Andrea Markkula

Caffeine and caffeic acid inhibit growth and modify estrogen receptor (ER) and insulin-like growth factor I receptor (IGF-IR) levels in human breast cancer

Purpose: Epidemiologic studies indicate that dietary factors, such as coffee, may influence breast cancer and modulate hormone receptor status. The purpose of this translational study was to investigate how coffee may affect breast cancer growth in relation to estrogen receptor-α (ER) status. Experimental Design: The influence of coffee consumption on patient and tumor characteristics and disease-free survival was assessed in a population-based cohort of 1,090 patients with invasive primary breast cancer in Sweden. Cellular and molecular effects by the coffee constituents caffeine and caffeic acid were evaluated in ER+ (MCF-7) and ER− (MDA-MB-231) breast cancer cells. Results: Moderate (2–4 cups/day) to high (≥5 cups/day) coffee intake was associated with smaller invasive primary tumors (Ptrend = 0.013) and lower proportion of ER+ tumors (Ptrend = 0.018), compared with patients with low consumption (≤1 cup/day). Moderate to high consumption was associated with lower risk for breast cancer events in tamoxifen-treated patients with ER+ tumors (adjusted HR, 0.51; 95% confidence interval, 0.26–0.97). Caffeine and caffeic acid suppressed the growth of ER+ (P ≤ 0.01) and ER− (P ≤ 0.03) cells. Caffeine significantly reduced ER and cyclin D1 abundance in ER+ cells. Caffeine also reduced the insulin-like growth factor-I receptor (IGFIR) and pAkt levels in both ER+ and ER− cells. Together, these effects resulted in impaired cell-cycle progression and enhanced cell death. Conclusions: The clinical and experimental findings demonstrate various anticancer properties of caffeine and caffeic acid against both ER+ and ER− breast cancer that may sensitize tumor cells to tamoxifen and reduce breast cancer growth. Clin Cancer Res; 21(8); 1877–87. ©2015 AACR.

Combined Androgen and Estrogen Receptor Status in Breast Cancer: Treatment Prediction and Prognosis in a Population-based Prospective Cohort.

Purpose: To evaluate whether tumor androgen receptor (AR) expression was prognostic and/or predictive for endocrine treatment alone or in combination with estrogen receptor (ER). The AR has been hypothesized to have differential prognostic roles in breast cancer depending on tumor ER status, and to influence endocrine treatment response. Experimental Design: A population-based prospective cohort of 1,026 patients diagnosed with primary invasive breast cancer in Lund, Sweden, between 2002 and 2012 was followed until June 2014. Associations between immunohistochemical AR expression in tumor tissue microarrays, patient and tumor characteristics, and AR genotypes were analyzed. Disease-free survival (DFS) by AR status, and combined ER/AR status was assessed in various treatment groups. Results: AR expression was assessable in 913 tumors. AR+ tumors (85.0%) were associated with higher age (P = 0.036) and favorable tumor characteristics. The AR+ status was a prognostic marker for DFS (LogRank P = 0.025). There was an interaction between AR and ER expression with respect to prognosis (adjusted Pinteraction ≤ 0.024). Tumors with discordant hormone receptor expressions (ER+AR− or ER−AR+) demonstrated worse prognosis compared with concordant tumor expressions (ER+AR+ or ER−AR−) in multivariable models [adjusted HRs (95% confidence intervals); ≥1.99 (1.28–3.10), P ≤ 0.002]. ER+AR− indicated early treatment failure with aromatase inhibitors (AI) among chemonaïve patients aged 50 or older. Conclusions: Prediction of breast cancer prognosis and treatment response was improved by combining AR and ER status. AR negativity predicted early treatment failure with AI but not tamoxifen, a finding that warrants confirmation in a randomized setting. Patients may benefit from anti-androgens or selective AR modulators. Clin Cancer Res; 21(16); 3640–50. ©2015 AACR.

