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Jerevall, Piiha-Lotta
Publications (9 of 9) Show all publications
Jerevall, P.-L. (2011). Homeobox B13 in breast cancer: Prediction of tamoxifen benefit. (Doctoral dissertation). Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Homeobox B13 in breast cancer: Prediction of tamoxifen benefit
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A major issue in the management of breast cancer is to identify patients who are less likely to be cured after primary treatment and would benefit from adjuvant chemotherapy. Of great importance is also identification of patients with only local disease who traditionally would be given chemotherapy but would survive without. In this thesis we have validated the utility of the two-gene ratio HOXB13:IL17BR, which previously has been demonstrated to predict disease-free survival in tamoxifen-treated breast cancer patients. We have also studied the prognostic and predictive utility of a single gene as a biomarker in breast cancer medicine.

We could confirm that HOXB13:IL17BR may classify patients with different treatment benefit; only patients with a low value showed benefit from prolonged duration of tamoxifen therapy, whereas for the group with high ratios, the long-term recurrence rate did not improve with longer treatment duration.

The combination of HOXB13:IL17BR and the molecular grade index (MGI), another prognostic marker, has been shown to outperform either alone in predicting risk of breast cancer recurrence. We validated the prognostic utility of HOXB13:IL17BR+MGI in a large randomized patient cohort and found that this risk classification identified more than 50% of the tamoxifen-treated lymph node-negative patients as having a less than 3% risk of distant recurrence and breast cancer death. Furthermore, we developed and tested a continuous risk model of HOXB13:IL17BR+MGI called Breast Cancer Index (BCI), for estimation of recurrence risk at the individual level. Our study shows that BCI has the ability to identify more than 50% of patients with a low risk of recurrence more accurately than using traditional risk assessment. These results suggest that BCI may help clinicians to make better informed treatment decisions and spare toxic chemotherapy for a large group of breast cancer patients.

The protein expression of HOXB13 was also shown to be a valuable predictor in postmenopausal patients. High expression was associated with worse outcome after tamoxifen therapy. In a premenopausal cohort, patients with hormone receptor-positive tumors showed benefit from tamoxifen regardless of HOXB13 expression. Further analysis indicated that estrogen receptor β (ERβ) modified the performance of HOXB13 as a predictor of treatment effect and should be taken into account when identifying patients less likely to respond to the therapy given.

In conclusion, BCI identifies patients with a very low risk of distant recurrence. It may be utilized in the management of breast cancer patients to optimize the use of chemotherapy. HOXB13 protein expression may be used as a marker for tamoxifen benefit, but its performance in premenopausal patients might be modified by ERβ.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. p. 69
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1243
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68137 (URN)978-91-7393-184-7 (ISBN)
Public defence
2011-06-01, Berzeliussalen, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-05-12 Created: 2011-05-12 Last updated: 2011-05-12Bibliographically approved
Jerevall, P.-L., Ma, X.-J., Li, H., Salunga, R., Kesty, N. C., Erlander, M. G., . . . Stål, O. (2011). Prognostic utility of HOXB13:IL17BR and Molecular Grade Index in early-stage breast cancer patients from the Stockholm trial. Paper presented at 32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium. December 10, San Diego. British Journal of Cancer, 104(11), 1762-1769
Open this publication in new window or tab >>Prognostic utility of HOXB13:IL17BR and Molecular Grade Index in early-stage breast cancer patients from the Stockholm trial
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2011 (English)In: British Journal of Cancer, ISSN 0007-0920, E-ISSN 1532-1827, Vol. 104, no 11, p. 1762-1769Article in journal (Refereed) Published
Abstract [en]

Background: A dichotomous index combining two gene expression assays, HOXB13:IL17BR (H:I) and molecular grade index (MGI), was developed to assess risk of recurrence in breast cancer patients. The study objective was to demonstrate the prognostic utility of the combined index in early-stage breast cancer.

