Annals of Oncology Advance Access originally published online on January 30, 2006
Annals of Oncology 2006 17(4):588-596; doi:10.1093/annonc/mdl001
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© 2006 European Society for Medical Oncology
Efficacy of high-dose alkylating chemotherapy in HER2/neu-negative breast cancer
1 Department of Medical Oncology, 2 Department of Pathology, 3 Biometrics Department, The Netherlands Cancer Institute, Amsterdam; 4 Department of Medical Oncology, The Erasmus Medical Center/Daniel den Hoed Cancer Center, Rotterdam; 5 Department of Medical Oncology, University Medical Center St. Radboud, Nijmegen; 6 Department of Medical Oncology, Medical Hospital Twente, Enschede; 7 Department of Medical Oncology, University Medical Center Leiden, Leiden; 8 Department of Medical Oncology, University Medical Center Utrecht, Utrecht; 9 Department of Medical Oncology, Free University Hospital Amsterdam, Amsterdam (present address: University Medical Center Utrecht); 10 Department of Medical Oncology, University Hospital Maastricht, Maastricht; 11 Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
* Correspondence to: Prof. S. Rodenhuis, Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands. Tel: +31-20-512 2870; Fax +31-20-512 2858; E-mail: sroden{at}nki.nl
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Background: High-dose chemotherapy in the adjuvant treatment of breast cancer has been abandoned by many.
Patients and methods: 885 patients with stage III primary breast cancer and four or more axillary lymph node metastases were randomised to receive either five courses of FEC (fluorouracil, epirubicin and cyclophosphamide) followed by radiation therapy and tamoxifen, or the same treatment but with high-dose alkylating chemotherapy (cyclophosphamide, thiotepa and carboplatin) replacing the fifth course of FEC. Of these patients, 621 had HER2/neu-negative disease, as determined by immunohistochemistry and chromogenic in situ hybridisation.
Results: At a median follow-up of 84 months, a trend for a better relapse-free survival was observed in the high-dose arm: (hazard ratio (HR) 0.84, P = 0.076, two-sided). The 621 patients with HER2/neu-negative disease benefited from high-dose therapy, while patients with HER2/neu-positive disease did not (test for interaction, P = 0.006). There was a marked relapse-free survival benefit for patients with HER2/neu-negative disease (71.5% versus 59.1%, 5 years after randomisation; HR 0.68, P = 0.002) and also a survival benefit (78.2% versus 71.0% at 5 years; HR 0.72, P = 0.02).
Conclusions: The findings from this subgroup analysis provide additional evidence that HER2/neu-positive breast cancer is relatively resistant to alkylating agents. For HER2/neu-negative tumours, however, high-dose chemotherapy should remain the subject of clinical studies.
Key words: breast cancer, alkylating agents, high-dose chemotherapy, peripheral blood progenitor cell transplant, adjuvant chemotherapy
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introduction |
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Despite progress in the adjuvant systemic treatment of breast cancer, patients with four or more tumour-positive axillary lymph nodes continue to face a poor prognosis and are therefore classified as having stage III disease in the new staging system [1
]. High-dose chemotherapy has been studied as a strategy to improve the efficacy of adjuvant chemotherapy in this patient group but it remains unclear what the role, if any, of this treatment modality should be. High-dose chemotherapy in the adjuvant treatment of breast cancer has been studied in 14 randomised trials, encompassing a total of 5627 patients. Unfortunately, all studies are underpowered and most have been published at a point in time when they were not sufficiently mature to analyse overall survival in a meaningful way. A further problem in the interpretation of these trials is the fact that their designs are very different. For example, at least 10 different high-dose chemotherapy regimens have been used, and in many studies high-dose therapy is compared with a ‘conventional’ chemotherapy arm which is by itself far from standard. Only six trials, with 2702 randomised patients, have a symmetrical design and compare two arms that are identical except for the presence of high-dose chemotherapy in one of them (Table 1). All these studies show less relapses after high-dose therapy than after conventional-dose therapy, although in only one of them, this difference is statistically significant. Nevertheless, based on many inconclusive studies and following the disclosure of scientific fraud in one of the positive ones, most oncologists have abandoned high-dose therapy and are reluctant to initiate further studies.
