1. Implicaciones clínicas de los subtipos intrínsecos de cáncer de mama
Joan Albanell
Servicio de Oncología Médica

2. The intrinsic breast cancer subtypes
PAM50: intrinsic subtypes and ROR
Studies in Hormone Receptor positive disease
Studies in HER2 positive disease
Studies in Triple Negative disease
Summary

3. Molecular classification in breast cancer: The intrinsec subtypes
Stanford classification
65 casos
456 genes
Sorlie, T et al. PNAS, 2001
Perou, CM et al. Nature, 2000
Perreard, L et al. Breast Cancer Res, 2006

4. Breast cancer intrinsic subtypes vary in subsets defined by ER and HER2
Prat, A & Perou, CM. Mol Oncol 2011

5. IHC-based definition of Luminal A versus Luminal B tumors
IHC-based definition of Luminal A is
ER+ and/or PR+
HER2-
Ki67<14%
PR>20%
IHC-based definition of Luminal B is
ER+ and/or PR+ / HER2- / Ki67<14% / PR<20% or
ER+ and/or PR+ / HER2- / Ki67>14%
ER+ and/or PR+ / HER2+
However, these definitions 1) do not fully recapitulate the intrinsic subtypes and 2) are technically challenging (i.e. precise scoring
of Ki-67 and PgR), and thus the Pathology Community needs to establish scoring standards and provide controls
Prat et al. J Clin Oncol 2013
Survival analyses within IHC-LumA tumors

6. The intrinsic breast cancer subtypes
PAM50: intrinsic subtypes and ROR
Studies in Hormone Receptor positive disease
Studies in HER2 positive disease
Studies in Triple Negative disease
Summary

7. Prosigna test (PAM50) RESEARCH DIAGNOSTICS FDA 510(k)
Extract RNA from FFPE tumor sample
Run RNA & CodeSet on nCounter Analysis System
RESEARCH
DIAGNOSTICS
Intrinsic Subtype
Adapted from Aleix Prat
Risk of Relapse (ROR)
FDA 510(k)

8. PAM50 Using nCounter Classifies Breast Cancer Into Intrinsic Subtypes
The qRT-PCR assay consists of 50 genes
The subtype classification accuracy of the 50 genes by qRT-PCR versus 2000 genes by microarray was 93%
The assay works using RNA from FFPE materials or fresh frozen tissues.
Parker J Clin Oncol 2009

9. PAM50 Generates a Risk Of Relapse (ROR) Score Specific to Each Patient
ROR is based on the similarity of the gene expression profile to intrinsic subtypes, proliferation score (i.e. mean expression prolif-related genes), nodes and tumor size.
ROR ranges from 0 through 100 (ROR) indicating the probability of distant recurrence in a “training cohort” of patients with tumors representing all subtypes and patients that did not receive any adjuvant systemic therapy.
Patient
expression profile
LumB
LumA
Basal-like
HER2-enriched
PAM50 centroids
ROR = aRLumA bRLumB+
cRHer2e+
dRBasal+
eP fT
Pearson’s correlation to centroids
Proliferation score
Tumor size
Parker et al. JCO 2009; Nielsen et al. CCR 2010

11. The intrinsic breast cancer subtypes
PAM50: intrinsic subtypes and ROR
Studies in Hormone Receptor positive disease
Studies in HER2 positive disease
Studies in Triple Negative disease
Summary

12. PAM50 (PROSIGNA®) Validation Studies
Primary Objective: Validate published observations that Prosigna/ROR Score provides additional prognostic information over and above standard clinical variables for DRFS at 10 yrs
Primary Analysis: All patients
Secondary Analysis: Node- negative, node-positive, and HER2-negative patients
Secondary Objective: Validate observations that Luminal A and Luminal B patients have statistically significantly different DRFS at 10 yrs1
ATAC study
Postmenopausal women with invasive BC (N=9366)
Tam alone (N=3116)
Arimidex alone (N=3125)
Tam + Arimidex (N = 3125)
TransATAC study
(N=1125 blocks)
ABCSG-8 study
Post-menopausal women with HR+ BC (N=3714)
Tamoxifen
(N=1849)
Anastrozole (N=1865)
(N = 1478 blocks)
Tam
2-years
3 years

