• breast cancer;
  • EGFR;
  • resistance to endocrine therapy;
  • chemotherapy resistance


  1. Top of page
  2. Abstract


Epidermal growth factor receptor (EGFR) expression is associated with aggressive phenotypes in preclinical breast cancer models, but in clinical studies, EGFR has been inconsistently linked to poor outcome. We hypothesized that EGFR expression in human breast tumors, when centrally and uniformly assessed, is associated with an aggressive phenotype and resistance to systemic therapy.


In a database of 47,286 patients with breast cancer, EGFR status was known on 2567 tumors. EGFR levels were measured centrally by ligand binding assay, and tumors with ≥10 fmol/mg were prospectively deemed positive. Clinical and biological features of EGFR-positive and EGFR-negative tumors were compared. Clinical outcomes were assessed by systemic therapy status.


Of 2567 tumors, 475 (18%) were EGFR positive. EGFR-positive tumors were more common in younger and in black women, were larger, had a higher S-phase fraction, and were more likely to be aneuploid. EGFR-positive tumors were more likely to be HER2-positive (26% vs 16%, P < .0001), but less likely to be estrogen receptor-positive (60% vs 88%, P < .0001) or progesterone receptor-positive (26% vs 65%, P < .0001). In multivariate analyses, EGFR expression independently correlated with worse disease-free survival (hazard ratio [HR] = 1.66; 95% confidence interval [CI], 1.4-2.41, P = .007) and overall survival (HR = 1.98, 95% CI, 1.36-2.88, P = .0004) in treated patients, but not in untreated patients.


EGFR expression is more common in breast tumors in younger and black women. It is associated with lower hormone receptor levels, higher proliferation, genomic instability, and HER2 overexpression. It is correlated with higher risk of relapse in patients receiving adjuvant treatment. Blocking EGFR may improve outcome in selected patients. Cancer 2010. © 2010 American Cancer Society.

The epidermal growth factor receptor (EGFR; ErbB-1; HER1 in humans) is a tyrosine kinase receptor of the epidermal growth factor receptor family. Other members are HER2, HER3, and HER4. These receptors are activated by ligand-dependent homodimerization and heterodimerization, which lead to kinase activation and initiation of signaling. Interaction between these 4 receptors and their various ligands may regulate and modulate their effects on cell growth and survival.1

EGFR expression, biological impact, and influence on clinical outcome have been reported in several tumor types.2, 3 In preclinical models of breast cancer, overexpression of EGFR leads to malignant transformation of mouse cells. It is associated with increased proliferation and resistance to apoptosis.4 In addition, its role in resistance to hormone therapy through crosstalk with estrogen receptor (ER) is now better understood.5

There also have been multiple reports on EGFR in clinical breast cancer. The studies were mostly small in size, used variable methodologies, and had inconsistent results.6-15 This may be explained in part by the many challenges facing studies of EGFR in clinical breast cancer samples. There has been little standardization of analytic techniques, and most studies used formalin fixation of tissue, a process that can vary considerably between institutions and may alter antigen detectability. Moreover, immunohistochemical staining of EGFR has had inconsistent results, and is not a functional assay. Radiolabeled ligand-binding is a functional assay but is time-consuming and requires frozen tissue, which is not widely collected or banked anymore in the United States. Antigen detection is less likely to be altered in frozen tissue.

We hypothesized that EGFR expression, when centrally and uniformly measured in frozen tissue obtained from a large number of patients, would be associated with an aggressive phenotype of breast cancer and would confer resistance to systemic adjuvant therapy. We tested these hypotheses using a large frozen tissue breast tumor bank in which EGFR was assessed by a central laboratory using ligand-binding assay, and results were correlated with clinical and biologic tumor characteristics as well as clinical outcomes.


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  2. Abstract

Patient Data and Specimens

The Lester and Sue Smith Breast Center at Baylor College of Medicine maintains a database of breast cancer patients whose tissue specimens were originally sent to a central reference laboratory for steroid receptor assays at the Nichols Institute in California, which serves more than 370 institutions throughout the United States. The patients and staff at each contributing institution reported demographics. Follow-up information as well as clinical and pathologic characteristics were obtained from tumor registries, medical records, or by data collection forms completed by the office staff of the referring physicians. This database comprises information on 47,286 patients diagnosed between 1984 and 1999 with early breast cancer (stage I-IIIA). The institutional review boards at the University of Texas Health Science Center at San Antonio and at Baylor College of Medicine reviewed this repository and both boards provided a waiver of informed consent. No patient identifiers were provided to the authors.