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The largest study of high-dose chemotherapy in this setting, is the Dutch National Study. Its first planned analysis at a median follow-up of 54 months [2
] showed that there was a trend for a better relapse-free survival (RFS) following high-dose therapy in the high-dose arm. An unplanned subgroup analysis suggested that patients with HER2/neu-positive tumours did not benefit from high-dose therapy. When the analysis was restricted to the 621 patients with HER2/neu-negative disease, there was a statistically significant disease-free survival advantage for high-dose therapy and a trend for a better overall survival. For this report, we have updated the analysis of the study now with a median follow-up of 87 months. We have also employed chromogenic in situ hybridisation (CISH) to test for gene amplification in tumours with 1+ or 2+ HER2/neu expression at immunohistochemistry. In this re-analysis, we focus specifically on the 621 patients who had a HER2/neu-negative tumour and who appeared to benefit substantially from the high-dose treatment.
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patients
The study was designed for women younger than 56 years, who had epithelial breast cancer and who had undergone either breast conserving surgery or radical mastectomy. Patients with pathological stage IIA, IIB or IIIA were eligible if at least four axillary lymph nodes had been found to contain metastases at surgery, which had to include an axillary clearance. The presence of tumour cells near or in the resection margins at microscopic examination of the breast or of the axilla was acceptable. No metastatic disease beyond the axilla was allowed. Physical examination, chest roentgenography, an ultrasound examination of the liver and a radio-isotope bone scan were required to be negative. In case of equivocal results of the bone scan, a negative MRI-examination of the involved area was also acceptable. Other eligibility criteria included ECOG-Zubrod performance status 0 or 1; normal bone marrow function with a white blood (WBC)-count
4000 per mm3, platelet count 100 000 per mm3; creatinine clearance 60 ml/min; and serum bilirubin 
25 µmol/l. The study chemotherapy had to begin within 6 weeks after the last surgery. No other malignancies, except adequately treated in situ carcinoma of the cervix or basal cell carcinoma of the skin, were allowed. Informed consent was obtained from all patients and the study was approved by the institutional review committees of each of the participating centres.
study design
The study was a prospective multi-centre phase III study. Eligible patients were randomised before treatment and stratified according to age (below 50 years or not), menopausal status (premenopausal or not), number of lymph node metastases (four to nine nodes or 10+) and tumour size (pT1, pT2 or pT3).
The conventional treatment arm consisted of five courses of anthracycline based conventional-dose chemotherapy (FEC). Subsequently, radiation therapy was administered and all patients were started on tamoxifen, independent of hormone receptor status. Treatment in the experimental arm was identical, except that the fifth course of FEC chemotherapy was replaced by high-dose alkylating chemotherapy (see trial profile in Figure 1).
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treatment
The conventional chemotherapy consisted of FEC courses, which were given every 3 weeks and consisted of intravenous push injections of 5-fluorouracil (500 mg/m2), epirubicin (90 mg/m2) and cyclophosphamide (500 mg/m2). In the high-dose arm, the third course of FEC chemotherapy was used to mobilise peripheral blood progenitor cells (PBPCs). This was done by administering G-CSF (filgrastim) in a dose of 300 µg daily as subcutaneous injections during 10 days. PBPC harvests were performed by leukocytapheresis, as described previously [3
, 4]. Leukocytapheresis continued until at least 3x106 CD34+ cells per kilogram body weight had been harvested. A bone marrow harvest was acceptable for patients in whom the target number of CD34+ peripheral blood progenitor cells could not be harvested. If required, the PBPC harvest could be postponed to or repeated following the fourth course of FEC.
The high-dose chemotherapy regimen consisted of cyclophosphamide (6 g/m2), thiotepa (480 mg/m2) and carboplatin (1600 mg/m2) divided over 4 days [4, 5]. This regimen resembles the STAMP V or CTCb regimen [6] but it contains a double dose of carboplatin and the three drugs are not administered as continuous 4-day infusions but rather as 30 to 60-min daily infusions. The PBPC infusions were administered 48 h after the last chemotherapy administration. Details of the supportive care prior to and following transplantation have been published previously [4].
