VOLUME

27

NUMBER

17

JUNE

10

2009

JOURNAL OF CLINICAL ONCOLOGY

O R I G I N A L

R E P O R T

Ki67 Expression and Docetaxel Efficacy in Patients With

Estrogen ReceptorPositive Breast Cancer
Frdrique Penault-Llorca, Fabrice Andre, Christine Sagan, Magali Lacroix-Triki, Yves Denoux,
Veronique Verriele, Jocelyne Jacquemier, Marie Christine Baranzelli, Frederic Bibeau, Martine Antoine,
Nicole Lagarde, Anne-Laure Martin, Bernard Asselain, and Henri Roche
From the Department of Pathology,
Centre Jean Perrin, Clermont-Ferrand;
Department of Medicine and Translational Research Unit, Institut Gustave
Roussy, Villejuif; Department of Pathology, Centre Hospitalier Universitaire,
Nantes; Departments of Pathology and
Medical Oncology, Institut Claudius
Regaud, Toulouse; Department of
Pathology, Centre Francois Baclesse,
Caen; Department of Pathology, Centre
Paul Papin, Angers; Department of
Pathology, Institut Paoli-Calmettes,
Marseille; Department of Pathology,
Centre Oscar Lambret, Lille; Department of Pathology, Centre Val
dAurelle, Montpellier; Department of
Pathology, Centre Hospitalier Universitaire Tenon; Federation Nationale des
Centres de Lutte Contre le Cancer;
Department of Biostatistics, Institut
Curie, Paris; and Department of Pathology, Centre Hospitalier Universitaire
Brest, Brest, France.
Submitted May 22, 2008; accepted
January 7, 2009; published online
ahead of print at www.jco.org on April
20, 2009.
Supported by the Federation Nationale
des Centres de Lutte Contre le Cancer,
the Ligue Nationale Contre le Cancer,
Sanofi-aventis, and a career development award from the American Society
of Clinical Oncology (to F.A.).
Authors disclosures of potential conflicts of interest and author contributions are found at the end of this
article.
Corresponding author: Frederique
Penault-Llorca, MD, Department of
Pathology, Centre Jean Perrin, EA
4233, Universit dAllvergne Clermont
1, 63000 Clermont-Ferrand, France;
e-mail: frederique.penault-llorca@cjp.fr.
The Appendix is included in the
full-text version of this article,
available online at www.jco.org.
It is not included in the PDF version
(via Adobe Reader).
2009 by American Society of Clinical
Oncology
0732-183X/09/2717-2809/$20.00
DOI: 10.1200/JCO.2008.18.2808

Purpose
The indications of adjuvant chemotherapy for patients with estrogen receptor (ER) positive breast
cancer are controversial. We analyzed the predictive value of Ki67, HER2, and progesterone
receptor (PR) expression for the efficacy of docetaxel in patients with ER-positive, node-positive
breast cancer.
Patients and Methods
Expression of Ki67, HER2, and PR was measured by immunohistochemistry in tumor samples from
798 patients with ER-positive breast cancer who participated in PACS01, a randomized trial that
evaluated the efficacy of docetaxel. Risk reduction was evaluated using a Cox model adjusted for age,
tumor size, nodal involvement, treatment arm, and biomarkers. The predictive value of biomarkers was
assessed by an interaction test. Disease-free survival (DFS) was the primary end point.
Results
Ki67, HER2, and PR were expressed in 21%, 9%, and 62% of samples, respectively. Hazard ratios
for relapse associated with docetaxel were 0.51 (95% CI, 0.26 to 1.01) in ER-positive/Ki67-positive
tumors and 1.03 (95% CI, 0.69 to 1.55) in ER-positive/Ki67-negative tumors (ratio for interaction:
0.53; 95% CI, 0.24 to 1.16; P .11). Five-year DFS rates were 81% (95% CI, 76% to 86%) and
84% (95% CI, 75% to 93%) in patients with ER-positive/Ki67-negative and ER-positive/Ki67positive tumors treated with docetaxel and 81% (95% CI, 76% to 86%) and 62% (95% CI, 52%
to 72%) in patients with ER-positive/Ki67-negative and ER-positive/Ki67-positive tumors treated
with fluorouracil, epirubicin, and cisplatin. No trend for interaction was observed between
docetaxel and HER2 (ratio for interaction: 0.83; 95% CI, 0.35 to 1.94; P .66), nor between
docetaxel and PR (ratio for interaction: 0.89; 95% CI, 0.47 to 1.66; P .71).
Conclusion
Ki67 expression identifies a subset of patients with ER-positive breast cancer who could be
sensitive to docetaxel treatment in the adjuvant setting.
J Clin Oncol 27:2809-2815. 2009 by American Society of Clinical Oncology