Prognostic Factors

EGFR levels were measured by radioligand binding assay. Tumor specimens were pulverized in liquid nitrogen, homogenized, and centrifuged. Cytosol fractions and suspended fat were removed. Membrane fraction samples were incubated with fixed concentrations of radiolabeled EGF and varying concentrations of unlabeled epidermal growth factor (EGF). Total protein was determined by the Lowry method.16 Levels of ≥10 fmol/mg of membrane protein were prospectively deemed positive as in previous studies.9

HER2 status was determined by Western blotting, using a rabbit polyclonal antibody directed against the C-terminus of the HER2 protein.17 The cutoff value for HER2 expression was set at 1U/μg protein, based on prior studies.17, 18

ER levels were measured by the dextran-coated charcoal method, as previously described.19 From 1970 to 1984, progesterone receptor (PR) levels were measured by sucrose density gradient.20 In 1985, the standard multipoint dextran-coated charcoal assay incorporated (I125)-estradiol and (3H)-R5020 in a single assay, allowing the simultaneous determination of ER and PR. Samples containing ≥3 fmol/mg protein were prospectively considered ER-positive, and those containing ≥5 fmol/mg protein were considered PR-positive, based on prior clinical studies.21-23

DNA ploidy and S-phase fraction were evaluated by flow cytometry and the histograms were analyzed by Modfit (Verify Software House, Topsham, Me) using single-cut, debris stripping.24 Cutoff points were determined by calibrating S-phase fraction with clinical outcome in a group of more than 28,800 patients with breast cancer (low, <6%; intermediate, 6%-10%; high >10%).26

Statistical Methods

Patient and tumor characteristics were summarized in the 2567 patients with EGFR data, and the relationship between these characteristics and EGFR status was examined using descriptive statistics and the chi-square test. Then, the study dataset was compared with the 44,719 patients without EGFR data in the overall dataset using descriptive statistics, the chi-square test, and Fisher exact test.

Disease-free survival (DFS) was calculated from the diagnostic biopsy date and a first recurrence was scored as an event, while patients without an event were censored at the time of death or last follow-up. Overall survival (OS) was calculated from the diagnostic biopsy date and death was scored as an event, whereas patients who were alive at the time of last follow-up were censored. Postrelapse survival was calculated from the recurrence date in patients who had a relapse, and death was scored as an event, while patients who were alive at the time of last follow-up were censored.

The effects of EGFR status on DFS, postrelapse survival, and OS were examined by treatment group using Kaplan-Meier curves, and differences in survival were evaluated with the log-rank test. Univariate Cox regression was used to model the effect of EGFR on survival in treatment subgroups. Multivariate analysis assessed the simultaneous importance of EGFR status and other patients and tumor characteristics on DFS and OS by treatment group and Cox regression was used to model the relationships. Final multivariate models were fitted using backwards selection and adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and P values were calculated for the final models. All analyses were performed using SAS 9.1 (SAS, Cary, NC) and Stata (Statacorp, College Station, Tex).


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  2. Abstract

Of 47,286 patients with breast cancer in this database, EGFR status was known on 2567 tumors. We compared this subset with the entire database and found that it was representative of the patient population (Table 1). Tumors without EGFR data were less likely to overexpress HER2, though this was probably because of the play of chance in a small sample size (n = 56). Eighteen percent of the dataset we studied overexpressed HER2, which is the expected rate in breast cancer.

Table 1. Comparison of EGFR Dataset to All Patients in the Database
Characteristic EGFR DataNo EGFR Data
  1. EGFR indicates epidermal growth factor receptor; ER, estrogen receptor; PR, progesterone receptor.

AgeNo. tested255252,293
 Median age6162
 <50 y27%25%
 >50 y73%75%
Tumor sizeNo. tested242050,229
 <2 cm51%51%
 2-5 cm42%42%
 >5 cm7%7%
Nodal statusNo. tested226348,376
Tumor ploidyNo. tested25154366
 % Diploid50%47%
 % Aneuploid50%53%
S-phaseNo. tested22513912
ERNo. tested256752,298
PRNo. tested256752,298
HER2No. tested220056
Hormone receptor groupsNo. tested256752,298

Of the tumors with known EGFR status, 18% (n = 475) were EGFR-positive (≥10 fmol/mg membrane protein) and 82% (n = 2092) were EGFR-negative (<10 fmol/mg). Levels varied widely among EGFR-positive tumors (10-11,084 fmol/mg), but 90% of them had concentrations less than 100 fmol/mg (Fig. 1).

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Figure 1. Epidermal growth factor receptor (EGFR) concentration histogram: EGFR concentration was determined using ligand binding assay. Tumors with protein concentration of ≥10 fmol/mg membrane protein were prospectively deemed positive. Of the tumors with known EGFR status, 18% (n = 475) were EGFR-positive and 82% (n = 2092) were EGFR-negative. EGFR levels of EGFR-positive tumors varied widely (10-11,084 fmol/mg) but 90% had concentrations less than 100 fmol/mg.

