer Res 2007 “Triple Negative” Breast CA Other Breast CA

33. Treatment

34. Response of Brca1/p53 Mammary Tumors to Doxorubicin or Cisplatin/Carboplatin in vivo

35. Characteristics of retrieved studies - I StudyComparison HER2 status determined (%) NSABP B11 Paik S et al, JNCI 1998 PF vs PAF 638/682 (94%) NSABP B15 Paik S et al, JNCI 2000 CMF vs AC 2.034/2.295 (89%) GUN 3 De Laurentiis M et al, ASCO 2001 CMF vs CMF/EV 123/220 (56%) Belgian Di Leo A et al, Clin Cancer Res 2002 CMF vs HEC/EC 354/777 (46%) Milan Moliterni A et al, J Clin Oncol 2003 CMF vs CMF→ A 506/552 (92%) Danish Knoop AS et al, J Clin Oncol 2005 CMF vs FEC 805/980 (82%) NCIC MA5 Pritchard KI et al, NEJM 2006 CMF vs CEF 628/710 (88%) Gennari et al, JNCI 2008 Total (determined/randomised) 5.088/6.216 (82%)

36. Characteristics of studies - II StudyMethod HER2 positive/screened % NSABP B11IHC239/63837% NSABP B15IHC599/2.03429% GUN 3IHC30/12324% BelgianFISH73/35421% MilanIHC95/50619% DanishIHC/FISH246/80533% NCIC MA5IHC/FISH/PCR 163/628 (FISH) 26% Total (positive/screened) 1.445/5.08828% Gennari et al, JNCI 2008

37. Adjuvant Anthracyclines and HER2: Disease Free Survival Anthra better StudyHER2 statusHR(95% CI) + 0.60(0.44 to 0.82) - 0.96(0.75 to 1.23) + 0.84(0.65 to 1.08) - 1.02(0.86 to 1.20) + 0.65(0.34 to 1.26) - 1.35(0.93 to 1.97) + 0.83(0.46 to 1.49) - 1.22(0.91 to 1.64) + 0.75(0.53 to 1.06) - 0.79(0.60 to 1.05) + 0.52(0.34 to 0.80) - 0.91(0.71 to 1.17) Overall0.90(0.82 to 0.98) + 0.71(0.61 to 0.83) - 1.00(0.90 to 1.11) NSABP B11 NSABP B15 Belgian Milan DBCG 89D NCIC MA5 HER2 specific 0.000.501.001.502.00 Test for interaction:  2 13.7, p<.001 Non anthra better Gennari A. et al. JNCI 2008

38. Adjuvant Anthracyclines and HER2 : Overall Survival StudyHER2 statusHR(95% CI) + 0.66(0.42 to 1.01) - 0.90(0.69 to 1.18) + 0.82(0.63 to 1.06) - 1.07(0.88 to 1.30) + 0.85(0.27 to 2.69) - 1.64(0.85 to 3.15) + 0.61(0.32 to1.16) - 1.26(0.89 to 1.79) + 0.73(0.50 to 1.05) - 0.82(0.59 to 1.13) + 0.65(0.42 to 1.01) - 1.06(0.80 to1.40) + 0.71(0.32 to 1.55) - 1.25(0.58 to 2.67) Overall0.91(0.79 to 1.04) + 0.73(0.62 to 0.85) - 1.03(0.92 to 1.16) NSABP B11 NSABP B15 GUN Milan DBCG 89D NCIC MA5 HER2 specific GOIRC 0.000.501.001.502.002.503.003.50 Test for interaction:  2 12.6, p<.001 Anthra better Non anthra better Gennari A. et al. JNCI 2008

39. Efficacy summary Risk of relapse 29% HR 0.71 (0.61-0.83) Risk of death 27% HR 0.73 (0.62-0.85) HER2 positive Risk of relapse anthra ≈ non anthra HR 1.00 (0.90-1.11) Risk of death anthra ≈ non anthra HR 1.03 (0.92- 1.16) HER2 negative p <0.001 Gennari et al, JNCI 2008

40. Highly hormon-sensitive Moderately hormon-sensitive HER-2 amplified Triple negative

42. Pathological Complete Response to Chemotherapy Differs by Subtipes AC → T Carey CCR 07 T → FAC Rouzier CCR 05 Luminal A/B4/62 (7%)2/30 (7%) Normal-likeNA0/10 (0) HER2+ and ER-4/11 (36%)9/20 (45%) Triple negative9/34 (27%)10/22 (45%)

43. Neoadjuvant Chemotherapy in Triple Negative Patients. MD Anderson Experience The largest date set available (1118 pts) 23% TNBC, pCR 15% RegimensptsTNBCnon-TNBC FAC/FEC/AC30820%5% TFAC/TFEC58828%17% Taxanes5812%2% Other16414%7% Total111822%11% p 0.034 Liedtke, M. et al. J Clin Oncol; aheadof print on Febr 4, 2008

44. Neoadjuvant Chemotherapy in TNBC Survival by Pathological Response Liedtke, M. et al. J Clin Oncol; aheadof print on Febr 4, 2008

45. Ixabepilone+Capecitabine a Phase III Trial Metastatic breast cancer N = 752 Ixabepilone+Capecitabine N = 375 Capecitabine N = 377 Previous Anthra Taxane Resistant Vahdat LT et al: ASCO2007

46. 1.0 0.0 Proportion Progression Free Months 0.6 0.8 0.4 0.2 0 0 Median 5.8 mo 4.2 mo 95 % Cl (5.5 - 7.0) (3.8 - 4.5) HR: 0.75 (0.64-0.88) p = 0.0003 4 4 8 8 12 16 20 24 28 32 36 Ixabepilone + Capecitabine Capecitabine Vahdat LT et al: ASCO2007 Ixabepilone+Capecitabine a Phase III Trial

47. Rugo et al: SABCS 2007

48. Perspectives

60. Basal-like Breast Cancer and BRCA1 = BRCA1+ Sorlie T et al. PNAS 03