INTRODUCTION

Genome-wide molecular analyses have established

that breast cancer is composed of at least two different entities that can be defined according to estrogen
receptor (ER) expression.1 ER-negative disease is
characterized by a high sensitivity to chemotherapy
and a more aggressive course.1 In contrast, for ERpositive disease, standard treatment is at least 5
years of endocrine therapy.1,2 The additional role
of adjuvant chemotherapy in this patient subgroup is a matter of controversy.2 Numerous published studies have shown that the efficacy of
anthracycline- and alkylating agent-based regimens
is lower in patients with ER-positive disease as compared with those with ER-negative disease.3-5 Some

data6-8 suggest that, although less chemosensitive,

ER-positive disease includes a subset of patients who
derive a significant benefit from adjuvant chemotherapy. Several molecular assays6,9,10 have been
tested in an attempt to identify such chemosensitive
ER-positive tumors. Most of these assays relate to
proliferative indexes,6 ER-regulated genes6,9 and
HER2 pathway,6,10 and suggest that tumors that
have a combination of a low proliferative index, high
expression of ER-regulated genes, and low HER2
expression derive little benefit from either firstor second-generation chemotherapy, whereas
the others are considered chemosensitive.6,7
Although some predictors could identify which
ER-positive patients derive benefit from either
first- or second-generation chemotherapy, there
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2809

Penault-Llorca et al

are no data about how to predict the efficacy of third-generation

chemotherapy agents (ie, those including anthracyclines and either
docetaxel or dose dense/weekly paclitaxel)11 in this specific group.
With the exception of a few studies,12 most randomized trials have
shown that third-generation adjuvant chemotherapy decreases relapse rate in patients with early breast cancer.13-16 All these studies
have reported a consistently large effect in patients with ERnegative disease. In contrast, the results were highly heterogeneous
in patients with ER-positive disease,12,17 leading to a controversy
about the usefulness of such third-generation regimens in that
subgroup. Although heterogeneous, data provided by randomized
trials suggested that a subset of patients with ER-positive disease
might derive benefit from adjuvant third-generation chemotherapy. The identification of such docetaxel-sensitive ER-positive disease could allow for better tailored indications of chemotherapy in
the adjuvant setting and better defined homogeneous molecular
groups, regardless of chemosensitivity, to be considered for clinical trials.
In the present study, we have analyzed the predictive value of
Ki67, progesterone receptor (PR), and HER2 expression for the efficacy of docetaxel in patients with ER-positive, node-positive breast
cancer included in the PACS01 trial.14