Radiotherapy was administered to the internal mammary nodes, to the axilla and supraclavicular region and in case of mastectomy to the chest wall (40 Gray in 20 fractions), or to the breast if breast conserving therapy had been performed (50 Gray in 25 fractions). In the latter case, boost doses were applied according to local prescriptions of the participating centres.
The original protocol prescribed tamoxifen, 40 mg daily, for 2 years to be initiated following the completion of chemotherapy. During the course of the trial, however, it became clear from the Oxford overview [7] that 5 years of tamoxifen was more efficacious than 2 years. From that time on, hormone receptor-positive patients were continued on tamoxifen for three more years following the two years of tamoxifen prescribed in the protocol.
follow-up
Patients were evaluated at every chemotherapy course, at the beginning of the radiation therapy and at its end. Patients were subsequently seen at least every 4 months. At the 4-monthly follow-up, blood counts, liver function tests and standard serum chemistries were performed. To monitor menopausal status, the date of the last menstruation was noted, and FSH and 17 beta-estradiol determinations were performed at least every year during tamoxifen, and also after discontinuation of tamoxifen if any uncertainty regarding postmenopausal status remained. In addition, a yearly mammography and a chest roentgenogram were performed.
pathology review
A centralised pathology review was performed by one of the authors (J.L.P.). An effort was made to obtain the paraffin blocks of the tumours of all patients in the study. Classification included histology (WHO), tumour grade [8], mitotic activity index (MAI) [9], presence of carcinoma in situ and angioinvasion. Additional sections were obtained for immunohistochemistry to examine the oestrogen receptor (ER), progesterone receptor (PR), HER2/neu, and p53 expressions.
immunohistochemistry and CISH
Immunohistochemical assays for the estrogen receptor, the progesterone receptor and HER2/neu were performed as described previously [2]. HER2/neu was scored employing the 3B5 antibody [10] in 826 tissue blocks according to the system for clinical testing (0; 1+ > 10% cells weakly positive; 2+ moderate homogeneous staining; 3+ strong homogeneous staining).
Chromogenic in situ hybridisation (CISH) for amplification of the HER2/neu gene was done employing 3 µm sections of the tumours with 1+ or 2+ HER2 staining result. CISH is now widely accepted as a reliable alternative for FISH. Many groups, including ours, have found an almost perfect concordance of CISH and FISH results [12, 13]. The slides were deparaffinised and incubated with SPOT-Light TM heat pretreatment buffer (Zymed Inc., South San Francisco, CA, USA) in a microwave oven for 7 min at 850 Watt and 15 min at 180 Watt. After washing with dH2O, 100 µl SPOT-Light TM heat pretreatment enzyme (Zymed) was applied at room temperature (RT) for 5 min. The slides were washed with distilled H2O and dehydrated with ethanol. A cover slip was applied onto the slide after application of 15 µl of a digoxigenin-labelled HER2 probe (Zymed). The slides were denatured on a 95°C hot plate for 5 min and incubated for > 10 h (overnight) in a humidity box at 37°C. After incubation, the slides were stringently washed with 0.5 x sodium chloride citrate for 5 min at 75°C. After washing with dH2O, the slides were treated with 3% hydrogen peroxyde for 10 min, 100 µl mouse anti digoxigenin (Zymed) was applied for 60 min after the application of 100 µl CAS-Block TM (Zymed) for 10 min. After washing with PBS/Tween, 100 µl horse radish peroxidase-goat anti-mouse (Zymed) was applied for 60 min. After washing with PBS, 100 µl 3,3-diaminobenzidine tetrahydrochloride was applied for 30 min. After washing with running tap water and dehydration with ethanol and xylene, the slides were counterstained with heamatoxylin. Amplification was defined as a gene copy number of over five per cell.
