Human epidermal growth factor receptor

2 (HER2)-positive and hormone receptor-positive

breast cancer: newinsights into molecular
interactions and clinical implications
F. Montemurro
1
*
, S. Di Cosimo
2
,

& G. Arpino
3
,

1
Unit of Investigative Clinical Oncology (INCO) and Division of Medical Oncology, Piedmont Oncology Foundation/Institute for Cancer Research and Treatment,
Candiolo;
2
Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan;
3
Department of Clinical Medicine and Surgery,
Federico II University, Naples, Italy
Received 25 November 2012; revised 15 May 2013 and 25 June 2013; accepted 26 June 2013
Recent data showa signicant benet from combining an anti-HER-2 agent with endocrine therapy in HER2-positive and
hormone receptor (HR)-positive metastatic breast cancer. However, as the clinical outcomes achieved by these
combinations do not favourably match those with chemotherapy, clinicians still perceive HER2-positive breast cancer as
an homogeneous group and consider chemotherapy with anti-HER2 agents as the preferred treatment option,
regardless of the HR status. Indeed, in HR-positive HER2-positive tumours, chemotherapy with anti-HER2 agents is the
backbone of treatment, while endocrine therapy is commonly used in sequence when HR and HER2 are co-expressed
rather than as a real alternative. Emerging biological and clinical data challenge this paradigm, suggesting that HER2-
positive tumours are rather heterogeneous that HRs co-expression may account for part of this heterogeneity and, nally,
that chemotherapy may represent an overtreatment in selected cases. The present reviewaims to summarise the
biological features of HER2-positive breast cancer according to HR status, the role of the bi-directional cross-talk
between HER2 and HR pathways on resistance development to anti-HER2 and endocrine therapy, and nally, the novel
therapeutic strategies, including but not limited to chemotherapy, targeting these two pathways.
Key words: breast cancer, cancer metastasis, drug therapy, her2/neu, hormone receptors, resistance
introduction
Amplication and/or overexpression of the human epidermal
growth factor 2 (HER2) oncogene, which belongs to the
epidermal growth factor receptor (EGFR/HER) family, occurs in
about 15% of invasive breast cancers, and enables constitutive
activation of growth factor signalling and triggering breast
cancer cell survival, proliferation, and invasion [1, 2]. Tumours
with HER2 amplication and/or overexpressionherein after
HER2-positive breast cancerare characterised by poor clinical
prognostic features, which translate into aggressive tumour
behaviour [1] and, importantly, by experimental and clinical
resistance to endocrine therapy. Current treatment of patients
with HER2-positive disease is primarily represented by
chemotherapy combined with HER2-targeted therapy, both in
the adjuvant and in the metastatic setting [36]. This approach
has dramatically changed the natural history of HER2-positive
breast cancer and is often suggested as a rst line option of
choice for patients with metastatic disease [7].
Recent studies suggest that HER-2 positive breast cancer is
biologically and clinically heterogeneous. Analysis on 169
HER2-positive early breast cancer by the 70-gene MammaPrint
signature reported that the 22% of cases were classied as
having good prognosis, with a 10-year distant disease-free
survival (DFS) of 84%, even in the absence of (neo)adjuvant
therapy with trastuzumab and chemotherapy. Of note, the
distant DFS for HER2-positive breast cancer patients classied
as having a poor prognosis signature was 55% [8]. Therefore, a
minority of patients with HER2-positive breast cancer patients
present an excellent prognosis even in the absence of treatment.
Hormone receptor co-expression may partially account for such
heterogeneity. For example recent data from neoadiuvant
studies suggest that response to therapy with anti-HER2 agents
largely depends on HR status [9, 10].
The present review explores the biological features and
clinical behaviour of HER2-positive breast cancer according to
HR status, describes the bi-directional cross-talk between HER2
and HR pathways and its implication on resistance development

These authors equally contributed to the work.

*Correspondence to: Dr Filippo Montemurro, Unit of Investigative Clinical Oncology
(INCO) and Division of Medical Oncology, Piedmont Oncology Foundation/Institute for
Cancer Research and Treatment, Strada Provinciale 142, Km 3.95-10060 Candiolo, Italy.
Tel: +39-011-9933250; Fax: +39-011-9933275; E-mail: lippo.montemurro@ircc.it
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Annals of Oncology 00: 110, 2013
doi:10.1093/annonc/mdt287
The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: journals.permissions@oup.com.