PATIENTS AND METHODS

Patients
This study is a biomarker, parallel study to the PACS01 trial. The PACS01
trial included 1,999 patients with node-positive breast cancer between 1998
and 2001. This randomized trial compared six cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) with three cycles of FEC followed by three
cycles of docetaxel (100 mg/m2). Results have been reported previously14 and
showed that adding three cycles of docetaxel to FEC reduced by 17% the risk of
relapse (hazard ratio [HR] 0.83; 95% CI, 0.69 to 0.99).
Tumor blocks were collected for 1,190 patients (55% of cases included in
the trials). Clinical characteristics and magnitude of docetaxel efficacy were not
different among the biomarker study group (n 1,190) and the patients who
were not included in the biomarker study (n 809; data not shown). These
1,190 tumors were centrally immunostained with ER, PR, Ki67, and HER2specific antibodies. ER expression was assessable in 1,136 tumors (95%). Of
these 1,136 tumors, 798 (70%) were found to be ER positive. Analysis of the
present report will focus on these 798 patients. A flowchart depicting patient
and sample selection is shown in Figure 1. All postmenopausal patients with
hormone receptorpositive disease received tamoxifen, but for premenopausal patients, tamoxifen use was at the treating physicians discretion from
June 1997 to December 1998. After that point, tamoxifen was also mandatory
for all premenopausal patients with hormone receptorpositive disease. Radiation therapy was recommended for all patients treated with conservative
surgery and was performed at investigators discretion after mastectomy. No
patients with HER2-overexpressing disease received trastuzumab in the adjuvant setting.
Procedures for Immunostaining
Immunostaining was performed centrally. Tumors were stained for ER
(Clone 6F11, Novocastra; dilution 1:40), PR (Clone 1A6, Novocastra, Newcastle Upon Tyne, United Kingdom; dilution 1:30), Ki67 (Clone MIB1, Dako,
Glostrup, Denmark; dilution 1:50), and HER2 (Ab A0485, Dako; dilution
1:250), according to manufacturers recommendations. Heat-induced antigen
retrieval (3 minutes, pH 7.3, pressure cooker for ER, PR, and Ki67 stainings;
and 40 minutes, pH 6, waterbath for HER2 staining) was used for all biomarkers. All immunohistochemical assays have been performed with a Ventana
NeXes automat (Ventana Medical Systems Inc, Tucson, AZ).
2810

2009 by American Society of Clinical Oncology

PACS 01 trial

1,999 patients with

node-positive breast cancer
randomly allocated between
6FE100C and 3FE100C + 3docetaxel

PACS 01
biomarker study

Tumor blocks
collected for
1,190 patients
ER immunostaining

798 patients with

ER-positive tumor

338 patients with

54 patients with
ER-negative tumor unknown ER status

population for
present analysis

Fig 1. Study flowchart shows the process for tumor blocks and patient
selection. F, fluorouracil; e, epirubicin; C, cyclophosphamide; D, docetaxel; ER,
estrogen receptor.

Procedure for Fluorescent In Situ Hybridization

Fluorescent in situ hybridization (FISH) for HER2 was performed in
cases that presented a 2 score for Her2 expression by immunohistochemistry
(IHC). The United States Food and Drug Administrationapproved Path
Vysion HER2 kit (Vysis-Abbott Diagnostic, Abbott Park, IL) was performed as
specified by the manufacturer, with minor modifications. Codenaturation of
probe and DNA target was made 5 minutes at 85C on a HYBrite instrument
(Vysis-Abbott Diagnostic) just before the overnight hybridization, and a
distilled water wash was added before counterstaining with 4,6-diamidino2-phenylindole.
Centralized Review and Scoring
A panel of 10 pathologists centrally and blindly reviewed the stained
slides. A consensus was reached for the difficult cases using multiheaded
microscope examination. All cutoffs were predefined before statistical analyses
and are representative of the ones used in daily practice.
ER and PR immunostainings were considered positive when 10% or
more tumor cells were immunostained. The tumors were scored as either
positive or negative according to the cutoff. Ki67 expression was quantified
using a visual grading system. An estimated percentage of Ki67-positive cells
was thus determined and scored according to three categories organized in
increasing percentage intervals: 0% to 20%, 20% to 40%, more than 40%. In
this study, the cutoff for positivity was established at 20% positive cells. HER2
was evaluated by IHC according to the manufacturers recommended scoring
system, as follows: 0, no staining; 1, weak, barely detectable membrane
staining; 2, weak to moderate complete membrane staining; 3, strong,
complete membrane staining. All staining measurements were determined to
be in more than 10% of the cells as described in the HercepTest (Dako)
protocol. Only invasive tumor components were scored. FISH was performed
only for the 2 cases. HER2-positive cases reported in the final results are the
IHC 3 or amplified cases. For FISH, the signals corresponding to the HER2
gene and chromosome probe 17 (CEP17) were counted per nucleus. The
HER2/CEP17 signal ratio was determined for each tumor specimen. Ratios
greater than 2.2 were considered to show gene amplification. Fluorescent
signals were evaluated with an epifluorescence microscope using a 100 oil
objective. At least 30 nuclei were counted per slide, and only invasive tumors
were scored.
Statistical Analysis
Biomarkers were preselected based on their use in daily practice and on
whether they have previously been reported to be associated with a higher
sensitivity to chemotherapy. Cutoffs were predefined and were the ones used
in daily practice in French centers. Disease-free survival (DFS) was the primary
end point of the trial and was therefore selected for the present biomarker
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Ki67 Expression and Docetaxel Efficacy

