Introduction: Progesterone (P4) and progesterone receptors (PR) play elusive roles in breast cancer. Synthetic progestins in hormone replacement therapy increase breast tumorigenesis, yet these same progestins at high doses can be an effective therapy for some advanced breast tumors. The literature supports that progestins can either stimulate or inhibit breast cancer cell growth, and an increasing body of evidence supports P4 promotes expansion of breast cancer stem cells. Interplay between PR and estrogen receptors (ER) is emerging as important in dictating growth and response to treatment. There is historical precedence for PR interference of ER dependent gene transcription; recent reports identify that PR modulate ER DNA binding events. Given the importance of PR as a biomarker and potential therapeutic target, and the uncertainty surrounding its context-dependent actions, we aimed resolve this using breast cancer PDX models. The purpose of this study was to evaluate the effects of natural and synthetic progestins on growth and estrogen-dependent gene expression in luminal breast tumors, and to define contexts that dictate their divergent effects.

Experimental procedures: Six luminal breast cancer PDX developed at UCD-AMC were used for these studies. Most profiled as Luminal B subtype. Tumors generally fell into two types: a pure luminal phenotype and a mixed luminal/basal phenotype based on cytokeratin expression. Tumors varied in expression of ER, PR, and androgen receptors (AR) from low (<10% positive cells), moderate (30-50%), to high (>90%). Tumors were grown in vivo under conditions of continuous placebo, 17β-estradiol (estrogen), estrogen plus progesterone (P4), or estrogen plus the synthetic progestin medroxyprogesterone acetate (MPA) for several months and growth parameters monitored. Receptor content was measure by immunohistochemistry and western blots. Gene expression profiles of select tumors were determined using Affymetrix® GeneChip human gene microarrays and/or RNAseq and results analyzed using Partek Genomics Suite™ software, and Metacore™ pathway analysis.

Summary: In two pure luminal PDX with high receptor levels (ER, PR, AR) both P4 and MPA significantly inhibited estrogen-dependent growth (growth-inhibited, GI). Two PDX (one pure luminal, one mixed) with moderate ER and low PR and AR showed no significant effect of P4 or MPA on estrogen-dependent growth (growth neutral, GN). One mixed luminal/basal PDX with low ER and PR and moderate AR showed no effect with P4, whereas MPA simulated tumor growth above that with estrogen alone (growth stimulated, GS). Study of one PDX is ongoing. In the GI tumors both P4 and MPA reversed expression of ~30% of estrogen regulated genes. In particular these tumors had high estrogen-dependent expression of the Notch pathway, which was blocked by both P4 and MPA. Progestins did not alter estrogen-dependent genes in the GN or GS tumors, which did not include the Notch pathway. MPA stimulated a unique set of genes in the GS tumor, and was able to mobilize AR to the nucleus whereas P4 did not.

Conclusion: Progestins have mixed effects on breast cancer PDX tumor growth. Tumors that have high ER and PR and are highly estrogen-dependent are more likely to exhibit strong growth inhibition by progestins (both P4 and MPA). Tumors with mixed luminal/basal phenotype that have less ER and PR and are moderately estrogen-dependent are less likely to be progestin-inhibited. In tumors with low ER and PR but high AR content MPA can act as an AR agonist to stimulate growth. Tumor-specific downstream estrogen-dependent pathways such as Notch may indicate whether progestins are therapeutic. Additional tumors are needed to confirm these results with the long term goal of developing a molecular assay to define those tumors that may benefit from progestin treatment.

Citation Format: Jessica Finlay-Schultz, Heather M. Brechbuhl, Rachel B. Rosen, Austin E. Gillen, Britta M. Jacobsen, Peter Kabos, Carol A. Sartorius. Context-dependent growth effects of progestins in estrogen receptor-positive breast cancer patient-derived xenografts (PDX). [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research; Oct 17-20, 2015; Bellevue, WA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(2_Suppl):Abstract nr A43.