PURPOSE: There is strong epidemiologic evidence indicating that estrogens may not be the sole steroid drivers of breast cancer. We hypothesize that abundant adrenal androgenic steroid precursors, acting via the androgen receptor (AR), promote an endocrine-resistant breast cancer phenotype. EXPERIMENTAL DESIGN: AR was evaluated in a primary breast cancer tissue microarray (n = 844). Androstenedione (4AD) levels were evaluated in serum samples (n = 42) from hormone receptor-positive, postmenopausal breast cancer. Levels of androgens, progesterone, and estradiol were quantified using LC/MS-MS in serum from age- and grade-matched recurrent and nonrecurrent patients (n = 6) before and after aromatase inhibitor (AI) therapy (>12 months). AR and estrogen receptor (ER) signaling pathway activities were analyzed in two independent AI-treated cohorts. RESULTS: AR protein expression was associated with favorable progression-free survival in the total population (Wilcoxon, P < 0.001). Pretherapy serum samples from breast cancer patients showed decreasing levels of 4AD with age only in the nonrecurrent group (P < 0.05). LC/MS-MS analysis of an AI-sensitive and AI-resistant cohort demonstrated the ability to detect altered levels of steroids in serum of patients before and after AI therapy. Transcriptional analysis showed an increased ratio of AR:ER signaling pathway activities in patients failing AI therapy (t test P < 0.05); furthermore, 4AD mediated gene changes associated with acquired AI resistance. CONCLUSIONS: This study highlights the importance of examining the therapeutic consequences of the steroid microenvironment and demonstrable receptor activation using indicative gene expression signatures.

Applied Bioinformatics of Cancer Institute of Genetics and Cancer University of Edinburgh Cancer Research Centre Edinburgh United Kingdom

Biomedical Center Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic

Data Science Centre RCSI University of Medicine and Health Sciences Dublin Ireland

Department of Biochemistry Manchester University NHS Foundation Trust London United Kingdom

Department of Pathology Beaumont Hospital Dublin Ireland

Department of Surgery Beaumont Hospital Dublin Ireland

Endocrine Oncology Research Department of Surgery RCSI University of Medicine and Health Sciences Dublin Ireland

Toxicogenomics Unit National Institute of Public Health Prague Czech Republic

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Prat A, Ellis MJ, Perou CM. Practical implications of gene-expression-based assays for breast oncologists. Nat Rev Clin Oncol 2011;9:48–57. PubMed PMC

Early Breast Cancer Trialists' Collaborative Group. Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials. Lancet 2015;386:1341–52. PubMed

Metivier R, Penot G, Hubner MR, Reid G, Brand H, Kos M, et al.  Estrogen receptor-alpha directs ordered, cyclical, and combinatorial recruitment of cofactors on a natural target promoter. Cell 2003;115:751–63. PubMed

Carroll JS, Liu XS, Brodsky AS, Li W, Meyer CA, Szary AJ, et al.  Chromosome-wide mapping of estrogen receptor binding reveals long-range regulation requiring the forkhead protein FoxA1. Cell 2005;122:33–43. PubMed

Hilton HN, Clarke CL, Graham JD. Estrogen and progesterone signalling in the normal breast and its implications for cancer development. Mol Cell Endocrinol 2018;466:2–14. PubMed

Obradovic MMS, Hamelin B, Manevski N, Couto JP, Sethi A, Coissieux MM, et al.  Glucocorticoids promote breast cancer metastasis. Nature 2019;567:540–4. PubMed

Creevey L, Bleach R, Madden SF, Toomey S, Bane FT, Vareslija D, et al.  Altered steroid milieu in AI-resistant breast cancer facilitates AR mediated gene-expression associated with poor response to therapy. Mol Cancer Ther 2019;18:1731–43. PubMed

Chia K, Milioli H, Portman N, Laven-Law G, Coulson R, Yong A, et al.  Non-canonical AR activity facilitates endocrine resistance in breast cancer. Endocr Relat Cancer 2019;26:251–64. PubMed

Mohammed H, Russell IA, Stark R, Rueda OM, Hickey TE, Tarulli GA, et al.  Progesterone receptor modulates ERalpha action in breast cancer. Nature 2015;523:313–7. PubMed PMC

Cochrane DR, Bernales S, Jacobsen BM, Cittelly DM, Howe EN, D'Amato NC, et al.  Role of the androgen receptor in breast cancer and preclinical analysis of enzalutamide. Breast Cancer Res 2014;16:R7. PubMed PMC

Huss L, Butt ST, Borgquist S, Elebro K, Sandsveden M, Rosendahl A, et al.  Vitamin D receptor expression in invasive breast tumors and breast cancer survival. Breast Cancer Res 2019;21:84. PubMed PMC