study. Events were defined as locoregional relapse, metastatic relapse, contralateral breast cancer, and death, whatever the cause. HRs for relapse were
assessed using a Cox model that included age, tumor stage (T), and nodal stage
(N) as categoric covariates, together with each biomarker. Age was considered
as a binary variable with a cutoff defined at 50 years (stratification variable).
Cutoffs for T and N were, respectively, more than 2 and more than 3. Predictive value of each biomarker was evaluated using a test for interaction between
treatment effect and biomarker expression. To evaluate treatment by biomarker interaction, a Cox model was conducted that included age, T, and N together
with Ki67 treatment interaction, PR treatment interaction, and HER2
treatment interaction. Subpopulation treatment effect pattern plot (STEPP)
analyses were performed to assess docetaxel effect according to Ki67 expression. The STEPP analysis is intended to evaluate the magnitude of the treatment effect as a function of the values of the continuous covariates.18 It was
carried out using the sliding window algorithm described by Bonetti et al,18
which allowed overlapping subpopulations of patients to be defined, ensuring
that each subpopulation contains a large enough number of observations and
reasonably spans the range of the covariate. In the present analysis, five subpopulations were defined (A, B, C, D, E) as listed in Appendix Table A1 (online
only). Absolute effect of treatment of DFS was assessed by Kaplan-Meier
curves and log-rank tests. This article was written in accordance with Reporting Recommendations for Tumor Marker Prognostic Studies guidelines.19

RESULTS

Patient Characteristics
Seven hundred ninety-eight patients were included in the present
analysis. Table 1 reports the patient characteristics for the whole pop-

ulation and for patients with Ki67-negative and Ki67-positive tumors.

As previously stated, all patients were selected to present an ERpositive tumor. Ki67 and PR positivity were respectively expressed in
21% and 62% of ER-positive tumors. Seventy-nine (9%) of 778 assessable tumors overexpressed HER2. As expected, ER-positive/Ki67positive tumors were more likely to be high grade (52%) and
HER2 (23%). Ki67 expression was not correlated with node
status (P .08), nor T stage (P .21). The distribution of Ki67
expression is reported in Appendix Table A1.
Survival Analysis
After a median follow-up of 58.7 months for living patients, 175
events (21.9%) were reported. In this population of ER-positive tumors, the HR for relapse associated with docetaxel was 0.82 (95% CI,
0.60 to 1.12; P .22). Five-year DFS rates were 82% (95% CI, 78% to
86%) and 77% (95% CI, 73% to 81%) in patients treated or not with
docetaxel (P .11, log-rank test).
Association Between HER2, Ki67, PR, and DFS
Table 2 reports the association between Ki67, HER2, PR expression, and DFS in patients with ER-positive, node-positive disease. All
three biomarkers were significantly associated with DFS in univariate
analyses. HRs for relapse were 1.72 (95% CI, 1.22 to 2.43; P .002),
1.94 (95% CI, 1.27 to 2.94; P .002), and 1.67 (95% CI, 1.24 to 2.25;
P .001) for patients with Ki67-positive, HER2-overexpressed, and

