VOLUME 28 䡠 NUMBER
JOURNAL OF CLINICAL ONCOLOGY
From the British Columbia Cancer
Agency; Genetic Pathology Evaluation
Centre, University of British Columbia,
Vancouver, British Columbia, Canada;
and the Lineberger Comprehensive
Cancer Center, University of North
Carolina at Chapel Hill, Chapel Hill, NC.
Submitted September 2, 2009;
accepted April 8, 2010; published online
ahead of print at www.jco.org on May
24, 2010.
Supported by a grant from the Cana-
dian Breast Cancer Foundation, British
Colubia-Yukon Division. The Genetic
Pathology Evaluation Centre is
supported by an unrestricted education
grant from sanofi-aventis, Canada and
by a unit grant from the Michael Smith
Foundation for Health Research.
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: Hagen
Kennecke, MD, MHA, FRCPC, Vancou-
ver Clinic, Division of Medical Oncol-
ogy, British Columbia Cancer Agency,
600 West 10th Ave, Vancouver, British
Columbia, V5Z 4E6, Canada; e-mail:
hkennecke@bccancer.bc.ca.
© 2010 by American Society of Clinical
Oncology
0732-183X/10/2820-3271/$20.00
DOI: 10.1200/JCO.2009.25.9820
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20 䡠 JULY 10 2010
O R I G I N A L R E P O R T
Metastatic Behavior of Breast Cancer Subtypes
Hagen Kennecke, Rinat Yerushalmi, Ryan Woods, Maggie Chon U. Cheang, David Voduc, Caroline H. Speers,
Torsten O. Nielsen, and Karen Gelmon
A B S T R A C T
Purpose
Prognostic and predictive factors are well established in early-stage breast cancer, but less is
known about which metastatic sites will be affected.
Methods
Patients with early-stage breast cancer diagnosed between 1986 and 1992 with archival tissue were
included. Subtypes were defined as luminal A, luminal B, luminal/human epidermal growth factor
receptor 2 (HER2), HER2 enriched, basal-like, and triple negative (TN) nonbasal. Distant sites were
classified as brain, liver, lung, bone, distant nodal, pleural/peritoneal, and other. Cumulative incidence
curves were estimated for each site according to competing risks methods. Association between the
site of relapse and subtype was assessed in multivariate models using logistic regression.
Results
Median follow-up time among 3,726 eligible patients was 14.8 years. Median durations of survival
with distant metastasis were 2.2 (luminal A), 1.6 (luminal B), 1.3 (luminal/HER2), 0.7 (HER2
enriched), and 0.5 years (basal-like; P ⬍ .001). Bone was the most common metastatic site in all
subtypes except basal-like tumors. In multivariate analysis, compared with luminal A tumors,
luminal/HER2 and HER2-enriched tumors were associated with a significantly higher rate of brain,
liver, and lung metastases. Basal-like tumors had a higher rate of brain, lung, and distant nodal
metastases but a significantly lower rate of liver and bone metastases. TN nonbasal tumors
demonstrated a similar pattern but were not associated with fewer liver metastases.
Conclusion
Breast cancer subtypes are associated with distinct patterns of metastatic spread with notable
differences in survival after relapse.
J Clin Oncol 28:3271-3277. © 2010 by American Society of Clinical Oncology
and bone metastasis gene signatures have been
INTRODUCTION
reported,7-12 and HER2 and ER expression status
Despite advances, 20% to 30% of patients with early has been associated with increased risk of spread to
breast cancers will experience relapse with distant specific sites.2,13-22 However, few studies have de-
metastatic disease.1 Risk of recurrence is influenced scribed patterns of metastasis according to the major
by stage at initial presentation and the underlying breast cancer intrinsic biologic subtypes,23 which
biology of the tumor. Tumor size, nodal involve- may be defined by gene expression profiles24,25 or
ment, grade, lymphovascular invasion, and estrogen immunohistochemical biomarkers.26-28 A better
receptor (ER)2 and human epidermal growth fac- understanding of patterns of metastatic spread may
tor receptor 2 (HER2)3 status are all independent influence adjuvant therapy and surveillance deci-
risk factors for relapse. However, we do not have a sions and determine which investigations and
comprehensive understanding of the patterns of therapies are appropriate once distant disease has
spread and specific sites of recurrence. been diagnosed.
Models of metastatic spread describe a com- The objectives of this study were to determine
plex interaction of seed and soil factors involving the association of breast tumor molecular subtypes
tumor intravasation, circulation, extravasation, on site of metastatic disease and to define the associ-
proliferation, and angiogenesis4 and the microen- ated patient outcomes using a large validated tissue
vironment of the target tissue.5 Characteristics of microarray (TMA) of primary invasive breast
the primary tumor are usually preserved in metasta- cancer specimens. The following analyses are pre-
ses.6 Among patients with breast cancer, some pre- sented: 15-year cumulative incidence of up to five
liminary associations have been identified. Lung distant sites of metastasis among patients with
© 2010 by American Society of Clinical Oncology 3271
Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
 Kennecke et al

