Milking the stroma in triple-negative breast cancer.

Investment in the post-genomic molecular dissection of breast cancer has resulted in an emphasis on prognostic and predictive markers, signatures derived to stratify the disease and the drive to generate targeted therapies. However, there remain significant challenges to individualize therapeutic targeting and improve the prognosis for the thousands of women who die each year from the heterogeneous range of breast cancers. This is particularly true for poor prognosis “triple-negative” breast cancers (TNBC), most prevalent in young and African American women, lacking the established therapeutic targets of estrogen receptor, progesterone receptor or HER2.

Research has largely focused on the epithelial component of breast cancer rather than the tumor microenvironment, now recognized as a key hallmark of cancer. In vitro, animal models and observations on clinical material are now moving to consider physiological mechanisms by which stromal cells may influence breast epithelial and carcinoma cells.

Witkiewicz et al. build on published evidence from the Lisanti group that cancer cells secrete hydrogen peroxide, initiating oxidative stress and aerobic glycolysis in tumor stroma, with L-lactate secretion from cancer-associated fibroblasts fueling oxidative mitochondrial metabolism in epithelial cancer cells: the “reverse Warburg effect.”

They demonstrate stromal monocarboxylate transporter 4 (MCT4), detected by immunohistochemistry, as a functional marker of stromal hypoxia, oxidative stress, aerobic glycolysis and L-lactate efflux. High stromal MCT4 expression (but, critically, not epithelial MCT4) was associated with poor prognosis in TNBC patients. Combined high stromal MCT4 and loss of stromal caveolin-1 identify particularly poor prognostic TNBC.

Thus, development of cancer may not lie solely in genetic or epigenetic epithelial changes, but with acquired functional changes in the stromal infrastructure of the breast. This supports the concept of epithelial malignant changes consequent with ecological and evolutionary opportunity.

The “parasitic” character of tumor cells feeding off stromal cells highlights the need to seriously consider both ecological and biophysical concepts. We need to think beyond “intraspecific” competition among clonal subpopulations in the tumor and to consider tumor and stromal cells as distinct populations in a cancer ecosystem, with a range of “interspecific” competitive, exploitative and opportunistic interactions. Furthermore, the reverse Warburg effect relies on the inefficient diffusion of nutrients from stromal cells to tumor cells in a complex three-dimensional space. The extracellular space is brought to the foreground, and physical properties of molecular transport in this space may have as much impact on tumor growth as intricate cellular processes.

The importance of the spatial arena is also apparent when contrasting the reverse Warburg effect with angiogenesis. In the former, tumor cells are exploiting their local environment, which will presumably be of limited yield, whereas angiogenesis taps the nutrients of the entire organism—­an effectively infinite reservoir for a growing tumor. In the reverse Warburg effect, a balance of ecological and biophysical factors underpins the sustainability of this mode of cancer nutrition.

A two-compartment model coupling oxidative epithelial cells with glycolytic fibroblasts reflects increased expression of hypoxia-associated genes as a component part of prognostic stromal signatures. Further evidence of stromal/epithelial interaction comes from evidence that the effects of radiation on normal breast epithelium in vivo is at least partially dependent on the stromal context.

Manipulation of the tumor microenvironment to promote an anticancer phenotype challenges the cancer treatment paradigm. The long-established antidiabetes biguanide drugs offer a low-toxicity opportunity to disrupt the reverse Warburg effect. Metformin may target the cancer mitochondria and phenformin induce stromal sclerosis, at least in a breast cancer xenograft model, in addition to in vivo AMPK pathway and insulin-mediated systemic effects of metformin in women with breast cancer.

The reverse Warburg effect challenges our therapeutic focus on breast cancer epithelium. Stromal MCT4 expression with caveolin-1 loss identifies poor prognostic TNBC patients and emphasizes the roles of the tumor microenvironment and ecological interactions between distinct populations of cells. The challenges now revolve around therapeutic manipulation of the stroma/epithelial interaction and the extracellular space, and testing these concepts in pre-invasive and metastatic settings where stromal changes may provide tissue niches of evolutionary opportunity for malignant cells.