ARTICLE IN PRESS

The Breast (2005) 14, 493–499

THE
BREAST
www.elsevier.com/locate/breast

ORIGINAL ARTICLE

Primary therapy of early breast cancer: 9th International St. Gallen consensus conference

Prognostic and predictive factors revisited

Daniel F. Hayes

Breast Oncology Program, University of Michigan Comprehensive Cancer Center, CCGC 6312,
1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA

KEYWORDS Summary Standard prognostic factors include clinical and pathological staging,
Breast cancer; especially lymph node status and tumor size. Tumor grade and estimates of
Prognostic factors; lymphatic invasion appear to be moderately strong predictive factors, but
Predictive factors; reproducibility is poor, especially for grade 2 tumors. Standard predictive factors
Multi-gene include hormone receptor status and HER-2 amplification and/or over-expression for
expression arrays selection of endocrine therapy and, at least for clinical trials and in the metastatic
setting, of trastuzumab, respectively. Three new markers appear particularly
promising: detection of bone marrow metastases, either at baseline or after 2–4
years of follow-up; expression of UPA/PAI-1 by the primary cancer; and recognition
of simultaneous multiple gene expression patterns, or ‘‘signatures.’’ Important
caveats exist for each of these. Although new technologies offer exciting and
promising new approaches to determining a patient’s prognosis and whether she will
or will not benefit from specific therapies, few have been validated in well-designed,
Level of Evidence I studies. In particular, available data are often confounded by
patient selection and the effects of systemic therapy, which are often not
determined prospectively, not included in analyses, and not reported adequately.
& 2005 Elsevier Ltd. All rights reserved.

Introduction tality reduction? Unfortunately, the side effects,

toxicities, and cost reduce the appeal of such a
Mortality from breast cancer is dropping in the strategy. Therefore, judicial application of accu-
Western world, principally due to the application of rate, validated, and powerful prognostic and
early systemic therapy.1–3 These encouraging data predictive factors is imperative to increase effi-
raise the question: should all patients with newly ciency of administration of adjuvant systemic
diagnosed breast cancer be treated with all therapy.4
available therapies to ensure breast cancer mor- In this regard, standard prognostic factors in-
clude clinical and pathological staging, especially
Tel.: +1 734 615 6725; fax: +1 734 615 3947. lymph node status and tumor size. Tumor grade and
E-mail address: [email protected]. estimates of lymphatic invasion appear to be

0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2005.08.023
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494 D.F. Hayes

moderately strong predictive factors, but reprodu- marrow positivity. Similarly, the clinical utility of
cibility is poor, especially for grade 2 tumors.5 monitoring bone marrow or circulating markers to
Standard predictive factors include hormone re- identify patients with a high risk of recurrence
ceptor status for selection of endocrine therapy after 2–3 years of follow-up has not been demon-
and HER-2 amplification and/or over-expression for strated.6,11 However, the latter might be used to
selection of trastuzumab in the metastatic setting elect to change hormone therapies in an otherwise
and at least for clinical trials in the adjuvant asymptomatic patient with estrogen receptor posi-
setting.6 tive disease. A prospective randomized trial to
address this question is being considered.