luminal A, luminal B, luminal/HER2, HER2-enriched, and basal-like
subtypes; frequencies of site-specific metastases by intrinsic subtype
among patients with distant disease; and multivariate analysis of clin-
icopathologic variables associated with site of metastasis.
METHODS
Patients with early-stage breast cancer diagnosed between 1986 and 1992 and
referred to the British Columbia Cancer Agency were included if archival tissue
was available. From an original TMA of 4,543 tumor samples derived from the
Estrogen Receptor Tissue Bank, 146 patients (3.2%) with metastatic (M1)
disease on presentation were excluded. A further 671 patients with nonmeta-
static disease (M0) were excluded as a result of incomplete data on molecular
subtype, leaving a final cohort for inclusion of 3,726 women.
Tissue cores were extracted from archival blocks of the primary breast
tumor and used to construct a TMA, and all scoring was performed by
pathologists blinded to outcomes.29,30 Immunohistochemical staining was
performed for ER, progesterone receptor (PR), HER2, Ki-67, epidermal
growth factor receptor (EGFR), and cytokeratin (CK) 5/6 using the standard

Table 1. Baseline Clinical and Pathologic Characteristics and Survival Estimates of 3,726 Patients With Early Breast Cancer According to Breast
Cancer Subtype
Luminal/HER2 HER2
Luminal A Luminal B Positive Enriched Basal-Like TN Nonbasal
(n ⫽1,639) (n ⫽893) (n ⫽ 243) (n ⫽ 266) (n ⫽ 367) (n ⫽ 318)
Characteristic No. % No. % No. % No. % No. % No. % P
Age at diagnosis, years
Median 62 60 58 56 53 56
Interquartile range 51-71 47-70 48-68 46-65 42-65 45-67 ⬍ .001
Menopausal status
Premenopausal 379 23.1 284 31.8 73 30.0 92 34.6 148 40.3 104 32.7 ⬍ .001
Unknown 43 2.6 27 3.0 11 4.5 4 1.5 13 3.5 11 3.5
Tumor stageⴱ
T0-2 1416 86.4 741 83 196 80.7 214 80.5 299 81.5 251 78.9 .0019
T3-4 66 4.0 45 5.0 20 8.2 21 7.9 22 6.0 25 7.9
Missing/unknown 157 9.6 107 12 27 11.1 31 11.7 46 12.5 42 13.2
Node stageⴱ
N0 909 55.5 446 49.9 102 42.0 114 42.9 218 59.4 179 56.3 ⬍ .001
N1 631 38.5 375 42 120 49.4 129 48.5 123 33.5 115 36.2
N2-3 19 1.2 24 2.7 9 3.7 5 1.9 4 1.1 8 2.5
Missing/unknown 80 4.9 48 5.4 12 4.9 18 6.8 22 6.0 16 5.0
LVI
Positive 618 37.7 440 49.3 146 60.1 141 53.0 147 40.1 128 40.3 ⬍ .001
Missing/unknown 86 5.2 46 5.2 6 2.5 8 3.0 20 5.4 17 5.3
Grade
1/2 970 59.2 364 40.8 71 29.2 56 21.1 41 11.2 100 31.4 ⬍ .001
3 549 33.5 490 54.9 162 66.7 203 76.3 317 86.4 199 62.6
Missing/unknown 120 7.3 39 4.4 10 4.1 7 2.6 9 2.5 19 6.0
Histology
Ductal 1489 90.8 826 92.5 237 97.5 259 97.4 334 91.0 274 86.2 ⬍ .001
Lobular/other 150 9.2 67 7.5 6 2.5 7 2.6 33 9.0 44 13.8
Margins at diagnosis
Positive/close 243 14.8 132 14.8 51 21.0 42 15.8 44 12.0 47 14.8 .1699
Negative 1190 72.6 651 72.9 169 69.5 195 73.3 267 72.8 231 72.6
NA/unknown 206 12.6 110 12.3 23 9.5 29 10.9 56 15.3 40 12.6
Hormones, yes 922 56.3 566 63.4 162 66.7 116 43.6 118 32.2 143 45.0 ⬍ .001
Chemotherapy, yes 392 23.9 329 36.8 104 42.8 142 53.4 176 48.0 129 40.6 ⬍ .001
Initial surgery†
No initial breast surgery 25 1.5 14 1.6 2 0.8 3 1.1 7 1.9 6 1.9 .0127
Complete mastectomy 888 54.2 510 57.1 160 65.8 162 60.9 200 54.5 173 54.4
Breast-conserving surgery 726 44.3 369 41.3 81 33.3 101 38.0 160 43.6 139 43.7
Time from metastases to
death, years‡
Median 2.2 1.6 1.3 0.7 0.5 0.9 ⬍ .001
95% CI 1.9 to 2.5 1.4 to 1.8 1.1 to 1.7 0.6 to 0.8 0.4 to 0.7 0.7 to 1.1
Overall survival at 10 years, %‡ 70 54.4 46.1 48.1 52.6 62.6
95% CI 67.8 to 72.3 51.2 to 57.7 39.8 to 52.4 42.1 to 54.1 47.5 to 57.7 57.3 to 67.9 ⬍ .001

