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Hereditary Genet. Author manuscript; available in PMC 2014 Oct 1. PMCID: PMC4181680
Published in final edited form as: NIHMSID: NIHMS631404
Hereditary Genet. 2013; 2013(Suppl 2): 001. PMID: 25285241
Published online 2013. doi: 10.4172/2161-1041.S2-001

Triple Negative Breast Cancer – An Overview

Kartik Aysola,1,# Akshata Desai,3,# Crystal Welch,1 Jingyao Xu,1 Yunlong Qin,1 Vaishali Reddy,1
Roland Matthews,1 Charlotte Owens,1 Joel Okoli,2 Derrick J Beech,2 Chandrika J Piyathilake,4
Shyam P Reddy,1 and Veena N Rao1

Abstract

Triple Negative Breast Cancer (TNBC) is a heterogeneous disease that based on immuno‐
histochemistry (IHC) is estrogen receptor (ER) negative, progesterone receptor (PR) nega‐
tive and human epidermal growth factor receptor 2 (HER2) negative. TNBC is typically
observed in young AA women and Hispanic women who carry a mutation in the BRCA1
gene. TNBC is characterized by a distinct molecular profile, aggressive nature and lack of
targeted therapies. The purpose of this article is to review the current and future novel sig‐
nalling pathways as therapeutic approaches to TNBC. Recent Identification of a new BR‐
CA1 trafficking pathway holds promise in the future for the development of targeted thera‐
pies for TNBC.

Keywords: TNBC, BRCA1, CISPLATIN, EGFR, PARP, Hedgehog, NOTCH, BCL-2,

UBC9, WNT/B-CATENIN

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 Triple Negative Breast Cancer (TNBC) is a subtype of breast cancer that based on immuno‐
histochemistry (IHC) is estrogens receptor (ER) negative, progesterone receptor (PR) nega‐
tive and human epidermal growth factor receptor 2 (HER2) negative [1]. TNBC is charac‐
terized by its unique molecular profile, aggressive nature, distinct metastatic patterns and
lack of targeted therapies. It is estimated that out of the worldwide breast cancer burden,
approximately 170,000 cases are TNBC and account for ~10-20% of invasive breast cancers
[1,2].

Molecular Profile and IHC Phenotype

Breast cancers are typically classified into seven subtypes (3): luminal A (ER positive and
histologic low grade), luminal B (ER positive and histologic high grade), HER2 overex‐
pressing, basal-like (2 types – BL1 and BL2), immunomodulatory (IM), mesenchymal (M),
mesenchymal stem-like (MSL) [3] and normal breast-like tumours [1]. Majority of the
TNBC are the basal-like subtype, and many basal-like breast cancers are triple negative;
they are not equivalent in terms of gene expression signatures and IHC analysis [4]. Basal-
like breast cancer is a classification based on gene expression profiling. Although they ap‐
pear to be synonymous, there is up to 30% discordance between the two groups [5,6]. In
addition to low expression of ER, PR and HER2, basal-like breast cancers are characterized
by a high expression of CK5, CK14, caveolin-1, caix, p63, EGFR (Epidermal Growth Fac‐
tor Receptor)/HER1, which reflects on the mammary gland basal/myoepithelial cell compo‐
nent [7].

Additionally, several proteins integrally involved in DNA repair are aberrantly expressed in
TNBC, which may have implications on sensitivity to chemotherapeutic agents like, plat‐
inum-based drugs. High p53 IHC expression is common in basal-like breast cancer [8].
Several additional and targetable molecular pathways implicated in the pathogenesis of
basal-like breast cancer include the mutagen activated protein (MAP) kinase pathway, the
Akt pathway, and the poly ADP-ribose polymerase1 (PARP1) pathway [9].

Association with BRCA1 Mutation status

It has been observed that a high percentage of BRCA1- associated hereditary and sporadic
breast cancers are triple negative and express a high proportion of basal like cytokeratins
(CK5,14,17), as well as P-Cadherin and HER1/EGFR [10,11]. Gene expression studies sup‐
port this association among patients with BRCA1 mutations that breast tumours tend to
cluster within the basal like category [12].

Epidemiology and Risk Factors

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 Several large scale population based studies indicate that TNBC are up to three times more
likely to occur among pre-menopausal women of African-American descent [13]. Certain
epidemiologic studies like the Carolina Breast Cancer Study illustrated that as compared to
the luminal a tumours, basal-like tumours were more likely to arise among women with
early menarche, higher parity, younger age at full term pregnancy, and shorter duration of
breast feeding, higher body mass index, and higher waist to hip ratio, especially among pre-
menopausal patients [14]. Another study done by Bauer et al. [13] found that younger, non-
Hispanic black and Hispanic women diagnosed with TNBC, had tumours that were more
aggressive, and these women had poorer survival regardless of stage. In addition, non-His‐
panic black women with late stage TNBC had the poorest survival of any comparable group
[13].