Methods: In a blinded retrospective analysis of 588 ER-positive tamoxifen-treated and untreated breast cancer patients from the randomized prospective Stockholm trial, H:I and MGI were measured using real-time RT-PCR. Association with patient outcome was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression. A continuous risk index was developed using Cox modeling.

Results: The dichotomous H:I+MGI was significantly associated with distant recurrence and breast cancer death. The >50% of tamoxifen-treated patients categorized as low-risk had <3% 10-year distant recurrence risk. A continuous risk model (Breast Cancer Index (BCI)) was developed with the tamoxifen-treated group and the prognostic performance tested in the untreated group was 53% of patients categorized as low-risk with an 8.3% 10-year distant recurrence risk.

Conclusion: Retrospective analysis of this randomized, prospective trial cohort validated the prognostic utility of H:I+MGI and was used to develop and test a continuous risk model that enables prediction of distant recurrence risk at the patient level.

Place, publisher, year, edition, pages
Nature Publishing Group, 2011
Keywords
Breast Cancer Index, recurrence, risk assessment, gene expression profiling, prognosis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68122 (URN)10.1038/bjc.2011.145 (DOI)000290953200016 ()
Conference
32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium. December 10, San Diego
Note
Original Publication: Piiha-Lotta Jerevall, Xiai-Jun Ma, Hongying Li, Ranelle Salunga, Nicole C. Kesty, Mark G. Erlander, Dennis Sgroi, Birgitta Holmlund, Lambert Skoog, Tommy Fornander, Bo Nordenskjöld and Olle Stål, Prognostic utility of HOXB13:IL17BR and Molecular Grade Index in early-stage breast cancer patients from the Stockholm trial, 2011, British Journal of Cancer, (104), 11, 1762-1769. http://dx.doi.org/10.1038/bjc.2011.145 Copyright: Nature Publishing Group http://npg.nature.com/ Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2017-12-11Bibliographically approved
Jerevall, P.-L., Jansson, A., Fornander, T., Skoog, L., Nordenskjöld, B. & Stål, O. (2010). Predictive relevance of HOXB13 protein expression for tamoxifen benefit in breast cancer. Breast Cancer Research, 12(4)
Open this publication in new window or tab >>Predictive relevance of HOXB13 protein expression for tamoxifen benefit in breast cancer
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2010 (English)In: Breast Cancer Research, ISSN 1465-5411, E-ISSN 1465-542X, Vol. 12, no 4Article in journal (Refereed) Published
Abstract [en]

ABSTRACT: INTRODUCTION: The HOXB13:IL17BR index has been identified to predict clinical outcome in the setting of adjuvant tamoxifen monotherapy of breast cancer. Further studies have shown that HOXB13 in particular can indicate benefit of prolonged tamoxifen treatment. Patients with high-expressing tumors did not benefit from prolonged treatment, suggesting that HOXB13 might be involved in tamoxifen resistance. No studies have been made regarding the HOXB13 protein levels in breast cancer. The aim of our study was to investigate whether tamoxifen benefit can be correlated to different levels of HOXB13 protein expression. METHODS: We used immunohistochemistry to analyze protein levels of HOXB13 in tumor samples from 912 postmenopausal node-negative breast cancer patients randomized to adjuvant tamoxifen therapy or no endocrine treatment. RESULTS: Tamoxifen-treated patients with estrogen receptor-positive tumors expressing none or low levels of HOXB13 had a clear benefit from tamoxifen in terms of longer distant recurrence-free survival (DRFS) (hazard ratio = 0.38, 95% confidence interval = 0.23 to 0.60, P = 0.000048). However, for patients with a high or intermediate HOXB13 tumor expression, tamoxifen did not prolong the DRFS compared with the untreated patients (hazard ratio = 0.88, 95% confidence interval = 0.47 to 1.65, P = 0.69). Interaction between HOXB13 expression and benefit from tamoxifen was statistically significant for DRFS (P = 0.035). No prognostic value could be ascribed to HOXB13 among systemically untreated patients. CONCLUSIONS: A high HOXB13 expression was associated with decreased benefit from tamoxifen, which indicates that HOXB13 protein level may be used as a predictive marker for tamoxifen treatment.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-58819 (URN)10.1186/bcr2612 (DOI)
Available from: 2010-08-27 Created: 2010-08-27 Last updated: 2017-12-12Bibliographically approved
Jerevall, P.-L., Jansson, A., Fornander, T., Skoog, L., Nordenskjöld, B. & Stål, O. (2009). HOXB13 protein expression predicts the benefit of tamoxifen treatment in breast cancer patients: in CANCER RESEARCH, vol 69, issue 2, Supplement 1, pp 358S-358S. In: CANCER RESEARCH. Paper presented at 32nd San Antonio Breast Cancer Symposium 2009, December 10-13, San Antonio, USA (pp. 358S-358S). , 69(2)
Open this publication in new window or tab >>HOXB13 protein expression predicts the benefit of tamoxifen treatment in breast cancer patients: in CANCER RESEARCH, vol 69, issue 2, Supplement 1, pp 358S-358S
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2009 (English)In: CANCER RESEARCH, 2009, Vol. 69, no 2, p. 358S-358SConference paper, Published paper (Refereed)
Abstract [en]