NOTE. Statistical tests for categorical variables were performed using the ␹ test; age was tested using the Wilcoxon rank sum test.
2

Abbreviations: HER2, human epidermal growth factor receptor 2; TN, triple negative; LVI, lymphovascular invasion; NA, not available.
ⴱ
According to American Joint Committee on Cancer, Sixth Edition, 2002.
†For test of surgery variable, no surgery was removed, thus comparing only mastectomy and breast-conserving surgery.
‡Time from metastases to death and overall survival were tested using the log-rank test.

3272 © 2010 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

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 Metastatic Behavior of Breast Cancer Subtypes
streptavidin-biotin complex method with diaminobenzidine chromogen.26,28
ER positivity and PR positivity were defined as any positive nuclear staining (ie,
ⱖ 1%), and HER2-positive cases were defined as immunohistochemistry
score of 3⫹ or immunohistochemistry score of 2⫹ plus fluorescent in situ
hybridization with amplification ratio ⱖ 2.0. Samples with less than 50 tumor
cells in the TMA cores were considered uninterpretable and were excluded
from analysis. All of the stained TMAs were digitally scanned, and primary
image data are available for public access (http://www.gpecimage.ubc.ca/tma/
web/viewer.php; username: luminalB; password: luminalb).
Breast cancer molecular subtypes were classified according to a gene
expression profile–validated immunohistochemical surrogate panel26-28 as
follows: luminal A (ER positive and/or PR positive and Ki-67 ⬍ 14%), luminal
B (ER positive and/or PR positive and Ki-67 ⱖ 14%), luminal/HER2 (ER
positive and/or PR positive and HER2 positive), HER2 enriched (ER negative
and PR negative and HER2 positive), and basal-like (ER negative and PR
negative and HER2 negative and EGFR positive and/or CK5/6 positive).
Triple-negative (TN) tumors that did not express EGFR or CK5/6 were con-
sidered as TN nonbasal in this study and were included as a separate group for
the multivariable analysis.
The Breast Cancer Outcomes Unit Database was used to link clinical,
pathologic, treatment, and outcome data, and the date of diagnosis and ana-
tomic site of up to the first five distant relapses were captured. Distant relapse
was defined as recurrences of breast cancer occurring beyond the confines of
the ipsilateral breast, chest wall, or regional lymph nodes. Sites of distant
relapse were categorized as follows: brain (including choroid, CNS, pituitary
gland, leptomeningeal, and frontal sinus), liver, lung (including lymphangitic
carcinomatosis), bone (including bone marrow), distant nodal (nodes beyond
the ipsilateral axillary/supraclavicular/internal mammary area), pleural/peri-
toneal (including ascites, omentum, pleural effusion, and peritoneal carcino-
matosis), other (including skin outside of breast/chest wall, ovaries, spinal
cord, eye, heart, and other organs not elsewhere classified), and unknown
(patient known to have distant metastases but site or sites unknown).
Patient and tumor characteristics were compared across the six breast
cancer subtypes using the ␹2 and Wilcoxon rank sum tests for categorical and
continuous variables, respectively. Cumulative incidence curves were esti-
mated for each site of relapse according to competing risks methodology.
These methods allow for the estimation of the cumulative incidence of an
event of interest in the presence of competing events. In our estimation of the
incidence of relapses to specific sites, patients who died of a non– breast cancer
cause before developing a relapse were included as competing risk events,31
whereas patients who had not developed a relapse and had not died before the
censoring cutoff date were censored at that time. Gray’s test31 was used to test
for differences in the cumulative incidence curves between breast cancer sub-
types. Survival from initial diagnosis and diagnosis of distant relapse was
estimated using the Kaplan-Meier method; survival was compared across
subtypes using the log-rank test. Association between the site of relapse and