Clinical Profiles Predict Early Nonadherence to Adjuvant Endocrine Treatment in a Prospective Breast Cancer Cohort

Nonadherence to adjuvant endocrine breast cancer treatment adversely affects disease-free and overall survival. Clinical predictors of nonadherence may allow for specific interventions to reduce nonadherence and improve survival. The aim was to investigate whether clinical characteristics predict nonadherence. Clinical characteristics and information on adherence were obtained from 417 patients with breast cancer in a population-based prospective cohort from southern Sweden using patient charts, pathology reports, and questionnaires filled out at the 1- and 2-year follow-up visits. At the 1- and 2-year follow-up visits, 36 (8.6%) and 33 (9.7%) patients were nonadherent, respectively. Thirteen of the nonadherent patients declined treatment and were never prescribed endocrine treatment. A body mass index (BMI) < 25 kg/m2, preoperative current smoking, and drinking alcohol less often than twice a month predicted nonadherence at the 1-year [relative risk (RR), 5.24; 95% confidence interval (CI), 2.75–9.97] and the 2-year visits (RR, 4.07; 95% CI, 2.11–7.84) in patients with at least two of these clinical characteristics. When low histologic grade (I) was added to the model, having at least two of these four clinical characteristics predicted nonadherence at the 1-year (RR, 4.94; 95% CI, 2.46–10.00) and the 2-year visits (RR, 4.74; 95% CI, 2.28–9.87), the two profiles had a sensitivity ranging from 60.6% to 72.7%, whereas the specificity ranged from 68.0% to 78.4%. Nonadherence at the 1-year visit was associated with an increased risk for early breast cancer events (HR, 2.97; 95% CI, 1.08–8.15), adjusted for age and tumor characteristics. In conclusion, two clinical profiles predicted early nonadherence and may allow for targeted interventions to increase adherence if validated in an independent cohort. Cancer Prev Res; 5(5); 735–45. ©2012 AACR.

Pre- and postoperative alcohol consumption in breast cancer patients: impact on early events.

PurposeTo investigate the association between pre- and postoperative alcohol consumption and risk for early breast cancer events, since the association between alcohol consumption and prognosis in breast cancer patients is unclear.MethodsAlcohol consumption was recorded for 934 primary breast cancer patients who underwent breast cancer surgery in Lund, Sweden, between 2002 and 2011 and were followed until December 31st 2012. Clinical data were obtained from medical records and population registries. Pre- and postoperative alcohol consumption was analyzed in relation to risk for early events.ResultsMedian follow-up time was 3.03 years and 100 breast cancer events, 65 distant metastases, and 76 deaths occurred. Compared to no consumption, any preoperative alcohol consumption was weakly associated with lower risk for early events, adjusted HR 0.69 (0.45-1.04), distant metastases, 0.60 (0.36-1.00) and death, 0.62 (0.38-1.01). In the 572 patients without axillary lymph node involvement, any alcohol consumption was not associated with risk for early events. However, in the 360 patients with axillary lymph node involvement, preoperative alcohol consumption was associated with lower risk for early events (adjusted HR 0.43 0.24-0.77; Pinteraction = 0.01).ConclusionPre- and postoperative alcohol consumption was weakly associated with lower risk for early breast cancer events. The data does not support recommending that all breast cancer patients abstain from low to moderate alcohol consumption.

No association found between CYP2D6 genotype and early breast cancer events in tamoxifen-treated patients.

Abstract Background. CYP2D6 is considered the key enzyme in tamoxifen metabolism. Several studies have investigated the relationship between the CYP2D6 genotype and tamoxifen treatment outcome, with discrepant results. CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy may account for some of the discrepancies. We examined the association between CYP2D6 genotype and early breast cancer events in tamoxifen-treated breast cancer patients, in relation to CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy. Material and methods. Pre- and postoperative questionnaires on lifestyle and concomitant medications were completed by 634 primary breast cancer patients between 2002 and 2008, among whom 333 patients had ER-positive tumors and received tamoxifen. CYP2D6*3, *4, *6, *10 and *41 were genotyped. Information on clinical data, breast cancer events, and tumor characteristics was obtained from patients’ charts, population registries, the Regional Tumor Registry, and pathology reports. Results. Median follow-up was 4.9 years. Neither poor metabolizers (adjusted HR 0.50; 95% CI 0.07–3.82) nor intermediate metabolizers (adjusted HR 1.00; 95% CI 0.47–2.11) had an increased risk of early breast cancer events when compared with extensive metabolizers. CYP2D6 activity score (taking into account genotype and CYP2D6 inhibitor use) was not associated with early breast cancer events (LogRank, Ptrend = 0.44). Conclusions. CYP2D6 genotype was not associated with tamoxifen treatment outcome, even when CYP2D6 inhibitor use, aromatase inhibitor use, or chemotherapy was taken into account. CYP2D6 genotype may be of minor importance for tamoxifen-treated patients in Scandinavia.

