http://content.nejm.

org/cgi/content/full/351/22/2337

Breast Cancer Loss of PTEN Predicts

Resistance to Treatment
Pier Paolo Pandolfi, M.D., Ph.D.
PTEN, the lipid phosphatase and tensin homologue, is a key tumor suppressor. Mutations
resulting in the loss of PTEN or the loss of its function are common and functionally
relevant in tumors of different histologic origins, including breast cancer.1 A recent study
by Nagata and colleagues2 shows that PTEN not only antagonizes tumorigenesis but also
sensitizes breast cancers to targeted therapy with trastuzumab (Herceptin), a humanized
monoclonal antibody against ErbB2 (also referred to as HER2/neu), a membrane-receptor
tyrosine kinase in the epidermal growth factor receptor family.3
PTEN normally opposes the activation of the proto-oncogenic phosphatidylinositol 3'
kinase (PI3K)Akt signaling pathway (Figure 1A).1 Approximately 50 percent of patients
with breast cancer have a mutation in or loss of at least one copy of the PTEN gene, which
results in the activation of PI3K signaling. The severity of PTEN mutations strongly
correlates with the tumor stage and grade. For example, complete loss of PTEN is more
frequent in metastatic cancer than in primary tumors.1 The loss of one copy of PTEN
increases the risk that a tumor will develop, and the level of expression of PTEN
dramatically affects the initiation and progression of tumors.4 The study by Nagata and
colleagues suggests that the gene dose and, therefore, the levels of expression of PTEN
may also determine the response to therapy.
Figure 1. Resistance to Trastuzumab Due to PTEN Deficiency.
In Panel A, the overexpression of ErbB2 leads to its activation
through autophosphorylation (P). As a result, Src kinase and
View larger version phosphatidylinositol 3' kinase (PI3K), with its regulatory subunits
p85 and p110, are recruited to the receptor and kept in their active
(39K):
[in this window] state. The activation of PI3K leads in turn to the activation of the
[in a new window] proto-oncogenic signaling pathway consisting of Akt and the
mammalian target of rapamycin (mTOR). Nagata and colleagues2
show that when active, Src can inactivate PTEN through the
phosphorylation of its C-terminal end. This triggers the
production of elevated levels of phosphatidylinositol 3,4,5triphosphate (PIP3), further potentiating the activation of PI3K.
On binding to the ErbB2 receptor, trastuzumab causes the
dissociation of the receptor from Src and its inactivation through
unknown mechanisms (Panel B). PTEN thus becomes free to
antagonize the activation of the PI3KAKTmTOR signaling
pathway through the dephosphorylation of PIP3. Trastuzumab
could be combined with drugs such as sirolimus (rapamycin) and

its analogues, everolimus (RAD001) and CCI-779, which inhibit

mTOR, to block this critical signaling pathway at two different
points. Nagata et al. show that a partial or total deficiency of
PTEN (Panel C) may account for resistance to trastuzumab.2
Up to 30 percent of human breast cancers overexpress ErbB2, as do other types of cancer,
and such overexpression correlates with extremely aggressive cancers and a poor
prognosis.3 In addition, intragenic ErbB2 mutations in the kinase domain of the receptor
have recently been identified in lung tumors.5 Trastuzumab binds specifically to the
extracellular domain of ErbB2 (Figure 1) and can induce down-regulation and
inactivation of the receptor through several mechanisms.3 Inactivation, in turn, results in
poorly understood antitumoral responses, including arrest of the cell cycle. Although
trastuzumab prolongs survival among patients with cancer when administered with
chemotherapy, it does not cure cancer. Furthermore, many patients have primary
resistance to trastuzumab for unknown reasons.3
Nagata and colleagues provide data that clarify the antitumoral mechanism of
trastuzumab and help clarify the mechanism underlying resistance. They show that, on
binding to the ErbB2 receptor, trastuzumab stabilizes and activates the PTEN tumor
suppressor and consequently down-regulates the PI3KAkt signaling pathway (Figure
1A).2 When the expression of PTEN is reduced or abrogated, this chain of events is
interrupted and the antitumoral effects of trastuzumab are impaired (Figure 1B). The
authors therefore predicted that the presence of low levels of PTEN would correlate with
unresponsiveness to trastuzumab treatment and subsequently confirmed this correlation in
a small group of patients.2 Prospective studies using larger cohorts of patients and
thorough in vivo genetic analyses of mice with various degrees of Pten function are
warranted.
Because the level of expression of PTEN is critical to tumorigenesis and apparently
modulates the response to therapy, the systematic analysis of the activation status and
level of expression of PTEN and PI3K in tumors is now imperative. So, too, are
experiments to determine whether gain-of-function mutations in the ErbB2 and PI3K
genes also correlate with unresponsiveness to trastuzumab and other small-molecule
inhibitors of ErbB2. The new findings call for a renewed focus on PTEN as a possible
target for therapeutic intervention in tumors that lack one copy of PTEN. Drugs that
augment PTEN levels may sensitize these tumors to trastuzumab and other drugs. One
could also envision the therapeutic use of a combination of trastuzumab and PI3K
inhibitors (when these become available) or downstream inhibitors of the PI3KAkt
signaling pathway, such as sirolimus (rapamycin) and its analogues.

