Accuracy of a Novel Scoring System for Prediction of Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer Patients

Background: Neoadjuvant chemotherapy (NAC) has become a widely accepted treatment option for locally advanced breast cancer (LABC). Furthermore, response to NAC is considered to be a predictor of favorable outcomes. It is known that some predictors are associated with NAC response. Objectives: To assess the accuracy of scoring system for prediction of response to neoadjuvant chemotherapy in LABC.


Introduction
Based on GLOBOCAN 2012, there were approximately 14.1 million new cancer cases and 8.2 million cancer deaths, while in 2008 there were 12.7 million new cases and 7.6 million deaths. Breast cancer is the second most common cancer in the world, it is also a type of cancer that is often diagnosed in women in 140 out of 184 countries. Breast cancer is the most common cause of death in women with cancer (522.000 deaths in 2012). This data shows an increase of more than 20% of cases compared to the estimate in 2008. 1 Cancer until now has become a health problem in the world, including Indonesia. 2 Breast cancer usually occurs because of the interaction between genetic factors and environmental factors. 3 Some of the risk factors for breast cancer include genetic or hereditary factors, a family history of having had breast cancer, a history of having had a benign breast tumor or before. breast cancer, factors of early menstruation (age under 12 years) and menopause over the age of 50 years and a history of reproduction such as childlessness and not breastfeeding, childbirth for the first child over the age of 35 years, use of hormonal contraceptives> 7 years, history of radiation During breast growth, consume foods that are high in saturated fat, as well as alcoholic beverages. 4 A high body mass index (BMI) in patients receiving neoadjuvant chemotherapy is associated with a low pathologic complete response (pCR). 5,6 The neutrophil-lymphocyte ratio value before administration of neoadjuvant chemotherapy is a predictor of complete pathological response, as well as a significant prognosis for recurrence. 7 The pioneers of the invasive breast cancer molecular classification were Perou and Sorlie who identified 5 subtypes of invasive breast cancer, namely Luminal A, Luminal B, normal breasts such as HER2 overexpression and basal like carcinoma, with different clinical results and different responses to neoadjuvant chemotherapy. 8 In breast cancer, intratumoral cytotoxic CD8 + T cell infiltration is closely associated with long-term survival of the patient and good response to chemotherapy. Mao et al said it was reported that CD8 + lymphocytes are the main cells that are effective in the immune response, which shows better disease-free survival (DFS) in breast cancer patients. 9 Al Saleh et al, in their study it was reported that high CD8 + expression was predictable. Significant complete pathologic response after neoadjuvant chemotherapy and is a prognostic factor independent of Overall Survival (OS). 10 According to Seo et al., CD8 + is an important component of Tumor Infiltrating Lymphocytes (TIL) associated with chemotherapy response and can be used as a predictor of response to anthracyclines or anthracyclines / taxa based on breast cancer. 11 CD4 + levels serve as the basis of the immune system cytotoxic T lymphocytes. CD4 + T helper cells have an important role in modulating the immune system, especially maintaining long-term anti-tumor effects.
Given the existence of various factors that act as predictors of response to neoadjuvant chemotherapy in locally advanced breast cancer, the researchers wanted to assess these factors as a single scoring system, which is expected to provide a more meaningful value in predicting the response to neoadjuvant chemotherapy.

Methods
This type of research is a prognostic test for the accuracy of various risk factors (patient age, age at menarche, past or menopause, history of hormonal contraception, age at first pregnancy, parity, family history, and nutritional status), immunohistochemistry subtypes, CD4 + serum, CD8 + serum, serum CD4 + / CD8 + ratio, and neutrophil-lymphocyte ratio as a scoring system used to predict the response of neoadjuvant chemotherapy in patients with locally advanced breast cancer. This research was conducted in the surgical oncology polyclinic and inpatient installation of Dr. Mohammad Hoesin Hospital Palembang.
The study period was from 01 July 2019 to 31 July 2020. The study population was patients with locally advanced breast cancer who received neoadjuvant chemotherapy at Dr. Muhammad Hoesin Hospital Palembang. The inclusion criteria in this study were patients with locally advanced breast cancer who were determined based on the criteria of the American Joint Committee of Cancer, underwent neoadjuvant chemotherapy, had a Karnofsky index ≥ 50, were willing to participate in the study and signed an informed consent. The exclusion criteria in this study were patients who had previously undergone chemotherapy and immunocompromised patients.

Results
There were 50 samples obtained at the surgical oncology polyclinic and the inpatient installation of Dr. Mohammad Hoesin Hospital Palembang from 01 July 2019 to 31 July 2020 who met the inclusion and exclusion criteria. Overall, it was found that 38 patients (76.0%) showed a good response to neoadjuvant chemotherapy. Patient ages ranged from 30 to 67 years with a mean of 48.2 ± 11.0 years. There was no difference in patient age between groups with good and bad response to neoadjuvant chemotherapy (p = 0.166). The mean age of menarche of all study samples was 13.22 ± 1.4 years, there was no difference between the two groups (p = 0.757). A total of 22 (44.0%) patients had already experienced menopause while 28 (56.0%) had not yet experienced menopause. There was no association between menopause and response to neoadjuvant chemotherapy (p = 0.852). Most of the patients (66.0%) had a history of using hormonal contraceptives, but there was no significant relationship between family planning history and response to neoadjuvant chemotherapy in this study (p = 0.520). In the group with a good response to neoadjuvant chemotherapy, the mean age at first pregnancy was 23.9 ± 4.6 years, while in the group with a poor response it was 22.5 ± 7.4 years. The age at first pregnancy among patients did not differ between the two groups (p = 0.423). Twenty-five (92.6%) patients with parity <3 had a good response to neoadjuvant chemotherapy. In patients with parity ≥ 3, most of the patients (56.5%) responded well and there was a significant relationship between parity and response to neoadjuvant chemotherapy (p = 0.003). In the analysis with the chi-square test found a significant relationship between parity and cut off = 3 (p = 0.003) with OR = 9.6. This means that patients with parity <3 (0-2) are nearly 10 times more likely to