Impacts of smoking on endocrine treatment response in a prospective breast cancer cohort

Background:The association between smoking and breast cancer prognosis remains unclear. The purpose of this study was to investigate whether preoperative smoking was associated with prognosis in different treatment groups.Methods:This population-based cohort consisted of 1065 breast cancer patients without preoperative treatment included between 2002 and 2012 in Lund, Sweden. Smoking status was examined in relation to patient and tumour characteristics, and prognosis in different treatment groups.Results:At the preoperative visit, 21.0% smoked. Median follow-up time was 5.1 years. Overall, in the 1016 patients included in the survival analyses, there was no significant association between smoking and risk of breast cancer events (adjusted hazard ratio (adjHR): 1.45; 95% confidence interval (CI): 0.95–2.20). For the 309 aromatase inhibitor (AI)-treated patients ⩾50 years with oestrogen receptor-positive (ER+) tumours, smoking was associated with risk of breast cancer events (adjHR: 2.97; 95% CI: 1.44–6.13), distant metastasis (adjHR: 4.19; 95% CI: 1.81–9.72), and death (adjHR: 3.52; 95% CI: 1.59–7.81). Smoking was not associated with breast cancer events or distant metastasis in other treatment groups.Conclusions:Preoperative smoking was only associated with an increased risk for breast cancer events and distant metastasis in AI-treated patients. If confirmed, smoking status should be taken into consideration when selecting an endocrine therapy.

High Estrogen Receptor β Expression Is Prognostic among Adjuvant Chemotherapy-Treated Patients-Results from a Population-Based Breast Cancer Cohort

Purpose: Isoform-specific tumor estrogen receptor β (ERβ) expression may hold prognostic information in breast cancer, especially among endocrine-treated breast cancer patients. The studys purpose was to evaluate ERβ isoform 1 (ERβ1) expression in relation to tumor characteristics, ESR2 genotypes, and prognosis in different treatment groups. Experimental Design: A population-based prospective cohort of 1,026 patients diagnosed with primary invasive breast cancer in Lund, Sweden, between October 2002 and June 2012 was followed until June 2014 (median 5 years). Associations between immunohistochemical ERβ1 expression, patient and tumor characteristics, as well as outcome within treatment groups were analyzed. Results: Tumor ERβ1 expression was available for 911 patients (89%) and was not associated with ESR2 genotypes. ERβ1 positivity, defined as >75% (ERβ175+, 72.7%), was positively associated with established favorable tumor characteristics. Overall, ERβ175+ was associated with lower risk of breast cancer events [HRadj = 0.60; 95% confidence interval (CI), 0.41–0.89]. The magnitude of the association was larger in patients with ERα− tumors (HRadj = 0.30; 95% CI, 0.12–0.76), compared with ERα+ tumors (HRadj = 0.66; 95% CI, 0.42–1.03). Among the 232 chemotherapy-treated patients, ERβ175+ tumors were associated with lower risk of breast cancer events compared with ERβ175− tumors (HRadj = 0.31; 95% CI, 0.15–0.64). Among the 671 chemonaïve patients, ERβ175 status was not associated with the outcome. Conclusions: High ERβ1 expression was a favorable prognostic marker in this breast cancer cohort, especially in chemotherapy-treated patients, but not in endocrine therapy–treated patients. These results warrant confirmation, preferably via a biomarker study in a previously conducted randomized trial. Clin Cancer Res; 23(3); 766–77. ©2016 AACR.

Combined and individual tumor-specific expression of insulin-like growth factor-I receptor, insulin receptor and phospho-insulin-like growth factor-I receptor/insulin receptor in primary breast cancer: Implications for prognosis in different treatment groups.