breast cancer subtype was assessed in patients who had distant relapses using
the ␹2 test. This association was further examined in multivariate models using
logistic regression with relapse to a specific site (yes or no) as the dependent
variable and breast cancer subtype and other patient/tumor characteristics
included as covariates. Analyses were performed using SAS (version 9.1.3; SAS
Institute, Cary, NC) and the R Statistical Language (version 2.9.0; http://
cran.r-project.org/). The study was approved by the Research Ethics Board of
the British Columbia Cancer Agency.
RESULTS
Among 3,726 eligible patients 44.0% were luminal A, 24.0% were
luminal B, 6.5% were luminal/HER2, 7.1% were HER2 enriched,
9.8% were basal-like, and 8.5% were TN nonbasal. Median follow-up
time for patients who were alive was 14.8 years. Clinical, pathologic,
and treatment characteristics are listed in Table 1. Women with lumi-
nal tumors were older than women in the HER2-enriched and basal
subgroups (P ⬍ .001). At initial presentation, 42% to 59% of tumors
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had no node involvement, with the highest rate observed among the
basal group (59%). Except for the luminal A group, the majority of
tumors were grade 3, with the highest frequency in the basal subgroup
(86.4%). Fifty-six percent, 63%, and 67% of patients with luminal A,
luminal B, and luminal/HER2 tumors received tamoxifen therapy;
approximately one third of patients with ER-negative tumors received
hormone therapy as a result of the treatment recommendations at that
time. Of patients in the basal-like, TN nonbasal, luminal/HER2, and
HER2-positive subgroups, 48%, 41%, 43%, and 53%, respectively,
received adjuvant chemotherapy.
Effect of Breast Cancer Subtypes on Overall Survival
and Relapse
Ten-year survival estimates were significantly different (P ⬍ .001)
among subgroups; 70% of patients with luminal A tumors were alive
at 10 years compared with 54.4% of luminal B, 46.1% of luminal/
HER2, 48.1% of HER2-enriched, 52.6% of basal-like, and 62.6% of
nonbasal TN patients. Median duration of survival from time of first
distant metastasis also differed significantly, with luminal A patients
achieving the longest survival (2.2 years) followed by luminal B (1.6
years), luminal/HER2 (1.3 years), HER2-enriched (0.7 years), basal-
like (0.5 years), and TN nonbasal patients (0.9 years; P ⬍ .001).
These differences in relapse according to subtype were main-
tained with 15-year distant relapse rates for luminal A (27.8%), lumi-
nal B (42.9%), luminal/HER2 (47.9%), HER2-enriched (51.4%),
basal-like (43.1%) and TN nonbasal (35.1%) subgroups. In Figure 1,
cumulative incidence curves for relapse to any distant site are pre-
sented by breast cancer subtype.
There were distinct differences in the timing of relapse, with
virtually all relapses occurring within the first 5 years among basal-like,
TN nonbasal, and HER2 groups, whereas luminal subtypes, including
luminal/HER2, experienced continued relapses between 5 and 15
years. Luminal B tumors attained a distant relapse rate equivalent to
that of basal tumors at 15 years (Fig 1).
Effect of Breast Cancer Subtype on Site of Metastasis
In Table 2, 15-year cumulative incidence rates according to met-
astatic site are listed for patients with early breast cancer. These rates
1.0 Luminal A
Luminal B
Cumulative Incidence
Luminal HER2+
0.8 HER2+ enriched
of Metastases
Basal
Nonbasal TN
0.6
0.4
0.2
P < .001
0 5 10 15
Time Since Diagnosis (years)
Fig 1. Cumulative incidence curves of first distant metastasis by breast cancer
subtype. HER2, human epidermal growth factor receptor 2; TN, triple negative.
© 2010 by American Society of Clinical Oncology 3273
 Kennecke et al

Table 2. Fifteen-Year Site-Specific Metastasis Cumulative Incidence Rates by Breast Cancer Subtype
Brain Liver Lung Bone Distant Nodal Pleural/Peritoneal Other

No. of Incidence Incidence Incidence Incidence Incidence Incidence Incidence 95% CI

Subtype Patients Rate (%) 95% CI (%) Rate (%) 95% CI (%) Rate (%) 95% CI (%) Rate (%) 95% CI (%) Rate (%) 95% CI (%) Rate (%) 95% CI (%) Rate (%) (%)