Table 1. Patient Characteristics

Total Patients
(n 798)
Characteristic
Age, years
Median
Range
No. of involved nodes
3
3
T stage
T1
T2
T3
Tumor grade (Elston-Ellis grade)
1/2
3
Ki67
20%
20%
HER2
Not overexpressed
Overexpressed
PR
10%
10%
Treatment arm
FE100C
3FE100C 3 docetaxel
Overall No. of events (DFS)

No.

Ki67-Negative
(n 549)
%

No.

50.0
25.0-66.0

Ki67-Positive
(n 150)
%

No.

49.0
25.0-64.0

%
50.0
26.0-66.0

305
493

38
62

211
338

38
62

62
88

41
59

359
310
38

51
44
5

256
201
31

52
42
6

65
70
6

46
50
4

644
143

82
18

499
50

91
9

71
78

48
52

549
150

79
21

NA

705
73

91
9

507
38

93
7

121
28

77
23

279
454

38
62

176
323

35
65

52
79

40
60

398
400
175

50
50
21

266
283
105

48
52
19

86
64
46

57
43
31

NA

Abbreviations: NA, not applicable; PR, progesterone receptor; F, fluorouracil; E, epirubicin; C, cyclophosphamide; DFS, disease-free survival.

P .01.
HER2 overexpression was defined as immunohistochemistry score 3 or HER2 amplification detected by fluorescent in situ hybridization analysis.

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Penault-Llorca et al

Table 2. Cox Univariate and Multivariate Regression Analysis of the Risk of Relapse According to Ki67, HER2, and PR Expression Together With Age,
Node Status, T Stage, and Treatment Covariates in Patients With ER-Positive Tumors
Treatment Arm, Biomarker, and
Clinical Characteristics
Age, years
50
50
No. of axillary nodes involved
3 nodes
3 nodes
T stage
T1-T2
T3-T4
Treatment with docetaxel
No
Yes
Ki67 expression
20%
20%
HER2 overexpression
Normal
Overexpressed
PR expression
10%
10%

Multivariate Analysis

Univariate Analysis
HR for Relapse

95% CI

HR for Relapse

1
0.7

0.6 to 1.0

.05

1
2.3

1.7 to 3.0

1
2.0

Multivariate Analysis

95% CI

HR for Relapse

95% CI

NA

1
0.7

0.5 to 1.0

.07

.0001

NA

1
2.2

1.5 to 3.1

.0001

1.2 to 3.4

.01

NA

1
1.6

1.2 to 2.4

.006

1
0.8

0.6 to 1.1

.1

NA

1
0.9

0.6 to 1.3

.6

1
1.7

1.2 to 2.4

.002

1
1.6

1.2 to 2.3

.01

1
1.5

1.0 to 2.2

.046

1
1.9

1.3 to 2.9

.002

1
1.6

1.0 to 2.5

.05

1
1.5

0.9 to 2.4

.12

1
1.7

1.2 to 2.3

.001

1
1.6

1.2 to 2.2

.005

1
1.8

1.3 to 2.5

.07

Abbreviations: PR, progesterone receptor; ER, estrogen receptor; HR, hazard ratio; NA, not applicable.

Cox multivariate regression analysis including only biomarkers.

Cox multivariate regression analysis including treatment arm, biomarkers, and clinical characteristics.