Biomarkers and chemotherapy response
There was also no association between immunohistochemistry subtypes and response to neoadjuvant  In this study, we want to see the relationship between several immunological parameters in serum, namely the number of CD4 +, CD8 +, CD4 + / CD8 + ratio, and Neutrophil Lymphocyte Ratio (NLR). Table 4.10 lists the average number and standard deviation of CD4 +, CD8 +, CD4 + / CD8 +, and NLR ratios. The results of statistical tests using unpaired t-test found no significant relationship between serum immunological parameters and the response to neoadjuvant chemotherapy (p > 0.05). analysis. Then for each sample is given a score of 1) if the predictor value is above the cut-off point and 2) if the value is below the cut-off point. Recapitulation of each predictor and the cut-off point value can be seen in Table 4 below.  17 There was no significant relationship between age and response to neoadjuvant chemotherapy (p = 0.166).
Family history such as mothers, mother's sisters, siblings or siblings who have had breast cancer have a 4-6 times risk than those without risk factors. 4 In this study, most of the 37 patients (74%) were not known to have a history of breast cancer in the family, and only 13 patients (26%) had a family history of breast cancer. Statistical analysis did not find a significant relationship between family history of breast cancer and response to neoadjuvant chemotherapy (p = 0.110). In contrast to this study, Rahestyningtyas in 2019 found a significant relationship with a moderate correlation between a history of breast cancer and chemotherapy response. It was concluded that patients with a family history tended to have a poor response to neoadjuvant chemotherapy. 18 In this study, the patient's body mass index (BMI) ranged from 17.8 to 37 with a mean of 25.5 ± 3.7.
Most of the patients (80%) had over nutritional status and 20% had normal nutritional status. There was no This study did not find a significant relationship between immunohistochemistry subtypes and response to neoadjuvant chemotherapy (p = 0.827). In line with Muhammad et al in 2020 who also did not find a significant relationship between immunohistochemistry and neoadjuvant chemotherapy response.
Furthermore, in this study, statistical tests were carried out on each hormone receptor. Overall, there were more ER + and PR + than ER-and PR-and Her2neu -more than Her2neu +, which showed a good response to neoadjuvant chemotherapy. However, only the difference in response to neoadjuvant chemotherapy at ER hormone receptors was statistically significant in this study (p = 0.025, OR = 4.5). 20 Analysis with the chi-square test found a significant relationship between parity and response to neoadjuvant chemotherapy, with a cut-off point = 3 (p = 0.003) and OR = 9.6. This means that patients with parity <3 (0-2) are nearly 10 times more likely to show good response to neoadjuvant chemotherapy than those with parity of 3 or more. In line with this study, Muhammad et al. In 2020 also found a significant relationship between parity> 3 and response to neoadjuvant chemotherapy with an OR value of 10.8. 20 Fortner et al. In 2019 also found the same thing where parity ≥ 3 had a worse chemotherapy response compared to patients with parity <3. Parity at risk increases the risk of negative hormone receptors that can worsen the response to neoadjuvant chemotherapy. 19 Lee et al. in 2019 concluded that there was a significant relationship, with high correlation strength, between parity> 4 and chemotherapy response.
There is a significant difference between patients with parous null and parity ≥ 2, where samples with parity ≥ 2 have a risk of experiencing poor chemotherapy response. 24 Of all the factors that could theoretically be potential predictors of response to neoadjuvant chemotherapy in this study, only 2 factors were found that were statistically significantly related to the response to neoadjuvant chemotherapy, namely 1) ER expression and 2) Parity, with a cut-off point of 3.

Conclusion
There was no significant relationship between age at diagnosis of breast cancer, age at menarche, menopause or not, history of hormonal contraceptive use, age at first pregnancy, family history of breast cancer, nutritional status, immunohistochemistry subtypes, expression of PR hormonal receptors, HER2neu, Ki67, serum CD4 + levels, serum CD8 + levels, serum CD4 + / CD8 + ratios, and NLR in blood with neoadjuvant chemotherapy response, which can be used to predict the response to neoadjuvant chemotherapy in patients with locally advanced breast cancer at Dr. Mohammad Hoesin Hospital Palembang.
The combination of parity <3 and positive ER expression showed better accuracy with a sensitivity of 96.3%, a specificity of 77.7% and a Youden index of 74. The total predictor score for neoadjuvant chemotherapy response in this study had a sensitivity value of 77.8%, specificity of 83.3%. , the positive predictive value is 18.4%, the negative predictive value is 24.4%, the false positive value is 22.2%, and the false negative value is 75.6%, with a Youden index of 66.1.