Clinical Characteristics

TNBC is well known for its aggressive behaviour and is characterized by onset at a younger
age, high mean tumour size, higher grade tumours and sometimes, a higher rate of node
positivity [15]. Additionally, this group is also known for an early peak of recurrence be‐
tween the first and third year after diagnosis, and more aggressive metastases which are
more likely to occur in viscera particularly in the lungs and brain, and less likely to spread
to the bone [16]. Based upon histological findings the majority of the triple negative breast
cancers are of ductal origin; however, several other aggressive phenotypes also appear to be
over represented, including metaplastic, apocrine and adenoid cystic [17]. A histological
study of basal-like tumours, all being ER/HER2 negative, yielded marked increase in mitot‐
ic count, geographic necrosis, pushing borders of invasion and stromal lymphocytic re‐
sponse [18].

Prognosis

An inferior prognosis in the basal-like breast cancer, as compared to the luminal type, has
been uniformly demonstrated by a variety of studies [19]. Population based studies have
also demonstrated similar results with reduced breast cancer specific survival among those
with TNBC, as compared with the luminal subtype [14].

A recently reported Canadian series [15] evaluating prognosis in over 1,500 women,
showed an increased likelihood of distant recurrence and death among women with triple
negative breast cancer, as compared to the non triple negative disease. Studies have consis‐
tently shown that more aggressive visceral and soft tissue relapses are more common and
bone relapses less common among those diagnosed with triple negative versus ER positive
disease [20]. An estimated 15% of all patients with breast cancer will develop brain metas‐

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 tasis. In a series of over 3,000 patients with brain metastasis arising from breast cancer
treated from 1989 to 2006, multivariate analysis indicated that triple negative status was the
greatest risk factor for the development of cerebral metastasis (odds ratio=4.16; p<0.001),
above that of HER2 positive status (OR=3.43; p=0.005) [21]. In another study using pa‐
tients with BRCA1 mutation, there was 82% complete pathologic response in those treated
with Cisplatinum alone [22].

Therapeutic Strategies

Although triple negative breast cancers are associated with a generally poor breast cancer
specific outcome, most are not resistant to chemotherapy. These patients have an extremely
poor prognosis and relapse and die quickly. Several therapies are being developed that tar‐
get specific biomarkers of TNBC or basal-like subtype [23]. These strategies include
EGFR-targeted agents, androgen receptor targeted agents, anti-antigenic agents, and PARP
inhibitors are offering an option in triple negative disease; however, their uses as of date are
limited to clinical trials and more work is needed to identify targets that yield high thera‐
peutic ratios [23]. TNBC with BRCA1 gene mutations may be more sensitive to agents that
cause DNA damage, such as Cisplatin [24]. Other, more recent promising therapeutic tar‐
gets for TNBC include the NOTCH, Hedgehog and Wnt/b-Catenin signalling pathways [2].
Studies have shown that these therapies alter the apoptotic pathway, inhibiting tumour pro‐
gression [2].

Chemotherapy

Adjuvant chemotherapy has been shown to not only prolong disease-free survival in pa‐
tients but overall survival as a whole; however, TNBC lacks the typical targeted receptors
found in luminal or HER-2 disease and therefore cannot be treated with hormonal agents,
such as SERMS, aromatise inhibitors or HER2 antagonists [25]. To combat this issue sever‐
al neoadjuvant studies have been done which accentuated the relationship between chemo
sensitivity and outcome, revealing proportionally higher sensitivity to anthracycline or an‐
thracycline/taxane–based chemotherapy such as Doxorubicin and Cyclophosphamide (stan‐
dard chemotherapeutic agents), for basal like/ER negative breast cancers as compared to the
luminal subtype [26]. Highest response rates were noticed among those classified as basal
like (85%) and HER2 positive (70%), as compared to luminal (47%, p<0.0001). Despite
initial chemo sensitivity, disease free survival (p=0.04) and overall survival (p=0.02) re‐
mained poorest among those with basal like and HER2 positive tumours, compared to the
luminal subtype [26]. Although triple negative disease is highly responsive to Anthracy‐
cline/Taxane chemotherapy treatment, a high risk of relapse still remains if the tumour is
not completely eradicated.

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 Additionally, pre-clinical and clinical studies indicate that tumours with BRCA1 dysfunc‐
tion are sensitive to platinum agents such as Cisplatin, and Carboplatin which function by
causing DNA damage and promote tumour cell apoptosis [25,27]. Studies have shown that
p63, a family member of p53, is responsible for controlling a survival pathway that directly
mediates Cisplatin sensitivity in TNBC; it therefore, can possibly be used as a biomarker to
predict response to platinum therapy in triple negative breast cancer. However, this finding
warrants further investigation and currently platinum’s are not recommended for the adju‐
vant treatment of TNBC [25].