Source Information
From the Cancer Biology and Genetics Program, Memorial-Sloan Kettering Cancer Center, New York.

References
1. Di Cristofano A, Pandolfi PP. The multiple roles of PTEN in tumor suppression.
Cell 2000;100:387-390.[ISI][Medline]
2. Nagata Y, Lan K-H, Zhou X, et al. PTEN activation contributes to tumor
inhibition by trastuzumab, and loss of PTEN predicts trastuzumab resistance in
patients. Cancer Cell 2004;6:117-127.[CrossRef][ISI][Medline]
3. Yu D, Hung MC. Overexpression of ErbB2 in cancer and ErbB2-targeting
strategies. Oncogene 2000;19:6115-6121.[CrossRef][ISI][Medline]
4. Trotman LC, Niki M, Dotan Z, et al. Pten dose dictates cancer progression. PLoS
Biol 2003;1(3):E59.
5. Stephens P, Hunter C, Bignell G, et al. Intragenic ERBB2 kinase mutations in
tumors. Nature 2004;431:525-526.

Figure 1. Resistance to Trastuzumab Due to PTEN Deficiency.

In Panel A, the overexpression of ErbB2 leads to its activation through
autophosphorylation (P). As a result, Src kinase and phosphatidylinositol 3' kinase
(PI3K), with its regulatory subunits p85 and p110, are recruited to the receptor and
kept in their active state. The activation of PI3K leads in turn to the activation of the
proto-oncogenic signaling pathway consisting of Akt and the mammalian target of
rapamycin (mTOR). Nagata and colleagues2 show that when active, Src can inactivate
PTEN through the phosphorylation of its C-terminal end. This triggers the production
of elevated levels of phosphatidylinositol 3,4,5-triphosphate (PIP3), further
potentiating the activation of PI3K. On binding to the ErbB2 receptor, trastuzumab
causes the dissociation of the receptor from Src and its inactivation through unknown
mechanisms (Panel B). PTEN thus becomes free to antagonize the activation of the
PI3KAKTmTOR signaling pathway through the dephosphorylation of PIP3.
Trastuzumab could be combined with drugs such as sirolimus (rapamycin) and its
analogues, everolimus (RAD001) and CCI-779, which inhibit mTOR, to block this
critical signaling pathway at two different points. Nagata et al. show that a partial or
total deficiency of PTEN (Panel C) may account for resistance to trastuzumab.2