Newer factors
UPA/PAI-1
More than 100 putative breast cancer prognostic
factors have been reported over the last 10–15 UPA/PAI-1 over-expression, as determined by a
years.4 Of these, three appear particularly promis- highly validated and accurate ELISA, appears to
ing for routine clinical use: be strongly prognostic.12,13 However, with longer
follow-up, the initial differences between positive
(1) Detection of bone marrow metastases, either at and negative patients may decrease, although a
baseline or after 2–4 years of follow-up; small study with ten years’ follow-up suggested
(2) Expression of UPA/PAI-1 by the primary cancer; otherwise.14 Regardless, with decreasing size of
(3) recognition of simultaneous multiple gene ex- primary tumors due to wide-spread screening,15 the
pression patterns, or ‘‘signatures’’. Important ELISA assay for UPA/PAI-1, which requires 4300 mg
caveats exist for each of these. fresh/frozen tissue may not be logistically practical
in many centers. Although a micro-ELISA has been
developed for smaller specimens, such as core
needle biopsies, the prognostic utility of this assay
Bone marrow micrometastases
has not been validated.
Several single institution studies have suggested
that patients with bone marrow metastases have a Multi-gene analysis
worse prognosis than those who do not.7 An analysis
of pooled results from several selected centers that Preliminary level of evidence 3 studies suggest that
have monitored outcomes in newly diagnosed multiple gene expression array analysis is an
breast cancer according to bone marrow status exciting new approach, with technologies that
has confirmed these observations with high statis- work in fresh/frozen or formalin-fixed, paraffin-
tical significance.8 However, both in the pooled embedded tissues.16–21 The most widely studied
analysis and in a single study from Norway, these such technologies so far are based on DNA segments
differences do not appear to be as striking in a sub- representing different genes arrayed on chips or
group analysis of patients with favorable standard glass slides to which RNA from a given specimen is
prognostic features who did not receive adjuvant hybridized. Using such technology developed by
systemic therapy (Fig. 1).8–10 Recently, the Norwe- Rosetta Inpharmatics (Seattle, WA, USA), investi-
gian group has published an interesting exploratory gators from the Netherlands Cancer Institute
analysis suggesting that in addition to baseline bone reported remarkable results in two separately
marrow status, micrometastases 3–4 years after published manuscripts.19,20 They initially screened
primary therapy are associated with a high rate of thousands of genes to develop a 70 gene prognostic
recurrence during the following few years.9 Taken signature that appears to distinguish patients with
together, these results do suggest that bone favorable from those with unfavorable prognosis
marrow metastases is associated with a poorer with astonishing accuracy.19 In their most recent
prognosis, but it is not clear how these data should publication, among 295 young patients with breast
be used clinically. For example, it is unlikely that cancer for whom tissue had been archived, 180 had
patients who have positive nodes but negative bone a poor-prognosis signature and 115 had a good-
marrow would forego the benefits of adjuvant prognosis signature (Fig. 2).19,20 At 10 years, the
systemic therapy, and likewise, as noted, it is not probability of remaining free of distant metastases
clear that patients with a favorable prognosis by was 50.674.5% in the group with a poor prognosis
routine clinical and pathological features should signature and 85.274.3% in the group with a good
receive adjuvant chemotherapy based on bone prognosis signature. The estimated hazard ratio for
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Prognostic and predictive factors 495

Figure 1 Distant disease-free survival (DDFS) and breast cancer-specific survival (BCSS) according to bone marrow
positivity for different prognostic subgroups. (A), (C), (E) DDFS and (B), (D), (F) BCSS in bone marrow-positive (BM+) and
bone marrow-negative (BM
) patients. Separate analysis for (A), (B) node-positive (N+), (C), (D) node-negative (N0),
(E), (F) and T1N0 patients (from Wiedswang et al.10 with permission).

distant metastases in the group with a poor TRANSBIG Consortium. Tissue from 301 patients
prognosis signature, as compared with the group followed for at least 10 years in one of six non-
with the good-prognosis signature, was 5.1 (95% Dutch European centers and one US center were
confidence interval, 2.9–9.0; Po0.001). More studied.22 Although the 70-gene profile signature
recently, a multi-center external validation study was again strongly prognostic, outperforming
of this 70 gene signature was reported by the classic prognostic criteria such as those used by
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496 D.F. Hayes

Figure 2 (A–F) Survival analysis using Amsterdam 70 gene signature for breast cancer patients. Kaplan–Meier analysis of
the probability that patients would remain free of distant metastases and the probability of overall survival according
to whether they had a 70-gene good prognosis or a poor prognosis signature. The P values were calculated with use of
the log-rank test (from Van de Vijver et al.20 with permission).

