Mammostrat as a tool to stratify breast cancer patients at risk of recurrence during endocrine therapy

Abstract

Introduction: Patients with early-stage breast cancer, treated with endocrine therapy, have approximately 90% 5-year disease-free survival. However, for patients at higher risk of relapse despite endocrine therapy, additional adjuvant therapy, such as chemotherapy, may be indicated. The challenge is to prospectively identify such patients. The Mammostrat® test uses five immunohistochemical markers to stratify patients on tamoxifen therapy into risk groups to inform treatment decisions. We tested the efficacy of this panel in a mixed population of cases treated in a single center with breast-conserving surgery and long-term follow-up.

Methods: Tissue microarrays from a consecutive series (1981 to 1998) of 1,812 women managed by wide local excision and postoperative radiotherapy were collected following appropriate ethical review. Of 1,390 cases stained, 197 received no adjuvant hormonal or chemotherapy, 1,044 received tamoxifen only, and 149 received a combination of hormonal therapy and chemotherapy. Median age at diagnosis was 57, 71% were postmenopausal, 23.9% were node-positive and median tumor size was 1.5 cm. Samples were stained using triplicate 0.6 mm2 tissue microarray cores, and positivity for p53, HTF9C, CEACAM5, NDRG1 and SLC7A5 was assessed. Each case was assigned a Mammostrat risk score, and distant recurrence-free survival (DRFS), relapse-free survival (RFS) and overall survival (OS) were analyzed by marker positivity and risk score.

Results: Increased Mammostrat scores were significantly associated with reduced DRFS, RFS and OS in estrogen receptor (ER)-positive breast cancer (P < 0.00001). In multivariate analyses the risk score was independent of conventional risk factors for DRFS, RFS and OS (P < 0.05). In node-negative, tamoxifen-treated patients, 10-year recurrence rates were 7.6 ± 1.5% in the low-risk group versus 20.0 ± 4.4% in the high-risk group. Further, exploratory analyses revealed associations with outcome in both ER-negative and untreated patients.

Conclusions: This is the fifth independent study providing evidence that Mammostrat can act as an independent prognostic tool for ER-positive, tamoxifen-treated breast cancer. In addition, this study revealed for the first time a possible association with outcome regardless of node status and ER-negative tumors. When viewed in the context of previous results, these data provide further support for this antibody panel as an aid to patient management in early-stage breast cancer.

Figure 1

Co-primary endpoints. Kaplan-Meier distant recurrence-free survival (DRFS) survival curves for breast-conserving surgery cases. Solid lines, Mammostrat^® score low risk; dotted lines, Mammostrat^® score medium risk; grey lines, Mammostrat^® score high risk. (a) Estrogen receptor (ER)-positive, node-negative breast cancers treated with adjuvant tamoxifen only. (b) ER-positive, tamoxifen-treated breast cancers (any nodal status).

Figure 2

Exploratory analysis. Kaplan-Meier distant recurrence-free survival (DRFS) survival cures for breast-conserving surgery cases. Solid lines, Mammostrat^® score low risk; dotted lines, Mammostrat^® score medium risk; grey lines, Mammostrat^® score high risk. (a) All estrogen receptor (ER)-positive breast cancers. (b) All breast cancers regardless of treatment and hormonal status. (c) Untreated breast cancers. (d) ER-negative breast cancers.