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Clinical and Biologic Characteristics

Table 2 compares demographic and clinical characteristics between EGFR-positive and EGFR-negative tumors. Notably, EGFR-positive tumors were more common in women younger than 50 years (40% vs 24%). In addition, there were more black women with EGFR-positive than EGFR-negative tumors. EGFR signaling may be a contributing reason to the worse prognosis in these groups.

Table 2. Clinical and Biological Characteristics Between EGFR-Positive and EGFR-Negative Groups
Variable EGFR PositiveEGFR NegativeP
  • EGFR indicates epidermal growth factor receptor; DCIS/LCIS, ductal carcinoma in situ/lobular carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; ER, estrogen receptor; PR, progesterone receptor.

  • a

    This chi-square test P value compares the distribution of EGFR status between white and black patients.

  • b

    This Fisher exact test P value compares the distribution of EGFR status between white and other race patients.

AgeNo. tested4732079 
 Median age5462 
 <50 yrs40%24%<.0001
 ≥50 yrs60%76% 
RaceNo. tested4011793 
Menopause statusNo. tested2581459 
HistologyNo. tested4752092 
Tumor sizeNo. tested4541966 
 ≤2 cm36%54%<.0001
Nodal statusNo. tested4241839 
DNA ploidyNo. tested4692046 
 % diploid32%54%<.0001
 % aneuploid68%46% 
S-phaseNo. tested3961855 
ERNo. tested4752092 
PRNo. tested4752092 
HER2No. tested4301770 
Hormone receptor groupsNo. tested4752092 

EGFR-positive tumors were also more likely to be associated with adverse pathologic or biologic characteristics compared with EGFR-negative tumors (Table 1). They were more likely to be larger than 2cm, (64% vs 46%), aneuploid (68% vs 46%), and modestly more likely to be lymph node-positive. Strikingly, EGFR-positive tumors were more than twice as likely to have a high proliferative fraction as EGFR-negative tumors, 53% versus 22%, respectively.

HER2 and Hormone Receptor Expression

Other biomarkers were studied to investigate how EGFR correlates to other prognostic markers. EGFR expressing tumors were more likely to overexpress HER2 than EGFR-negative tumors, (26% vs 16%), further indicating the more aggressive nature of this phenotype.

Preclinical and clinical evidence has indicated that growth factor receptor signaling can downregulate hormone receptor expression.6-9, 11-15, 25-32 We, therefore, examined the relationship between ER and PR status and EGFR expression in this dataset. EGFR-positive tumors were less likely to express ER than EGFR-negative tumors (60% vs 88%), and only 26% of EGFR-positive tumors expressed PR compared with 65% of EGFR-negative tumors. EGFR-positive tumors were also more likely to be hormone receptor negative than EGFR-negative tumors (37% vs 9%).

Currently, there is substantial interest in the ER-negative, PR-negative, and HER2 negative subset of breast cancer. EGFR-positive tumors were 4 times more likely to have this “triple-negative” phenotype than EGFR-negative tumors (29% vs 7%). Of 284 patients in our dataset with triple-negative tumors, 48% expressed EGFR (data not shown).

Clinical Outcomes

In our dataset, 1068 patients (46%) did not receive any systemic adjuvant therapy and 1256 (54%) did: 529 (23%) received chemotherapy, 497 (21%) hormonal therapy, and 230 (10%) received both. Of patients receiving hormonal therapy, 97% got tamoxifen.

To separate any prognostic effect of EGFR from prediction of treatment effect, outcome was analyzed separately for systemically treated versus untreated patients. In patients who were not treated with systemic adjuvant therapy, DFS was not significantly different between EGFR-positive and EGFR-negative groups (HR = 1.37; 95% CI, 0.85-2.21; P = .20) (Fig. 2A). In contrast, patients who received adjuvant therapy had a significantly worse DFS in the EGFR-expressing group (HR = 1.77; 95% CI, 1.36-2.29; P < .0001) (Fig. 2B), suggesting that EGFR expression may be associated with resistance to some forms of systemic therapy. Findings were very similar in OS analysis as well (data not shown).

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Figure 2. Kaplan-Meier curves for disease-free survival by epidermal growth factor receptor status. A) In patients who did not receive any adjuvant systemic therapy (untreated patients), hazard ratio = 1.37, 95% confidence interval (CI), 0.85-2.21, and P = .20. B) In patients who received any form of adjuvant systemic therapy: chemotherapy, hormonal therapy, or both (treated patients), HR = 1.77, 95% CI, 1.36-2.29, and P < .0001.