the St. Gallen consensus panel,23 the magnitude of published literature, genomic databases, and in-
effect was much less than what was previously house experiments performed on frozen tissue.
reported in the Dutch series, with hazard ratios for Three separate sets of archived tissue from
time to distant metastases ¼ 1.85 [1.14–3.0] and different clinical data sets were then used to test
for overall survival ¼ 2.5 [1.4–4.5]. The European the relation between quantitative analysis of
Organization for Research and Treatment of Cancer expression of these 250 candidate genes and breast
(EORTC) and the Breast International Group (BIG) cancer recurrence. From these data, a panel of 16
are now designing a large, prospective clinical trial cancer-related genes and five reference genes
to validate the utility of this assay in patients with were used to develop an algorithm to compute a
newly diagnosed breast cancer (the ‘‘MINDACT’’ ‘‘recurrence score,’’ ranging from 0 to 100, that
study). can be used to estimate the odds of recurrence
In the era of screening, the phenomenon of over ten years from diagnosis.21 Of these three
smaller tumors at diagnosis has decreased the datasets, the most influential was an important
availability of frozen tissue for marker analysis.24 National Surgical Adjuvant Breast and Bowel
Therefore, a multi-gene assay that can be applied Project (NSABP) study: clinical trial B20, in which
to formalin fixed paraffin embedded (FFPE) tissue node negative patients with ER-positive tumors
would be of great value. Such an assay has been were randomly assigned to tamoxifen alone or with
developed by Genomics Health Inc (Redwood City, MF (methotrexate and 5-fluorouracil) or CMF (with
CA, USA). This assay, designated ‘‘Oncotype DXTM,’’ cyclophosphamide) chemotherapy. Only those who
is based on performance of multiple real time took tamoxifen alone, without chemotherapy, were
reverse transcriptase polymerase chain reaction studied in this initial evaluation.
(RT-PCR) assays to quantify expression of several Using these data, patients were categorized into
selected genes in FFPE tissue. Two hundred and three recurrence score groups using the results
fifty candidate genes were selected from the from the three separate data sets, including B20:
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Prognostic and predictive factors 497