statistical analysis
The main endpoints for the comparison of treatments were RFS and overall survival. RFS was defined as time from randomisation to appearance of first relapse of disease or death from any cause; patients known to be alive and without relapse of disease at the time of analysis were censored at the time of their last follow-up. Second breast cancers or other malignancies were not counted as events. Overall survival was defined as time from randomisation to death from any cause; patients known to be alive at the time of analysis were censored at the time of their last follow-up. All treatment comparisons are based on the intention-to-treat principle. The Kaplan–Meier method was used to estimate curves for RFS and overall survival and comparisons were made by the log-rank test. Cox proportional hazards models were fit in order to estimate hazard ratios and confidence intervals. Differences of the overall treatment comparison and the treatment comparison within the two groups based on the number of nodes are expressed in terms of hazard ratios with 95% confidence intervals. The relative benefit of high-dose treatment on RFS was further investigated in subgroups of potential prognostic variables by means of Forest-plots showing the hazard ratio (black square) with 99% confidence intervals. To test for differences in the relative size of effect in different subgroups, we used a 
2 test for interaction, or, when appropriate, a 2 test for trend. All P values are two-sided. Analyses were performed with SAS system version 8.2 and S-Plus version 6.2.
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previously published results
Data on demographic characteristics of the patients, characteristics of the tumours and the distribution over the two arms of the study have been published [2
]. The same is true for the toxicity of the treatment. Briefly, a total of 885 patients from 10 centres were entered in the study. All patients were randomised, as randomisation was part of the phone call-based registration procedure. A total of 37 patients were found to be ineligible when the definitive patient record forms were reviewed, because of the following reasons: prior radiation therapy for unrelated disease (n = 4), evidence of distant metastases (n = 2); prior cervical cancer (n = 1) and minor abnormalities in the laboratory values (n = 30). All were kept in the study and all patients, including the ineligible ones, were included in the intention-to-treat analysis. Two patients (one in each arm) never started chemotherapy because they refused any chemotherapy after randomisation. The conventional chemotherapy (FEC) was well-tolerated. There was, however, one treatment-related death during FEC chemotherapy: a patient in the high-dose arm died of cardiac arrhythmia during an emergency hospital admission because of diarrhoea and electrolyte imbalance. This event occurred 14 days after the third FEC course. Of the 442 patients randomised to the high-dose arm of the protocol, 397 (90%) actually received the planned CTC course after four courses of FEC. None of the 443 patients randomised to the conventional-dose chemotherapy arm crossed over to high-dose treatment or received high-dose therapy off protocol elsewhere. Thirty-four received a fifth course of FEC instead of the CTC course. There were 4 transplant-related deaths (within 100 days of the PBPC re-infusion), two from septicaemia, and 2 from cardiac toxicity. Adjuvant radiation therapy, to the parasternal area, chest wall and/or periclavicular nodes was administered in 776 patients. Radiation-induced pneumonitis requiring therapy with corticosteroids was observed in 25 cases, seven in the conventional and 18 in the high-dose arm. All improved, with the single exception of a patient treated in the high-dose arm of the study. This patient developed severe lung fibrosis and died of pulmonary complications, 18 months after randomisation.
survival analysis
At the time of the analysis, and with a median follow-up of 87 months, a total of 396 events (45%) had been reported. There was a better RFS in the high-dose treatment group (hazard ratio, 0.84; P = 0.076 (two-sided); Figure 2a). The 5-year RFS estimates were 58.9% and 64.3% for the conventional group and for the high-dose group, respectively. A total of 317 patients had died and the 5-year overall survival estimates were 70.0% and 73.0% for the conventional group and for the high-dose group, respectively (Figure 2b). This difference is not statistically significant (P = 0.22).
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The only set of subgroup analyses planned in the original protocol was that of the intermediate risk (four to nine tumour-positive axillary lymph nodes) and the high-risk (>10 positive nodes) groups. Patients with 10 or more axillary lymph node metastases had significantly better RFS after high-dose therapy (P = 0.013, log-rank test), with a hazard ratio of 0.68. There was, however, no statistical interaction between lymph node status and treatment (P = 0.073), indicating that this difference in effect of high-dose therapy may have been due to chance. Overall survival was superior as well (hazard ratio 0.77) but this difference was not statistically significant (P = 0.13). Further subgroup analyses were performed for several predictive factors. Age under 40 years, negativity for HER2/neu expression and lower grade were all associated with a significantly stronger positive effect of high-dose therapy on RFS. In all three cases, a statistical test for interaction with treatment arm was positive: P = 0.0469, 0.0059 and 0.0041, respectively.