Background: The two-gene expression ratio HOXB13:IL17BR, originally from a microarray analysis, has been shown to be indicative of clinical outcome in the setting of adjuvant tamoxifen monotherapy of breast cancer, with a high ratio associated with decreased disease-free survival. Analysis of a cohort of breast cancer patients randomized to 2 or 5 years of adjuvant tamoxifen therapy showed that the two-gene ratio and expression of the HOXB13 gene alone were predictive of the benefit of prolonged tamoxifen treatment. Patients with tumors expressing HOXB13 at high levels were unresponsive to prolonged adjuvant treatment, suggesting that this gene is involved in tamoxifen resistance. It is suggested that a high two-gene ratio may indicate impaired ER signaling, which is known to predict resistance to tamoxifen. To our knowledge, there are no studies investigating the HOXB13 protein levels in breast cancer.

Methods: We have analyzed the protein expression of HOXB13 with immunohistochemistry in tumor samples from 912 postmenopausal node negative breast cancer patients randomized to 2 years of tamoxifen or no endocrine treatment. After 2 years, recurrence-free patients were randomized to 3 more years of tamoxifen, or no further therapy. This selection enabled us to investigate the treatment predictive value of HOXB13.

Results: Data on HOXB13 protein expression were obtained from 866 patients (see table). Tamoxifen treated patients with estrogen receptor (ER) positive tumors expressing none or low levels of HOXB13 had a clear benefit from tamoxifen in terms of longer distant recurrence-free survival (hazard ratio (HR) 0.37, 95% CI 0.23-0.60, p=0.000048). However, for patients with a high or intermediate HOXB13 tumor expression, tamoxifen did not prolong the distant recurrence-free survival compared to the untreated patients (HR=0.83, 95% CI 0.45-1.54, p=0.55). The interaction between HOXB13 expression and benefit from tamoxifen was statistically significant (p=0.046). HOXB13 did not have any prognostic value among systemically untreated patients.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53872 (URN)10.1158/0008-5472.SABCS-6038 (DOI)000262583201509 ()
Conference
32nd San Antonio Breast Cancer Symposium 2009, December 10-13, San Antonio, USA
Available from: 2010-02-06 Created: 2010-02-06 Last updated: 2011-04-12Bibliographically approved
Stål, O., Jerevall, P.-L., Ma, X.-J., Li, H., Salunga, R., Erlander, M., . . . Fornander, T. (2009). Validation of Prognostic Utility of HOXB13:IL17BR and Molecular Grade Index in Early Stage Breast Cancer: in CANCER RESEARCH, vol 69, issue 24, pp 504S-504S. In: . Paper presented at 32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium. December 10, San Diego (pp. 504S-504S). , 69(24)
Open this publication in new window or tab >>Validation of Prognostic Utility of HOXB13:IL17BR and Molecular Grade Index in Early Stage Breast Cancer: in CANCER RESEARCH, vol 69, issue 24, pp 504S-504S
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2009 (English)Conference paper, Published paper (Refereed)
Abstract [en]