Clinical trials examining insulin-like growth factor-I receptor (IGF1R)-targeting strategies have emphasized that better predictive biomarkers are required to improve patient selection. Immunohistochemical tumor-specific protein expression of IGF1R, insulin receptor (InsR), and phosphorylated IGF1R/InsR (pIGF1R/InsR) individually and combined in relation to breast cancer prognosis was evaluated in a population-based cohort of 1,026 primary invasive breast cancer patients without preoperative treatment diagnosed in Sweden. IGF1R (n = 923), InsR (n = 900), and pIGF1R/InsR (n = 904) combined cytoplasmic and membrane staining was dichotomized. IGF1Rstrong/InsRmod/strong/pIGF1R/InsRpos tumors were borderline associated with 2-fold risk for events, HRadj (2.00; 95%CI 0.96-4.18). Combined IGF1R and pIGF1R/InsR status only impacted prognosis in patients with InsRmod/strong expressing tumors (Pinteraction = 0.041). IGF1Rstrong expression impacted endocrine treatment response differently depending on patients’ age and type of endocrine therapy. Phospho-IGF1R/InsRpos was associated with lower risk for events among non-endocrine-treated patients irrespective of ER status, HRadj (0.32; 95%CI 0.16-0.63), but not among endocrine-treated patients (Pinteraction = 0.024). In non-endocrine-treated patients, pIGF1R/InsRpos was associated with lower risk for events after radiotherapy, HRadj (0.31; 95%CI 0.12-0.80), and chemotherapy, HRadj (0.29; 95%CI 0.09-0.99). This study highlights the complexity of IGF hetero-and homodimer signaling network and its interplay with endocrine treatment, suggesting that combinations of involved factors may improve patient selection for IGF1R-targeted therapy.

The prognostic impact of COX-2 expression in breast cancer depends on oral contraceptive history, preoperative NSAID use, and tumor size

The association between tumor cyclooxygenase 2 (COX‐2) expression and breast cancer prognosis has been inconsistent. The purpose of this study was to evaluate the prognostic significance of COX‐2 tumor expression according to adjuvant treatment, and potential effect modifications of non‐steroid anti‐inflammatory drug (NSAID) use, and other tumor and lifestyle factors. A prospective cohort of 1,116 patients with primary breast cancer in Lund, Sweden, included 2002‐2012 was followed until June 2014 (median 5 years). Tumor‐specific COX‐2 expression was evaluated on tissue microarrays using immunohistochemistry. Associations between COX‐2 intensity (negative, weak‐moderate, high) and patient and tumor characteristics as well as prognosis were analyzed. Tumor‐specific COX‐2 expression was available for 911 patients and was significantly associated with higher age at diagnosis and less aggressive tumor characteristics. Higher COX‐2 expression was associated with lower risk for breast cancer events during the first five years of follow‐up, adjHR 0.60 (95%CI: 0.37‐0.97), per category. The association between COX‐2 expression and prognosis was significantly modified by oral contraceptive (OC) use (Pinteraction = 0.048), preoperative NSAID use (Pinteraction = 0.009), and tumor size (Pinteraction = 0.039). COX‐2 negativity was associated with increased risk for events during the first five years in ever OC users, adjHR 1.94 (1.01‐3.72) and during the 11‐year follow‐up in preoperative NSAID users, adjHR 4.51 (1.18‐11.44) as well as in patients with large tumors, adjHR 2.57 (1.28‐5.15). In conclusion, this study, one of the largest evaluating COX‐2 expression in breast cancer, indicates that the prognostic impact of COX‐2 expression depends on host factors and tumor characteristics.

Excessive milk production during breast-feeding prior to breast cancer diagnosis is associated with increased risk for early events

Breast-feeding is a known protective factor against breast cancer. Breast-feeding duration is influenced by hormone levels, milk production, and lifestyle factors. The aims were to investigate how breast-feeding duration and milk production affected tumor characteristics and risk for early breast cancer events in primary breast cancer patients. Between 2002 and 2008, 634 breast cancer patients in Lund, Sweden, took part in an ongoing prospective cohort study. Data were extracted from questionnaires, pathology reports, and patients’ charts from 592 patients without preoperative treatment. Breast-feeding duration ≤12 months of the first child was associated with higher frequency of ER+/PgR+ tumors (P=0.02). Median follow-up time was 4.9 years. Higher risk for early events was observed for breast-feeding duration of first child >12 months (LogRank P=0.001), total breast-feeding duration >12 months (LogRank P=0.008), as well as ‘excessive milk production’ during breast-feeding of the first child (LogRank P=0.001). Patients with ‘almost no milk production’ had no events. In a multivariable model including both ‘excessive milk production’ and breast-feeding duration of the first child >12 months, both were associated with a two-fold risk for early events, adjusted HRs 2.33 (95% CI: 1.25-4.36) and 2.39 (0.97-5.85), respectively, while total breast-feeding duration was not. ‘Excessive milk production’ was associated with a two-fold risk of early distant metastases, adjusted HR 2.59 (1.13-5.94), but not duration. In conclusion, ‘excessive milk production’ during breast-feeding was associated with higher risk for early events independent of tumor characteristics, stressing the need to consider host factors in the evaluation of prognostic markers.