HER2/neu classification
Tumours with 0+ HER2/neu expression at IHC were classified as HER2/neu-negative and those with 3+ as HER2/neu-positive. In case of 1+ or 2+ results at IHC, CISH was performed in order to establish the presence or absence of gene amplification. Two of 15 1+ tumours and 16 of 23 2+ tumours were shown to harbour an amplified HER2/neu gene and these were termed HER2/neu-positive. For three tumours with an IHC 1+ result and for a single tumour with a 2+ result at IHC, no material was available for CISH and these tumours were considered as HER2/neu-negative for the analysis. Twenty-five additional specimens, not included in the previous analysis could be obtained and analysed by CISH; 19 of these proved to be negative and six positive for HER2/neu amplification.
HER2/neu-negative tumours
Although the subgroup analysis for HER2/neu-negative tumours was not planned in the original protocol, the differences in terms of both biology and drug-sensitivity between HER2/neu-positive and -negative disease have become sufficiently clear in the last few years to justify separate analyses. The subgroup of HER2/neu-negative tumours contained 621 patients. The characteristics of these patients are listed in Table 2. Patients with HER2/neu-negative disease had a markedly improved RFS after high-dose therapy (Figure 3a). For this subgroup, the hazard ratio for relapse decreased by about one-third after high-dose therapy to 0.68 (P = 0.0020). There was also a significant overall survival benefit for the high-dose chemotherapy group (hazard ratio: 0.72, P = 0.021, Figure 3b).
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Explorative subgroup analyses are shown in the Forest-plots of Figures 4a and 4b. Again, both age below 40 and low histological grade remain strong indicators of responsiveness to high-dose therapy. There was no interaction of nodal status or of hormone receptor expression with treatment arm. Also, the advantage in premenopausal women did not depend on becoming post-menopausal (data not shown).
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Since more patients became postmenopausal in the high-dose group than in the conventional-dose group, an endocrine effect could have contributed to the benefit of high-dose therapy. In Figure 5, the RFS is shown for the 209 HER2/neu negative patients who had tumours with both hormone receptors negative. In these patients, in whom a castration effect was of course absent, the benefit of high-dose chemotherapy was similar in size for all patients with HER2/neu-negative disease.
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long-term toxicities and second cancers
The main long-term toxicity was the induction of post-menopausal status, which was more frequent in the high-dose chemotherapy arm [2
]. One patient on the high-dose arm developed irreversible lung disease, which was considered to be a result of radiation pneumonitis (see paragraph on radiation therapy). Some degree of lymph oedema developed in about 30% of patients and was usually minor. This complication, which is caused by the combined effects of lymph node dissection and radiation therapy, was not more frequent after high-dose chemotherapy (data not shown). A total of 56 second malignancies have been observed, 27 in the conventional-dose arm and 29 in the high-dose arm (Table 3).
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discussion |
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The Dutch National trial of high-dose chemotherapy in the adjuvant treatment of high-risk breast cancer was undertaken to determine if high-dose alkylating chemotherapy would improve the RFS when added to conventional anthracycline-based chemotherapy. To avoid a difference in the number of chemotherapy-courses between the arms, the conventional chemotherapy arm contained a fifth course of FEC while the fifth chemotherapy course in the high-dose arm consisted of high-dose cyclophosphamide, thiotepa and carboplatin. Since this combination of agents is clearly not associated with a high toxic death rate [14
] or with a strongly elevated risk of second malignancies (such as leukaemias or myelodysplastic syndromes [15]), the RFS is an almost pure function of the relapse-rate. With a median follow-up of 87 months, the analysis of this study can now be considered mature with respect to the endpoint of RFS. As in the previous analysis [2], high-dose chemotherapy in high-risk breast cancer was associated with a small RFS benefit of borderline statistical significance. RFS appeared to be substantially improved by high-dose chemotherapy in the subgroup of patients with 10 or more positive axillary lymph nodes. Further analysis, however, which included a comprehensive pathology review, revealed that the number of lymph nodes was a much less significant predictor of the effect of high-dose chemotherapy than biology.