13. Findings From the Combined Analysis of >2400 Patient Samples
Prosigna Low Risk patients remain Low Risk over 10yrs
DRFS by Risk-Group for Node-negative Patients
DRFS by Risk-Group for Node-positive Patients (1-3 positive nodes)
1.0
0.9
0.8
0.7
0.6
1.0
0.9
0.8
0.7
0.6
1.0
0.9
0.8
0.7
0.6
1.0
0.9
0.8
0.7
0.6
Percent Without Distance Recurrence
Percent Without Distance Recurrence
Low-risk
Intermediate-risk
High-risk
Low-risk
Intermediate-risk
High-risk
Follow-Up Time (yrs)
Follow-Up Time (yrs)
Risk Group
N (%)
Events Through 10 Yrs
% Without Recurrence at 10 yrs [95% CI]
Low
875 (49%) 31
96%.2 [94.7% %]
Intermediate
551 (31%) 53
89.2% [86.% %]
High
360 (20%) 73
77.7% [72.8% %]
Total
1,786 (100%)
157
Risk Group
N (%)
Events Through 10 yrs
% Without Recurrence at 10 yrs [95% CI]
Low
24 (4%) 2
91.7% [70.6% %]
Intermediate
211 (36%) 18
90.4% [85.2% %]
High
355 (60%) 87
71.8% [66.3% %]
Total
590 (100%)
107
Source: Dowsett M, Sestak I, Lopez-Knowles E, et al. Comparison of PAM50 risk of recurrence score with Oncotype DX and IHC4 for predicting risk of distant recurrence after endocrine therapy. J Clin Oncol. 2013;31(22): : Gnant M, Filipits M, Greil R, et al; Austrian Breast and Colorectal Cancer Study Group. Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 Risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone. Ann Oncol. 2014;25(2):

14. Knowledge of Luminal Status May Improve Disease Management
DRFS by Risk-Group for Node-Negative Patients
DRFS by Risk-Group for Node-Positive Patients (1-3 Positive Nodes)
Risk Group
N (%)
Events Through 10 yrs
% Without Recurrence at 10 yrs [95% CI]
Luminal A
1254 62
94.6% [93.1% – 95.8%]
Luminal B
460 75
81.9% [77.7% – 85.3%]
Total
1,714
137
Risk Group
N (%)
Events Through 10 yrs
% Without Recurrence at 10 yrs [95% CI]
Luminal A
375 41
87.6% [83.5% – 90.8%]
Luminal B
186 52
68.3% [60.4% – 75.0%]
Total
561 93
Source: Dowsett M, Sestak I, Lopez-Knowles E, et al. Comparison of PAM50 risk of recurrence score with Oncotype DX and IHC4 for predicting risk of distant recurrence after endocrine therapy. J Clin Oncol. 2013;31(22): : Gnant M, Filipits M, Greil R, et al; Austrian Breast and Colorectal Cancer Study Group. Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 Risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone. Ann Oncol. 2014;25(2):

15. Discordance between ROR and RS groups of 43% at the individual level
JCO 2013
Discordance between ROR and RS groups of 43% at the individual level

16. Prospective study of the impact of the Prosigna® assay on adjuvant clinical decision-making in an unselected population of women with ER+, HER2-negative, node-negative breast cancer: a GEICAM study

17. OncotypeDX RS, PAM50 ROR and IHC4 (Ki67, PgR, ER, HER2 status)
TransATAC study
OncotypeDX RS, PAM50 ROR and IHC4 (Ki67, PgR, ER, HER2 status)
JNCI 2013

18. San Antonio Breast Cancer – Cancer Therapy and Research Center at UT Health Science Center – December 10-14, 2013
Prediction of late distant recurrence after 5 years of endocrine treatment:
A combined analysis of 2137 patients from the ABCSG-8 and transATAC studies using the PAM50 Risk of Recurrence (ROR) score
Ivana Sestak
Jack Cuzick, Mitch Dowsett, Martin Filipits, Peter Dubsky, J. Wayne Cowens, Sean Ferree, Carl Schaper, Christian Fesl, Michael Gnant
Centre for Cancer Prevention, Wolfson Institute of Prevention Medicine, Queen Mary University, London, UK
Academic Department of Biochemistry, Royal Marsden Hospital, London, UK
Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
Department of Surgery and Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
NanoString Technologies, Seattle, WA, USA
MyRAQA, Redwood Shores, CA, USA

19. Luminal A vs Luminal B HR (95% CI) P-value Luminal A (N=1530 (71.6%))
San Antonio Breast Cancer – Cancer Therapy and Research Center at UT Health Science Center – December 10-14, 2013
Luminal A vs Luminal B
HR (95% CI)
P-value
Luminal A (N=1530 (71.6%)) -
Luminal B (N=542 (25.4%))
2.89 ( )
<0.0001 5 10 15 6 7 8 9
Follow-up time [years]
Luminal B
Luminal A
Distant recurrence (%)
4.1%
12.9%
Sestak et al. SABCS 2013 and JCO 2014