Luminal A 1639 2.2 1.6 to 3 7.9 6.7 to 9.4 6.7 5.5 to 7.9 18.7 16.8 to 20.7 4.5 3.5 to 5.6 7.8 6.6 to 9.2 3.8 2.9 to 4.8
Luminal B 893 4.7 3.4 to 6.2 13.8 11.6 to 16.2 13.4 11.2 to 15.8 30.4 27.4 to 33.5 9.6 7.8 to 11.7 14.7 12.5 to 17.2 8.1 6.4 to 10
HER2 positive, ER/
PR positive 244 7.9 4.8 to 12 21.3 16.3 to 26.7 17.7 13.2 to 22.8 30.9 25.2 to 36.7 10.5 7 to 14.8 16 11.7 to 21 6.6 3.9 to 10.2
HER2 positive, ER/
PR negative 266 14.3 10.4 to 18.8 23.3 18.4 to 28.6 24.1 19.1 to 29.3 30.1 24.7 to 35.7 13 9.2 to 17.4 16.2 12 to 20.9 8.8 5.8 to 12.7
Basal-like 367 10.9 8 to 14.3 9.3 6.6 to 12.5 18.5 14.7 to 22.7 16.6 13 to 20.6 17.2 13.5 to 21.2 12.8 9.6 to 16.5 10.4 7.5 to 13.7
TN nonbasal 318 7.2 4.7 to 10.4 10.7 7.6 to 14.4 12.5 9.1 to 16.5 15.1 11.4 to 19.4 12.3 8.9 to 16.1 9.2 6.3 to 12.7 9.2 6.2 to 12.9
P ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001

NOTE. P values are based on Gray’s test comparing cumulative incidence curves across subtypes.
Abbreviations: HER2, human epidermal growth factor receptor 2; ER, estrogen receptor; PR, progesterone receptor; TN, triple negative.

are a reflection of both the primary risk and the subtype’s predisposi-
tion to spread to a specific site. Low risks of brain metastases of 2.2%
and 4.7% are seen with luminal A and B disease, respectively. Both
HER2-enriched and luminal/HER2 subtypes had a relatively high rate
of metastasis to brain, liver, bone, and lung sites. Basal-like tumors
exhibited high rates of brain, lung, bone, and distant nodal metastases
of 10.9%, 18.5%, 16.6%, and 17.2%, respectively, but a comparatively
lower rate of liver metastases (9.3%).
To adjust for the confounding effect of early-stage disease on rate
of distant relapse, an analysis is presented in Table 3 among only
patients who developed metastatic disease, and we observed distinct
patterns of metastatic spread. High rates of brain metastases are dem-
onstrated among HER2-enriched (28.7%), basal-like (25.2%), and
TN nonbasal (22%) groups, whereas brain metastases are less fre-
quently seen in the luminal/HER2 (15.4%) and other groups
(P ⬍ .001). Bone was the predominant site of metastasis for the
luminal A (66.6%), luminal B (71.4%), and luminal/HER2 (65%)
groups and the least common site in the basal group (39%).
Univariate and multivariate analyses of site of metastases were
performed (Table 4) in patients who developed metastatic disease.
Luminal A tumors with the lowest risk were used as the reference
variable. Because nodal stage at initial diagnosis was not associated
with any site of metastasis on univariate analysis, it was not included in
multivariate analysis.
Multivariate analysis revealed that patients who received adju-
vant systemic therapy (chemotherapy and/or hormonal therapy) had
a higher prevalence of distant relapse in liver, bone, distant nodal, and
pleural sites. Older age was associated with a lower prevalence of brain
(odds ratio [OR] ⫽ 0.5; 95% CI, 0.4 to 0.8) and bone metastases
(OR ⫽ 0.6; 95% CI, 0.5 to 0.8). Both HER2-positive subtypes were
associated with a significantly higher rate of brain, liver, and lung
metastases compared with luminal A tumors. Basal-like tumors had a
higher rate of brain (OR ⫽ 3.7; 95% CI, 2.1 to 6.5), lung (OR ⫽ 2.5;
95% CI, 1.6 to 3.8), and distant nodal metastases (OR ⫽ 2.8; 95% CI,
1.8 to 4.5) but a significantly lower rate of liver (OR ⫽ 0.5; 95% CI, 0.3
to 0.8) and bone metastases (OR ⫽ 0.4; 95% CI, 0.2 to 0.6) compared
with luminal A tumors. TN nonbasal tumors demonstrated a similar
pattern to basal-like tumors but were not associated with a lower rate
of liver metastasis.
When analyses were repeated among patients who received ad-
juvant chemotherapy and/or hormonal therapy, the associations be-
tween site of metastasis and breast cancer subtype were similar, with
the exception of the HER2-enriched subtype, which was associated
with a lower frequency of bone metastasis (OR ⫽ 0.6; 95% CI, 0.4 to
0.9) and an increased prevalence of distant nodal disease (OR ⫽ 1.8;
95% CI, 1.0 to 3.0; Appendix Table A1, online only).
DISCUSSION
Our understanding of the different subtypes of breast cancer has been
mainly limited to early breast cancer with an acceptance of different
risks of relapse and response to adjuvant therapies. This large study

