The RB pathway is one of the best-studied and most frequently altered pathways leading to loss of proliferative control in cancer. It can be disrupted by a variety of means including, but not limited to, epigenetic silencing, allelic loss or mutation of RB1. In some cancers including breast cancer, amplification of the CCND1 gene or overexpression of cyclin D1 is commonly observed.1 In others, the CDK4 gene is amplified or mutated within the p16INK4A-binding domain. Finally, many cancers lack p16INK4 expression due to deletion or promoter hypermethylation of CDKN2A. By increasing cyclin D1-CDK4 kinase activity, these genetic events all restrict the ability of underphosphorylated RB to inhibit cell cycle progression.
Genetic alterations at the RB1 locus, or lack of RB expression, occur in up to a third of breast cancers.2 Breast cancer can be divided into a number of biologically distinct phenotypes, and RB loss is more common in some of these subtypes, i.e. basal breast cancers, which are typically estrogen receptor (ER)-negative, poorly-differentiated and aggressive and luminal B cancers, which are a poor-prognosis subgroup accounting for approximately a third of ER-positive breast cancers.3 Interestingly, RB deletion in mouse mammary progenitor cells leads to the formation of tumors with basal or luminal B characteristics,4 suggesting that RB loss may not simply be a marker of these subtypes.
Confounding issues in examining the association between RB loss and breast cancer therapeutic responsiveness and outcome include the poor correlation between RB1 LOH and low or absent RB protein expression5 as well as technical difficulties in measuring RB expression by immunohistochemistry. In addition, cyclin D1 overexpression or p16INK4A methylation, both of which are common in breast cancer1,6, are usually mutually exclusive with RB loss but are expected to have similar biological consequences. In a previous issue of Cell Cycle, Ertel et al.7 used a “RB-loss signature” composed of genes that are upregulated by RB deletion or repressed by RB activation to identify breast cancers where the RB pathway is deregulated. In ER-positive cancers the RB-loss signature was correlated with cyclin D1 overexpression and low RB1 levels but not with p16INK4A levels, whereas it was correlated with p16INK4A/CDKN2A expression but not cyclin D1 or RB expression in ER-negative cancer. Although aberrant expression of these genes is to some degree a marker of RB pathway deregulation, the correlation is not strong, and none are useful biomarkers of pathway activity in all breast cancer subtypes.
Although in both ER-positive and ER-negative breast cancer, RB pathway deregulation was associated with increased proliferation, it was correlated with poorer outcome in ER-positive disease but with better outcome in ER-negative disease.7 In ER-positive breast cancer this relationship was apparent both in patients treated with surgery alone and in patients receiving adjuvant antiestrogen (tamoxifen) therapy, indicating that ER-positive breast cancers with RB pathway deregulation are inherently more aggressive. They are also more likely to metastasise, possibly because of the decreased expression of cell-cell communication genes that Ertel et al. find to be associated with the RB-loss signature.7 These observations are consistent with the widely-held view that more proliferative cancers have a poorer outcome, and the association between markers of increased proliferation and poor response to endocrine therapy.8
In ER-negative cases, the association of RB pathway deregulation with better outcome appears to be due to improved response to some types of chemotherapy.7,9 This is likely to result, at least in part, from an impaired cellular DNA damage/genotoxic stress response in the absence of functional RB.2 In ER-positive cancers, RB pathway deregulation may be a marker of increased sensitivity to small molecule inhibitors of CDK4.7 These important findings provide impetus for further studies aimed at developing a clinically useful panel of biomarkers that can identify cancers with RB pathway deregulation and sensitivity to new therapies following independent validation in other patient cohorts. The importance of Ertel et al.'s work lies not only in that it points towards a potential role for measuring RB pathway aberrations in order to inform treatment decisions in breast cancer. It also illustrates the power of using gene signatures based on biological function to probe determinants of prognosis and response to therapy, as has been suggested in the context of endocrine therapy.8
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