Annals of Oncology Advance Access published August 1, 2013

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to anti-HER2 agents and endocrine therapy, and illustrates the
novel therapeutic strategies, including but not limited to
chemotherapy, employable in the HER2-positive and HR-
positive breast cancer patients.
immunohistochemical and genetic
subtyping of HER2-positive and
HR-positive tumours
While about 10% of estrogen receptor (ER)-positive tumours
reveal HER2 overexpression, among the subgroup revealing
HER2 amplication and/or overexpression, about half are ER
positive. ER-positive tumours overexpressing HER2 in general
express ER at a lower level compared with ER-positive tumours
of the luminal A class [11]. Of note, in HER2-positive tumours,
ER and HER2 levels are inversely correlated at both the RNA
and the protein levels [12, 13].
A number of published reports consistently indicate that
HER2-positive breast cancers show different clinical
characteristics and prognosis according to the IHC status of
HRs [1416]. For example HR co-expression seems to mitigate
adverse prognosis in HER2-positive operable breast cancer
patients. More recently, data with the PAM50 demonstrated that
up to one-third of HER-positive early breast cancer may be
intrinsically classied as luminal A or B. Of note, the HER2-
enriched subtype according to PAM 50 signature predominates
in HER2-positive and ER-negative cases (35%51%) and
predicts response to neoadjuvant trastuzumab-based
chemotherapy [17, 18].
An additional evidence that HER2-positive tumours
heterogeneity is related to the HR co-expression came from a
study integrating DNA copy number arrays, DNA methylation,
exome sequencing, messenger RNA arrays, micro RNA
sequencing and reverse-phase protein [19]. In particular, a
HER2-enriched mRNA (HER2E-mRNA) subtype/HER2-
positive group was characterised by increased expression of
tyrosine kinase (TK) receptors FGFR4, EGFR, HER2 itself
together with genes within the HER2 amplicon (i.e. GRB7). A
second group, called luminal-mRNA subtype/HER2-positive,
enriched in HR-positive tumours, showed a higher expression of
luminal genes like GATA3, BCL2 and ESR1. These two groups
presented also distinct recurrent somatic mutations and protein
expression patterns. Further studies are warranted to
prospectively conrm these ndings. Collection and analyses of
tumour tissue are also needed to dissect the role of ER pathway
in HER2 signalling and vice-versa and to identify novel
predictive biomarkers and more targeted therapeutic strategies.
differential sensitivity of HER2-positive
tumours to combinations of
chemotherapy and HER2-targeting
agents according to HR status
Since the pivotal trial published by Slamon et al., the therapeutic
platform of chemotherapy combined with HER2-targeting has
undergone a constant development through randomised trials
in the metastatic setting. Table 1 summarises the details of most
of the inuential clinical studies in the rst-line setting (details
of each trial are reported in the supplementary Appendix,
available at Annals of Oncology online). Chemotherapy and
anti-HER2 agents combination is often considered a preferred
rst-line option for most patients with HER2-positive disease
[7], regardless of HR status, based on the following evidence: (i)
retrospective analyses of patients treated in the pre-trastuzumab
era showed that, overall, HER2-positive tumours are more
chemo-sensitive than their HER2-negative counterparts,
especially when anthracycline-containing regimens are used;
[20] (ii) as single agents, both trastuzumab and lapatinb are
modestly active; [2125] (iii) pre-clinical studies have suggested
synergistic effects between trastuzumab and agents such as
paclitaxel, docetaxel, vinorelbine and platinoids; [26] and (iv)
the pivotal trial [3] and a myriad of phase II studies, including
one inuential randomised trial, [4] conrmed the cooperative
effects of chemotherapy and trastuzumab, resulting in
impressive gains in response rates (RRs), progression-free
survival (PFS) and OS.
Newer regimens with double HER2 targeting, such as the
one used in the experimental arm of the Clinical Evaluation of
Pertuzumab and Trastuzumab (CLEOPATRA) study, have
established a newer efcacy benchmark for future
developments [27].
The chemotherapy plus HER-targeting paradigm has been
translated into the management of patients with operable breast
cancer, where all randomised studies have been designed to
include this monoclonal antibody in conjunction with
chemotherapy, for treatment, again regardless of the HR status
[6, 28, 29].
However, the biological heterogeneity of HER2-positive
tumours according to HR status may have potential therapeutic
implications. A correlation between hormone-receptor levels
and endocrine responsiveness/reduced chemosensitivity is
already recognised in HER2-negative tumours [30, 31], where
increased ER and PR are associated with endocrine
responsiveness and reduced chemosensitivity and, therefore, has
therapeutic implications [32]. A recently published analysis in
patients with HER2-positive metastatic tumours, treated with
chemotherapy and trastuzumab showed that ER expression in
more than 30% of cancer cells was associated with a
signicantly lower RR to treatment, compared with the RR
observed in tumours with lower or absent ER expression [33].