There was no statistical interaction between nodal subgroup and treatment arm, while there was a highly significant interaction between HER2/neu and treatment. This finding is unchanged in comparison with the first report of this study [2]. Patients with HER2/neu-positive tumours derived no benefit from high-dose therapy, with a RFS at 5 years of only 43.9% versus 55.9% in the conventional-dose arm.
The HER2/neu positive patients appeared to have a higher relapse rate after high-dose therapy than after conventional-dose, with a hazard ratio of 1.24. Possibly because this part of the analysis involves only 205 patients, this difference is not statistically significant. As mentioned previously, the statistical test for interaction between HER2/neu and treatment arm was highly significant, with a P value of 0.0059. Even when corrected for multiple testing, this strongly suggests that the effects of high-dose alkylating chemotherapy are different for HER2/neu-positive and HER2/neu-negative tumours.
These findings are consistent with the existing literature on HER2/neu and chemotherapy. Evidence is accumulating that HER2/neu-positive breast cancer must be viewed as a separate subgroup of breast cancer [16]. Unsupervised hierarchical clustering of mRNA expression analysis has shown that HER2/neu-positive breast tumours represent a distinct biological entity [17, 18], a finding that has been shown to be replicable in microarray data of other groups [19].
The sensitivities to alkylating agents and to anthracyclines have been reported to differ markedly between HER2/neu positive and -negative breast cancers. The Oxford meta-analysis has demonstrated that anthracycline-based therapies are slightly, but significantly, more effective than CMF-like regimens in the adjuvant setting [20]. From retrospective studies, this benefit may be confined to tumours overexpressing HER2/neu [21–27]. Relative resistance of HER2/neu-positive tumours to alkylating adjuvant therapy such as CMF [23, 28] has been suggested by several authors, although it is not universally accepted [29]. There is, however, strong evidence that HER2/neu overexpression is associated with sensitivity to (adequate doses of) anthracyclines but not with particular sensitivity to other agents. First reported by Muss and co-workers in 1994 [30], this finding has been corroborated in independent studies. For instance, Petit et al. [31] reported a study in which neo-adjuvant chemotherapy was employed as either FE50C or FE100C in 79 patients. There was no difference in objective response rate for the HER2/neu negative tumours between the two regimens, but FE100C was more effective than FE50C in HER2/neu-positive disease. For HER2/neu negative disease, the response rate was independent of the anthracycline dose. A recent European study has also shown that anthracycline-dose is important in HER2/neu positive disease, but not in HER2/neu-negative tumours [32]. The addition of doxorubicin to CMF adjuvant chemotherapy significantly improved survival in HER2/neu-positive tumours [26]. These and other studies suggest that the difference in cumulative epirubicin dose between the conventional arm (450 mg/m2) and the high-dose arm (360 mg/m2), could be responsible for the higher relapse rate of HER2/neu-positive tumours in the high-dose arm.
Breast cancer patients with HER2/neu positive tumours are widely believed to have a poor prognosis despite conventional adjuvant chemotherapy [27] and have therefore often been considered for dose-intensive approaches [33, 34]. Interestingly, however, retrospective analyses of uncontrolled high-dose chemotherapy series, both in the adjuvant and in the metastatic setting, have consistently shown that HER2/neu-positive tumours do very poorly. To date, 10 of these analyses [35–44] have been published, five regarding high-risk primary breast cancer and five in advanced disease. Together over 1000 patients undergoing high-dose therapy have been retrospectively analyzed. All five adjuvant studies and three of the studies on advanced disease (together including 781 of the 1007 patients) find that HER2/neu amplification as determined by IHC and/or FISH is an independent unfavourable prognostic factor. In fact, positive staining for HER2/neu was often found to be among the strongest adverse predictive factors for relapse and/or survival after high-dose alkylating chemotherapy. High-dose therapy is therefore clearly inappropriate for these patients.
