Skip to main content

Advertisement

Log in

Evidence for biological effects of metformin in operable breast cancer: a pre-operative, window-of-opportunity, randomized trial

  • Clinical trial
  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Metformin may reduce the incidence of breast cancer and enhance response to neoadjuvant chemotherapy in diabetic women. This trial examined the effects of metformin on Ki67 and gene expression in primary breast cancer. Non-diabetic women with operable invasive breast cancer received pre-operative metformin. A pilot cohort of eight patients had core biopsy of the cancer at presentation, a week later (without treatment; internal control), then following metformin 500-mg o.d. for 1 week increased to 1-g b.d. for a further week continued to surgery. A further 47 patients had core biopsy at diagnosis were randomized to metformin (the same dose regimen) or no drug, and 2 weeks later had core biopsy at surgery. Ki67 immunohistochemistry, transcriptome analysis on formalin-fixed paraffin-embedded cores and serum insulin determination were performed blinded to treatment. Seven patients (7/32, 21.9%) receiving metformin withdrew because of gastrointestinal upset. The mean percentage of cells staining for Ki67 fell significantly following metformin treatment in both the pilot cohort (P = 0.041, paired t-test) and in the metformin arm (P = 0.027, Wilcoxon rank test) but was unchanged in the internal control or metformin control arms. Messenger RNA expression was significantly downregulated by metformin for PDE3B (phosphodiesterase 3B, cGMP-inhibited; a critical regulator of cAMP levels that affect activation of AMP-activated protein kinase, AMPK), confirmed by immunohistochemistry, SSR3, TP53 and CCDC14. By ingenuity pathway analysis, the tumour necrosis factor receptor 1 (TNFR1) signaling pathway was most affected by metformin: TGFB and MEKK were upregulated and cdc42 downregulated; mTOR and AMPK pathways were also affected. Gene set analysis additionally revealed that p53, BRCA1 and cell cycle pathways also had reduced expression following metformin. Mean serum insulin remained stable in patients receiving metformin but rose in control patients. This trial presents biomarker evidence for anti-proliferative effects of metformin in women with breast cancer and provides support for therapeutic trials of metformin.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Evans JM, Donnelly LA, Emslie-Smith AM, Alessi DR, Morris AD (2005) Metformin and reduced risk of cancer in diabetic patients. BMJ 330(7503):1304–1305

    Article  PubMed  Google Scholar 

  2. Monami M, Lamanna C, Balzi D, Marchionni N, Mannucci E (2009) Sulphonylureas and cancer: a case–control study. Acta Diabetol 46(4):279–284

    Article  PubMed  CAS  Google Scholar 

  3. Jiralerspong S, Palla SL, Giordano SH, Meric-Bernstam F, Liedtke C, Barnett CM et al (2009) Metformin and pathologic complete responses to neoadjuvant chemotherapy in diabetic patients with breast cancer. J Clin Oncol 27(20):3297–3302

    Article  PubMed  CAS  Google Scholar 

  4. Zhou G, Myers R, Li Y, Chen Y, Shen X, Fenyk-Melody J et al (2001) Role of AMP-activated protein kinase in mechanism of metformin action. J Clin Invest 108(8):1167–1174

    PubMed  CAS  Google Scholar 

  5. Hawley SA, Ross FA, Chevtzoff C, Green KA, Evans A, Fogarty S et al (2010) Use of cells expressing gamma subunit variants to identify diverse mechanisms of AMPK activation. Cell Metab 11(6):554–565

    Article  PubMed  CAS  Google Scholar 

  6. Hardie DG (2007) AMP-activated/SNF1 protein kinases: conserved guardians of cellular energy. Nat Rev Mol Cell Biol 8(10):774–785

    Article  PubMed  CAS  Google Scholar 

  7. Kahn BB, Alquier T, Carling D, Hardie DG (2005) AMP-activated protein kinase: ancient energy gauge provides clues to modern understanding of metabolism. Cell Metab 1(1):15–25

    Article  PubMed  CAS  Google Scholar 

  8. Salt IP, Johnson G, Ashcroft SJ, Hardie DG (1998) AMP-activated protein kinase is activated by low glucose in cell lines derived from pancreatic beta cells, and may regulate insulin release. Biochem J 335(Pt 3):533–539