However, regardless of RR, PFS of patients with ER-positive
tumours was signicantly improved when maintenance
endocrine therapy was added to trastuzumab treatment. These
results suggest that RRs with chemotherapy and trastuzumab
may be lower than those summarised in Table 1 in HER2-
positive tumours expressing high ER levels and that HER2-
inhibition may overcome the de novo endocrine resistance of
these tumours.
Data from recent neoadjuvant trials further support the
hypothesis that, in HER2-positive tumours, the HR status
inuences response to anti-HER2-based therapy. Table 2
summarises the results of three of these trials where for the rst
time the pathological complete remission rate ( pCR), a
recognised surrogate of good clinical outcome [34], were
reported according to hormone-receptor status. The
Neoadjuvant Lapatinib and/or Trastuzumab Treatment
Optimization (NEO-ALLTO) and the Neoadjuvant Study of
review
Annals of Oncology
i | Montemurro et al.

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Pertuzumab and Herceptin in an Early Regimen Evaluation
(NEOSPHERE) trials were designed to deliver a short pre-
surgical treatment, followed by post-surgical adjuvant
chemotherapy and anti-HER2 therapy. In the German
Preoperative Adriamycin and Docetaxel (GEPAR) QUINTO
study, a full sequential anthracycline and taxane-based
chemotherapy regimen was delivered before surgery, and
trastuzumab was started concurrently with pre-operative
chemotherapy and continued after surgery to complete a year of
targeted therapy. Chemotherapy was part of the neoadjuvant
programme in all trials, with the exception of one arm of the
NEOSPHERE trial, where the association of trastuzumab and
Table 2. Rate of pathological complete response (pCR) and hormone receptor (HR) status in neo-adjuvant studies with anti-HER2 agents
Study No. of patients Regimen
a
anti-HER2 agent
a
Overall pCR
rate (%)
pCR rate according to
HR (%)
HR pos HR neg
GEPARQUINTO [87] 620 EC-Docetaxel Trastuzumab 30.3 25.8 38.7
Lapatinib 22.7 16.2 28.3
NEO-ALTTO [9] 455 Paclitaxel Trastuzumab 29.5 22.7 37.5
Lapatinib 24.7 16.1 33.7
Trastuzumab + Lapatinib 51.3 41.6 61.3
NEOSPHERE [10] 417 Docetaxel Trastuzumab 29.0 20 36.8
Pertuzumab 24.0 17.4 30
Pertuzumab + Trastuzumab 45.8 26 63.2
None Pertuzumab + Trastuzumab 16.8 5.9 29.1
a
See supplementary Appendix, available at Annals of Oncology online for details of treatments and schedule used in these studies.
pCR, pathological complete remission according to the denition given by each author for the main analysis; HR, hormone receptor; GEPAR, German
Preoperative Adriamycin and Docetaxel; NEO-ALTTO, Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimization; NEOSPHERE, Neoadjuvant
Study of Pertuzumab and Herceptin in an Early Regimen Evaluation.
Table 1. Phase III trials comparing chemotherapy HER2 targeting agents or different treatment combinations of chemotherapy and HER2 targeting agents
Study Design Treatment
a
N ORR
(%)
PFS or TTP
(months)
OS
H0648g [3] Randomised phase III, rst-line MBC Chemotherapy 234 32 4.6 20.3
Chemotherapy + Trastuzumab 235 50* 7.4* 25.1*
M7701 [4] Randomised phase II, rst-line MBC Docetaxel 94 34 6.1 22.7
Docetaxel + Trastuzumab 92 61* 11.7* 31.2*
CHAT [80] Randomised phase II, rst-line MNC Doxetaxel + Trastuzumab 110 72.7 12.8 NR
Docetaxel + Trastuzumab + Capecitabine 112 70.5 17.9*
BCIRG 007 [81] Randomised phase III, rst-line MBC Docetaxel + Trastuzumab 131 72 11.0 37.1
Docetaxel + Trastuzumab + Carboplatin 132 72 10.4 37.4
US Oncology [82] Randomised phase III, rst-line MBC Paclitaxel + Trastuzumab 98 36 7.1 32.2
Paclitaxel + Trastuzumab + Carboplatin 98 52 10.7* 35.7
HERNATA [83] Randomised phase III, rst-line
LABC or MBC
Docetaxel + Trastuzumab 143 59.9 12.4 35.7
Docetaxel + Vinorelbine 141 59.9 15.3 38.8
CLEOPATRA [27] Randomised phase III, rst line Docetaxel + Trastuzumab + Placebo 406 69.3 12.4 N.R**
Docetaxel + Trastuzumab + Pertuzumab 402 80.2* 18.5*
EGF30001 [84] Unplanned subgroup analysis of randomised
phase III trial, rst-line LABC or MBC
Paclitaxel + Placebo 37 37.8 6.3 20.6
Paclitaxel + Lapatinib 49 63.3 9.1* 26.2
EGF104535 [85] Randomised phase III trial, rst-line MBC Paclitaxel + Placebo 222 50 6.5 20.5
Paclitaxel + Lapatinib 222 69* 9.7* 27.8
TDM4450g [86] Randomised phase II trial, rst-line MBC Docetaxel + Trastuzumab 70 58 9.2 30
TDM1 67 64.2 14.2* N.R.**
*The difference was statistically signicant at the P < 0.05 level.