Rangel N, Rondon-Lagos M, Annaratone L, Osella-Abate S, Metovic J, Mano MP, et al.  The role of the AR/ER ratio in ER-positive breast cancer patients. Endocr Relat Cancer 2018;25:163–72. PubMed

Rangel N, Rondon-Lagos M, Annaratone L, Aristizábal-Pachon AF, Cassoni P, Sapino A, et al.  AR/ER ratio correlates with expression of proliferation markers and with distinct subset of breast tumors. Cells 2020;9:1064. PubMed PMC

Cao L, Xiang G, Liu F, Xu C, Liu J, Meng Q, et al.  A high AR:ERα or PDEF:ERα ratio predicts a sub-optimal response to tamoxifen therapy in ERα-positive breast cancer. Cancer Chemother Pharmacol 2019;84:609–20. PubMed

Venema CM, Bense RD, Steenbruggen TG, Nienhuis HH, Qiu SQ, van Kruchten M, et al.  Consideration of breast cancer subtype in targeting the androgen receptor. Pharmacol Ther 2019;200:135–47. PubMed

Bleach R, McIlroy M. The divergent function of androgen receptor in breast cancer; analysis of steroid mediators and tumor intracrinology. Front Endocrinol 2018;9:594. PubMed PMC

Beatson GT. On the treatment of inoperable cases of carcinoma of the mamma: suggestions for a new method of treatment, with illustrative cases. Trans Med Chir Soc Edinb 1896;15:153–79. PubMed PMC

Inda MA, Blok EJ, Kuppen PJK, Charehbili A, den Biezen-Timmermans EC, van Brussel A, et al.  Estrogen receptor pathway activity score to predict clinical response or resistance to neoadjuvant endocrine therapy in primary breast cancer. Mol Cancer Ther 2020;19:680–9. PubMed

van de Stolpe A, Holtzer L, van Ooijen H, Inda MA, Verhaegh W. Enabling precision medicine by unravelling disease pathophysiology: quantifying signal transduction pathway activity across cell and tissue types. Sci Rep 2019;9:1603. PubMed PMC

van Ooijen H, Hornsveld M, Dam-de Veen C, Velter R, Dou M, Verhaegh W, et al.  Assessment of functional phosphatidylinositol 3-kinase pathway activity in cancer tissue using forkhead box-O target gene expression in a knowledge-based computational model. Am J Pathol 2018;188:1956–72. PubMed

Charmsaz S, Doherty B, Cocchiglia S, Vareslija D, Marino A, Cosgrove N, et al.  ADAM22/LGI1 complex as a new actionable target for breast cancer brain metastasis. BMC Med 2020;18:349. PubMed PMC

Ricciardelli C, Bianco-Miotto T, Jindal S, Butler LM, Leung S, McNeil CM, et al.  The magnitude of androgen receptor positivity in breast cancer is critical for reliable prediction of disease outcome. Clin Cancer Res 2018;24:2328–41. PubMed

Hawley JM, Adaway JE, Owen LJ, Keevil BG. Development of a total serum testosterone, androstenedione, 17-hydroxyprogesterone, 11beta-hydroxyandrostenedione and 11-ketotestosterone LC-MS/MS assay and its application to evaluate pre-analytical sample stability. Clin Chem Lab Med 2020;58:741–52. PubMed

Chadwick CA, Owen LJ, Keevil BG. Development of a method for the measurement of dehydroepiandrosterone sulphate by liquid chromatography-tandem mass spectrometry. Ann Clin Biochem 2005;42:468–74. PubMed

Verhaegh W, van Ooijen H, Inda MA, Hatzis P, Versteeg R, Smid M, et al.  Selection of personalized patient therapy through the use of knowledge-based computational models that identify tumor-driving signal transduction pathways. Cancer Res 2014;74:2936–45. PubMed

Vidula N, Yau C, Wolf D, Rugo HS. Androgen receptor gene expression in primary breast cancer. NPJ Breast Cancer 2019;5:47. PubMed PMC

Wilson BJ, Giguere V. Meta-analysis of human cancer microarrays reveals GATA3 is integral to the estrogen receptor alpha pathway. Mol Cancer 2008;7:49. PubMed PMC

Selli C, Turnbull AK, Pearce DA, Li A, Fernando A, Wills J, et al.  Molecular changes during extended neoadjuvant letrozole treatment of breast cancer: distinguishing acquired resistance from dormant tumours. Breast Cancer Res 2019;21:2. PubMed PMC

Turnbull AK, Arthur LM, Renshaw L, Larionov AA, Kay C, Dunbier AK, et al.  Accurate prediction and validation of response to endocrine therapy in breast cancer. J Clin Oncol 2015;33:2270–8. PubMed

Moon JY, McNamara KM, Lee JJ, Chung BC, Sasano H, Choi MH. Improved detectability of sex steroids from frozen sections of breast cancer tissue using GC-triple quadrupole-MS. J Steroid Biochem Mol Biol 2018;178:185–92. PubMed

Gardner DG. Greenspan's basic and clinical endocrinology. 10th ed. New York: McGraw-Hill Education; 2017.