low risk (recurrence score o18), intermediate risk predictive factor for benefit from CMF; and various
(recurrence score 18–30), and high risk (recurrence markers of proliferation, which also probably
score 31–100). These data were then validated predict for response to chemotherapy. Indeed, in
using archival FFPE tissue samples from patients a study of neoadjuvant chemotherapy, Italian
with node-negative, ER-positive breast cancer who investigators have observed that pathologic com-
were randomly assigned to tamoxifen in a different plete response to doxorubicin and paclitaxel was
NSABP trial: B14. Kaplan–Meier estimates of rate of statistically more likely in those with higher
distant recurrence at 10 years for patients in B14 Oncotype DXTM recurrence scores.27 Not surpris-
who took tamoxifen were found to be remarkably ingly, the NSABP investigators found that the
close to those predicted from the training algo- Oncotype DXTM assay was a strong predictor of
rithm: 6.8% (4.0–9.6%), 14.3% (8.3–20.3%), and benefit from MF or CMF in B20.26 There was little or
30.5% (23.6–37.4%; Fig. 3).21 Results from a no benefit from the addition of chemotherapy to
separate case control study from the Northern tamoxifen for patients with low or intermediate
California Kaiser system are very similar.25 These recurrence scores, but substantial benefit for those
results are highly suggestive that the Oncotype with high recurrence scores. In the high recurrence
DXTM assay is a reproducible and accurate prog- score group, 10-year distant recurrence free
nostic test in node negative patients with ER- survival for tamoxifen-only patients was approxi-
positive breast cancers who received tamoxifen. mately 65% vs. approximately 90% for those who
The NSABP has recently updated their analysis to received CMF (P ¼ 0.001; with a test for interaction
include patients in the other arms of B14 and B20.26 p value of 0.037). Conversely, in B14, the benefit
In this regard, the investigators were now analyzing from tamoxifen vs. observation was almost totally
the 21-gene signature as a predictive factor as well confined to the low and intermediate risk cate-
as a prognostic factor. The 16 cancer-related genes gories, with a P value for interaction of 0.001.
were not randomly chosen. They include ER and Taken together, these data suggest that in patients
PgR, which are known positive predictive factors who have an apparently favorable prognosis based
for endocrine therapy and probably negative pre- on clinical features (negative nodes, positive ER),
dictive factors for chemotherapy; HER2, which is the Oncotype DXTM assay helps determine those
likely a negative predictive factor for tamoxifen, if most likely to benefit from tamoxifen only (low
not all endocrine therapies, and may be a negative recurrence scores) vs. those less likely to benefit
from tamoxifen, but likely to benefit from che-
motherapy (high recurrence scores). The benefits
of chemotherapy in the 25% of patients who have
intermediate recurrence scores remain uncertain.
These results are the basis of a planned prospective
randomized trial that will be performed by the
Breast Cancer Intergroup (TBCI) of North America
(the so-called Program for the Assessment of
Cancer Clinical Tests [PACCT] trial) for patients
with node-negative, ER-positive breast cancer. In
the PACCT trial, patients with low recurrence
scores will all receive endocrine therapy and will
be asked to participate in a registry study for future
prognostic assay validation. Those with high recur-
rence scores will be treated with endocrine therapy
and chemotherapy, preferably within other pro-
spective trials. Those with intermediate recurrence
scores, for whom we have equipoise regarding the
Figure 3 Likelihood of distant recurrence, according to benefits of adjuvant chemotherapy, will be ran-
recurrence-score categories for patients with ER-posi- domly assigned to endocrine therapy only or
tive, node-negative breast cancer treated with tamox-
endocrine and chemotherapy. This trial takes on
ifen. A low risk was defined as a recurrence score of less
than 18, an intermediate risk as a score of 18 or higher even greater importance in the light of ongoing
but less than 31, and a high risk as a score of 31 or higher. progress in the field. It is likely that the overall
There were 28 recurrences in the low-risk group, 25 in prognosis of low and intermediate score patients
the intermediate-risk group, and 56 in the high-risk will be even better in the modern era with
group. The difference among the groups is significant application of aromatase inhibitors instead of or
(Po0.001) (from Paik et al.21 with permission). in sequence with tamoxifen. In contrast, it is also
 ARTICLE IN PRESS
498 D.F. Hayes