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We then examined DFS by different treatment types. In patients who received only chemotherapy, we found only a nonsignificant trend towards worse DFS in the EGFR-expressing group (HR = 1.30; 95% CI, 0.91-1.86; P = .15) (Fig. 3A). In patients who received only hormonal therapy, the EGFR-positive group had a significantly worse DFS (HR = 1.99; 95% CI, 1.13-3.49; P = .015) (Fig. 3B). In patients who received both hormonal therapy and chemotherapy, the difference in DFS by EGFR status was even more prominent (HR = 2.20; 95% CI, 1.30-3.71; P = .003) (Fig. 3C).

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Figure 3. Kaplan-Meier curves for disease-free survival by EGFR status. A) In patients who received only adjuvant chemotherapy, hazard ratio (HR) = 1.30, 95% confidence interval (CI), 0.91-1.86, and P = .15. B) In patients who received adjuvant hormonal therapy, HR = 1.99, 95% CI, 1.13-3.49, P = .015. C) In patients who received both chemotherapy and hormonal therapy, HR = 2.20 and 95% CI, 1.30-3.71 (P = .003).

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Similar patterns were also found in OS in these groups. Specifically, patients who were EGFR-positive and received only chemotherapy had worse OS (HR = 1.56; 95% CI, 1.09-2.23; P = .0142), and those who received both hormone therapy and chemotherapy had worse OS than EGFR-negative patients (HR = 2.97; 95% CI, 1.77-4.99; P < .0001).

In the subgroup of patients who experienced relapse, patients with EGFR-positive tumors had significantly worse postrelapse survival than patients with EGFR-negative tumors regardless of their treatment status before relapse (17 months vs 28 months, respectively; HR = 1.72; 95% CI, 1.34-2.20; P < .0001) (Fig. 4).

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Figure 4. Kaplan-Meier curves for postrelapse survival by epidermal growth factor receptor (EGFR) status. In the subgroup that suffered tumor relapse (n = 416), patients whose primary tumors were EGFR-positive had a significantly worse postrelapse survival than those with EGFR-negative primary tumors (hazard ratio = 1.72; 95% confidence interval, 1.34-2.20; P < .0001).

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In multivariate analyses by treatment group, the role of EGFR as a prognostic variable for DFS and OS was evaluated. Variables included were as follows: age, race, tumor size, nodal status, ER, PR, HER2, S-phase fraction, DNA ploidy, and EGFR status. In untreated patients, EGFR was not associated with DFS or OS after adjusting for the effect of other characteristics (data not shown). However, in patients treated with systemic adjuvant therapy, EGFR expression was independently associated with worse DFS and OS (Table 3). EGFR-positive patients had 66% higher risk of relapse and almost double the risk of death than EGFR-negative patients (DFS adjusted HR = 1.66; 95% CI, 1.15-2.41; P = .0074; OS adjusted HR = 1.98; 95% CI, 1.36-2.88; P = .0004).

Table 3. Final Fitted Model of Main Effects on Survival in Patients Treated Who Received Systemic Treatment
VariableMultivariate DFS HR (95% CI)Multivariate DFS PMultivariate OS HR (95% CI)Multivariate OS P
  1. DFS indicates disease-free survival; HR, hazard ratio; CI, confidence interval; OS, overall survival; EGFR, epidermal growth factor receptor.

EGFR-positive vs EGFR-negative1.66 (1.145-2.408).00741.98 (1.360-2.880).0004
Race, black vs white1.96 (1.143-3.370).01452.94 (1.765-4.887)<.0001
Tumor size, >2 cm vs <2 cm  2.08 (1.413-3.064).0002
Node positive vs node negative2.72 (1.875-3.939)<.00012.15 (1.478-3.136)<.0001
Age >50 y vs <50 y  1.51 (1.039-2.193).0308


  1. Top of page
  2. Abstract

This is the largest and most comprehensive study to date analyzing EGFR expression in breast cancer patients. It demonstrates that EGFR expression is associated with an aggressive phenotype with distinct clinical and biologic characteristics. EGFR-expressing tumors occurred more often in young and minority women. These tumors were larger and slightly more likely to metastasize to the lymph nodes. They had a substantially higher proliferation rate and greater genomic instability. They were also more likely to coexpress HER2 but much less likely to express hormone receptors, especially PR.

EGFR has been extensively studied in the preclinical and clinical settings in different types of cancer. In breast cancer, preclinical evidence has indicated its clear role in increasing proliferation, resistance to apoptosis, and ligand-independent activation of the estrogen receptor, and in mediating hormone therapy resistance.4, 33, 34 In addition, activating mutations of pathway elements downstream of EGFR in cancer cells may render them resistant to EGFR inhibition.35 This was recently shown in colon and lung cancers.36-38

In the clinical setting, multiple studies have examined EGFR expression in breast cancer, but results have varied possibly because of relatively small sample sizes and nonuniform methodologies for the measurement of EGFR.29, 35, 39 These studies reported that EGFR is expressed in 15%-45% of breast tumors, is inversely related to hormone receptor expression, and inconsistently linked EGFR expression to poor prognosis.6-15, 39, 40 A recent study utilized a quantitative immunofluorescence-based technology to measure EGFR in a subset of premenopausal women treated with adjuvant tamoxifen.41 The authors found EGFR in 39% of the tumors they tested and linked its expression to higher tumor grade and worse clinical outcome in patients treated with tamoxifen but not in untreated patients. However, that study found no correlation with tumor size, lymph node status, or coexpression of HER2. This technology is promising and warrants further study.