**The hazard ratio for overall survival was 0.64 favouring the combined arm (P = 0.005).
a
See supplementary Appendix, available at Annals of Oncology online for details of treatments and schedule used in these studies.
MBC, metastatic breast cancer; LABC, locally advanced breast cancer; ORR, overall response rate (complete + partial remission); CBR, clinical benet rate
(complete + partial remission and disease stabilisation lasting 6 months or longer); PFS, progression-free survival; TTP, time to progression; OS, overall
survival; N.R., not reached; CHAT, Capecitabine, Herceptin And Taxotere; BCIRG, breast cancer international research group; HERNATA, HERceptin plus
NAvelbine or TAxotere; CLEOPATRA, CLinical Evaluation Of Pertuzumab And TRAstuzumab.
Annals of Oncology
review
doi:10.1093/annonc/mdt287 |

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pertuzumab was delivered pre-operatively without
chemotherapy. The NEO-ALTTO and the NEOSPHERE trials
included arms with combinations of HER2-targeting agents,
whereas the GEPARQUINTO trial compared lapatinib with
trastuzumab. Despite differences in the denition of the primary
end point, the neoadjuvant studies with trastuzumab lapatinib
and trastuzumab pertuzumab reported pCR rates ranging
from 22.7% to 30% when a single HER2-targeting agent was
given in addition to chemotherapy. The pCR rates increased to
between 45.8% and 51.3%, respectively, when pertuzumab and
lapatinib were added to trastuzumab and chemotherapy. The
NEOSPHERE study reported a pCR rate of 16.8% in the arm
with trastuzumab and pertuzumab without chemotherapy. This
nding is remarkable as it suggests that a subgroup exists for
whom anti-HER2 therapy alone may offer signicant efcacy
without the addition of chemotherapy.
Importantly, all the studies consistently showed that pCR
rates to neoadjuvant therapy were signicantly lower in ER-
positive compared with ER-negative tumours (Table 2). This
also occurred in the chemotherapy-free arm of the
NEOSPHERE trial, where treatment led to disease eradication
in about one-third of ER-negative tumours, compared with just
6% in their ER-positive counterparts. A similar observation was
made in a small study exploring the activity of exclusive dual
blockade therapy with lapatinib and trastuzumab in the
neoadjuvant setting [35]. This Translational Breast Cancer
Research Council (TBCRC) 006 trial reported an overall pCR
rate of 42% after 12 weeks of therapy in HER2-positive/ER-
negative operable and/or locally advanced breast cancer.
Interestingly, in patients with HER2-positive/ER-positive
disease, letrozole was added to lapatinib and trastuzumab,
resulting in a pCR rate of 21%. This pCR rate favourably
compares with that observed in the subset of HER2-positive/
ER-positive tumours treated in the trastuzumab/pertuzumab
arm of the NEOSPHERE trial. While this may result as being
just an additive effect, the hypothesis that endocrine therapy
may partially restore sensitivity to HER2-targeting is intriguing
and deserves further study.
Lack of long-term survival data suggests that results of
neoadjuvant trials should not impact on the way that early,
HER2-positive breast cancer is currently treated. However, the
rate of tumour response from neoadjuvant studies foster the use
of HER2-targeted therapy in combination with endocrine
therapy for advanced breast cancer patients with tumours that
co-express high-levels of HRs.
differential sensitivity of HR-positive
tumours to endocrine-therapy according
to HER2 status
In ER-positive early breast cancer, endocrine treatment reduces
the recurrence and mortality rates, regardless of the use of
chemotherapy [36]. Clinical data suggest that overexpression of
HER2 and the lesser-studied EGFR is associated with a poorer
outcome in breast cancer patients treated with endocrine
therapy [3742]. However, data are not denitive as while some
studies indicated no benet or even a potentially detrimental
effect of tamoxifen on outcomes in women with HER2-positive/
HR positive tumours, [39, 40], other studies failed to show such
effect [41, 42].