likely that modern chemotherapy, incorporating 3. Peto R, Boreham J, Clarke M, Davies C, Beral V. UK and USA
anthracyclines and taxanes in a dose-dense fashion, breast cancer deaths down 25% in year 2000 at ages 20–69
will be more effective than the standard CMF used years. Lancet 2000;355:1822.
4. Isaacs C, Stearns V, Hayes DF. New prognostic factors for
in B20. Thus, especially in the intermediate group, breast cancer recurrence. Semin Oncol 2001;28:53–67.
chemotherapy may be needed less (because hor- 5. Singletary SE, Allred C, Ashley P, et al. Staging system for
mone therapy is better), but may be more breast cancer: revisions for the 6th edition of the AJCC
effective, further increasing the clinician’s equi- Cancer Staging Manual. Surg Clin North Am 2003;83:803–19.
poise for this population. 6. Bast Jr. RC, Ravdin P, Hayes DF, et al. 2000 Update of
recommendations for the use of tumor markers in breast and
colorectal cancer: clinical practice guidelines of the Amer-
ican Society of Clinical Oncology. J Clin Oncol 2001;19:
Other factors 1865–78.
7. Braun S, Naume B. Circulating and disseminated tumor cells.
J Clin Oncol 2005;23:1623–6.
Promising new predictive factors for endocrine
8. Braun S, Vogl FD, Naume B, Janni W, Osborne MP, Coombes
agents include HER2 and ER co-activators and co- RC, et al. A pooled analysis of bone marrow micrometastasis
repressor expression.28–30 In vitro chemo-resistance in breast cancer. N Engl J Med 2005;353(8):793–802.
assays for selected chemotherapeutic agents are 9. Wiedswang G, Borgen E, Karesen R, et al. Isolated tumor
appealing, but evidence supporting their clinical cells in bone marrow three years after diagnosis in disease-
utility in breast cancer is lacking.31 Multi-gene free breast cancer patients predict unfavorable clinical
outcome. Clin Cancer Res 2004;10:5342–8.
expression assays have been applied in preliminary 10. Wiedswang G, Borgen E, Karesen R, et al. Detection of
neo-adjuvant studies with exciting results, but isolated tumor cells in bone marrow is an independent
these require substantial confirmation to be clini- prognostic factor in breast cancer. J Clin Oncol 2003;21:
cally helpful.32,33 3469–78.
11. Bast Jr. RC, Ravdin P, Hayes DF, et al. Errata: 2000 update of
recommendations for the use of tumor markers in breast and
colorectal cancer: clinical practice guidelines of the Amer-
Conclusion ican Society of Clinical Oncology. J Clin Oncol 2001;19:
4185–8.
In conclusion, although new technologies offer 12. Look M, van Putten W, Duffy M, et al. Pooled analysis of
prognostic impact of uPA and PAI-1 in breast cancer patients.
exciting and promising new approaches to deter-
Thromb Haemost 2003;90:538–48.
mining a patient’s prognosis and whether she will or 13. Janicke F, Prechtl A, Thomssen C, et al. Randomized
will not benefit from specific therapies, few have adjuvant chemotherapy trial in high-risk, lymph node-
been validated in well-designed, Level of Evidence negative breast cancer patients identified by urokinase-type
I studies.34,35 In particular, available data are often plasminogen activator and plasminogen activator inhibitor
confounded by patient selection and the effects of type 1. J Natl Cancer Inst 2001;93:913–20.
14. Zemzoum I, Kates RE, Ross JS, et al. Invasion factors uPA/
systemic therapy, which are often not determined
PAI-1 and HER2 status provide independent and complemen-
prospectively, not included in analyses, and not tary information on patient outcome in node-negative
reported adequately.34–37 It is gratifying to see breast cancer. J Clin Oncol 2003;21:1022–8.
newer prognostic and predictive factor studies 15. Cady B. New era in breast cancer. impact of screening on
follow well-designed strategies so that validation disease presentation. Surg Oncol Clin N Am 1997;6:195–202.
16. Perou CM, Jeffrey SS, van de Rijn M, et al. Distinctive
of clinical utility will occur more quickly and with
gene expression patterns in human mammary epithelial
greater reliability. cells and breast cancers. Proc Natl Acad Sci USA 1999;96:
9212–7.
17. Perou CM, Sorlie T, Eisen MB, et al. Molecular portraits of
Acknowledgments human breast tumours. Nature 2000;406:747–52.
18. Sorlie T, Perou CM, Tibshirani R, et al. Gene expression
patterns of breast carcinomas distinguish tumor subclasses
This work was supported in part by NIH CA092461 with clinical implications. Proc Natl Acad Sci USA 2001;98:
and by a grant from the Fashion Footwear Founda- 10869–74.
tion/QVC Presents Shoes on Sales. 19. Van ‘t Veer LJ, Dai H, van de Vijver MJ, et al. Gene
expression profiling predicts clinical outcome of breast
cancer. Nature 2002;415:530–6.
20. Van de Vijver MJ, He YD, van’t Veer LJ, et al. A gene-
References expression signature as a predictor of survival in breast
cancer. N Engl J Med 2002;347:1999–2009.
1. Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality 21. Paik S, Shak S, Tang G, et al. A multi-gene RT-PCR assay using
from major cancers in the European Union, including fixed, paraffin-embedded tumor tissue to predict the like-
acceding countries, in 2004. Cancer 2004;101:2843–50. lihood of breast cancer recurrence in node negative,
2. Jatoi I, Miller AB. Why is breast-cancer mortality declining? estrogen receptor positive, tamoxifen-treated patients. N
Lancet Oncol 2003;4:251–4. Engl J Med 2004;351:2817–26.
 ARTICLE IN PRESS
Prognostic and predictive factors 499

