BIOLOGICAL DETERMINANTS IN PATIENTS WITH BREAST CANCER

ALBERT SEGALOFF, BS, MS, MD*

Many biochemical measures have been applied to populations who either have breast cancer or might be expected to. It seems apparent that, of themselves, individual measurements or the few combinations of measurements that have been tried do not as yet add sufficiently to our ability to determine prognosis for the patients involved. It is to be hoped that suitable combinations of in- dependent variables can be found which will improve our ability to predict the course of this deadly disease.

T HAS LONG BEEN OUR HOPE TO DEVELOP I biocl!emical procedures of sufficient so- phistication and simplicity so that they might be applied to the many problems of breast cancer. Essentially we need a cancer de- tection test in the sense that we could find a group of women with a substantially increased risk of developing breast cancer; or a cancer detection test which couId dis- cover breast cancer before it has reached sufficient size to be detectable by any of our present means. We need biochemical mea- surements applicable to either the patient or the tumor which will give us a clue to judg- ing the prognosis of the patient, so that this may be employed as a ma,jor determinant for decision about the type and vigor of ther- apy for the specific patient.

It should be recognized that breast cancer is a chronic illness with a prolong.ed course for the vast majority of patients. This poses the very delicate question of what constitutes an adequate control population for any bio- chemical determination. This, then, becomes the crux of the problem. When we are trying to compare a group of people to the rest of the population we need suitable healthy con- trols. If we are trying to decide whether or not a biochemical finding is due to breast

Presented at the First National Conference on Breast Cancer, Washington, D.C., May 8-10, 1969.

Supported by Public Health Service Research Grant No. CA-03364 from the National Cancer Institute.

Head, Endocrinology, Section I , Alton Ochsner Medical Foundation; Professor of Clinical Medicine, Tulane University School of Medicine, New Orleans, La.

Address for reprints: Albert Segaloff, MD, Alton Ochsner Medical Foundation, 1520 Jefferson Highway, New Orleans, La. 70121.

Received for publication August 26, 1969.

cancer specifically or its chronicity we will require both henlthy controls and controls from an equivalent chronic illness, prefer- ably a nonmalignant one. On the other hand, if we are trying to stratify patients with known breast cancers into groups of varying prognosis, then we do not require an external group of controls since we are in essence dealing with a closed population-patients who already have breast cancer. The impor- tance of this stratification can scarcely be overemphasized. For example, we have gen- erally come to agree that positive axillary nodes represent essentially systemic disease, yet about half of these patients will be alive 5 years after radical mastectomy, even though nothing else is done. Thus, if because of positive nodes alone we are to apply a vig- orous type of therapy aimed at eradication of the systemic disease immediately after the mastectomy, we must realize that we are creating morbidity and mortality even though the prognosis, if nothing more is done, is for about half of these people to live 5 years, most of them apparently free of dis- ease. To put it bluntly, how much immediate mortality are we willing to risk in hopes of increasing the 5-year survival? This is a very difficult question to answer. I feel that the answer must be that we are unwilling to risk such therapy unless we can improve our abil- ity to estimate survival. If it is possible to apply a wide spectrum of biochemical and other measures to patients at the time of radical mastectomy, so that instead of a 50- 50 chance of predicting survival at 5 years we can have a better than 95% chance of predicting failure to survive at perhaps 2 years, then I would be more willing to at-

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tempt to increase the survival of this subset by the application of vigorous systemic ther- apy. It is this difference between the flip of a coin predictability and the 95+ percent pre- dictability that we are looking for from bio- chemistry for the patient with a primary malignancy.