The present study sought to overcome these deficiencies by analyzing frozen tumors from a large number of patients. EGFR expression was objectively quantified by ligand-binding assay and all measurements were performed at a central lab with strict quality control.

Only a minority of breast cancer specimens (18%) expressed EGFR and apparently only low levels are needed to exert an effect on biologic and clinical characteristics. The association with a different biology, such as downregulation of ER or PR, was strong: 37% of EGFR-positive tumors were negative for both ER and PR compared with only 9% of EGFR-negative tumors, representing a 4-fold difference.

This study provides further evidence of the inverse relation between hormone receptor expression and growth factor receptor expression and signaling, in this case EGFR. This relationship was most pronounced with PR expression, where only a quarter of EGFR-positive tumors expressed PR compared with almost two thirds of the EGFR-negative tumors.

In recent years, DNA microarray profiling studies on breast tumors defined distinct subtypes of breast carcinomas and linked them to varying clinical outcomes.42, 43 Basal-type breast cancer is one such subtype that has been associated with EGFR expression45, 46 and a poorer prognosis.42, 46 The triple-negative phenotype (ER-negative, PR-negative, HER2 negative) is considered a surrogate for this basal type breast cancer. In our study, nearly half (48%) of these triple-negative tumors were EGFR-positive compared with 18% of the overall study tumors. These findings are also consistent with other studies of triple-negative or basal tumors, which also found a higher incidence of EGFR expression.44, 45

EGFR expression was positively correlated with HER2 overexpression, which has been associated with worse prognosis as well. The 2 molecules may be potent signaling partners, and based on animal models, an effective EGFR and HER2 double blockade may result in improved clinical therapies and, thus, warrants further study in the clinical setting.

One of our most intriguing findings is the association of EGFR expression with clinical outcome. There were notable associations between EGFR expression and worse DFS and OS in patients who received systemic treatment (chemotherapy, tamoxifen, or both) but not in those who did not receive systemic therapy.

These findings have 2 possible explanations. First, the 2 groups were unbalanced in regards to a number of factors. As expected, the untreated patients tended to have tumors with more favorable clinical and biologic features (Table 4). If the event rate in this group is relatively low, then the effect of EGFR expression would need even larger numbers to become evident. In a higher risk population with greater event rates, the adverse prognostic effect of EGFR would be more clearly discernable.

Table 4. Comparison of Tumor Characteristics by Treatment Group
  Any Treatment n=1256No Treatment n=1068P
  1. EGFR indicates epidermal growth factor receptor; ER, estrogen receptor; PR, progesterone receptor.

Age, yMedian age5765<.0001
Tumor size, cm>2 cm55%41%<.0001
 <2 cm45%59% 
Positive nodes>322%6%<.0001
Tumor ploidyAneuploid53%45%.0002

Alternatively, EGFR may result in poorer outcome by causing resistance to systemic treatments. In support of this, EGFR expression has been associated with resistance to hormone therapy and chemotherapy in a number of studies.9, 11, 34, 41, 47, 48 These possibilities may also explain the significant difference in postrelapse survival between patients with EGFR-positive and EGFR-negative tumors.

Targeting EGFR therapeutically resulted in limited efficacy with the use of small molecules such as gefitinib and erlotinib,49-51 or with monoclonal antibodies such as cetuximab.52 Reasons for this may be the complexity and redundancy of its signaling network and, therefore, multiple points in the pathway may need to be blocked.54 Unlike lung cancer, there is no evidence that altered forms of the receptor influence the efficacy of current therapeutics.54, 55 However, there may be activating mutations of downstream components of the signaling axis. Recent evidence shows that downstream mutations in K-RAS limits response to EGFR-targeted therapies in colon and lung cancer38-38 and warrants investigation in breast cancer. In addition, there is a clear need for technologies that functionally or globally assess the activated status of EGFR and related downstream pathways.

This study has several limitations: It is a retrospective review of a nonrandomized database collected over a long period of time. Treatment was not controlled or specified, and chemotherapy was heterogeneous, although most patients received cyclophosphamide, methotrexate, and fluorouracil (CMF) or a CMF-like regimen. However, this remains the largest and most comprehensive study of EGFR in breast cancer. It provides further insight into this, so far, elusive biomarker, its effect on tumor biology, and its clinical impact.