Background. HOXB13:IL17BR (H:I) is a two gene expression index, which has been shown to be an independent prognostic factor in estrogen receptor (ER)-positive lymph node-negative (N0) breast cancer. A molecular grade index (MGI) measures the expression of five proliferation-related genes. An algorithm based on dichotomized H:I and MGI stratifying patients into three risk groups has been shown to be superior to either alone in predicting risk of distant metastasis in ER+/N0 patients. Further validation in larger cohorts is needed to establish its clinical performance. A continuous predictor combining H:I and MGI is desirable for making individualized risk assessment in the clinical setting.

Methods. During 1976 through 1990 the Stockholm Breast Cancer Group conducted a randomized clinical trial comparing adjuvant tamoxifen with control in 1780 postmenopausal women considered to be at low risk of recurrence (N0 and tumor size < 3 cm). We measured H:I and MGI using a real time PCR assay in 769 patients from this trial based on sample availability. Correlation of gene expression indices with distant metastasis and death due to breast cancer was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression. Modeling was also used to develop a continuous risk index as a function of both H:I and MGI.

Results. Using pre-specified cutoff points and combination algorithm, H:I, MGI and their combination each was significantly associated with both distant metastasis-free survival and breast cancer-specific survival (Table 1). Furthermore, we used the ER+ tamoxifen-treated subset (n=314) to develop a continuous risk model (Breast Cancer Index or BCI) combining both H:I and MGI. The prognostic utility of BCI was then successfully validated in the untreated subset in this trial and three additional previously published cohorts. BCI consistently identified ∼50% patients with a very low 10-year recurrence risk (< 5%). Discussion. This large retrospective analysis of a randomized clinical trial cohort validated the prognostic utility of H:I, MGI, and their combination. With the continuous risk model, this RT-PCR-based assay allows prediction of risk of recurrence at the individual level, which may help tailor personalized treatment strategy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53829 (URN)000272920700070 ()
Conference
32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium. December 10, San Diego
Available from: 2010-02-05 Created: 2010-02-05 Last updated: 2011-05-11Bibliographically approved
Gunnarsson, C., Jerevall, P.-L., Hammar, K., Olsson, B., Nordenskjöld, B., Jansson, A. & Stål, O. (2008). Amplification of HSD17B1 has prognostic significance in postmenopausal breast cancer. Breast Cancer Research and Treatment, 108(1), 35-41
Open this publication in new window or tab >>Amplification of HSD17B1 has prognostic significance in postmenopausal breast cancer
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2008 (English)In: Breast Cancer Research and Treatment, ISSN 0167-6806, E-ISSN 1573-7217, Vol. 108, no 1, p. 35-41Article in journal (Refereed) Published
Abstract [en]

In situ synthesis of estrogens is believed to be of great importance for the progression of breast cancer. In postmenopausal women most estrogens are synthesized in peripheral hormone-target tissues from circulating precursor steroids, by the enzymes involved in formation of active estrogens. One of the enzymes involved in this process is 17β-hydroxysteroid dehydrogenase (17β-HSD) type 1. This enzyme catalyzes the interconversion of estrone (E1) to the biologically more potent estradiol (E2). The gene coding for 17β-HSD type 1 (HSD17B1) is located at 17q12-21. The aim of this study was to investigate altered gene copy number of HSD17B1 in breast cancer. We used real-time PCR and examined 387 postmenopausal breast tumors for amplification of HSD17B1, and if an increased mRNA level of this enzyme is associated with amplification of the gene. We also investigated whether amplification of HSD17B1 has a prognostic value. There was a significant correlation between gene copy number of HSD17B1 and mRNA expression level (P = 0.00002). ER-positive patients with amplification of HSD17B1 showed lower breast cancer survival than patients without amplification (P = 0.025). Among ER-negative patients there was no significant correlation between increased gene copy number of HSD17B1 and prognosis. Furthermore, we found that amplification of the gene had prognostic significance in multivariate analysis adjusting for other clinicopathological variables. © 2007 Springer Science+Business Media, LLC.

