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Article: The Role of Chemotherapy in Advanced Estrogen Receptor Positive Breast Cancer Back to article | View all comments

Author: Tamer M. Fouad, M.D. | September 03, 2009

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October 10, 2009 11:23 PM
M. Aroon Kamath, M.D.'s avatar

Dear Dr.Tamer,
I must commend you for the very prompt and succinct explanation.


October 10, 2009 08:04 PM
Tamer M. Fouad, M.D.'s avatar

Great question Dr. Aroon. The controversies surrounding this topic are endless and have been going on for a very long time. It is clear that our understanding of the predictive power of PR receptor expression in breast cancer is incomplete.

Your statement is absolutely correct for breast cancer in the metastatic setting. Indeed, measurement of PR improves the predictive power for obtaining a response in ER positive tumors. Metastatic patients that express both ER and PR are associated with a 70% response rate to hormonal therapy. While ER+/PR- or ER-/PR+ have a 40% chance of response. Those with both ER and PR negativity respond in less than 10% of cases. There is also some evidence that HER2 positivity may affect hormonal response in ER/PR positive patients.

It’s a different story when we discuss PR status in the adjuvant setting. Initial reports from the ATAC trial (9366 patients) which randomized patients to receive either initial tamoxifen or anastrazole, suggested better outcome in ER+/PR- as compared to ER+/PR+. This benefit was not confirmed in follow up data or in another important trial, the BIG 1-98, which tested a different aromatase inhibitor (letrozole) against standard tamoxifen. Here there was clearly no difference between ER+/PR- and ER+/PR+ groups.

Again, you are right in saying that the PR status has been overshadowed by ER status. This was later overshadowed by the role that HER-2 status played in modulating response to hormonal therapy. Currently, the focus is on genetic profiling, with Luminal A patients showing superior responses compared to Luminal B hormone positive tumors, which is probably why your point is not mentioned in this review.

Thanks again for this important question.


October 09, 2009 01:11 PM
M. Aroon Kamath, M.D.'s avatar

Dear Dr.Tamer,
Went through the very informative and thought provoking article of yours on the role of chemotherapy in advanced estrogen receptor positive breast cancer.I just thought i should make a mention the importance of the progesterone receptors-PR(PgR) in relation to this topic.Generally the role progesterone receptors tends to be overshadowed by that of the estrogen receptors. A low level of PgR’s is sited as one of the reasons for a poor response to hormonal manipulation. Does the study that you have sited make any mention of the PgR levels in the patients studied?
Thank you again Dr.Tamer,

Dr.M.Aroon kamath.


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