EGFR needs to be studied as part of a robust signaling network with multiple signaling partners, intricate downstream components, and crosstalk with other pathways. Only small amounts of this receptor may need to be expressed to exert an effect on tumors. Assessment of the EGFR pathway may also need a functional assay to discern its signaling activity. This may help identify subgroups of patients, in whom EGFR or related pathways play an important role and may enable specific and effective inhibition of these active signaling elements by targeting EGFR, its signaling partners, or downstream pathways. This may be the best way to realize the promise of EGFR as a biomarker and therapeutic target, a promise that is earnestly awaited and long overdue.


  1. Top of page
  2. Abstract

This work was supported in part by NIH grants P50 CA58183 (SPORE) and P01 CA30195.


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  2. Abstract
  • 1
    Citri A, Yarden Y. EGF-ERBB signalling: towards the systems level. Nat Rev Mol Cell Biol. 2006; 7: 505-516.
  • 2
    Nicholson RI, Gee JM, Harper ME. EGFR and cancer prognosis [abstract]. Eur J Cancer. 2001; 37( suppl 4): S9-15 Abstract.
  • 3
    Normanno N, De Luca A, Bianco C, et al. Epidermal growth factor receptor (EGFR) signaling in cancer. Gene. 2006; 366: 2-16.
  • 4
    Di Fiore PP, Pierce JH, Fleming TP, et al. Overexpression of the human EGF receptor confers an EGF-dependent transformed phenotype to NIH 3T3 cells. Cell. 1987; 51: 1063-1070.
  • 5
    Massarweh S, Osborne CK, Jiang S, et al. Mechanisms of tumor regression and resistance to estrogen deprivation and fulvestrant in a model of estrogen receptor-positive, HER-2/neu-positive breast cancer. Cancer Res. 2006; 66: 8266-8273.
  • 6
    Ferrero JM, Ramaioli A, Largillier R, et al. Epidermal growth factor receptor expression in 780 breast cancer patients: a reappraisal of the prognostic value based on an eight-year median follow-up. Ann Oncol. 2001; 12: 841-846.
  • 7
    Fox SB, Smith K, Hollyer J, Greenall M, Hastrich D, Harris AL. The epidermal growth factor receptor as a prognostic marker: results of 370 patients and review of 3009 patients. Breast Cancer Res Treat. 1994; 29: 41-49.
  • 8
    Knoop AS, Bentzen SM, Nielsen MM, Rasmussen BB, Rose C. Value of epidermal growth factor receptor, HER2, p53, and steroid receptors in predicting the efficacy of tamoxifen in high-risk postmenopausal breast cancer patients. J Clin Oncol. 2001; 19: 3376-3384.
  • 9
    Klijn JG, Berns PM, Schmitz PI, Foekens JA. The clinical significance of epidermal growth factor receptor (EGF-R) in human breast cancer: a review on 5232 patients. Endocr Rev. 1992; 13: 3-17.
  • 10
    Newby JC, Johnston SR, Smith IE, Dowsett M. Expression of epidermal growth factor receptor and c-erbB2 during the development of tamoxifen resistance in human breast cancer. Clin Cancer Res. 1997; 3: 1643-1651.
  • 11
    Nicholson RI, McClelland RA, Gee JM, et al. Epidermal growth factor receptor expression in breast cancer: association with response to endocrine therapy. Breast Cancer Res Treat. 1994; 29: 117-125.
  • 12
    Pawlowski V, Révillion F, Hebbar M, Hornez L, Peyrat JP. Prognostic value of the type I growth factor receptors in a large series of human primary breast cancers quantified with a real-time reverse transcription-polymerase chain reaction assay. Clin Cancer Res. 2000; 6: 4217-4225.
  • 13
    Tsutsui S, Ohno S, Murakami S, Hachitanda Y, Oda S. Prognostic value of epidermal growth factor receptor (EGFR) and its relationship to the estrogen receptor status in 1029 patients with breast cancer. Breast Cancer Res Treat. 2002; 71: 67-75.
  • 14
    Rampaul RS, Pinder SE, Nicholson RI, Gullick WJ, Robertson JF, Ellis IO. Clinical value of epidermal growth factor receptor expression in primary breast cancer. Adv Anat Pathol. 2005; 12: 271-273.
  • 15
    Skasko E, Paszko Z, Mazur S. A new look at the prognostic value of the estrogen, progesterone and epidermal growth factor receptors in breast cancer tissue. Neoplasma. 2005; 52: 10-17.
  • 16