Keywords
Breast Neoplasms/*genetics/mortality Disease-Free Survival Estradiol Dehydrogenases/*genetics Female *Gene Amplification Humans Kaplan-Meiers Estimate Middle Aged Postmenopause Prognosis RNA, Messenger/analysis Receptors, Estrogen/metabolism Reverse Trans
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-43344 (URN)10.1007/s10549-007-9579-7 (DOI)73588 (Local ID)73588 (Archive number)73588 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2017-12-13Bibliographically approved
Jerevall, P.-L., Brommesson, S., Strand, C., Gruvberger-Saal, S., Malmström, P., Nordenskjöld, B., . . . Stål, O. (2008). Exploring the two-gene ratio in breast cancer – independent roles for HOXB13 and IL17BR in prediction of clinical outcome. Breast Cancer Research and Treatment, 107(2), 225-234
Open this publication in new window or tab >>Exploring the two-gene ratio in breast cancer – independent roles for HOXB13 and IL17BR in prediction of clinical outcome
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2008 (English)In: Breast Cancer Research and Treatment, ISSN 0167-6806, E-ISSN 1573-7217, Vol. 107, no 2, p. 225-234Article in journal (Refereed) Published
Abstract [en]

Background: The two-gene expression ratio HOXB13:IL17BR has been proposed to predict the outcome of tamoxifen-treated breast cancer patients. We intended to examine whether this ratio can predict the benefit of 5 years vs. 2 years of tamoxifen treatment of postmenopausal patients. A further objective was to investigate any prognostic effects of the ratio in systemically untreated premenopausal patients. Based on the current knowledge of HOXB13 and IL17BR, we hypothesized that these genes may have individual prognostic or predictive power.

Patients and methods: Expression of HOXB13 and IL17BR were quantified by real-time PCR in tumors from 264 randomized postmenopausal patients and 93 systemically untreated premenopausal patients.

Results: A high HOXB13:IL17BR ratio was associated with aggressive tumor characteristics, as were low levels of IL17BR alone. The ratio and HOXB13 alone predicted recurrence-free survival after endocrine treatment, with a benefit of prolonged treatment in estrogen receptor-positive patients correlated to a low ratio (recurrence rate ratio: RR=0.39; p=0.030), or low expression of HOXB13 (RR=0.37; p=0.015). No difference in recurrence-free survival was seen for the high ratio or high HOXB13 subgroups. The predictive value of HOXB13 and HOXB13:IL17BR was significant in multivariate analysis. In the systemically untreated cohort, only IL17BR showed independent prognostic significance.

Conclusion: We conclude that the ratio or HOXB13 alone can predict the benefit of endocrine therapy, with a high ratio or a high expression rendering patients less likely to respond. We have also shown that IL17BR might be an independent prognostic factor in breast cancer.