EGFR Inhibitors

EGFR expression is approximately seen in 60% of triple negative breast tumors, thus pro‐
viding a reasonable targeted treatment approach [6]. A phase II trial evaluating the combi‐
nation of Cetuximab (a chimeric monoclonal antibody targeting EGFR) and Carboplatin,
weekly for 3 to 4 weeks reported a response rate of 18% and overall clinical benefit of 27%
among 102 patients with advanced TNBC [28].

Another study evaluating the combination of Irinotecan and Carboplatin with or without
Cetuximab reported response rates of 49% and 30% respectively, among 72 patients with
pre-treated TNBC. EGFR inhibitor Panitumumab, when used in combination with standard
chemotherapeutic agents for neoadjuvant therapy for inoperable TNBC was recently report‐
ed to have shown a pathological complete response rate of 65% [25]. Other studies have
recently demonstrated that EGFR inhibitors when used in combination with Texans or plat‐
inum’s may increase the efficacy of the other agents [25]. To date, the majority of data with
EGFR inhibitors has generally been interpreted as negative.

PARP Inhibitors

PARP1, a gene that encodes an enzyme involved in the molecular events leading to cell re‐
covery from DNA damage, when inhibited, leads to the accumulation of double-stranded
DNA breaks. Cells deficient in BRCA1 and BRCA2 (required for normal homologous re‐
combination), are exquisitely sensitive to PARP1 inhibition. Several PARP inhibitors Ola‐
parib, Velaparib and PF-01367338 are currently in clinical trials and hold a promising fu‐
ture [25]. The study demonstrated a statistically significant 50% reduction in the risk of
death; however, phase III trials failed to show statistically significant benefit for this combi‐
nation, hence, the drug has been discontinued but some biomarker analysis is still underway
to determine if a specific subset of patient may benefit from the drug [16,28,29]. This there‐
fore highlights the need for continued research and clinical trials.

Antiangiogenic Agents

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 The antiangiogenic agent Bevacizumab, a monoclonal antibody that targets all forms of
VEGF, has been evaluated in a number of large phase III trials as treatment of metastatic
breast cancer [25]. The landmark study E2100 illustrated improvement in progressionfree
survival (11.8 vs. 5.9 months, HR=0.60, p<0.001) when adding Bevacizumab to Paclitaxel
chemotherapy compared with single-agent Paclitaxel alone in first-line treatment of
metastatic disease [25]. This subsequently led to subgroup analysis that demonstrated simi‐
lar progression free survival benefits in both patients with TNBC and non-TNBC with the
use of Bevacizumab plus a taxane [25]. Currently, the BEATRICE trial is prospectively
investigating this combination as adjuvant therapy in TNBC [25]. Additionally, several
small-molecule inhibitors of the VEGF pathway appear to have activity in the subset of pre-
treated triple-negative breast cancer and definitive studies showing overall survival benefit
will be needed prior to re approval [30,31].

Conclusion

In conclusion, TNBC is a difficult and complex disease entity that is both confusing and
frustrating for researchers, physicians and patients. To date there are multiple approaches
attempting to improve care of triple negative breast cancer patients, including DNA damag‐
ing agents like platinum’s, targeted EGFR and VEGF inhibitors, and, PARP inhibitors;
however, none have been as clinically successful as anticipated and more targeted therapies
need to be developed and explored. The Wnt/b-Catenin, NOTCH and Hedgehog signaling
pathways are being considered as novel therapeutic targets for TNBC [2].

Future Direction

The key to developing targeted therapies for TNBC will depend on understanding the mole‐
cular mechanism for the development of these cancers. There are seminal studies by Hosey
et al. [32] and by our group [33,34] (unpublished results) on the possible molecular mecha‐
nisms of BRCA1 dysfunction which could result in ER negative breast cancers. Recently
Ubc9, a sole SUMO-E2-conjugating enzyme for sumoylation was found to bind BRCA1
proteins and ferry it to the nucleus unlike disease associated mutant BRCA1 proteins [34].
Over expression of Ubc9 was observed in breast tumours and TNBC cell lines [34]. BR‐
CA1 function-based cellular assays have been designed to detect loss of binding to Ubc9 by
BRCA1 mutants (Patent number US 8,372,580). These assays not only predict the risk for
developing TNBC but may also lead to the development of targeted therapies for hereditary
and sporadic TNBC.

Acknowledgements

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 We thank Ms Wimes and Mr. Hill for editorial assistance. This work was supported in part
by Georgia Cancer Coalition Distinguished Cancer Scholar award, NIH-NCRR-RCMI grant
G-12-RR003034, U54 RR02613, 5P20RR11104 and NIHMD research endowment grant
2S21MD000101, U54 CA118638 and ING foundation grant to V.N.R.

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