In this study, patients with HER2/neu-negative disease had a significantly lower relapse rate after high-dose therapy: the 621 patients with a HER2/neu-negative tumour have a 27.8% relapse-rate after 5 years when randomised to the high-dose group, compared with a relapse-rate of 38.4% in the conventionally treated group (two-sided P value, 0.002 in the log-rank analysis). This corresponds with a 32% reduction of the hazard ratio. For this subgroup, there is also a statistically significant survival benefit (Figure 3b).
This finding fits well with both laboratory studies of drug resistance and with randomised studies in the adjuvant treatment of breast cancer. The rationale for high-dose alkylating chemotherapy in this disease, building on steep log–linear dose–response relationships for these agents in vitro, has always been strong and persuasive [45]. The beneficial effect of this approach could, however, have been partially masked in many randomised studies by the fact that about 25% of the patients had HER2/neu positive disease and therefore did not benefit from high-dose therapy or even did worse. Our analysis indicates that the planned subgroup analysis of the high-risk group (10 or more axillary lymph node metastases) is probably misleading: it may not be the number of lymph node metastases that is important, but rather the absence or presence of HER2/neu gene amplification that predicts the efficacy of high-dose alkylating chemotherapy.
The overview of the subgroup analyses presented in the Forest plots of Figure 4 shows that young patients with tumours of lower grades may optimally benefit of the high-dose therapy. Since (i) lower grade tumours are usually hormone receptor-positive; (ii) younger patients with receptor-positive disease may be expected to derive most benefit from ovarian ablation and (iii) ovarian failure is more common after high-dose therapy than after conventional dose therapy, some of the benefit for patients with HER2/neu-negative disease might be explained by ovarian ablation rather than the direct cytotoxicity of the treatment. This study was not designed to estimate the relative contribution of this effect, but it is clear from the data that it cannot be the only (or most important) determinant of the high-dose chemotherapy effect. First, the expression of ER or PR did not define groups with different efficacy of high-dose therapy (Figure 4b), while tumour grade and age did. Second, if one examines the results in HER2/neu-negative patients with negative hormone receptors, in whom the castration effect cannot have played a role, the advantage for high-dose therapy is as large as in receptor-positive patients (Figure 5). In addition, younger age remained associated with more benefit in patients with ER-negative/PR-negative tumours as well (results not shown).
Our findings suggest that there exists a subgroup of breast cancers that is specifically sensitive to high-dose alkylating agents. These tumours are characterised by the absence of a HER2/neu gene amplification, they may occur more frequently in younger patients and may appear to have a relatively low-grade of malignancy at microscopic evaluation. High-dose alkylating chemotherapy with cyclophosphamide, thiotepa and carboplatin is reasonably safe in multi-centre setting, but it is still more demanding for the patient than conventional-dose chemotherapy. It would be highly desirable to study other randomised trials [14, 15, 50] to confirm the association of HER2/neu negativity with sensitivity for high-dose alkylating chemotherapy. It will also be important to employ novel techniques, such as mRNA expression microarrays, to establish gene expression patterns associated with alkylating agent sensitivity. Clearly, adjuvant chemotherapy regimens that include one of the taxanes (paclitaxel or docetaxel) have been shown to significantly improve relapse-free and overall survival in early breast cancer. Future studies of high-dose chemotherapy should make optimal use of these agents in order to show that additional benefit can be obtained.
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S. Rodenhuis and E.G.E. de Vries were responsible for the study idea and coordinated the conduct of the study. J.L. Peterse and M.J. van de Vijver conducted the centralised pathology review and were responsible for the immunohistochemistry. H. van Tinteren and S. Rodenhuis were responsible for the data-analysis and interpretation and had full access to all data in the study and had final responsibility for the decision to submit for publication. All authors contributed patients, supervised the collection and communication of patient data and critically reviewed the article.
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Acknowledgements |
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This study was supported by grant OG 94–051 of the Dutch Health Insurance Council. We declare no conflicts of interest.
Received for publication October 20, 2005. Revision received December 13, 2005. Accepted for publication December 19, 2005.
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References |
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