http://content.nejm.org/cgi/content/full/347/16/1212

New Stars in the Sky of Treatment for Early Breast

Cancer
Martine J. Piccart-Gebhart, M.D., Ph.D.
Since Sir George Beatson observed in 1896 that breast tumors in premenopausal women
sometimes regressed after oophorectomy,1 numerous investigations have established that
estrogen stimulates the growth of breast-cancer cells. Three newer strategies reduce the
growth-stimulating signals of estrogen: interfering with the binding of estrogen to its
receptor, the primary mode of action of the antiestrogen agent tamoxifen in
premenopausal and postmenopausal women; decreasing the estrogen levels in the blood
and the tumor, the mechanism of action of aromatase inhibitors in postmenopausal
women; and destroying the estrogen receptor, which is how the drug fulvestrant exerts its
antitumor activity.
During the course of the clinical development of these antiestrogen strategies, we have
learned four major lessons. First, they work only in hormone-receptorpositive tumors,
which account for two thirds of breast cancers. Second, cross-resistance can be
circumvented in advanced disease (e.g., tamoxifen-resistant tumors are generally not
resistant to aromatase inhibitors). Third, as adjuvant treatment, tamoxifen has had
unprecedented success in reducing breast-cancerrelated mortality worldwide. Finally,
tamoxifen, and probably the other agents, can prevent breast cancer.2
Information concerning untoward side effects of these endocrine therapies is solid only
with regard to tamoxifen, as indicated by the Oxford Overview, which has analyzed,
among other topics, the adjuvant use of this drug in more than 30,000 women, some of
whom have been followed for 15 years.3 It is clear that tamoxifen is associated with a
small risk of thromboembolic disease and endometrial cancer and that this risk increases
with the duration of treatment. The drug has positive effects, however, on bone mineral
density and blood lipid profiles. These divergent effects of tamoxifen, which are caused
by its estrogen-agonist activity in certain tissues, weaken its therapeutic index to some
extent.
There is intense interest in the molecular mechanisms of endocrine resistance in general
and in resistance to tamoxifen in particular. Growth factors, cellular stress, and other
cellular pathways that signal directly to the estrogen receptor and some of its key
regulators are prominent in mediating resistance; this process can modulate the estrogen
receptor in a way that causes the activity of tamoxifen to switch from an antagonist to an
agonist effect.4
The current knowledge regarding resistance to tamoxifen provides a sound molecular
basis for the impressive results of the large and well-conducted adjuvant trial reported by
Coombes and colleagues in this issue of the Journal.5 The study involves postmenopausal
women who had undergone excision of primary breast cancer and were then treated with
tamoxifen for two to three years before randomization. At the time of the second planned

interim analysis of this trial, the group of women who had been assigned to switch to the
aromatase inactivator exemestane had significantly longer disease-free survival than
women who continued to receive tamoxifen. The total planned duration of both the
sequential and the standard adjuvant endocrine therapy was five years.
This observation is not a surprise to the medical oncology community. There is
considerable evidence that aromatase inhibition is superior to other endocrine
manipulations in postmenopausal women with tamoxifen-resistant advanced breast
cancer. Moreover, aromatase inhibitors are superior to tamoxifen as first-line endocrine
therapy for metastatic disease and as neoadjuvant (preoperative) treatment.6
Exemestane, an irreversible steroidal inhibitor that inactivates the enzyme aromatase,
thereby blocking the conversion of androgens to estrogens in peripheral tissues, is
effective in women whose breast cancer has progressed despite therapy with both
tamoxifen and anastrozole or letrozole, which are competitive, reversible, nonsteroidal
aromatase inhibitors. Exemestane is also superior to megestrol acetate, in terms of
survival, in women in whom disease has progressed despite tamoxifen therapy, and it may
also be superior to tamoxifen for advanced disease.7
The strengths of the study by Coombes et al. include its adequate statistical power, the
fact that it involved multiple groups of investigators in 37 countries, its independent
management, its double-blind treatment comparison, its acceptable ineligibility and
dropout rates, its efficacy analysis according to the intention-to-treat principle, and the
consistency of the treatment effect among all clinically relevant subgroups. The
weaknesses of the study are the immaturity of the data in terms of overall survival and
safety and the lack of information on estrogen-receptor status for 17 percent of the
participants. As we progressively leave the era of empirical medicine and enter one of
molecular medicine, it is becoming essential to secure tumor-tissue collection in trials of
adjuvant agents, for the purpose of translational research. Such research is important
because analysis of the expression profiles of breast-cancer genes has shown striking
differences between tumors that express estrogen receptors and those that do not. The
method has also identified at least three subgroups of estrogen-receptorpositive tumors
with distinct molecular signatures; in addition to different prognoses, these subgroups
may have different responses to endocrine treatments.8
Will the study show a survival benefit with longer follow-up? The answer is uncertain.
The hazards of death could be disproportionate over time; moreover, endocrine therapy
profoundly affects the rates of contralateral breast cancer and local relapses, for which
curative treatment exists. However, in the present trial, the risk that an early crossover
masks a survival benefit is small, given that more than 90 percent of the participants had
completed their randomly assigned therapy at the time the report was written. This
attribute represents a sharp contrast with another important trial of adjuvant therapy, by
Goss et al., involving letrozole.9 In that placebo-controlled trial, which showed an early
benefit of extended adjuvant therapy with letrozole after five years of tamoxifen
treatment, less than 1 percent of the participating women had completed their randomly
assigned therapy when the study-group assignments were revealed. When the first results