James RE, Lukanova A, Dossus L, Becker S, Rinaldi S, Tjonneland A, et al.  Postmenopausal serum sex steroids and risk of hormone receptor-positive and -negative breast cancer: a nested case-control study. Cancer Prev Res 2011;4:1626–35. PubMed

McDonnell DP, Park S, Goulet MT, Jasper J, Wardell SE, Chang CY, et al.  Obesity, cholesterol metabolism, and breast cancer pathogenesis. Cancer Res 2014;74:4976–82. PubMed PMC

Nelson ER, Chang CY, McDonnell DP. Cholesterol and breast cancer pathophysiology. Trends Endocrinol Metab 2014;25:649–55. PubMed PMC

Africander D, Storbeck KH. Steroid metabolism in breast cancer: where are we and what are we missing? Mol Cell Endocrinol 2018;466:86–97. PubMed

Ali A, Creevey L, Hao Y, McCartan D, O'Gaora P, Hill A, et al.  Prosaposin activates the androgen receptor and potentiates resistance to endocrine treatment in breast cancer. Breast Cancer Res 2015;17:123. PubMed PMC

Venturelli E, Orenti A, Fabricio ASC, Garrone G, Agresti R, Paolini B, et al.  Observational study on the prognostic value of testosterone and adiposity in postmenopausal estrogen receptor positive breast cancer patients. BMC Cancer 2018;18:651. PubMed PMC

Key T, Appleby P, Barnes I, Reeves G, Endogenous H. Breast Cancer Collaborative G. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst 2002;94:606–16. PubMed

Kensler KH, Regan MM, Heng YJ, Baker GM, Pyle ME, Schnitt SJ, et al.  Prognostic and predictive value of androgen receptor expression in postmenopausal women with estrogen receptor-positive breast cancer: results from the breast international group trial 1–98. Breast Cancer Res 2019;21:30. PubMed PMC

McIlroy M, McCartan D, Early S, O Gaora P, Pennington S, Hill AD, et al.  Interaction of developmental transcription factor HOXC11 with steroid receptor coactivator SRC-1 mediates resistance to endocrine therapy in breast cancer [corrected]. Cancer Res 2010;70:1585–94. PubMed

Fankhauser M, Tan Y, Macintyre G, Haviv I, Hong MK, Nguyen A, et al.  Canonical androstenedione reduction is the predominant source of signaling androgens in hormone-refractory prostate cancer. Clin Cancer Res 2014;20:5547–57. PubMed

Husing A, Fortner RT, Kuhn T, Overvad K, Tjonneland A, Olsen A, et al.  Added value of serum hormone measurements in risk prediction models for breast cancer for women not using exogenous hormones: results from the EPIC cohort. Clin Cancer Res 2017;23:4181–9. PubMed

Bozovic-Spasojevic I, Zardavas D, Brohee S, Ameye L, Fumagalli D, Ades F, et al.  The prognostic role of androgen receptor in patients with early-stage breast cancer: a meta-analysis of clinical and gene expression data. Clin Cancer Res 2017;23:2702–12. PubMed

Krop I, Abramson V, Colleoni M, Traina T, Holmes F, Garcia-Estevez L, et al.  A randomized placebo controlled phase II trial evaluating exemestane with or without enzalutamide in patients with hormone receptor–positive breast cancer. Clin Cancer Res 2020;26:6149–57. PubMed

Abderrahman B, Maximov PY, Curpan RF, Hanspal JS, Fan P, Xiong R, et al.  Pharmacology and molecular mechanisms of clinically relevant estrogen estetrol and estrogen mimic BMI-135 for the treatment of endocrine-resistant breast cancer. Mol Pharmacol 2020;98:364–81. PubMed PMC

Hickey TE, Selth LA, Chia KM, Laven-Law G, Milioli HH, Roden D, et al.  The androgen receptor is a tumor suppressor in estrogen receptor-positive breast cancer. Nat Med 2021;27:310–20. PubMed

Osako T, Lee H, Turashvili G, Chiu D, McKinney S, Joosten SEP, et al.  Age-correlated protein and transcript expression in breast cancer and normal breast tissues is dominated by host endocrine effects. Nat Cancer 2020;1:518–32. PubMed

Bernhardt SM, Dasari P, Wrin J, Raymond W, Edwards S, Walsh D, et al.  Discordance in 21-gene recurrence scores between paired breast cancer samples is inversely associated with patient age. Breast Cancer Res 2020;22:90. PubMed PMC