BACKGROUND:Prior studies have examined survival in patients with epithelial ovarian cancer (EOC); however, few consider race and ethnicity, particularly disaggregating Asian and Native Hawaiian/Pacific Islander women. METHODS:We analysed data from 18 Ovarian Cancer Association Consortium studies, including women with EOC from Asian (n = 697), non-Hispanic Black (n = 267), Hispanic (n = 492), Native Hawaiian/Pacific Islander (n = 98) and non-Hispanic White (n = 12,998) racial and ethnic groups. We ran Cox proportional hazards models estimating overall survival by race and ethnicity, adjusting for age, stage, year of diagnosis, and histotype, with fully adjusted models accounting for body mass index, smoking, and postmenopausal hormone use. We also examined associations between hormone-related factors and family history and overall survival by race and ethnicity, testing for heterogeneity. RESULTS:Compared to non-Hispanic White women with EOC, Native Hawaiian/Pacific Islander and non-Hispanic Black women had poorer overall survival (Hazard Ratios, HR = 1.58, 95% CI = 1.16-2.16, and HR = 1.31, 95% CI = 1.12-1.54, respectively). The association was more pronounced for Native Hawaiian/Pacific Islander women with high-grade serous carcinoma (HR = 2.00, 95% CI = 1.37-2.92). There was no significant heterogeneity in the associations between epidemiological factors and survival by racial and ethnic groups (p ≥ 0.31). DISCUSSION:Native Hawaiian/Pacific Islander and non-Hispanic Black women with EOC had poorer survival, highlighting the need to address disparities in outcome.

Abstract BRCA-associated homologous recombination deficiency (HRD) is present in ~50% of high-grade serous carcinomas (HGSC) and predicts sensitivity to platinum-based therapy. However, there is little understanding of why some patients with BRCA-deficient tumors experience poor outcomes. In a large HGSC cohort (n = 1389) including 282 individuals with pathogenic germline BRCA variants (gBRCApv), residual disease after primary surgery has limited prognostic effect in gBRCApv-carriers compared to non-carriers, and prognostic outcomes differ based on the mutation location within functional domains of the BRCA genes. Multi-omic profiling is performed on 154 tumors, enriched for patients with BRCA-deficient tumors that experienced short overall survival ( ≤ 3 years, n = 42). Patients with BRCA2-deficient HGSC and loss of NF1 survive twice as long as those without NF1 loss, whereas PIK3CA, RAD21 and MYC amplification define BRCA2-deficient HGSC with exceptionally short survival. Patients with BRCA1-deficient HGSC and a more elevated HRD score survive significantly longer. BRCA1-deficient tumors in short survivors have evidence of immunosuppressive c-kit signaling and EMT. Our findings confirm that outcome is not determined by BRCA status alone, but rather a combination of co-occurring genomic alterations, the extent of DNA repair deficiency, and the tumor-immune microenvironment.

BRCA-associated homologous recombination deficiency (HRD) is present in ~50% of high-grade serous carcinomas (HGSC) and predicts sensitivity to platinum-based therapy. However, there is little understanding of why some patients with BRCA-deficient tumors experience unexpectedly poor outcomes. We profiled 154 tumors, enriched for patients with BRCA-deficient tumors that experienced short overall survival (≤3 years, n=42), using whole-genome, transcriptome, and methylation analyses. All but one BRCA-deficient tumor exceeded an accepted HRD genomic scarring threshold. However, patients with BRCA1-deficient HGSC with a more elevated HRD score survived significantly longer. Patients with BRCA2-deficient HGSC and loss of NF1 survived twice as long as those without NF1 loss, whereas PIK3CA or RAD21 amplification defined BRCA2-deficient HGSC with exceptionally short survival. BRCA1-deficient tumors in short survivors had evidence of immunosuppressive c-kit signaling and EMT. In a large HGSC cohort (n=1,389) including 282 individuals with pathogenic germline BRCA variants (gBRCApv), the location of the mutation within functional domains stratified clinical outcomes. Notably, residual disease after primary surgery had limited prognostic effect in gBRCApv-carriers compared to non-carriers. Our findings indicate that tumor HR proficiency in the context of therapy response and survival is not a binary property, and highlight genomic and immune modifiers of outcomes in BRCA-deficient HGSC.