22. Piccart MJ, Loi S, van ‘t Veer LJ, et al. Multi-center external breast cancer: evidence from a phase III randomized trial.
validation study of the Amsterdam 70-gene prognostic J Clin Oncol 2001;19:3808–16.
signature in node negative untreated breast cancer: are 30. Osborne CK, Bardou V, Hopp TA, et al. Role of the estrogen
the results still outperforming the clinical-pathological receptor coactivator AIB1 (SRC-3) and HER-2/neu in tamox-
criteria? Breast Cancer Res Treat 2004;88:S17 (abstract 38). ifen resistance in breast cancer. J Natl Cancer Inst 2003;95:
23. Goldhirsch A, Wood WC, Gelber RD, Coates AS, Thurlimann 353–61.
B, Senn HJ. Meeting highlights: updated international expert 31. Schrag D, Garewal HS, Burstein HJ, Samson DJ, Von Hoff DD,
consensus on the primary therapy of early breast cancer. Somerfield MR. American Society of Clinical Oncology
J Clin Oncol 2003;21:3357–65. Technology Assessment: chemotherapy sensitivity and re-
24. Cady B, Stone MD, Schuler JG, Thakur R, Wanner MA, Lavin sistance assays. J Clin Oncol 2004;22:3631–8.
PT. The new era in breast cancer. Invasion, size, and nodal 32. Chang JC, Wooten EC, Tsimelzon A, et al. Gene expression
involvement dramatically decreasing as a result of mammo- profiling for the prediction of therapeutic response to
graphic screening. Arch Surg 1996;131:301–8. docetaxel in patients with breast cancer. Lancet 2003;362:
25. Habel L, Quesenberry CP, Jacobs MK, et al. A large 362–9.
case–control study of gene expression and breast cancer 33. Ayers M, Symmans WF, Stec J, et al. Gene expression profiles
death in the Northern California Kaiser Permanente popula- predict complete pathologic response to neoadjuvant
tion. Breast Cancer Res Treat 2004;88:S118 (abstract 3019). paclitaxel and fluorouracil, doxorubicin, and cyclophospha-
26. Paik S, Shak S, Tang G, et al. Expression of 21 genes in mide chemotherapy in breast cancer. J Clin Oncol 2004;22:
the recurrence score assay and prediction of clinical 2284–93.
benefit from tamoxifen in NSABP study B-14 and chemo- 34. Hayes DF, Bast R, Desch CE, et al. A tumor marker utility
therapy in NSABP B-20. Breast Cancer Res Treat 2004;88:S15 grading system (TMUGS): a framework to evaluate clinical
(abstract 24). utility of tumor markers. J Natl Cancer Inst 1996;88:
27. Gianni L, Zambetti M, Clark K, et al. Gene expression of 1456–66.
paraffin-embedded core biopsy tissue predicts response to 35. Hayes DF. Clinical importance of prognostic factors: moving
chemotherapy in patients with locally advanced breast from scientifically interesting to clinically useful. In:
cancer. Proc Am Soc Clin Oncol 2004;23:3 (abstract 501). Bronchud MH, Foote M, Giaccone G, Olapade O, Workman
28. Yamauchi H, Stearns V, Hayes DF. When is a tumor marker P, editors. Principles of molecular oncology. 2nd ed. Totowa,
ready for prime time? A case study of c-erbB-2 as a NJ: Humana; 2004. p. 51–72.
predictive factor in breast cancer. J Clin Oncol 2001;19: 36. Hayes DF, Trock B, Harris A. Assessing the clinical impact of
2334–56. prognostic factors: when is ‘‘statistically significant’’ clini-
29. Ellis MJ, Coop A, Singh B, et al. Letrozole is more effective cally useful? Breast Cancer Res Treat 1998;52:305–19.
neoadjuvant endocrine therapy than tamoxifen for ErbB-1- 37. Ransohoff DF. Cancer. Developing molecular biomarkers for
and/or ErbB-2-positive, estrogen receptor-positive primary cancer. Science 2003;299:1679–80.