Abstract
Breast Cancer (BC) is a highly prevalent disease. A woman living in the United States has a 12.3% lifetime risk of being diagnosed with breast cancer [1]. It is the most common female cancer and the second most common cause of cancer death in women [2]. Of note, amplification or overexpression of Human Epidermal Receptor 2 (HER2) oncogene is present in approximately 18 to 20% of primary invasive breast cancers, and until personalized therapy became available for this specific BC subtype, the worst rates of Overall Survival (OS) and Recurrence-Free Survival (RFS) were observed in the HER2+ BC cohort, compared to all other types, including triple negative BC (TNBC) [3].HER2 is a member of the epidermal growth factor receptor (EGFR) family. Other family members include EGFR or HER1, HER3 and HER4. HER2 can form heterodimers with any of the other three receptors, and is considered to be the preferred dimerization partner of the other HER or ErbB receptors [4]. Phosphorylation of tyrosine residues within the cytoplasmic domain is the result of receptor dimerization and culminates into initiation of a variety of signalling pathways involved in cellular proliferation, transcription, motility and apoptosis inhibition [5].In addition to being an important prognostic factor in women diagnosed with BC, HER2 overexpression also identifies those patients who benefit from treatment with agents that target HER2, such as trastuzumab, pertuzumab, trastuzumab emtansine (T-DM1) and small molecules tyrosine kinase inhibitors of HER2 [6, 11, 127]. In fact, trastuzumab altered the natural history of patients diagnosed with HER2+ BC, both in early and metastatic disease setting, in a major way [8–10]. Nevertheless, there are many women that will eventually develop metastatic disease, despite being treated with anti-HER2 therapy in the early disease setting. Moreover, advanced tumors may reach a point where no anti-HER2 treatment will achieve disease control, including recently approved drugs, such as T-DM1.This review paper will concentrate on major biological pathways that ultimately lead to resistance to anti-HER2 therapies in BC, summarizing their mechanisms. Strategies to overcome this resistance, and the rationale involved in each tactics to revert this scenario will be presented to the reader.
Highlights
LandmarkImprovements in Human Epidermal Receptor 2 (HER2)+ DiseaseSince the approval of trastuzumab in the adjuvant setting by the FDA in 2006, most patients with HER2+early Breast Cancer (BC) are doing very well with standard trastuzumab therapy added to chemotherapy
Amplification or overexpression of Human Epidermal Receptor 2 (HER2) oncogene is present in approximately 18 to 20% of primary invasive breast cancers, and until personalized therapy became available for this specific BC subtype, the worst rates of Overall Survival (OS) and Recurrence-Free Survival (RFS) were observed in the HER2+ BC cohort, compared to all other types, including triple negative BC (TNBC) [3]
Slamon et al [8] evaluated the addition of trastuzumab to chemotherapy among women diagnosed with metastatic HER2+ BC in the landmark trial that lead to trastuzumab approval in the metastatic setting
Summary
Since the approval of trastuzumab in the adjuvant setting by the FDA in 2006, most patients with HER2+. Patients nearly diagnosed with localized HER2+ BC have an excellent prognosis, even if treated with less toxic adjuvant systemic therapy, as recently demonstrated by Dana Farber investigators [10]. This nonrandomized prospective trial evaluated an adjuvant chemotherapy regimen consisting of weekly paclitaxel at 80mg/m2 and trastuzumab at 2 mg/kg for 12 weeks, followed by 9 months of trastuzumab in 406 women with HER2-positive, node-negative tumors ≤ 3 cm. The authors found that the addition of trastuzumab to chemotherapy was associated with a longer time to disease progression, higher rate of objective response, and a longer survival Since this first trial, many others corroborated trastuzumab benefit in survival outcomes among women with metastatic HER2+ BC. Research has been dedicated to a better understanding of the molecular mechanisms involved of trastuzumab resistance. [16]
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