T o the best of my knowledge, the largest and best oriented effort at delineating a high risk population by biochemical means is the Guernsey study of Bulbrook and his associates of the Imperial Cancer Research Fund. They have been particularly interested in measuring a discriminant based on the urinary excretion of ketogenic steroids and etiocholanolone which they believe is pre- dictive for response to major ablative ther- apy. This will be discussed later. Their study plan, in brief, was to enlist the cooperation of the people on the island of Guernsey, which has a stable population, to collect 24- hour urine samples on as many women on the island as they feasibly could, to store these urines in the deep freeze, and to continue to observe the population. When a woman in the study group develops breast cancer her urines are removed from storage and the discriminant determined. Urines of other Guernsey women who have not developed breast cancer, but who match the patient as closely as possible, are also removed from the deep freeze and their discriminants are si- multaneously measured.3 T o date, 21 women have developed breast cancer in this group.1 The results are about as expected, and dis- appointing. Essentially, what has been found so far is that the women who develop breast cancer show a greater deviation from normal in their values for urinary steroids than pa- tients who have not developed breast cancer. This is the expected finding when patients who already have breast cancer are compared to apparently healthy controls. I t is less true when they are compared to controls with other chronic illnesses. We ourselves have been interested in this problem, measuring different parameters, and have always found that no matter what biochemical parameter we measure in patients with breast cancer there is a larger range of values and a greater standard deviation than when the same mea- sure is applied to a matched healthy control group.12 There is some difference of opinion about this, since one of the investigators of the Guernsey study group has expressed the hope that they have indeed delineated a high

risk population.1 It seems to me that the real importance of their observation lies in the demonstration that women who develop breast cancer in the Guernsey study actually have the greater biochemical variation char- acteristic of breast cancer before the onset of clinical breast cancer. This, hopefully, may be exploited as a diagnostic aid, even though it may not be specific for breast can- cer.

Many of the determinations of biochemical parameters in patients proved to have breast cancer have been based upon urinary excre- tion, including the discriminant mentioned earlier. In this regard, it is important to recognize that, if one uses endogenous creatinine clearance6 as an index of the ability of the kidney to excrete various sub- stances, as breast cancer advances the endo- genous creatinine clearance decreases. It is further noteworthy that when it is possible to induce a remission with additive hor- monal therapy in such patients, the remission has generally been accompanied by an in- crease in the endogenous creatinine clearance and a subsequent decline when the tumor is again advancing.

We ourselves did studies, particularly of endocrine biochemical parameters, and found that the means of their determinations were generally close to those of healthy con- trols but that the standard deviations and ranges were considerably greater for the breast cancer patients as opposed to the healthy controls. We showed, for example, that the excretion of gonad-stimulating hor- mone in the urine was lower and higher than expected in the breast cancer group, i.e., different than we found in matched healthy controls. Indeed, we believed that having a lower gonad-stimulating hormone than expected was associated with a failure of good results upon administrative hormonal therapy.11, l2 It is interesting that other work- erst0 thought that having high gonadotro- phins was associated with failure to respond to stilbestrol therapy. Of course, essentially what this means is that we represented the 2 extremes of the spread. I t is my opinion that there are more people treated for their disseminated breast cancer who fail to respond than people who do respond favorably, and there are fewer patients, even with advanced breast cancer, at the extremes of biochemical measures, in this case, gonadotrophin excre- tion. These 2 factors together produced what

No. 6 BIOLOGICAL DETERMINANTS IN

I believe to be the illusion that gonadotro- phins may be used as prognostic factors in response.

T h e Bulbrook discriminant was originally developed retrospectively from multiple en- docrine studies which were then correlated with the clinical response of these patients to adrenalectomy. Though there was not a signif- icant correlation between any single excretion value and response, it was found that there was a significant correlation when both keto- genic corticoids and etiocholanolone were taken into account, and from this the dis- criminant was developed. This discriminant has been more widely applied and is believed by them to be helpful in predicting the re- sponse to hypophysectomy as well as to the sur- vival after radical mastectomy. They have re- cently summarized their experience with the application of the discriminant and it does appear that people do better with major abla- tive procedures if their discriminant is posi- tive and less well if the discriminant is nega- tive.1 They find, in summary, that one must at least also consider whether the patient had primary inoperable disease, how long a free period there was following mastectomy, and the menopausal status before having a reason- able chance of predicting the objective re- sponse to major ablative therapy. I t also ap- pears that patients with positive discriminants have a better survival experience than those with negative discriminants when treated for their primary malignancy by radical mastect- omy. However, it is evident that the discrim- inant is only one factor in the pattern, and whether or not the disease is apparently local- ized to the breast itself or also found in the lymph nodes makes as big a difference as the discriminant, but if both these factors are taken into account one has a greater degree of predictability.

We do not as yet know whether these stud- ies have some factor in them peculiar to England. It should be noted that there is suggestive evidence in other hands that this is more widely applicable, but we are initiat- ing prospective studies of the application of

BREAST CANCER - Segalotj 1261

these excretion discriminants to see whether or not we can predict the outcome for major ablative surgery here in the United States.