Place, publisher, year, edition, pages
Institutionen för klinisk och experimentell medicin, 2008
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-11861 (URN)10.1007/s10549-007-9541-8 (DOI)
Note
The original publication is available at www.springerlink.com: Piiha-Lotta Jerevall, Sara Brommesson, Carina Strand, Sofia Gruvberger-Saal, Per Malmström, Bo Nordenskjöld, Sten Wingren, Peter Söderkvist, Mårten Fernö and Olle Stål, Exploring the two-gene ratio in breast cancer – independent roles for HOXB13 and IL17BR in prediction of clinical outcome, 2008, Breast Cancer Research and Treatment, (107), 2, 225-234. http://dx.doi.org/10.1007/s10549-007-9541-8. Copyright: Springer, www.springerlink.comAvailable from: 2008-05-21 Created: 2008-05-21 Last updated: 2017-12-13Bibliographically approved
Jerevall, P.-L., Ahmadi, A., Bergman, M., Stål, O. & Wingren, S. (2005). Sulfotransferase1A1 and risk of postmenopausal breast cancer. Anticancer Research, 25(3 C), 2515-2517
Open this publication in new window or tab >>Sulfotransferase1A1 and risk of postmenopausal breast cancer
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2005 (English)In: Anticancer Research, ISSN 0250-7005, E-ISSN 1791-7530, Vol. 25, no 3 C, p. 2515-2517Article in journal (Refereed) Published
Abstract [en]

The detoxification enzyme sulfotransferase1A1 (SULT1A1) is implicated in the inactivation of estrogens and the activation of promutagens andprocarcinogens. SULT1A1 activity varies among individuals, and this difference in phenotype is, in part, controlled by genetic polymorphism (Arg→His in codon 213). It is hypothesized that the His allele contributes to the risk of postmenopausal breast cancer. Frequencies of the Arg/His alleles were estimated in 229 postmenopausal breast cancer patients and 227 age-matched controls using a PCR-RFLP assay. Allele frequencies and genotype distributions were not statistically different between postmenopausal breast cancer patients and the population-based controls, i.e. neither of the alleles is associated with an increased risk of breast cancer in the present study.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-31348 (URN)17114 (Local ID)17114 (Archive number)17114 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
Jerevall, P.-L., Jansson, A., Källström, A.-C., Landberg, G., Fernö, M. & Stål, O.Homeobox B13 protein expression in a randomized tamoxifen trial of premenopausal breast cancer.
Open this publication in new window or tab >>Homeobox B13 protein expression in a randomized tamoxifen trial of premenopausal breast cancer
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Homeobox B13 (HOXB13), part of the two-gene expression index HOXB13:IL17BR, has proven its capacity as a predictive factor of tamoxifen benefit in breast cancer. HOXB13 mRNA expression, as well as protein levels, have shown predictive value in postmenopausal patients. High levels were associated with decreased tamoxifen benefit and may indicate endocrine resistance. Here, we have analyzed HOXB13 protein expression in premenopausal breast cancer. We quantified the levels of HOXB13 with immunohistochemistry in tumor samples from 487 patients on tissue microarrays. Patients were diagnosed with stage II invasive breast cancer and randomized to tamoxifen or no endocrine treatment. HOXB13 protein analysis was successful for 367 patients. Data were correlated with clinicopathological variables. Investigation of tamoxifen benefit in patients with tumors expressing estrogen receptor (ER) α, progesterone receptor, or both, showed that patients with high HOXB13 levels had benefit from tamoxifen (hazard ratio for recurrences 0.43, 95% CI: 0.28-1.01, p=0.053). Corresponding numbers for the low HOXB13 group were 0.69 (95% CI: 0.44-1.07, p=0.10). For further analysis, we stratified the patients based on tumor ERβ status, which may function as a modifier of the performance of HOXB13 as a treatment predictive factor. For the ERβ positive subset of patients, there was a tendency towards a low HOXB13 expression associated with a better tamoxifen response. However, an increased benefit from tamoxifen, in terms of a longer recurrence-free survival (RFS), was associated with high HOXB13 expression in the ERβ negative group. The interaction between HOXB13 and treatment effect for RFS in the ERβ-negative group was significant in a multivariate model (p=0.04). In conclusion, in our study cohort, ERβ seems to be an additional determinant to HOXB13 protein expression for endocrine treatment prediction in premenopausal breast cancer. To identify patients less likely to respond to tamoxifen therapy, both HOXB13 and ERβ status should be taken into account.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68120 (URN)
Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2011-05-12Bibliographically approved
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