    Lowry OH, Rosebrough NJ, Farr AL, Randall RJ. Protein measurement with the Folin phenol reagent. J Biol Chem. 1951; 193: 265-275.
  • 17
    Ciocca DR, Fujimura FK, Tandon AK, et al. Correlation of HER-2/neu amplification with expression and with other prognostic factors in 1103 breast cancers. J Natl Cancer Inst. 1992; 84: 1279-1282.
  • 18
    Tandon AK, Clark GM, Chamness GC, Ullrich A, McGuire, WL. HER-2/neu oncogene protein and prognosis in breast cancer. J Clin Oncol. 1989; 7: 1120-1128.
  • 19
    McGuire WL, De La Garza M, Chamness GC. Evaluation of estrogen receptor assays in human breast cancer tissue. Cancer Res. 1977; 37: 637-639.
  • 20
    Powell B, Garola RE, Chamness GC, McGuire WL. Measurement of progesterone receptor in human breast cancer biopsies. Cancer Res. 1979; 39: 1678-1682.
  • 21
    Ravdin PM, Green S, Dorr TM. Prognostic significance of progesterone receptor levels in estrogen receptor-positive patients with metastatic breast cancer treated with tamoxifen: results of a prospective Southwest Oncology Group study. J Clin Oncol. 1992; 10: 1284-1291.
  • 22
    Bardou VJ, Arpino G, Elledge RM, Osborne CK, Clark GM. Progesterone receptor status significantly improves outcome prediction over estrogen receptor status alone for adjuvant endocrine therapy in 2 large breast cancer databases. J Clin Oncol. 2003; 21: 1973-1979.
  • 23
    Clark GM, Osborne, CK, McGuire WL. Correlations between estrogen receptor, progesterone receptor and patient characteristics in human breast cancer. J Clin Oncol. 1984; 2: 1102-1109.
  • 24
    Wenger CR, Clark GM. S-phase fraction and breast cancer—a decade of experience. Breast Cancer Res Treat. 1998; 51: 255-265.
  • 25
    Huang H, Neven P, Drijkoningen M. Association between tumor characteristics and HER-2/neu by immuniohistochemistry in 1362 women with primary operable breast cancer. J Clin Pathol. 2005; 58: 611-616.
  • 26
    Balleine RL, Earl MJ, Greenberg ML, Clarke CL. Absence of progesterone receptor associated with secondary breast cancer in postmenopausal women. Br J Cancer. 1999; 79: 1564-1571.
  • 27
    Dowsett M, Bundred NJ, Decensi A. Effect of raloxifene on breast cancer cell Ki67 and apoptosis: a double- blind, placebo-controlled, randomized clinical trial in postmenopausal patients. Cancer Epidemiol Biomarkers Prev. 2001; 10: 961-966.
  • 28
    Bamberger AM, et al. Progesterone receptor isoforms, PR-B and PR-A, in breast cancer: correlations with clinicopathologic tumor parameters and expression of AP-1 factors. Horm Res. 2000; 54: 32-37.
  • 29
    Arpino G, Green SJ, Allred DC, Lew D, Martino S, Osborne CK, Elledge RM. HER-2 amplification, HER-1 expression, and tamoxifen response in estrogen receptor-positive metastatic breast cancer: a Southwest Oncology Group study. Clin Cancer Res. 2004; 10: 5670-5676.
  • 30
    Arpino G, Weiss H, Lee AV, et al. Estrogen receptor-positive, progesterone receptor-negative breast cancer: association with growth factor receptor expression and tamoxifen resistance. J Natl Cancer Inst. 2005; 97: 1254-1261.
  • 31
    Konecny G, Pauletti G, Pegram M, et al. Quantitative association between HER-2/neu and steroid hormone receptors in hormone receptor-positive primary breast cancer. J Natl Cancer Inst. 2003; 95: 142-153.
  • 32
    Dowsett M, et al. Benefit from adjuvant tamoxifen therapy in primary breast cancer patients according to oestrogen receptor, progesterone receptor, EGF receptor and HER2 status. Ann Oncol. 2006; 17: 818-826.
  • 33
    Massarweh S, Schiff R. Resistance to endocrine therapy in breast cancer: exploiting estrogen receptor/growth factor signaling crosstalk. Endocr Relat Cancer. 2006; 13( suppl 1): S15-24.
  • 34
    Massarweh S, Osborne CK, Creighton CJ. Tamoxifen resistance in breast tumors is driven by growth factor receptor signaling with repression of classic estrogen receptor genomic function. Cancer Res. 2008; 68: 826-833.
  • 35
    She QB, Solit DB, Ye, Q, O'Reilly KE., Lobo J, Rosen N. The BAD protein integrates survival signaling by EGFR/MAPK and PI3K/Akt kinase pathways in PTEN-deficient tumor cells. Cancer Cell. 2005; 8: 287-297.