of the Anastrozole, Tamoxifen Alone or in Combination (ATAC) trial were released, none
of the participants had completed their assigned therapy.10
The results of these three trials at a median follow-up of only 30 months does not allow
us to conduct a useful riskbenefit analysis, which is an integral part of making
appropriate treatment decisions. Although the short-term toxic effects of aromatase
inhibitors have not been particularly worrisome5,9,10 and clear advantages over tamoxifen
in terms of thromboembolic and uterine complications have emerged,10 the long-term
consequences of estrogen deprivation in postmenopausal women remain a concern.
Particular attention will need to be paid to bone and cardiovascular health, cognitive and
sexual function, and quality of life. It will also be important to see whether, with longer
follow-up, the suggested reduction in the incidence of second, nonbreast cancers
associated with exemestane treatment is a real phenomenon.
Considering these three important trials, what should clinicians do? Many more years will
be required to fine-tune the riskbenefit assessment of adjuvant aromatase inhibitors, but
the use of these agents should be discussed with patients who are suitable candidates, and
they should be informed about the limitations of the current data. In my opinion, women
whose risk of recurrence is high are reasonable candidates for the inclusion of an
aromatase inhibitor in plans for adjuvant treatment, whereas women with a low risk of
recurrence might give more weight to long-term safety and be better served by tamoxifen
therapy.
Women and their physicians are now confronted with difficult choices, and clinical
investigators suddenly realize that the acceleration of the conduct of trials of adjuvant
therapy can create problems, particularly in the case of early reporting: the National
Surgical Adjuvant Breast and Bowel Project B33 trial, the sister of the trial reported by
Goss et al. in which exemestane was used instead of letrozole for extended adjuvant
therapy, was "killed" by the publication of the letrozole study; the ArimidexNolvadex
(ARNO) study and the Breast International Group 01-98 trial, which are exploring
sequences of tamoxifen with anastrozole and letrozole, respectively, might be in danger as
well.
The breast-cancer research community must rethink the rules for the early reporting of
results from trials of adjuvant therapy. These rules must be amended to reflect a better
tradeoff between the desire to inform women and society rapidly about a more effective
therapy for a potentially lethal disease and the need to collect solid data on the safety of
the therapy.
Although some advocate that results be disclosed early for reasons of safety only or after
some preset minimal follow-up period,11 a more realistic approach is to base early
disclosure on significant differences between the rates of distant relapse. Indeed, treating
such relapses may prolong lives but does not save lives. Since distant relapses accounted
for roughly half the events that triggered early reporting in the three trials of adjuvant
aromatase inhibitors, perhaps the use of stopping rules based on distant-diseasefree
survival could have provided an extra year of follow-up before reporting. This proposal

will be put on the agenda of the Breast International Group12 and, if deemed appropriate,
will be discussed with its closest partner, the North American Breast Intergroup
http://content.nejm.org/cgi/content/full/347/16/1270

Rational Local Therapy for Breast Cancer

In a 1976 lecture to the Society of Surgical Oncology, the late Jerome Urban lamented the
loss of a rational approach to the treatment of breast cancer, which he thought had been
replaced "by an emotional appeal to the patient's vanity. A great cry has been raised in the
public media to save the breast, despite the long-term consequences."1 In this issue of the
Journal, Fisher and colleagues2 and Veronesi and colleagues3 describe the long-term
outcomes of two pivotal randomized trials comparing breast-conserving surgery and
mastectomy. These studies document how far our understanding of breast cancer has
evolved since Urban's lecture. Breast cancer has a long natural history, and conclusions
drawn from short-term follow-up studies may give an inaccurate picture of the ultimate
outcome. The failure to observe a survival advantage of mastectomy after 20 years should
convince even the most determined skeptics that mastectomy is not superior to breast
conservation for the treatment of breast cancer.
In addition to the belief that a more extensive operation for cancer must be a better
operation for cancer, the potential for local failure in the preserved breast has been a
cause for concern. These two reports provide reassurance that at 20 years the incidence of
recurrence in the ipsilateral breast is low: 8.8 percent in the study by Veronesi et al.3 and
14.3 percent in the trial by Fisher et al.2 In both studies, the incidence of recurrences in the
node-positive women who received adjuvant chemotherapy was approximately half the
incidence in their node-negative counterparts who did not receive systemic therapy.
Today, the widespread use of adjuvant systemic therapy for both node-negative and nodepositive breast cancer, coupled with improvements in the mammographic and
pathological evaluation of patients undergoing breast-conserving surgery, has resulted in a
decreased incidence of local failure, and 10-year actuarial rates of recurrence that are less
than 5 percent4,5 are not uncommon.
Despite these low rates of local failure in women who were selected for breast-conserving
surgery on the basis of physical examination and mammography, it has been suggested
that both ultrasonographic studies of the whole breast6 and magnetic resonance imaging7
should be part of the preoperative evaluation. These recommendations are based on the
identification of unsuspected foci of carcinoma in 16 percent to 37 percent of women6,7
who undergo these studies. The possibility that small foci of carcinoma can be present in
apparently normal breast tissue has been recognized since the 1970s. Pathological studies
of breast-tissue specimens from women with localized tumors have shown occult
carcinoma in similar proportions of women.8 In fact, these pathological studies formed the
cornerstone of the argument that breast-conserving therapy was inappropriate. The B-06
trial conducted by Fisher et al.2 demonstrates that these foci of tumor are clinically
significant. Among patients treated with lumpectomy alone, the incidence of a recurrence
in the ipsilateral breast was 39.2 percent, whereas it was 14.3 percent when the treatment
was lumpectomy plus irradiation of the breast. Subjecting women to mastectomy because