PR-negative tumors, respectively. We then included the three biomarkers in a Cox model together with age, number of axillary node
involved, T stage, and treatment. Ki67 (HR 1.47; 95% CI, 1.01 to
2.16; P .046) and PR expressions (HR 1.79; 95% CI, 1.26 to 2.54;
P .07) were associated with a significantly higher risk of relapse.
Among the clinicopathologic characteristics, a high number of axillary
nodes involved ( three) and a large tumor size (T stage 2) were

Biomarker

associated with a significantly higher risk of relapse (HR 2.16 [95%

CI, 1.52 to 3.06] and HR 1.64 [95% CI, 1.15 to 2.35], respectively).
Treatment Efficacy According to Ki67, HER2, and
PR Expressions
Figure 2 shows docetaxel efficacy according to Ki67, HER2, and
PR expression. HRs for relapse associated with docetaxel were 0.51

Hazard ratio for

relapse associated
with docetaxel
(95% CI)

Hazard ratio for

interaction with
docetaxel
(95% CI), P

Positive (n = 150)

0.51 (0.26 to 1.01)

0.53 (0.24 to 1.16),

Negative (n = 549)

1.03 (0.69 to 1.55)

.11

Overexpressed (n = 73)

1.34 (0.55 to 3.21)

0.83 (0.35 to 1.94),

Normal (n = 705)

0.85 (0.60 to 1.20)

.66

Positive (n = 454)

0.83 (0.53 to 1.30)

0.89 (0.47 to 1.66),

Negative (n = 279)

0.86 (0.54 to 1.39)

.71

Ki67

HER-2

PR

0.5

1.0

1.5

2.0

2.5

3.0

Hazard Ratio (95% CI)

Fig 2. Forest plots showing hazard ratios associated with docetaxel according to biomarker expression. PR, progesterone receptor.
2812

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Ki67 Expression and Docetaxel Efficacy

DISCUSSION

The precise role and indications of adjuvant chemotherapy for ERpositive breast cancer are matters of controversy. The present data give
rise to the hypothesis that Ki67 determination could be allowed to
identify a subset of patients with ER-positive breast cancer who would
potentially derive a high benefit from adjuvant docetaxel. Ki67 is a
protein expressed during cell cycle that is correlated with short-term
prognosis20 and has been associated with a higher sensitivity to preoperative chemotherapy.21 Several studies have evaluated the predictive
value of Ki67 for efficacy of first-generation adjuvant chemotherapy in

Disease-Free Survival
(probability)

1.0

0.8

0.6

0.4

0.2

ER+ and Ki67Arm A n = 266

Arm B n = 283
ER+ and Ki67+
Arm A n = 63
Arm B n = 86

Time (years)
Fig 3. Disease-free survival (DFS) according to treatment and Ki67 expression in
patients with estrogen receptor (ER) positive tumors. Arm A, fluorouracil,
epirubicin, and cyclophosphamide (FEC) arm; arm B, sequential FEC followed by
docetaxel arm.
www.jco.org

100
n = 331

n = 150
n = 244

5-Year Disease-Free
Survival (%)

(95% CI, 0.26 to 1.01) in ER-positive/Ki67-positive tumors and 1.03

(95% CI, 0.69 to 1.55) in ER-positive/Ki67-negative tumors. Ratio for
interaction between Ki67 and docetaxel was 0.53 (95% CI, 0.24 to
1.16; P .11). As shown in Figure 3, 5-year DFS rates were, respectively, 81% (95% CI, 76% to 86%) and 84% (95% CI, 75% to 93%),
in patients with ER-positive/Ki67-negative and ER-positive/Ki67positive tumors treated with the sequential FEC-docetaxel regimen
and, respectively, 81% (95% CI, 76% to 86%) and 62% (95% CI, 52%
to 72%) in patients with ER-positive/Ki67-negative and ER-positive/
Ki67-positive tumors treated with the FEC regimen alone. STEPP
analyses were used to evaluate patients 5-year DFS according to treatment regimen and quantitative values of Ki67 (Fig 4). Subpopulations
for STEPP analysis are described in Appendix Table A1. STEPP analyses showed a differential benefit of docetaxel versus no docetaxel
according to the value of Ki67, with a maximum benefit for highest
values of Ki67 (median Ki67, 35%; minimum, 25%; maximum, 90%).
Treatment effect according to HER2 and PR expressions are
reported in Figure 2. Ratio for interaction between biomarker and
treatment were 0.83 (95% CI, 0.35 to 1.94; P .66) and 0.89 (95% CI,
0.47 to 1.66; P .71) for HER2 and PR, respectively. HRs for relapse
associated with docetaxel were 1.34 (95% CI, 0.55 to 3.21) and 0.85
(95% CI, 0.60 to 1.20) for patients with HER2-overexpressing and
HER2-normal tumors, respectively.