Table 3. Frequency of Site-Specific Metastasis Among Patients Who Developed Distant Disease
Distant Pleural/
Brain Liver Lung Bone Nodal Peritoneal Other Unknown
No. of
Subtype Patients No. % No. % No. % No. % No. % No. % No. % No. %
Luminal A 458 35 7.6 131 28.6 109 23.8 305 66.6 73 15.9 129 28.2 62 13.5 36 7.9
Luminal B 378 41 10.8 121 32.0 115 30.4 270 71.4 88 23.3 133 35.2 73 19.3 13 3.4
HER2 positive, ER/PR positive 117 18 15.4 52 44.4 43 36.8 76 65.0 26 22.2 40 34.2 16 13.7 6 5.1
HER2 positive, ER/PR negative 136 39 28.7 62 45.6 64 47.1 81 59.6 34 25.0 43 31.6 23 16.9 6 4.4
Basal-like 159 40 25.2 34 21.4 68 42.8 62 39.0 63 39.6 47 29.6 38 23.9 11 6.9
TN nonbasal 109 24 22.0 35 32.1 39 35.8 47 43.1 39 35.8 31 28.4 28 25.7 6 5.5
P ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001 ⬍ .001 .3214 .0056 .1338

NOTE. P values were obtained using Pearson’s ␹2 test.

Abbreviations: HER2, human epidermal growth factor receptor 2; ER, estrogen receptor; PR, progesterone receptor; TN, triple negative.

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 Metastatic Behavior of Breast Cancer Subtypes

Table 4. Multivariate Analysis of Metastatic Site Among Patients With Distant Relapse
Brain Liver Lung Bone Distant Nodal Pleural/Peritoneal Other

Variable OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Luminal A (reference) 1 1 1 1 1 1 1
Luminal B 1.4 0.8 to 2.3 1.1 0.8 to 1.5 1.4 1.0 to 1.9 1.2 0.9 to 1.7 1.4 0.9 to 2.0 1.3 0.9 to 1.8 1.3 0.8 to 1.9
HER2 positive, ER/PR positive 2.1 1.1 to 4.1 2.3 1.4 to 3.7 2.0 1.3 to 3.3 0.9 0.6 to 1.5 1.1 0.6 to 1.9 1.3 0.8 to 2.0 0.8 0.4 to 1.5
HER2 positive, ER/PR negative 5.3 3.0 to 9.2 1.7 1.1 to 2.6 3.2 2.1 to 5.0 0.9 0.6 to 1.3 1.5 0.9 to 2.5 1.1 0.7 to 1.7 1.1 0.6 to 2.0
Basal-like 3.6 2.1 to 6.4 0.5 0.3 to 0.9 2.5 1.6 to 3.9 0.4 0.2 to 0.6 2.9 1.8 to 4.5 1.0 0.6 to 1.6 2.0 1.2 to 3.3
TN nonbasal 3.6 1.9 to 6.9 1.0 0.6 to 1.7 2.1 1.3 to 3.5 0.4 0.2 to 0.6 2.9 1.7 to 4.9 0.9 0.5 to 1.5 1.8 1.0 to 3.2
T3/4 0.2 0.1 to 0.4 0.5 0.3 to 0.8 — — — — — — — — — —
LVI, yes — — 1.4 1.1 to 1.9 0.7 0.6 to 1.0 — — — — — — — —
Chemotherapy, yes — — 2.3 1.8 to 3.1 — — — — 2.1 1.6 to 2.9 1.5 1.2 to 2.0 2.2 1.6 to 3.1
Hormones, yes — — — — — — 2.2 1.6 to 3.0 — — — — 1.5 1.0 to 2.3
Age ⬎ 50 years 0.5 0.4 to 0.7 — — — — 0.6 0.5 to 0.8 — — — — — —