Neoadjuvant trials provide a unique platform to correlate
molecular determinants of response and resistance with the
clinical response of primary breast cancer to medical therapy.
Results in this setting show more consistently that HER2 and, to
a lesser extent, EGFR may act as mediators of resistance to
tamoxifen. In women with locally advanced, HR-positive breast
cancer randomised to neoadjuvant treatment with tamoxifen or
with the aromatase inhibitor (AI) letrozole [43], letrozole
signicantly increased RR compared with tamoxifen. However,
differences in RRs between the two drugs were most marked for
ER-positive and EGFR and/or HER2-positive tumours,
suggesting that the growth-promoting effects of these growth
factor receptors on ER-positive breast cancer can be most
effectively inhibited by potent estrogen deprivation therapy.
Dowsett et al. analysed changes in tumour proliferation
occurring in patients randomised to another AI, anastrozole,
tamoxifen or the combination of the two agents given for 3
months before surgery [44]. Similarly to the previously
described trial, the superiority of anastrozole over tamoxifen in
terms of RR was mostly observed in HER2-positive/HR-positive
tumours. Intriguingly, after 2 weeks of treatment, tamoxifen was
less effective than anastrozole in suppressing proliferation in
HER2-positive tumours compared with HER2-negative
tumours. Among patients receiving anastrozole at the end of 12
weeks of treatment, those with HER2-positive tumours showed
a signicantly lower degree of proliferation suppression than
their HER2-negative counterparts as, after an initial response,
resistance to AIs depending on HER2 signalling may rapidly
emerge. A recent follow-up of the study by Ellis et al. also
supports the idea that in HER2-positive/HR-positive tumours,
there is an estrogen-independent signalling mechanism that
leads to increased proliferation [45].
A retrospective analyses of the Arimidex, Tamoxifen, Alone
or in Combination (ATAC) and the Breast International Group
(BIG) 1 studies, two large randomised trials of adjuvant
endocrine therapy [46, 47], failed to demonstrate any
interaction between type of endocrine therapy and HER2 status
on long-term efcacy outcomes. Indeed, AIs were found to be
more effective than tamoxifen in the overall patient population,
regardless of the HER2 status. Importantly, HER2-positivity
predicted a worse clinical outcome regardless of treatment type,
conrming its role as a marker of resistance to endocrine
manipulation in general.
HR and HER bi-directional cross-talk:
implications on the development of
resistance to endocrine therapy and
anti-HER agents
Based on the above, clinically dened HER2-positive subtype of
breast cancer is not clinically and biologically homogenous.
There is increasing evidence that the ER and HER2 pathways
cross-talk and thereby synergise in tumour progression. The
following paragraphs summarise molecular evidence of such bi-
directional cross-talk and its role in differential sensitivity to
therapies.
review
Annals of Oncology
| Montemurro et al.

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HER /ERcross-talk as a mechanism
for resistance to endocrine therapy
Aberrant signalling through the growth factor receptors
pathway has long been identied as a mediator of resistance to
endocrine manipulation in HR-positive cancer cells [48].
Clinical and laboratory evidence support a critical role for the
cross-talk between the ER and HER2 signalling pathways in
resistance to endocrine therapy [20], especially when both the
receptors are co-expressed. Mechanisms of ER signalling in
breast cancer are described in Figure 1. Estrogens, by activation
of the ER nuclear function, can increase transcription and
expression of ligands such as transforming growth factor-
(TGF) and insulin-like growth factor 1 (IGF1) [4951], that, in
turn, can trigger the growth factor receptor pathway [50, 52].
