Hindawi

International Journal of Breast Cancer

Volume 2017, Article ID 1796145, 5 pages
https://doi.org/10.1155/2017/1796145

Research Article
Clinical Characteristics in Patients with Triple Negative
Breast Cancer

Janet Yeh,1 Jennifer Chun,1 Shira Schwartz,1 Annie Wang,2 Elizabeth Kern,3
Amber A. Guth,1 Deborah Axelrod,1 Richard Shapiro,1 and Freya Schnabel1
1
Department of Surgery, New York University Langone Medical Center, New York, NY, USA
2
School of Medicine, New York University Langone Medical Center, New York, NY, USA
3
Drexel University, School of Medicine, Philadelphia, PA, USA

Correspondence should be addressed to Freya Schnabel; freya.schnabel@nyumc.org

Received 15 February 2017; Accepted 16 July 2017; Published 17 August 2017

Academic Editor: Debra A. Tonetti

Copyright © 2017 Janet Yeh et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. The purpose of this study was to compare and contrast the clinical characteristics of the triple negative breast cancer
(TNBC) and non-TNBC patients, with a particular focus on genetic susceptibility and risk factors prior to diagnosis. Methods.
Our institutional database was queried for all patients diagnosed with invasive breast cancer between January 2010 and May 2016.
Results. Out of a total of 1964 patients, 190 (10%) patients had TNBC. The median age for both TNBC and non-TNBC was 59 years.
There was a significantly higher proportion of African American and Asian patients with TNBC (𝑝 = 0.0003) compared to patients
with non-TNBC. BRCA1 and BRCA2 were significantly associated with TNBC (𝑝 < 0.0001, 𝑝 = 0.0007). A prior history of breast
cancer was significantly associated with TNBC (𝑝 = 0.0003). There was no relationship observed between TNBC and a history of
chemoprevention or patients who had a history of AH or LCIS. Conclusions. We found that having Asian ancestry, a prior history
of breast cancer, and a BRCA1 or BRCA2 mutation all appear to be positively associated with TNBC. In order to develop more
effective treatments, better surveillance, and improved prevention strategies, it is necessary to improve our understanding of the
population at risk for TNBC.

1. Introduction of TNBC patients are carriers for deleterious BRCA1 and

BRCA2 germline mutations, especially BRCA1 [7, 10, 13, 14].
Triple negative breast cancer (TNBC) is the subtype of breast Routine BRCA mutation testing is not recommended for all
cancer that does not overexpress human epidermal growth patients with breast cancer due to its high cost and the low
factor 2 receptors (HER2), while also lacking expression of prevalence of mutations [15–17]. However, the National Com-
estrogen receptors (ER) and progesterone receptors (PR). prehensive Cancer Network (NCCN) guidelines recommend
TNBC, which accounts for an estimated 15–20% of invasive referral for consideration of genetic counseling for women 60
breast cancers [1–3], has been associated with rapid growth, years of age or younger with TNBC [13, 18]. Recent reports
distant metastasis, and shorter overall and relapse-free sur- have also shown strong associations between TNBC and
vival when compared to other breast cancer subtypes across diagnosis of breast cancer at a younger age [19, 20].
multiple studies [4–6]. Another population with increased incidence of TNBC
Much of the literature surrounding TNBC has been is African American patients [1, 21–23]. Carey et al. devised
focused on identifying populations at risk. In particular, a case-control study in North Carolina in which African
BRCA1 and BRCA2 genotypes have been shown to predis- American patients were overrepresented to allow for statisti-
pose carriers to TNBC [5, 7–11]. The BRCA genes encode cal comparison to mostly Caucasian patients; this landmark
tumor suppressors that repair DNA damage by homologous study found that 39% of African American patients presented
recombination; when mutated, the carrier is susceptible to with TNBC, compared to 16% of non-African American
breast and ovarian cancer [12]. Studies suggest 10.6–30.9% patients [1]. Amirikia and colleagues analyzed the prevalence
2 International Journal of Breast Cancer