NOTE. Variables included were T stage, N stage, LVI, age, chemotherapy, and hormone therapy. Nodal stage was not significant in any of the univariate analyses
and thus not included in the multivariate model. A blank (—) field indicates that the variable was not significant in the univariate analysis and not included in the
multivariate analysis. Boldface indicates statistical significance.
Abbreviations: OR, odds ratio; HER2, human epidermal growth factor receptor 2; ER, estrogen receptor; TN, triple negative; LVI, lymphovascular invasion.

demonstrates that breast cancer subtypes are associated with unique
patterns of metastatic spread with notable differences in survival after
relapse. In multivariate analysis, subtypes were associated with signif-
icant differences in pattern of distant spread independent of conven-
tional clinicopathologic variables. The observations illustrate the
impact of the seed on the metastatic disease process and have clinically
relevant implications.
A limitation of the study is that adjuvant therapy guidelines
during the era of this cohort are not representative of current practice
patterns, thereby potentially overestimating relapse risk and possibly
influencing sites of metastasis. Only 56% to 67% of the patients with
luminal subtypes were treated with adjuvant hormonal therapy, which
did not include aromatase inhibitors. Modern chemotherapy regi-
mens1,32 and adjuvant trastuzumab have reduced relapse risk in
HER2-positive disease.33,34 Adjuvant chemotherapy was only pre-
scribed for 37% to 53% of patients with non–luminal A tumors in this
study. However, although clinical studies suggest that changes in treat-
ment of early breast cancer are improving outcomes, it is not clear that
this will affect patterns of relapse. In randomized trials of patients with
metastatic HER2-positive breast cancer, trastuzumab did not affect
the incidence of isolated CNS metastases.35 Thus, the data from this
study likely remain relevant even with contemporary guidelines.
A further consideration is that conventional imaging would not
necessarily detect all metastatic disease, with subclinical metastases
being missed simply because no or inappropriate imaging was per-
formed. This diagnostic bias would be present for all breast cancer
subtypes and not affect the differences we report. Also, follow-up
recommendations for patients with early breast cancer have not
changed over time, and the diagnosis of metastases is still based on
history and physical examination.
A major strength of this study is that a full review of the medical
records allowed the documentation of all the clinically and patholog-
ically documented metastatic lesions, thereby providing a detailed
picture. The inclusion of only patients with early-stage disease allowed
the description of timing of relapse and site-specific relapse rates for
early-stage disease, as well as the inclusion of conventional predictive
variables of early-stage disease in multivariate analyses.
Previous studies have demonstrated significant differences in the
timing of distant recurrence36,37; ER-negative tumors are associated
with early relapse, and ER-positive tumors are associated with a per-
sistent late risk beyond 5 years.36,38 In this study, both basal/TN and
HER2 subtypes demonstrated a high rate of early relapse. Although
HER2-enriched tumors had a significantly higher relapse rate than
luminal/HER2 tumors at the 5-year time point, this difference was lost
at 15 years as a result of more late relapses in the luminal/HER2 group.
Luminal A was the only subset with a substantially lower relapse rate
15 years after diagnosis.
Two larger studies of TN breast cancer (ER/PR/HER2 negative)
have reported brain metastasis in 6% of patients with early breast
cancer.18,39,40 This compares with rates of 10.9% and 7.2% among the
basal-like and TN nonbasal groups, respectively, in this study. Previ-
ous studies have reported a 10% to 16% rate of CNS metastasis among
patients with early-stage HER2-positive breast cancer,41,42 which is
similar to the 14.3% rate described in this study but higher than rate
found for the luminal/HER2 group (7.9%). The incidence of brain
involvement among patients with metastatic HER2-positive disease
has been described to be 25% to 34%,13,15,43,44 which is consistent with
the frequency of 28.7% in the HER2-enriched subgroup in this study
but significantly higher than 15.4% rate observed for luminal/HER2
patients. Higher rates of CNS metastasis among ER-negative/HER2-
positive tumors compared with ER-positive/HER2-positive tumors
have been observed in a previous study,13 a finding confirmed in this
study. Bone has been previously described as a preferred site of metas-
tasis among ER-positive tumors.2,16,23
On multivariate analysis, basal-like and TN nonbasal tumors had
a distinctive pattern of relapse, with higher frequencies of lung, brain,
and distant nodal metastasis. This is consistent with observations from
previous studies describing a lung metastasis signature7,10 among pre-
dominantly basal tumors that was associated with increased lung
metastasis and a decreased frequency of liver and bone metastasis.
Signature genes include the epidermal growth factor receptor ligand
epiregulin, the cyclooxygenase COX2, and the matrix metalloprotein-
ases 1 and 2. These genes collectively allow angiogenesis, tumor intra-
vasation into the circulation, and breaching of lung capillaries by