Our knowledge of steroid action of a cel- lular level is rapidly improving. It is of great interest that estradiol-17B is apparently bound to a specific proteinaceous cytoplasmic recep- tor, and, in the process of estrogenic activity, the estrogen receptor complex moves into the nucleus, and the receptor is altered in this movement.7, I t appears that there is a differ- ence in animal tumor systems between their ability to respond to estrogen deprivation and the ability of the tumor to bind estra- diol-17P. Hopefully this may be developed into a clinically applicable biochemical mea- sure.9

We have also learned that, in the process of androgen activity, testosterone and its receptor move into the nucleus and the testos- terone itself is altered.2 As yet, we are not aware of the application of these studies to the effort at predicting the outcome in hu- man breast cancer from various therapies.

There are specific enzymes in tissues re- sponsible for the conjugation of natural steroid hormones. Studies in these areas by Dao and his associates4~ 5 have, in a pre- liminary way, indicated that there may be a correlation between the ability of a mam- mary tumor to conjugate various steroid sub- strates with sulfuric acid (sulfokinase) with the response of the patient to major ablative therapy. This, too, we hope will be pursued further and may indeed be of great assistance.

In summary, from the history of biochem- ical and other means of predicting the out- come in breast cancer, both when seen initially and with widespread disease, initial optimism gradually gives way to knowledge that many factors must be taken into ac- count. However, it is well within the realm of possibility that if we study a sufficient number of factors, each one of which helps somewhat in the predictability, we will be able to achieve our desired high level of predictability, at least for various subsets of the patient spectrum.

REFERENCES 1 . Atkins, H.: Cancer Prediction (cditorial). Surg.

Gynec. Obstet. 128:1305-1306, 1969.

2. Bruchovsky, N., and Wilson, J. D.: The conver- sion of testosterone to 5a-androstan-17fi-ol-9-one by rat prostate in v i m and in uitro. J . B i d . Chern. 243: 201 2-202 1, 1968.

3. Bulbrook, R. D., and Hayward, J. L.: Abnormal urinary steroid excretion and subsequent breast cancer. A prospective study in the island of Guernsey. Lancet 519-522, 1967.

4. D ~ ~ , T. L., and Libby, p. R.: conjugation of steroid hormones by normal and tissues. J. Clin. E n d o n . 28:1431-1439, 1968.

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5. - , and -* . Conjugation of steroid hor- mones by breast cancer tissue and selection of patients for adrenalectomy. Surgery 66:1G2-166, 1969.

6. Graham, W. P. 111, Gardner, B., and Gordan, G. S.: Glomerular filtration in disseminated brcast can- cer. Arch. Znlern. M e d . 1132337-839, 1964.

7. Jensen, E. V., Suzuki, T., Numata, M., Smith, S., and DeSombre, E. R.: Estrogen-binding substances of target tissues. Steroids 13:417-427, 1969.

8. Jungblut, P. W., DeSombre, E. R., and Jensen, E. V.: Estrogen receptors in induced rat mammary tu- mor. In Hormone in Genese und Therapie des Mam- macarcinoms. Panel Discussion der Unio Internationalis contra Cancrum, Sept. 27-Oct. 3, 1965, Berlin und Jena. Abhandlungen der Deutschen Akademie der Wis- senschaften zu Berlin. Berlin, Akademie-Verlag. 1967; pp. 109-123.

9. King, R. B. J., Cowan, D. M., and Inman, D. R.: The uptake of (6,7-SH)oestradiol by dimethylbenzan- thracene-induced rat mammary tumours. J. Endom.

10. Loraine, J. A,, Douglas, M., Falconer, C. W. A., and Strong, J. A.: Further studies on the value of pituitary gonadotrophin assays in patients with mam- mary carcinoma. Acta Un. Znt. Cancr. 15:1132-1135, 1959.

11. Segaloff, A.: Testosterone and miscellaneous ste- roids in the treatment of advanced mammary cancer. Cancer 10:808-812, 1957.

12. Segaloff, A.: Alteration of hormone balance in the treatment of mammary cancer. Proc. 3rd National Cancer Conference, 1957; pp. 257-267.

32~83-90, 1965.