Activation of the PI3K/AKT and the p42/44 MAPK pathways
Figure 1. Mechanisms of estrogen receptor (ER) action in breast cancer. Three distinct pathways of ER regulation of gene expression are shown. First, in
classic estrogen signalling, ligand-bound ER activates gene expressioneither through direct binding of dimeric ER to specic DNA response elements,
estrogen receptor elements (EREs), in complexes that include co-activators (CoA) and histone acetyl transferases (HAT), or through proteinprotein
interactions with other transcription factors, particularly members of the activation protein 1 (Ap1) and specicity protein 1 (Sp1) familiesto facilitate
binding to serum response elements (SRE) and activation of gene transcription including genes encoding for growth factors (GFs) and receptor tyrosine
kinases (RTKs) (A). Secondly, ER can also be activated as a consequence of signalling events downstream of receptor tyrosine kinases (RTKs) such as the
epidermal growth factor receptor (EGFR), ERBB2 (also known as HER2) and the insulin-like growth factor receptor (IGFR). Phosphorylation (P) of
transcription factors (TFs) and coregulators, including components of the ER pathway that enhance gene expression on Estrogen response elements (EREs)
and other response elements (REs) by the Erk or Akt serine/threonine kinases leads to ligand-independent activation of the ER (B). Thirdly, signalling can be
mediated through non-genomic mechanisms by ER that is localised at the cell membrane or in the cytoplasm (C). Ligand binding induces the assembly of
functional protein complexes that involve other signalling molecules and that activate intracellular signalling cascades, resulting in TF activation. However, the
clinical role of membrane ER needs further investigation as its incidence in human breast cancer is very low.
Annals of Oncology
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doi:10.1093/annonc/mdt287 | ,

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by these receptors, may subsequently result in phosphorylation
of ER and its co-activator such as AIB1, thus leading to
enhancement of genomic ER activities, even in the absence of its
ligand, or in the presence of selective ER modulators (SERMs)
such as tamoxifen [52, 53]. Phosphorylation of co-repressors,
on the other hand, can result in their export from the nucleus,
thereby preventing regulation of ER transcriptional complexes
in the nucleus [54, 55]. Down-regulation of ER and PgR
expression has been demonstrated to occur as a result of HER-
mediated activation of the PI3K/AKT and the p42/44 MAPK
pathways [56, 57]. Thus, while receptor tyrosine kinases can
activate the transcriptional function of the ER, they can also
reduce estrogen dependence by down-regulating the expression
of the ER or estrogen-related genes, such as the PgR. This could
possibly contribute to the relative resistance to endocrine
therapies in tumours harbouring abnormalities in HER
receptors members.
Hurtado et al. [34] have recently shown that estrogen-ER and
tamoxifen-ER complexes directly repress HER2 transcription.
The Paired Box 2 transcription factor (PAX2) seems to be the
mediator of this cross-talk and its loss or deregulation causes
tamoxifen resistance by the acquisition of a HER2-driven
phenotype in the ER-positive luminal cells.
In addition to genomic signalling [58], in breast cancer
culture models, the membrane (nonnuclear) ER, bound to
either oestradiol or tamoxifen [52, 55], by triggering EGFR,
HER2, and IGFR1 [59] and their downstream pathways [60],
ultimately contribute to tamoxifen resistance development by
increasing nuclear ER gene transcription [61]. However, the
average incidence of cytoplasmic ER in nearly 3200 cases of
breast cancer was only 1.5%, strongly suggesting that its
measurement is unlikely to be of routine clinical value at the
present [62].
The following laboratory evidences suggest that inhibition of
HER pathways may delay endocrine resistance onset and that
the dual inhibition of both HER2 and ER pathways may exert
optimal antitumour activity in HR and HER2-positive breast
cancer.
In a xenograft model using MCF7 human breast cancer cells
stably transfected with HER2 (MCF7/HER2-18) [63], the
selective HER1 tyrosine kinase inhibitor getinib transiently
slowed tumour growth. However, further studies have shown
that complete inhibition of the HER pathway and its multiple
potential homo- and heterodimer pairs by combining several
anti-HER inhibitors, such as pertuzumab (a HER2-specic
monoclonal antibody that inhibits heterodimerization with
other HER members), trastuzumab and getinib, or
trastuzumab and lapatinib (a dual EGFR and HER2 TK
inhibitor) is needed to achieve the best activity in HER2-
positive/ER-positive breast tumour cells [64, 65]. Importantly,
these potent anti-HER combinations were only modestly
effective when implemented in the absence of concomitant
endocrine therapy as, in such tumours, both ER and HER2
appear to drive tumour cell survival, and both pathways should
be blocked for optimal outcome. These molecular ndings have
provided the rationale for clinical studies of endocrine therapy
and HER2-targeting agents in an attempt to block growth
factor signalling pathways and restore endocrine responsiveness
[64, 66, 67].