n = 288

80

n = 242
Arm B

60

Arm A

40

20

10

15

20

25

30

35

40

45

Average Ki67 in Subpopulations (%)

Fig 4. Subpopulation treatment effect pattern plot analyses evaluating docetaxel efficacy for estrogen receptorpositive, lymph nodepositive disease
(PACS01 trial) according to quantitative values of Ki67.

patients with ER-positive disease. Viale et al22 reported that Ki67

expression was not predictive for cyclophosphamide, methotrexate,
and fluorouracil efficacy in the International Breast Cancer Study
Group VIII and IX trials. Nevertheless, no trend for chemotherapy
efficacy was observed in the whole ER-positive group in these trials5
that renders unlikely the identification of a chemosensitive group.
Using samples from National Surgical Adjuvant Breast and Bowel
Project B20 trial, Paik et al6 reported a trend for a higher efficacy of
cyclophosphamide, methotrexate, and fluorouracil in patients with
ER-positive/Ki67-positive tumors as compared with those with ERpositive/Ki67-negative tumors (ratio for interaction 0.66; P .16).
These latter data are consistent with our study to suggest that a high
Ki67 expression could define a subset of chemosensitive tumors
within ER-positive breast cancers.
Other biomarkers are complementary to Ki67 expression in the
identification of chemosensitive ER-positive tumors. One study10 recently reported that HER2 expression could predict the efficacy of 3
weekly paclitaxel in the adjuvant setting. In the present analyses, we
were not able to detect a difference of docetaxel efficacy according to
HER2 expression. Nevertheless, it must be pointed out that, in the
present study, docetaxel was substituted for anthracyclines, a drug
whose efficacy is predicted by HER2 overexpression. This imbalance
of anthracyclines doses between the two arms probably explains the
lack of predictive value for HER2 expression. Further molecular analyses, including FISH for TOP2A gene, will better define which subsets
of HER2 derive benefit from six cycles of FEC and which ones derive
benefit from substituting FEC with docetaxel. Among the bioassays
under development, Oncotype DX (Genomic Health Inc, Redwood
City, CA) has shown highest level of evidence as predictive parameter
for the efficacy of adjuvant chemotherapy. This bioassay was indeed
predictive for efficacy of adjuvant chemotherapy in two different
adjuvant trials comparing chemotherapy with no chemotherapy.6,7 Because Oncotype DX is mainly based on ER, HER2, and
proliferation, one could argue that ER, HER2, PR, and Ki67 quantifications by IHC could provide similar results. Studies are ongoing to
address this hypothesis.
Although the present data could give rise to the hypothesis that
Ki67 determination identifies a subset of docetaxel-sensitive ERpositive breast cancer, it presents several limitations. First, only 55% of
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Penault-Llorca et al