we now have an imaging technique that is sensitive enough to detect microscopical foci
of tumor is not a step forward. Instead, we may be able to use such techniques to identify
women who require radiation therapy only in the quadrant in which the primary tumor is
located or those who do not require radiation therapy at all.
The risk of local failure in the preserved breast will never be entirely eliminated. Some
local failures reflect biologically aggressive disease and are similar to recurrences in the
chest wall that occur after mastectomy. Local failures that occur many years after the
initial diagnosis are often new primary tumors, indicating that irradiation of the whole
breast does not provide long-term protection against cancer. This phenomenon is apparent
in the study by Veronesi et al.3: the rate of new ipsilateral tumors at a distance from the
site of the original primary tumor was similar to the rate of new contralateral tumors (0.42
and 0.66 per 100 woman-years of observation, respectively). Twenty years of experience
have shown us that local recurrences due to inappropriate selection of patients or
inadequate therapy can be largely eliminated with the use of high-quality diagnostic
mammography, excision with negative margins, and postoperative irradiation.
The focus on local recurrence has distracted us from a more serious problem with breastconserving therapy. Despite a large body of mature scientific data from randomized trials,
which is unequaled in the literature on the local treatment of cancer, many women today
are not offered the option of breast-conserving therapy. My colleagues and I9 found that in
a national sample of 16,643 women with stage I or II breast cancer who were treated in
1994, only 42.6 percent were treated with a breast-conserving approach. There was a
significant correlation between treatment with mastectomy and factors associated with a
poor prognosis, such as the size of the tumor, nodal status, and histologic grade. The
preferential use of mastectomy for women who have a poor prognosis strongly suggests
that 20 years later breast-conserving therapy is still not accepted as equivalent to
mastectomy, but is instead viewed as a less aggressive therapy appropriate only for
women with a good prognosis.
What proportion of women with breast cancer should receive breast-conserving therapy?
The answer depends on the particular population of women, but a reasonable goal is that
every woman should be informed of the availability of breast-conserving therapy and of
the suitability of the procedure in her particular case. In a study of 231 women with breast
cancer who were seen for a second opinion between 1996 and 1999, Clauson et al.10
reported that 29 percent of the women had been offered only the option of a mastectomy
during the initial consultation. The women in this study were from a metropolitan area, 70
percent had more than a high-school education, 62 percent reported an annual family
income of more than $30,000, and more than 90 percent had health insurance. If a
substantial proportion of educated and insured women do not receive complete
information about options for treatment, the problem may be even more serious in
disadvantaged populations.
Efforts to expand eligibility for breast-conserving therapy and to reduce the associated
morbidity are well under way. Preoperative chemotherapy and endocrine therapy have
been shown to be safe and effective ways to shrink tumors that are too large for a

lumpectomy with a good cosmetic result. Accelerated fractionation schedules and

brachytherapy are being studied as alternatives to six weeks of external-beam irradiation.
However, if we do not apply what we have learned from the pioneering work of Fisher
and Veronesi and their colleagues to the treatment of the women with breast cancer we
see today, we will have made little or no progress over the past 20 years in the search for
a rational approach to the local treatment of breast cancer. It is time to declare the case
against breast-conserving therapy closed and focus our efforts on new strategies for the
prevention and cure of breast cancer.