  • 36
    Bokemeyer C, Bondarenko I, Hartmann JT., et al. KRAS status and efficacy of first-line treatment of patients with metastatic colorectal cancer (mCRC) with FOLFOX with or without cetuximab: The OPUS experience [abstract]. J Clin Oncol. 2008; 26( suppl). Abstract 4000.
  • 37
    Darwish, S., Ludovini, V., Pistola, L., et al. EGFR, KRAS, PIK3CA mutations and response to tyrosine kinase inhibitors (TKIs) in advanced NSCLC patients [abstract]. J Clin Oncol. 2008; 26( suppl). Abstract 22003.
  • 38
    Van Cutsem, E., Lang, I., D'haens, G., et al. KRAS status and efficacy in the first-line treatment of patients with metastatic colorectal cancer (mCRC) treated with FOLFIRI with or without cetuximab: The CRYSTAL experience [abstract]. J Clin Oncol. 2008. 26( suppl). Abstract 2.
  • 39
    Chan SK, Hill ME, Gullick WJ. The role of the epidermal growth factor receptor in breast cancer. J Mammary Gland Biol Neoplasia. 2006; 11: 3-11.
  • 40
    Emlet DR, Schwartz R, Brown KA, Pollice AA, Smith CA, Shackney SE. HER2 expression as a potential marker for response to therapy targeted to the EGFR. Br J Cancer. 2006; 94: 1144-1153.
  • 41
    Giltnane JM, Rydén L, Cregger M, Bendahl PO, Jirström K, Rimm DL. Quantitative measurement of epidermal growth factor receptor is a negative predictive factor for tamoxifen response in hormone receptor positive premenopausal breast cancer. J Clin Oncol. 2007; 25: 3007-3014.
  • 42
    Sorlie T, Perou CM, Tibshirani R. Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. Proc Natl Acad Sci U S A. 2001; 98: 10869-10874.
  • 43
    Perou CM, Sørlie T, Eisen MB, et al. Molecular portraits of human breast tumours. Nature. 2000; 406: 747-752.
  • 44
    Livasy CA, Karaca G, Nanda R, et al. Phenotypic evaluation of the basal-like subtype of invasive breast carcinoma. Mod Pathol. 2006; 19: 264-271.
  • 45
    Nielsen TO, Hsu FD, Jensen K, et al. Immunohistochemical and clinical characterization of the basal-like subtype of invasive breast carcinoma. Clin Cancer Res. 2004; 10: 5367-5374.
  • 46
    van't Veer LJ, Dai H, van de Vijver MJ, et al. Gene expression profiling predicts clinical outcome of breast cancer. Nature. 2002; 415: 530-536.
  • 47
    Shou J, Massarweh S, Osborne CK, Wakeling AE, Ali S, Weiss H, Schiff R. Mechanisms of tamoxifen resistance: increased estrogen receptor-HER2/neu cross-talk in ER/HER2-positive breast cancer. J Natl Cancer Inst. 2004; 96: 926-935.
  • 48
    Yarden Y, Sliwkowski MX. Untangling the ErbB signalling network. Nat Rev Mol Cell Biol. 2001; 2: 127-137.
  • 49
    Albain, K., Elledge, R.M., Gradishar, W.J., et al. Open-label, phase II, multicenter trial of ZD1839 (“Iressa”) in patients with advanced breast cancer. Breast Cancer Res Treat. 2002; 76( 1 suppl). Abstract 20.
  • 50
    Osborne, C.K., Neven, P., Dirix, L., et al. Randomized phase II study of gefitinib (Iressa) or placebo in combination with tamoxifen in patients with hormone receptor positive metastatic breast cancer. Breast Cancer Res Treat. 2007; 106( S1): 1-350.
  • 51
    Polychronis A, Sinnett HD, Hadjiminas D, et al. Preoperative gefitinib versus gefitinib and anastrozole in postmenopausal patients with oestrogen-receptor positive and epidermal-growth-factor-receptor-positive primary breast cancer: a double-blind placebo-controlled phase II randomised trial. Lancet Oncol. 2005; 6: 383-391.
  • 52
    Carey LA, Rugo HS, Marcom PK, et al on behalf of the Translational Breast Cancer Research Consortium. TBCRC 001: EGFR inhibition with cetuximab added to carboplatin in metastatic triple-negative (basal-like) breast cancer. J Clin Oncol. 2008; 26( suppl). Abstract 1009.
  • 53
    Bianco R, Shin I, Ritter CA, et al. Loss of PTEN/MMAC1/TEP in EGF receptor-expressing tumor cells counteracts the antitumor action of EGFR tyrosine kinase inhibitors. Oncogene. 2003; 22: 2812-2822.
  • 54
    Paez JG, Jänne PA, Lee JC, et al. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science. 2004; 304: 1497-1500.
  • 55
    Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med. 2004; 350: 2129-2139.