of TNBC among non-Hispanic White, non-Hispanic Black, were 31 (5%) patients who were BRCA1 positive and 29 (5%)
and Hispanic patients in the California Cancer Registry; who were BRCA2 positive. As expected, the majority of breast
they confirmed the association and asserted a steeper rise cancer patients had tumors that were early stage, stage I or II,
in incidence of TNBC with age among African American (91%) and of ductal histology (81%).
women [21]. Multiple locoregional studies demonstrate that Out of a total of 1964 patients, 190 (10%) patients had
TNBC comprises 20–40% studies of African American breast TNBC and 1774 (90%) had non-TNBC. The median age
cancer patients [1, 21–24]. However, there have not been any for both TNBC and non-TNBC was 59 years. There was
American studies analyzing TNBC in the Asian population. a significantly higher proportion of African American and
Among 972 breast cancer patients at the Dr. B. Borooah Asian patients with TNBC (𝑝 = 0.0003) compared to
Cancer Institute in India, 31.9% were defined as TNBC patients with non-TNBC (Table 1). BRCA1 and BRCA2 were
[25]. Additionally, the University Malaya Medical Center in significantly associated with TNBC (𝑝 < 0.0001, 𝑝 = 0.0007).
Malaysia reports a 17.6% incidence of TNBC among 1147 A prior history of breast cancer was significantly associated
breast cancer patients of Chinese, Malay, and Indian descent with triple negative histology in our study (𝑝 = 0.0003).
[26]. From these international reports, we suspect that TNBC There was no relationship observed between TNBC status
may affect a large proportion of Asian American patients. and a history of chemoprevention. Likewise, there was no
The present study was designed to compare and contrast relationship between TNBC status and patients who had a
the clinical characteristics of the TNBC and non-TNBC history of AH or LCIS (Table 1). When compared to patients
patients in the New York University Breast Cancer Database with non-TNBC, patients with TNBC were more likely to
(BCD), with a particular focus on genetic susceptibility and have undergone neoadjuvant treatment (𝑝 < 0.0001). As
risk factors prior to cancer diagnosis. compared to patients with non-TNBC, patients with TNBC
were also more likely to have later stage disease (𝑝 = 0.0001),
2. Methods invasive ductal carcinomas (𝑝 < 0.0001), and higher Ki-67
(𝑝 < 0.0001) (Table 2).
2.1. Study Participants. The Breast Cancer Database (BCD)
is a longitudinal study that was established at our institution 4. Discussion
in January 2010. All patients undergoing definitive breast
cancer surgery for a newly diagnosed breast cancer at our The results of our study both confirm known associations of
institution are eligible to enroll in the BCD. The variables TNBC and identify significant notable findings specific to our
collected for the database include information on personal TNBC population. Similar to findings in previous studies,
and family history, screening history, methods of diagnosis, our TNBC patients had an increased proportion of African
tumor histology and stage at diagnosis, details of treatment, American patients and a higher percentage of BRCA muta-
and outcomes. All clinical data are obtained from detailed tion carriers when compared to the non-TNBC population. A
questionnaires that are filled out at the time of surgery and significant association between TNBC and previous history
from a review of electronic medical records. The Breast of breast cancer was also seen. No association was found
Cancer Database was queried for all patients who were between TNBC and prior history of atypical hyperplasia or
diagnosed with invasive breast cancer between January 2010 LCIS. Contrary to many previously published studies, we
and May 2016. This study was approved by the Institutional found a higher proportion of Asians with TNBC. We also
Review Board. found that the median age in both TNBC and non-TNBC
cohorts was 59 years.
2.2. Statistical Analyses. Descriptive statistics were used to TNBC has been shown to be associated with a 10.6–30.9%
summarize the data and to see the distribution of the variables carrier rate of deleterious BRCA1 and BRCA2 mutations
between patients with TNBC and patients with non-TNBC. [7, 10, 13, 14]. Our data is consistent with an increased number
The variables of interest included age, race, personal and of carriers in our TNBC population. This may be due to
family history of breast cancer, BRCA1 and BRCA2 status, the unique racial distribution of our patients. Internationally,
and tumor characteristics. Pearson’s chi-square and Fisher’s there are differences in BRCA1 and 2 prevalence; for example,
exact tests were used to assess any associations between among 190 TNBC patients in Mexico City, 23% were found
the categorical variables of interest and TNBC status with to have a founder BRCA1 mutation (BRCA1 ex9-12del)
a significance level of 0.05. Logistic regression was used to [27], while BRCA risk calculators developed in Caucasian
test for any associations between the continuous predictor populations consistently underestimate BRCA risk in Asian
variables, age and tumor size, and TNBC. All analyses were patients [28]. We postulate that the higher proportion of
performed using SAS version 9.3 (SAS Institute Inc., Cary, Asian American patients in our database may account for this
NC). discrepancy with previous literature. The NCCN guidelines
recommend that all women with TNBC and 60 years of age or
3. Results younger should undergo genetic counseling [18]; moreover,
our study supports the NCCN guideline and underlines the
During the study period, a total of 1964 patients with invasive importance of genetic counseling for TNBC patients.
breast cancer were enrolled in the Breast Cancer Database. There was a significant association between TNBC and
The majority of patients in the study cohort were Caucasian individuals of African American and Asian heritage within
(76%). The median age was 59 years (22–95 years). There our cohort. We identified 18% and 13% of individuals in the
International Journal of Breast Cancer 3

Table 1: Clinical characteristics.

Variables TNBC (𝑁 = 190, 10%) % Non-TNBC (𝑁 = 1774, 90%) % 𝑝 value
Median age, in years 59 (25–92) 59 (22–95) 0.52
Race
African American 31 16 147 8
Asian 23 12 152 9
White 122 64 1363 77 0.0003
Hispanic 11 6 103 6
Other 3 2 9 1
AH
No 188 99 1741 98
0.57
Yes 2 1 33 2
LCIS
No 190 100 1751 99
0.16
Yes 0 0 23 1
Previous history of breast cancer
No 156 82 1605 90
0.0003
Yes 34 18 169 10
Family history of breast cancer
No 144 76 1352 76
0.90
Yes 46 24 442 24
BRCA1
Negative 65 82 481 97
Positive 14 18 17 3 <0.0001
Unknown/not tested 111 — 1276 —
BRCA2
Negative 68 86 480 96
Positive 11 14 18 4 0.0007
Unknown/not tested 111 — 1276 —
Chemoprevention
No 179 94 1695 96
0.40
Yes 11 6 79 4

Table 2: Tumor characteristics.

Variables TNBC (𝑁 = 190, 10%) % Non-TNBC (𝑁 = 1774, 90%) % 𝑝 value
Neoadjuvant
No 157 83 1669 94
<0.0001
Yes 33 17 105 6
Median tumor size (cm) 1.6 (0.1–9.4) 1.3 (0.04–12.5) 0.06
Stage
I 101 53 1111 63
IIA, IIB 55 29 513 29
0.0001
IIIA, IIIB, IIIC 33 17 138 8
IV 1 1 12 1
Histology
IDC 178 94 1422 80
ILC 5 3 242 14 <0.0001
Invasive other 7 4 110 6
Median Ki-67 60 (1–99) 10 (1–99) <0.0001
4 International Journal of Breast Cancer

TNBC population as African American and Asian, respec- Conflicts of Interest

tively. African American and Asian patients each comprise
8% of the non-TNBC population. The association between The authors declare that they have no conflicts of interest.
African American patients and TNBC is well established in
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