HER2/ERcross-talk as a mechanismfor
resistance to HER2-targeted agents
Resistance to HER2-targeting has been intensively investigated
in the last decade [68]. Until recently, there has been little
recognition of the fact that up-regulation of ER expression and/
or activity can function as an escape mechanism leading to
resistance to HER2-targeted therapy in HER2 and HR-positive
breast cancer patients. Preclinical studies show that in ER and
HER2-positive breast cancer cell lines initially sensitive to
lapatinib, enhanced ER signalling is evident upon acquisition of
resistance to lapatinib and that this resistance may be prevented
by the simultaneous inhibition of HER2 and ER signalling [69,
70]. Intriguingly, increased ER activity was also conrmed in
patients with HER2 and ER-positive metastatic breast cancers
progressing to lapatinib monotherapy [70]. An analogous
phenomenon was also documented in chronically trastuzumab
exposed patients, whose tumours revealed up-regulation of the
ER [71].
To further elucidate the potential role of the ER in the onset
of resistance to anti-HER2-targeted therapies, Wang et al.
studied different HER2-positive human breast cancer cell lines
with de novo or acquired resistance to trastuzumab, lapatinib, or
lapatinib plus trastuzumab [72]. Authors found that with
sustained HER2 inhibition, the ER functions as a key escape/
survival pathway in HER2-positive/ER-positive cells and that a
dynamic transition between HER2 and ER activity plays a role
in resistance to lapatinib-containing regimens. Thus, in HER2-
positive/ER-positive breast cancer cells, either the ER or HER2
can initially function as the major promoter of proliferation and
survival. Eventually, however, with sustained, effective HER2
inhibition using lapatinib or lapatinib + trastuzumab, the ER
becomes the primary controller of cell survival, resulting in
resistance to lapatinib, or lapatinib + trastuzumab therapy.
Findings from these studies underline the importance of dual
inhibition of both HER2 and ER to achieve the best antitumour
activity in ER-positive HER2-positive breast cancer and, if
further conrmed in the clinical setting, will provide a strong
rationale to optimise biologically targeted therapies, in selected
breast cancer patients, by completely blocking the HER
network, in conjunction with ER inhibition.
novel strategies to optimise treatment
in HER2-positive/HR-positive breast
tumours
A logical therapeutic approach in these HER2 positive and HR-
positive breast cancer is to combine target therapies to block
both ER and HER2 pathways. This hypothesis was explored in
three trials conducted in patients with locally advanced and/or
metastatic breast cancer (Table 3) [7376]. While the
Trastuzumab and Anastrozole Directed Against ER-Positive
HER2-Positive Mammary Carcinoma (TanDEM) and the
Efcacy and Safety of Letrozole Combined With Trastuzumab
in Patients With Metastatic Breast Cancer (eLEcTRA) studies
were phase III randomised trials conducted in HER2-positive/
ER-positive breast cancer patients, the EGF30008 study was
conducted in 1286 women with HR-positive breast cancer
review
Annals of Oncology
o | Montemurro et al.

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patients not selected on the basis of their HER2 status [74].
Almost 17% of the patients had centrally conrmed HER2-
positive disease and were analysed separately as planned [75].
The three trials provided consistent results, indicating that the
combination of an anti-HER2 agent and an AI signicantly
improved RR, clinical benet rate (CBR) and PFS, compared
with endocrine therapy alone. No signicant difference on OS
estimates was observed in any of the trials, possibly due to the
inuence of crossover, the lines of treatment after progression
and to the number of events at the time of the analysis for the
primary end point PFS, when 47% and 58% of death had
occurred in the EGF30008 and TANDEM, respectively. These
trials provided a strong proof-of-concept for these
chemotherapy-free therapeutic options. However, the
complexity and redundancy of the HER network may require
more complete inhibition of the HER family receptors by
combining different anti HER2 agents with endocrine therapy
to further optimise clinical efcacy, an option currently tested in
ongoing clinical trials.
The combination of endocrine therapy and trastuzumab or
lapatinib is today an available rst-line therapeutic option in
patients with HER2-positive/HR-positive metastatic tumours
[77]. However, the comparison of RRs and PFS results between
the trials summarised in Tables 1 and 2, is a recurring argument
in favour of the use of chemotherapy-based combinations in
HER2-positive, metastatic breast cancer patients [7]. In fact, a
recent survey conducted in the United States shows that about
70% of these patients receive chemotherapy as part of rst line
treatment, with only about 10% receiving endocrine therapy and
trastuzumab [78]. Interestingly, though, about a half of patients
receiving rst-line chemotherapy and trastuzumab also received
and endocrine agent either concomitantly with chemotherapy
or added sequentially as a form of maintenance therapy.
conclusions
In the clinical practice, there is increasing recognition that
HER2-positive breast cancer patients are not a homogeneous
group. In particular, the HR status is emerging as a relevant
stratication factor with practical clinical implications. Data
from neoadjuvant studies show that HR status account for
different sensitivity to treatments. Molecular analysis provides
potential explanations for this effect, indicating that the HER
and ER pathways are strictly related in a bi-directional way.
