The Use of Blood Tests in Breast Cancer For Detection and Treatment

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1 The Use of Blood Tests in Breast Cancer For Detection and Treatment Dr. Emanuel Petricoin George Mason University Center for Applied Proteomics and Molecular Medicine Manassas, VA phone fax

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3 Duffy et al: Conclusions: The main disadvantages of existing serum markers for breast cancer are a lack of sensitivity for low-volume disease and a lack of specificity. Consequently, the available markers are of no value in either screening or diagnosing early breast cancer. Although of little use for early diagnosis, however, CA 15-3 may be the first independent circulating prognostic marker described for breast cancer. Preoperative CA 15-3 concentrations may thus be combined with established prognostic factors for use in deciding which lymph node-negative breast cancer patients should receive adjuvant chemotherapy. Currently, one of the most widely used applications of tumor markers in breast cancer is in the follow-up of patients with diagnosed disease. In the absence of data from a large randomized trial, however, the clinical value of this practice is unclear. Finally, CA 15-3 and other markers are potentially useful in monitoring therapy in advanced disease, particularly in patients who cannot be assessed by standard modalities.

4 None of the available markers is increased in all patients with breast cancer even in the presence of advanced disease. For those patients with advanced disease who do not have increased CA 15-3 concentrations, other markers, such as CEA, TPA, TPS, or the shed form of HER-2, may be considered for monitoring purposes. The available markers are most sensitive for detecting distant metastases and are of little value in diagnosing locoregional recurrences. The magnitude of change between successive marker concentrations that constitutes a critical change is not clear. Paradoxical patterns of tumor marker concentrations after initiation of chemotherapy may occur. For example, transient alterations in marker concentrations can occur after the commencement of chemotherapy Certain benign diseases may give rise to increased marker concentrations. Thus, chronic active hepatitis, liver cirrhosis, sarcoidosis, hypothyroidism, and megablastic anemia have all been reported to increase CA 15-3 concentrations.

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7 Conclusions: We have performed feature-selection and classification techniques to identify blood serum proteins that are indicative of breast cancer in premenopausal women. The best features to detect breast cancer were MIF, MMP-9, and MPO. While the proteins could distinguish normal tissue from cancer and normal tissue from benign lesions, they could not distinguish benign from malignant lesions. it is likely that these proteins play a role in the inflammatory response to a lesion, whether benign or malignant, rather than in a role specific for cancer. While the current set of proteins show moderate ability for detecting breast cancer, their true usefulness in a screening program remains to be seen in their integration with imaging-based screening practices.

8 EDRN s Mission To implement biomarker research through systematic, evidence-based discovery, development and validation of biomarkers for: cancer risk assessment, early detection, diagnosis and prognosis of cancer

9 Biomarker Development Pipeline BDL BRL CVC

10 Objectives Provides a National Infrastructure to support a vertical collaborative approach to move promising biomarker/technology to clinical validation Established guidelines and criteria for the validation Developing and instituting quality assurance regimens, Standard Operating Procedures, etc. Conduct early clinical and epidemiological studies to evaluate predictive value of biomarkers Foster Public- Private Partnership

11 Meeting Objectives National Infrastructure Prior to EDRN Fragmented studies, with discoveries using convenience samples Results of studies not generalizable Lack of Standard Operating Procedures for sample collection and study designs Studies compromised by chance, bias and confounders Lack of evidence for the claimed clinical use After EDRN Clinically annotated samples for discovery Roadmap for biomarker discovery and validation using EDRN five-phase guidelines and PRoBE design Well designed multi-center, multi-discipline validation study to minimize chance, bias, confounders Well-designed Standard Reference Sample Sets to quickly evaluate biomarkers for intended clinical uses Adoption of EDRN-developed guidelines and concept of validation throughout the biomarker research community Adoption of EDRN-developed study-design evaluation criteria by the biomarker community and the NIH study sections

12 Meeting Objectives Adoption of Clinical Assays Detection/ Biomarker Assay Blood propsa Urine PCA3 Urine/TMA assay for T2S:Erg fusion for Prostate Cancer FISH to detect T2S:Erg fusion for Prostate Cancer Aptamer-based markers for Lung Cancer Proteomic Panel for Lung Cancer Discovery Refine/ Adapt for Clin Use Clinical Validation Clinical Translation FDA approved FDA approved CLIA in process In CLIA Lab In CLIA Lab In CLIA Lab OVA1 TM for Ovarian Cancer FDA Approved SOPs for Blood (Serum, Plasma), Urine, Stool, Vimentin Methylation Marker for Colon Cancer ROMA Algorithm for CA125 and HE4 Tests for Pelvic Mass Malignancies Blood/DCP and AFP-L3 for Hepatocellular Carcinoma In CLIA Lab Frequently used by biomarker research community FDA Approved FDA Approved Blood GP73 Together with AFP-L3 used in China for monitoring/risk assessment of cirrhotic patients for HCC