the patients included in the trial were analyzed in this biomarker study.
Although the clinical characteristics did not differ with the original
cohort, we cannot exclude the possibility that the analyzed population
could be biased as compared with the original one. Second, although
performed on one of the largest trials that addressed taxane efficacy
(PASC01), the study was not powered enough to successfully address
interaction between biomarkers and treatment efficacy in ER-positive
breast cancer. This limitation is shared with other unplanned analyses
from randomized trials that compared two different chemotherapy
regimens. This is related to the small relative effect of the investigational drug (HR 0.82 in the present study) and to the low number of
events observed in early breast cancer patients (n 175 of 798 in the
present study). The probability of detecting significant interaction
between treatment and biomarker in an unplanned analysis of a single
randomized trial is therefore very low in ER-positive disease. This
consideration highlights the need for pooled analyses to address the
question of predictive biomarkers for taxanes efficacy within ERpositive cancers. Finally, it is important to acknowledge the fragility of
subset analyses performed in unplanned analyses, including the
present one. These analyses, especially those reporting treatment effects in subsets, are indeed associated with a high rate of false positivity.23 This concern highlights the need for validation sets to confirm
that Ki67 could be a robust biomarker candidate to predict docetaxel
efficacy in ER-positive breast cancer. These validation studies are
ongoing using tumor samples from the PACS04 trial, a randomized
trial that addresses docetaxel efficacy in patients with node-positive
breast cancer.
Overall, the present study suggests that Ki67 is a biomarker
candidate for predicting docetaxel efficacy in ER-positive breast
cancer, to be validated in further larger studies. These data confirm
the heterogeneity of ER-positive tumors and make the argument to
perform further trials in well molecularly defined groups to reduce
the inconsistencies among trials.24 Finally, these data, together
with other retrospective studies,3-7,10 could provide a rationale for
performing a prospective trial that would tailor the indications and
choice of adjuvant chemotherapy according to ER, HER2, and
Ki67 immunostaining.
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2009 by American Society of Clinical Oncology

AUTHORS DISCLOSURES OF POTENTIAL CONFLICTS

OF INTEREST
Although all authors completed the disclosure declaration, the following
author(s) indicated a financial or other interest that is relevant to the subject
matter under consideration in this article. Certain relationships marked
with a U are those for which no compensation was received; those
relationships marked with a C were compensated. For a detailed
description of the disclosure categories, or for more information about
ASCOs conflict of interest policy, please refer to the Author Disclosure
Declaration and the Disclosures of Potential Conflicts of Interest section in
Information for Contributors.
Employment or Leadership Position: None Consultant or Advisory
Role: Frederique Penault-Llorca, Sanofi (C); Fabrice Andre, Sanofi (C);
Henri Roche, Sanofi (C) Stock Ownership: None Honoraria: Frederique
Penault-Llorca, sanofi; Fabrice Andre, Sanofi; Henri Roche, Sanofi
Research Funding: None Expert Testimony: None Other
Remuneration: None

AUTHOR CONTRIBUTIONS
Conception and design: Frederique Penault-Llorca, Anne-Laure Martin,
Henri Roche
Financial support: Frederique Penault-Llorca
Administrative support: Anne-Laure Martin, Henri Roche
Provision of study materials or patients: Frederique Penault-Llorca,
Christine Sagan, Magali Lacroix-Triki, Yves Denoux, Veronique Verriele,
Jocelyne Jacquemier, Marie Christine Baranzelli, Frederic Bibeau,
Martine Antoine, Nicole Lagarde
Collection and assembly of data: Frederique Penault-Llorca, Christine
Sagan, Magali Lacroix-Triki, Yves Denoux, Veronique Verriele, Jocelyne
Jacquemier, Marie Christine Baranzelli, Frederic Bibeau, Martine
Antoine, Nicole Lagarde, Anne-Laure Martin, Henri Roche
Data analysis and interpretation: Frederique Penault-Llorca, Fabrice
Andre, Christine Sagan, Magali Lacroix-Triki, Yves Denoux, Veronique
Verriele, Jocelyne Jacquemier, Marie Christine Baranzelli, Frederic
Bibeau, Martine Antoine, Nicole Lagarde, Bernard Asselain, Henri Roche
Manuscript writing: Frederique Penault-Llorca, Fabrice Andre,
Henri Roche
Final approval of manuscript: Frederique Penault-Llorca, Fabrice
Andre, Anne-Laure Martin, Henri Roche

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Acknowledgment
We thank Vale`re Lounnas for his analyses, Anne Cayre, Christiane Jullien, and Matthieu Roche for technical support, and the French and
Belgium pathologists involved in PACS01 study for providing kindly the tumor blocks.

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