Page 252 - Haematologica - Vol. 105 n. 6 - June 2020

C. Giaccherini et al.
tion to the primary outcome of the study, we analyzed the patient thrombotic biomarkers according to DR. Relapses occurred in 71 patients, with distant metastasis in 69% and loco-regional metastasis in 31% of cases, respectively, providing a 10.8% cumulative incidence of DR after four years of follow up. As expected, most patients with DR belong to the Luminal B HER2-neg (46.5%) and TN (26.8%) subtypes. As regards thrombotic biomarkers, patients who subsequently experienced DR showed sig- nificantly (P<0.05) higher circulating levels of F1+2, com- pared to disease-free subjects. Remarkably, high fibrino- gen levels were significantly associated with shorter time to DR, also after age and gender correction by multivariate analysis. Recurrence can be considered to be the result of cancer cells that persist in the host after treatments and start to proliferate and disseminate after years of quies- cence. Activation of the clotting system might represent the first sign of tumor cell proliferation, and increased lev- els of thrombotic biomarkers can be an echo of occult tumor cell action on the hemostatic system. This is prob- ably what is happening in our population, as detected by hypercoagulability biomarkers. That blood clotting activa- tion might be an overt sign of an occult cancer is support- ed by clinical studies in cancer-free subjects, showing that hypercoagulability is a risk factor for subsequent death from cancer.33,34 Analyses of hemostatic biomarkers in 19,303 male participants from three English cohorts fol- lowed for up to 30 years identified elevated circulating levels of fibrinogen and F1+2 as predictors of risk of smok- ing-related cancers.35 In the setting of breast cancer, in a Scandinavian case-control study, high D-dimer and low antithrombin significantly predicted for breast cancer diagnosis,36 while fibrinogen, in combination with cancer antigen 15-3 and platelet distribution width, distinguished breast cancer from benign breast disease in non-conclusive mammography patients.37
Furthermore, we were able to combine a clotting bio- marker with previously established breast cancer prognos- tic factors in order to improve the individual prediction recurrence in this high-risk population. In fact, we found that higher F1+2 values, TN and Luminal B HER2-neg molecular subtypes, and tumor size were independent risk factors for DR. Therefore, F1+2 might be very helpful to identify those subjects who deserve special attention and those who can instead avoid the side effects of sustained chemotherapy. Finally, the significant association between fibrinogen levels and time to DR suggests the potential utility of this marker in those subjects identified at greater risk of DR as a parameter indicative of time to DR.
Other authors have reported different results as regards the F1+2 prognostic role in breast cancer. Specifically, in a recently published study including 235 patients with stage I-IIA breast cancer, F1+2 was not predictive for disease- free survival.11 This discrepancy may be due to different characteristics of that study: a single center study, involv- ing a smaller cohort of patients with stage I and IIa breast cancer (whereas our study enrolls patients up to stage IIIC). In addition, in that study, the disease-free survival was evaluated in a subgroup of 62 patients and blood sam- ples for biomarker testing were obtained before surgery, while our samples were collected in tumor-resected condi- tion before starting chemotherapy.
One limitation of our study is that some data on factors which can have an impact on coagulation cascade, includ- ing treatments with corticosteroids, oral contraceptives,
and hormone replacement therapy, were not collected at the time of blood sampling. In any case, the hemostatic assays performed in this study directly represent the in vivo activity of the coagulation system, which already reflects all possible factors. In addition, at the time of this analysis, data on hormone therapy and radiotherapy were not available for all patients, and therefore were not included in the analysis. An evaluation of the contribution of these data on prognosis in these patients should be a subject of future study.
Several patients relapsed after a relatively long period of time and, therefore, the question may arise as to whether the time elapsed between blood collection and cancer relapse might be a source of uncontrolled confounding bias. This is a common limitation of prognostic biomark- ers which aim to predict the cancer patient outcomes in order to decide on a best treatment option strategy. Validated genetic and biochemical prognostic biomarkers in early breast cancer provide a risk of DR for an event that may occur up to ten years later. In this study, we aimed to identify new prognostic biomarkers to help the selection of patients at highest risk of relapse at presenta- tion, before planning the antitumor strategy. In this sense, we are consistent with the aim of the study, as our results identify a prognostic score based on the F1+2 applicable at presentation.
In conclusion, our prospective study is the first to demonstrate the utility of F1+2 as a potential circulating independent predictive biomarker for DR in a large cohort of patients with high-risk early breast cancer. Having reached this goal, we are now planning to validate the results in an independent cohort of patients. Our findings stimulate future investigations into the utility of longitudi- nal measurement of plasma F1+2 in the surveillance of women following surgery for primary breast cancer and to provide the rationale for new therapeutic strategies.
Appendix 1
The members of the HYPERCAN Study Group (all in Italy) are as follows: Investigators (by center) - Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo: Falanga A., Brevi S., Caldara G., Diani E., Gamba S., Giaccherini C., Marchetti M., Russo L., Schieppati F., Tartari C.J., Verzeroli C., Vignoli A.; Oncology Unit, IRCCS Humanitas Institute, Rozzano: Santoro A., Masci G.; Oncology Unit, IRCCS National Cancer Institute, Milan: De Braud F., Celio L., Nichetti F., Martinetti A.; Oncology Unit, Hospital Papa Giovanni XXIII, Bergamo: Tondini C.; Oncology Unit, Hospital San Filippo Neri, Rome: Gasparini G., Sarmiento R., Gennaro E, Meoni G; Oncology Unit, Hospital San Giovanni, Rome: Minelli M.; Oncology Unit, Hospital Treviglio- Caravaggio, Treviglio: Barni S., Petrelli F., Ghilardi M.; Dept. of Management, Information and Production Engineering, University of Bergamo: Malighetti P., Spinelli D.; Dept. Oncology Bergamo Province, Hospital Papa Giovanni XXIII, Bergamo: Labianca R.; IRCCS Cancer Institute Giovanni Paolo II, Bari: Giuliani F.; Medical Oncology and Internal Medicine, Policlinico San Marco, Zingonia-Bergamo: D’Alessio A., Cecchini S.
Acknowledgments
The authors would like to thank “Associazione Italiana Ricerca sul Cancro” for grant “AIRC 5xmille n. 12237”, and the CRO (Contract Research Organization) “High Research srl” for project management trial monitoring.
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