13 Biomarker Discovery Technical Barriers Biomarkers exist in very low concentration: Significantly below the detection limits of mass spectrometry Obscured by abundant resident blood proteins such as albumin Rapidly degraded by enzymes post collection Hard to validate: Lack of antibodies specific for candidate biomarkers The Center for Applied Proteomics and Molecular Medicine Proteomics Tools for Clinical Medicine

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15 Blood Protein Biomarker Discovery An Overwhelming Analytical Challenge PSA 1% Dynamic Range Anderson, N.L., Anderson, N.G. (2002 ) Mol. Cell. Proteomics. 1, proteins constitute 99% blood protein mass - Biomarkers likely are low abundance proteins - No analytical method has sufficient dynamic range Log Distance Mount Everest Wintergreen VA Washington Monument 170m height US Capitol 1m height Meter stick Human hand length Large artery diameter 1cm diam. Small capillary diameter Human hair diameter 100um diam. Cell diameter Virus diameter 50nm diam. Small peptide length Object Preferred MS method to discover biomarker proteins (in blood)? - Targeted Proteomics - Selective protein sampling, enrichment, fractionation - Combine biological hypothesis and new technology

16 Tissue microenvironment Endothelial basement membrane Circulation Fibroblast Immune cell Endothelial cells Proteinase Tumor cell Biomarker protein Proteinase LMW Proteins and Fragments Biomarker Cascades Generated In the Tissue Microenvironoment Products of cell-cell cell-ecm interactions Enzymatic cascades; specific cleavage products Proteins shed during cell metabolism and death

17 Novel technology to overcome biomarker technical barriers Smart Core Shell Affinity Bait Nanoporous Particles Three independent functions within minutes, in one step, in solution: a) Molecular size sieving b) Affinity capture of all solution phase target molecules c) Complete protection of harvested proteins from enzymatic degradation Amplify the effective concentration of very low abundance molecules The Center for Applied Proteomics and Molecular Medicine Proteomics Tools for Clinical Medicine

18 Particles can be produced in large quantities Stable at room temperature indefinitely Low cost Uniform in size (0.7 micron) Reproducibility among batches

19 In-solution harvesting Smart particles amplify the biomarker concentration 5 ml Nanoparticles in vacutainer blood collection tubes 50 ml 100 fold amplification

20 New Biomarker Discovery-Verification Workflow Objective: Identify native serum protein fragments Peptidomics Raw serum a. Collect proteins/peptides with MW<10kDa b. No digestion or Lys-C digestion d. C18 RP-HPLC gradient elution Elute the tryspin protein digestion... Electrospray ionization e. LC/MS-MS Analysis c. C18 RP-HPLC gradient elution... Electrospray ionization VERIFICATION + + Thermo LTQ-ETD Mass Spectrometer Thermo LTQ-Orbitrap Hybrid Mass Spectrometer MRM Thermo Quantum Triple Quad Mass Spectrometer

21 T1a Breast Cancer > Benign Control Gelsolin isoforms a and b 2 peptides

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24 Development and initial validation of a metabolite profile for the early detection of breast cancer recurrence. J Clin Oncol 30: 2012 (suppl 30; abstr 5) Author(s): Daniel Raftery et al Metabolite profiles of 116 serial serum samples from 20 recurring patients and 141 serial samples from 36 breast cancer survivors with no evidence of disease (NED). Multivariate analysis was used to identify 11 metabolite markers that were used to build a model with high accuracy (AUROC >0.88 using 10 fold cross validation) with a sensitivity of 68% and specificity of 94%. Strikingly, over 55% of the patients could be correctly predicted to have recurrence on average 13 months before clinical diagnosis, representing a large improvement over the current diagnostic assays CA and CA 15-3 (Cancer Res. 2010; 70, ).. The profile was tested using a separate validation set of 96 patient samples run identically. The performance was similar to the training set with a sensitivity of 65% and specificity of 93%. Recurrence detection was approximately 11 months ahead of clinical diagnosis (based on imaging for symptomatic patients) and about 2 years ahead of CA alone.

25 RESEARCH FUNDING THANK YOU!!!!!!!!!!