20. Risk groups – ROR score (N=2137)
San Antonio Breast Cancer – Cancer Therapy and Research Center at UT Health Science Center – December 10-14, 2013
Risk groups – ROR score (N=2137)
HR (95% CI)
Low (N=1183 (55.4%)) -
Intermediate (N=538 (25.2%))
3.26 ( )
High (N=416 (19.5%))
6.90 ( )
2.4%
16.6%
8.3% 5 10 15 20 6 7 8 9
Follow-up time [years]
Low
Intermediate
High
Distant recurrence (%)
Sestak et al. SABCS 2013

21. The intrinsic breast cancer subtypes
PAM50: intrinsic subtypes and ROR
Studies in Hormone Receptor positive disease
Studies in HER2 positive disease
Studies in Triple Negative disease
Summary

22. The HER2-enriched subtype is associated wit higher responses and improved survival outcomes in HER2+ breast cancer in the NOAH study
Chemotherapy:
AT x 3  T x 4  CMF x 3
156 (46.7%) pre-treatment samples were PAM50 profiled.
HER2+
HER2+/HR-
Note: interaction test between HER2E subtype and treatment was not statistically significant.
Prat et al. Clin Cancer Res 2014

24. The intrinsic breast cancer subtypes
PAM50: intrinsic subtypes and ROR
Studies in Hormone Receptor positive disease
Studies in HER2 positive disease
Studies in Triple Negative disease
Summary

25. Prat et al. BJC 2014

28. Summary
The PAM50 assay provides better intrinsic subtype molecular (Luminal A and B, HER2-enriched and Basal-like) classification than current pathology-based surrogate definitions.
PAM50 ROR provides robust prognostic information in ER+/HER2- early breast cancer and influenced systemic treatment recommendations in a prospective clinical impact study.
PAM50 ROR and classification of luminal A vs B tumors may also help to estimate the risk of late recurrences (> 5 years) in ER+ disease.
HER2+ disease includes all the intrinsic subtypes (i.e. not just Luminal B and HER2-enriched). HER2+enriched tumors appear to benefit the most from anti-HER2 treatments in combination with chemotherapy in the neoadjuvant setting. The role of HER2+ subtyping may vary by disease burden (neoadjuvant, micrometastasis, overt metastasis) and type of regimen.
Within TNBC, distinguishing Basal-like vs. Other subtypes predicted benefit from chemotherapy and docetaxel vs. carboplatin benefit.

29. Chemo vs Chemo+Tam (n=395)
PAM50 Subtype Testing
in Phase III Clinical Trials (n=5,486)
NCIC MA.12
(Chia, CCR 2012)
Chemo vs Chemo+Tam (n=395)
NCIC MA.5
(Cheang, CCR 2012)
CMF vs CEF (n=475)
GEICAM 9906
(Martin, BCRT 2013)
FEC vs FEC-T (n=820)
TransATAC
(Dowsett, JCO 2013)
Tam vs AI (n=1007)
CALGB 9741
(Liu, SABCS 2012)
q2 AC-T vs q3 AC-T (n=1311)
ABCSG8
(Gnant, SABCS 2012)
Tam-Tam vs Tam-AI (n=1478)
LumA
LumB

30. PIs: Dr. Llombart, Dr. Cortés and Dr. Prat
PAM50 HER2-enriched phenotype as a predictor of early-response to neoadjuvant lapatinib plus trastuzumab in Stage I to IIIA HER2-positive breast cancer
(PAMELA TRIAL)
PIs: Dr. Llombart, Dr. Cortés and Dr. Prat

31. Predicted risk of distant recurrence by number of positive nodes (TransATAC)
PAM50 (PROSIGNA®)
Nodal status
ROR range
Risk categorization
Node-negative
0-40
Low
41-60
Intermediate
61-100
High
Node-positive (1-3 nodes)
0-15
16-40
41-100
Node-positive (> 4 nodes)
0-100
Dowsett et al. J Clin Oncol 2013
10-year probability of distant recurrence of < 10% is considered low risk
10-year probability of distant recurrence of > 20% is considered high risk

32. Survival Outcomes of the Intrinsic Subtypes within HER2+ disease
METABRIC dataset (no trastuzumab)
Clinical HER2 status
Prat et al. JNCI 2014