    PubMed  CAS  Google Scholar 

  9. Marsin AS, Bertrand L, Rider MH, Deprez J, Beauloye C, Vincent MF et al (2000) Phosphorylation and activation of heart PFK-2 by AMPK has a role in the stimulation of glycolysis during ischaemia. Curr Biol 10(20):1247–1255

    Article  PubMed  CAS  Google Scholar 

  10. Zakikhani M, Dowling R, Fantus IG, Sonenberg N, Pollak M (2006) Metformin is an AMP kinase-dependent growth inhibitor for breast cancer cells. Cancer Res 66(21):10269–10273

    Article  PubMed  CAS  Google Scholar 

  11. Hadad SM, Fleming S, Thompson AM (2008) Targeting AMPK: a new therapeutic opportunity in breast cancer. Crit Rev Oncol Hematol 67(1):1–7

    Article  PubMed  Google Scholar 

  12. Zhuang Y, Miskimins WK (2008) Cell cycle arrest in metformin treated breast cancer cells involves activation of AMPK, downregulation of cyclin D1, and requires p27Kip1 or p21Cip1. J Mol Signal 3:18

    Article  PubMed  Google Scholar 

  13. van der Burg B, Rutteman GR, Blankenstein MA, de Laat SW, van Zoelen EJ (1988) Mitogenic stimulation of human breast cancer cells in a growth factor-defined medium: synergistic action of insulin and estrogen. J Cell Physiol 134(1):101–108

    Article  PubMed  Google Scholar 

  14. Hadad SM, Baker L, Quinlan PR, Robertson KE, Bray SE, Thomson G et al (2009) Histological evaluation of AMPK signalling in primary breast cancer. BMC Cancer 9(1):307

    Article  PubMed  Google Scholar 

  15. Goodwin PJ, Stambolic V, Lemieux J, Chen BE, Parulekar WR, Gelmon KA et al (2011) Evaluation of metformin in early breast cancer: a modification of the traditional paradigm for clinical testing of anti-cancer agents. Breast Cancer Res Treat 126(1):215–220

    Article  PubMed  CAS  Google Scholar 

  16. Vojtesek B, Bartek J, Midgley CA, Lane DP (1992) An immunochemical analysis of the human nuclear phosphoprotein p53. New monoclonal antibodies and epitope mapping using recombinant p53. J Immunol Methods 151(1–2):237–244

    Article  PubMed  CAS  Google Scholar 

  17. Detre S, Saclani Jotti G, Dowsett M (1995) A “quickscore” method for immunohistochemical semiquantitation: validation for oestrogen receptor in breast carcinomas. J Clin Pathol 48(9):876–878

    Article  PubMed  CAS  Google Scholar 

  18. Harvey JM, Clark GM, Osborne CK, Allred DC (1999) Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 17(5):1474–1481

    PubMed  CAS  Google Scholar 

  19. Purdie CA, Jordan LB, McCullough JB, Edwards SL, Cunningham J, Walsh M et al (2010) HER2 assessment on core biopsy specimens using monoclonal antibody CB11 accurately determines HER2 status in breast carcinoma. Histopathology 56(6):702–707

    Article  PubMed  Google Scholar 

  20. Yerushalmi R, Woods R, Ravdin PM, Hayes MM, Gelmon KA (2010) Ki67 in breast cancer: prognostic and predictive potential. Lancet Oncol 11(2):174–183

    Article  PubMed  CAS  Google Scholar 

  21. de Azambuja E, Cardoso F, de Castro G, Colozza M Jr, Mano MS, Durbecq V et al (2007) Ki-67 as prognostic marker in early breast cancer: a meta-analysis of published studies involving 12,155 patients. Br J Cancer 96(10):1504–1513

    Article  PubMed  Google Scholar 

  22. Cheang MC, Chia SK, Voduc D, Gao D, Leung S, Snider J et al (2009) Ki67 index, HER2 status, and prognosis of patients with luminal B breast cancer. J Natl Cancer Inst 101(10):736–750

    Article  PubMed  CAS  Google Scholar 

  23. Vendrell JA, Robertson KE, Ravel P, Bray SE, Bajard A, Purdie CA et al (2008) A candidate molecular signature associated with tamoxifen failure in primary breast cancer. Breast Cancer Res 10(5):R88