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Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
 Kennecke et al

circulating tumor cells to seed the pulmonary parenchyma.9 The sig-
nificantly higher rate of distant nodal disease observed among bas-
al/TN tumors in this study is, to our knowledge, a novel observation.
Previous studies have not demonstrated associations between
age, adjuvant therapy, tumor stage, grade, or lymphovascular invasion
and site of relapse.7,14 In the current study, age greater than 50 years
was associated with a reduced rate of brain metastasis possibly as a
result of the significantly higher age in patients with luminal-subtype
tumors. Large tumor size (T3/4) was associated with a significantly
lower rate of brain and liver metastasis, a finding with no obvious
explanation. However, in models of metastatic spread and tumor
self-seeding put forward by Norton and Massague,4 tumors with a
high propensity of intravasation, proliferation, and angiogenesis may
relocate early from the primary site, allowing the disease to establish
distant sites without ever demonstrating a large primary mass. Thus,
there may be overlapping mediators between early dissemination and
establishment of disease in the brain and liver.
Current American Society of Clinical Oncology surveillance
guidelines for patients diagnosed with early-stage disease recom-
mend regular follow-up with mammogram, history and physical
examination, and no other routine laboratory or imaging studies.45-47
The high frequency of brain metastases among patients with HER2-
enriched (28.7%), basal-like (25.2%), and TN nonbasal (22%) disease
may support a more aggressive approach to imaging for patients
with newly diagnosed distant disease. Studies of specific CNS pre-
ventive agents may be of benefit in basal-like and HER-positive
early breast cancer.
In the current study, a greater than 30% cumulative rate of bone
metastases was documented among patients with early-stage disease
that was luminal B, luminal/HER2, or HER2 enriched, making bone
the most commonly diagnosed site of metastases. This high rate may
point to the central role that the bone marrow plays as a common
homing organ for metastatic breast cancer cells, independent of the
pattern of overt metastasis.48 A change in relapse sites may be expected
from the introduction of bisphosphonates in early breast cancer. Stud-
ies suggest that their effect may not be restricted to bone and may also
decrease relapse in other sites.49 In addition, luminal B, luminal/
HER2, and HER2-enriched groups may be particularly relevant pop-
ulations to include in trials of adjuvant bisphosphonates or therapies
targeting the RANK ligand pathway. Thus, the impact of bisphospho-
nates and newer bone agents50 in adjuvant therapy and their effect on
sites of metastases need to be studied in future cohorts. Although other
classifications for tumor subtype have been described, the classifica-
tion we used in this study has been previously validated and described
as both a prognostic and predictive classification.27,28,51
Despite improving breast cancer outcomes, distant recurrence
remains common and incurable. This study demonstrates important
differences in metastatic behavior between the breast cancer subtypes
as defined by a panel of immunohistochemical markers and contrib-
utes to an expanding knowledge of prognostic and predictive markers
that will allow individualized therapy for metastatic breast cancer
similar to current approaches in development for early-stage disease.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
The author(s) indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Conception and design: Hagen Kennecke, Rinat Yerushalmi, Ryan
Woods, Maggie Chon U. Cheang, Karen Gelmon
Financial support: Hagen Kennecke, Torsten O. Nielsen, Karen Gelmon
Administrative support: Hagen Kennecke, Ryan Woods,
Caroline H. Speers
Provision of study materials or patients: Ryan Woods, Maggie Chon U.
Cheang, David Voduc, Caroline H. Speers, Torsten O. Nielsen,
Karen Gelmon
Collection and assembly of data: Ryan Woods, Maggie Chon U.
Cheang, David Voduc, Caroline H. Speers, Torsten O. Nielsen,
Karen Gelmon
Data analysis and interpretation: Hagen Kennecke, Rinat Yerushalmi,
Ryan Woods, Maggie Chon U. Cheang, David Voduc, Caroline H.
Speers, Torsten O. Nielsen, Karen Gelmon
Manuscript writing: Hagen Kennecke, Rinat Yerushalmi, Ryan Woods,
Maggie Chon U. Cheang, David Voduc, Caroline H. Speers, Torsten O.
Nielsen, Karen Gelmon
Final approval of manuscript: Hagen Kennecke, Rinat Yerushalmi, Ryan
Woods, Maggie Chon U. Cheang, David Voduc, Caroline H. Speers,
Torsten O. Nielsen, Karen Gelmon

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