Mechanisms of resistance and sensitivity to anti-HER2 therapies in HER2+ breast cancer

Abstract

Breast Cancer (BC) is a highly prevalent disease. A woman living in the United States has a 12.3% lifetime risk of being diagnosed with breast cancer [1]. It is the most common female cancer and the second most common cause of cancer death in women [2]. Of note, amplification or overexpression of Human Epidermal Receptor 2 (HER2) oncogene is present in approximately 18 to 20% of primary invasive breast cancers, and until personalized therapy became available for this specific BC subtype, the worst rates of Overall Survival (OS) and Recurrence-Free Survival (RFS) were observed in the HER2+ BC cohort, compared to all other types, including triple negative BC (TNBC) [3].HER2 is a member of the epidermal growth factor receptor (EGFR) family. Other family members include EGFR or HER1, HER3 and HER4. HER2 can form heterodimers with any of the other three receptors, and is considered to be the preferred dimerization partner of the other HER or ErbB receptors [4]. Phosphorylation of tyrosine residues within the cytoplasmic domain is the result of receptor dimerization and culminates into initiation of a variety of signalling pathways involved in cellular proliferation, transcription, motility and apoptosis inhibition [5].In addition to being an important prognostic factor in women diagnosed with BC, HER2 overexpression also identifies those patients who benefit from treatment with agents that target HER2, such as trastuzumab, pertuzumab, trastuzumab emtansine (T-DM1) and small molecules tyrosine kinase inhibitors of HER2 [6, 11, 127].In fact, trastuzumab altered the natural history of patients diagnosed with HER2+ BC, both in early and metastatic disease setting, in a major way [8-10]. Nevertheless, there are many women that will eventually develop metastatic disease, despite being treated with anti-HER2 therapy in the early disease setting. Moreover, advanced tumors may reach a point where no anti-HER2 treatment will achieve disease control, including recently approved drugs, such as T-DM1.This review paper will concentrate on major biological pathways that ultimately lead to resistance to anti-HER2 therapies in BC, summarizing their mechanisms. Strategies to overcome this resistance, and the rationale involved in each tactics to revert this scenario will be presented to the reader.

Keywords: HER2 disease; anti-HER2 therapy; breast cancer; resistance to treatment; trastuzumab.

Figure 1. HER2 dimerizes with other partners from the HER2 family, activating intracellular proliferative pathways

Also, p95HER2/611CTF has intrinsic kinase activity, lacking the extracellular domain and the binding site of trastuzumab (T), enabling activated signaling, despite the presence of trastuzumab. Upon activation of proliferative pathways, such as PI3K/AKT/mTOR, the cell undergoes proliferation. Trastuzumab blocks HER2 dimerization and phosphorylation, but p95HER2/611CTF might still phosphorylate and enable cancer cell proliferation. In contrast, treatment with doxorubicin (D) and trastuzumab induces apoptosis more efficiently in p95HER2/611CTF-positive cells and, destabilizing phospho-HER2 and stabilizing HER2 in p95HER2/611CTF-positive cells. Therefore, cells are sensitized to trastuzumab and suffer apoptosis through trastuzumab therapy.