HER2 signalling causes endocrine resistance and ER modulate
the response not only to chemotherapy, but also to HER2
targeted agents. Finally, clinical trials have conrmed the
preclinical rationale of combining endocrine therapy and anti
HER2-agents to interfere with this cross-talk.
Two important points to discuss are (i) where combinations
of endocrine agents and HER2-targeting agents can be currently
considered a reasonable rst-line option for HER2-positive/
hormone-receptor positive metastatic breast cancer patients; (ii)
what are the possible future developments of this therapeutic
approach. Given that response rates to chemotherapy plus
HER2-targeted therapy combinations typically exceed the 28%
reported for these combinations, such an approach cannot be
recommended in young patients or those with life-threatening
or symptomatic disease. However, understanding that no
treatment is curative in this setting, a therapeutic trial of this
generally well-tolerated strategy, could be considered in
postmenopausal patients with less extensive or asymptomatic
metastatic disease. Such an approach offers the possibility of
delaying initiation of a more toxic chemotherapy-based HER2-
targeted combination for 612 months, and occasionally longer.
In addition, despite lack of data from randomised trials, it seems
reasonable to offer patients maintenance endocrine therapy
with ongoing HER2 targeting once chemotherapy becomes too
toxic or its benets hit a plateau. The survey of patterns of care
published by Tripathy et al. [78] shows that these concepts are
being taken on by oncologists in the clinical practice.
We believe, however, that a real step forward would be
represented by the identication of factors other than clinical
features (i.e. age, performance status, pattern of disease) that
may dene patients where endocrine therapy combined with
HER2-targeting agents may be an elective rather than a
reasonable, option. For example high-hormone receptor
expression [33] or belonging to a luminal, rather than pure-
HER2 intrinsic subtype may represent biomarkers of reduced
efcacy of chemotherapy [79]. Patients whose tumours show
Table 3. Summary of randomised trials evaluating the addition of HER2 targeting agents to rst-line endocrine therapy with aromatase inhibitors in HER2-
positive and hormone receptor-positive breast cancer patients
Study Design Treatment
a
N ORR
(%)
CBR
(%)
PFS
(months)
OS
TANDEM [73] Randomised phase III trial, rst-line MBC Anastrozole 104 6.8 27.9 2.4 23.9
Anastrozole + Trastuzumab 103 20.3* 42.7* 4.8* 28.5
EGF30008 [75] Pre-planned subgroup analysis of a larger
randomised phase III trial, rst-line LABC or MBC
Letrozole + Placebo 108 15 29 3 32.3
Letrozole + Lapatinib 111 28* 48* 8.2* 33.3
eLEcTRA [76] Randomised phase III, closed prematurely because of
slow accrual, rst-line MBC
Letrozole 31 13 39 3.3 NR
Letrozole + Trastuzumab 26 27 65 14.1 NR
*The difference was statistically signicant at the P < 0.05 level.
a
See supplementary Appendix, available at Annals of Oncology online for details of treatments and schedule used in these studies.
TAnDEM, Trastuzumab and Anastrozole Directed Against ER-Positive HER2-Positive Mammary Carcinoma; eLEcTRA, Study of the Efcacy and Safety of
Letrozole Combined With Trastuzumab in Patients With Metastatic Breast Cancer; MBC, metastatic breast cancer; LABC, locally advanced breast cancer; ORR,
overall response rate (complete + partial remission); CBR, clinical benet rate (complete + partial remission and disease stabilisation lasting 6 months or
longer); PFS, progression-free survival; OS, overall survival; NR, not reported.
Annals of Oncology
review
doi:10.1093/annonc/mdt287 | ,

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these features are, in our opinion, the optimal candidates for
clinical trials assessing chemotherapy-free combinations.
Despite the tremendous challenges in the research of
biomarkers that could predict treatment efcacy, large tissue-
banks have been collected in the context of neoadjuvant
randomised trials. Hopefully, these efforts will provide
candidate biomarkers that may further dene personalised
treatment strategies patients with HER2-positive breast cancer.
acknowledgements
The authors are indebted to Stefano de Angelis and Carmine de
Angelis for their help in producing the artwork for Figure 1.
funding
This manuscript had no funding.
disclosure
FM and GA are members of the speakers bureau for Roche S.p.
A. and GlaxoSmithKline S.p.A. SDC is member of the speakers
bureau for GlaxoSmithKline S.p.A. and is a Consultant for
TEVA pharmaceuticals
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1o | Montemurro et al.

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