    Article  PubMed  Google Scholar 

  24. Choi YH, Park S, Hockman S, Zmuda-Trzebiatowska E, Svennelid F, Haluzik M et al (2006) Alterations in regulation of energy homeostasis in cyclic nucleotide phosphodiesterase 3B-null mice. J Clin Invest 116(12):3240–3251

    Article  PubMed  CAS  Google Scholar 

  25. Harndahl L, Wierup N, Enerback S, Mulder H, Manganiello VC, Sundler F et al (2004) Beta-cell-targeted overexpression of phosphodiesterase 3B in mice causes impaired insulin secretion, glucose intolerance, and deranged islet morphology. J Biol Chem 279(15):15214–15222

    Article  PubMed  Google Scholar 

  26. Zmuda-Trzebiatowska E, Oknianska A, Manganiello V, Degerman E (2006) Role of PDE3B in insulin-induced glucose uptake, GLUT-4 translocation and lipogenesis in primary rat adipocytes. Cell Signal 18(3):382–390

    Article  PubMed  CAS  Google Scholar 

  27. Vogelstein B, Lane D, Levine AJ (2000) Surfing the p53 network. Nature 408(6810):307–310

    Article  PubMed  CAS  Google Scholar 

  28. Buzzai M, Jones RG, Amaravadi RK, Lum JJ, DeBerardinis RJ, Zhao F et al (2007) Systemic treatment with the antidiabetic drug metformin selectively impairs p53-deficient tumor cell growth. Cancer Res 67(14):6745–6752

    Article  PubMed  CAS  Google Scholar 

  29. Henry LA, Johnson DA, Sarrio D, Lee S, Quinlan PR, Crook T et al (2011) Endoglin expression in breast tumor cells suppresses invasion and metastasis and correlates with improved clinical outcome. Oncogene 30(9):1046–1058

    Article  PubMed  CAS  Google Scholar 

  30. Lucke CD, Philpott A, Metcalfe JC, Thompson AM, Hughes-Davies L, Kemp PR et al (2001) Inhibiting mutations in the transforming growth factor beta type 2 receptor in recurrent human breast cancer. Cancer Res 61(2):482–485

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors are particularly grateful to the patients who were willing to give written informed consent in support of this clinical trial and thank the Tayside Multidisciplinary breast team (Dougal Adamson, Douglas Brown, Emad Elsedawy, Andrew Lee, Denis Mclean, Marta Reis and Valerie Walker) for supporting patient recruitment and facilitating accrual of clinical materials and clinical data to this study. The trial was conducted through funding from Breast Cancer Research (Scotland), Tenovus Tayside, the Anonymous Trust and Cancer Research-UK.

Conflict of interest

G Jellema and S Deharo are employees of Almac Dignostics, manufacturer of the Breast Disease Specific Array used in the clinical trial for transcriptome analyses.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Alastair M. Thompson.

Electronic supplementary material

Below is the link to the electronic supplementary material.

10549_2011_1612_MOESM1_ESM.ppt

Supplementary Figure A. Gene networks revealed by differentially expressed genes using t-test. These figures were generated using Ingenuity Pathway Analysis tool loading the genes that were identified as significantly over- or underexpressed between baseline and follow-up biopsies by t-test. (P ≤ 0.01). The top 10 networks are shown, red = genes overexpressed post-metformin and green = underexpressed post-metformin. White = pathway member not present in the gene list of interest. (PPT 1298 kb)

Supplementary material 2 (DOC 374 kb)

Supplementary material 3 (DOC 165 kb)

10549_2011_1612_MOESM4_ESM.ppt

Supplementary Figure B Gene networks revealed by GSA for metformin effect These 20 figures were generated using Ingenuity Pathway Analysis loading genes that were significant from the Gene Set Analysis. The genes from Supplementary Table 2 were used and genes were included if parametric P value ≤ 0.1 (red = genes overexpressed post-metformin, green = underexpressed post-metformin, grey = no significant change (P ≤ 0.1), white = pathway member not present in the gene list of interest). (PPT 3419 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hadad, S., Iwamoto, T., Jordan, L. et al. Evidence for biological effects of metformin in operable breast cancer: a pre-operative, window-of-opportunity, randomized trial. Breast Cancer Res Treat 128, 783–794 (2011). https://doi.org/10.1007/s10549-011-1612-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10549-011-1612-1

Keywords

Navigation