OBJECTIVE:Many epithelial ovarian cancer (EOC) risk factors relate to sex hormones. The association between these factors and the expression of androgen receptor (AR), estrogen receptor-α (ER), and progesterone receptor (PR) in tumors is unknown. METHOD:We linked epidemiologic, AR/ER/PR tumor expression, and survival data from 19 studies in the Ovarian Cancer Association Consortium (OCAC; 4762 cases, 20,888 controls) and the Ovarian Tumor Tissue Analysis (OTTA) consortium (5737 cases). We estimated odds ratios (ORs) and 95 % confidence intervals (CIs) between hormonally-linked factors and tumor AR/ER/PR expression using polytomous logistic regression. We assessed survival by AR/ER/PR tumor expression overall and by histotype using Kaplan-Meier curves and Cox proportional hazards models. RESULTS:Overweight/obesity was associated with higher risk of ER- tumors (OR:1.53, 95 % I:1.18-1.98). Hysterectomy was associated with greater risk of ER+ tumors (OR:4.99, 95 % CI:4.27-5.83), which varied by AR expression (Pheter=0.003). Postmenopause was associated with a higher risk of PR- tumors (OR 1.52, 95 % CI 1.26-1.83), which varied based by AR (Pheter < 0.001) and ER (Pheter < 0.001) expression. Gravidity, oral contraception duration, and breastfeeding duration showed differing dose-response relationships according to AR/ER/PR expression. Hormone therapy use, postmenopause, physical inactivity, and being obese/overweight prior to diagnosis were differentially associated with survival based on AR/ER/PR expression and histotype. CONCLUSION:EOC has varying risk and prognostic profiles depending on both histotype and AR/ER/PR expression. Biological mechanisms underlying the association between hormonally-linked factors and EOC need to be studied by both histotypes and by AR, ER, and PR expression.

Supplementary Table S5. Summary of cell lines used in this study.

Supplementary Table S10. Number of patients by study and histotype.

Supplementary Table S4. Differential gene expression analysis comparing transcriptomes of tumors based on BRCA and RB1 alteration status.

Supplementary Table S15. Clinical characteristics of patients with HGSC according to RB1 and BRCA status.

Multivariate analysis of molecular alterations and OS in patients with HGSC and ENOC.

Supplementary Table S13. Clinical and molecular characteristics of ENOC.

Sensitivity to therapeutic agents in BRCA1-altered cell lines with RB1 knockout. A,RB1 was knocked out using CRISPR/Cas9 in three patient-derived Australian Ovarian Cancer Study (AOCS) HGSC cell lines with either wild-type or altered BRCA1 (BRCA1 var) background. Representative Western Blots show protein levels of RB1 and phosphorylated RB1 (pRB1) compared with GAPDH loading control in single-cell cloned, homozygous RB1 wild-type (WT) and knockout (KO) colonies in comparison with heterogeneous populations with a scramble single guide RNA (sgRNA). Independent blots were used for RB1 and pRB1. B, Cell viability was compared between RB1 WT and KO clones following treatment with cisplatin (72 h), paclitaxel (72 h), or olaparib (120 h). Nonlinear regression drug curves are shown; P values are shown in Supplementary Table S18 (n = 3). Error bars indicate ± SEM; for some values, error bars are shorter than the symbols and thus are not visible. C, Proportion of surviving colonies following 16 days of treatment with cisplatin, paclitaxel, or a combination of both (Cis/Pac; with half of the IC50 determined per drug and cell line respectively) relative to DMF vehicle control (n = 3 replicates). Data are presented as mean ± SEM. Mean values were compared by Student’s t test (ns, not significant; *, P < 0.05; **, P < 0.01). Representative scans of the fixed cell colonies stained with crystal violet are shown for each condition.

Supplementary Table S7. Sequences of single guide RNAs used for CRISPR-mediated gene knockout.

Clinicopathologic characteristics and RB1 expression patterns across histotypes.

Supplementary Table S11. Multivariable adjusted association of molecular alterations and overall survival in HGSC and ENOC among patients with residual disease* status.

Supplementary Table S8. Antibodies and reagents.

Supplementary Table S9. Primers used in this study.

Supplementary Figure S1. Patients and tumor samples analyzed in this study.

Supplementary Table S19. Relative expression of BRCA1 and RB1 by qPCR in AOCS30 CRISPR knockout model.

BACKGROUNDDespite an overall poor prognosis, about 15% of patients with advanced-stage tubo-ovarian high-grade serous carcinoma (HGSC) survive 10 or more years after standard treatment.METHODSWe evaluated the tumor microenvironment of this exceptional, understudied group using a large international cohort enriched for long-term survivors (LTS; 10+ years; n = 374) compared with mid-term (MTS; 5-7.99 years; n = 433) and short-term survivors (STS; 2-4.99 years; n = 416). Primary tumor samples were immunostained and scored for intraepithelial and intrastromal densities of 10 immune-cell subsets (including T cells, B cells, plasma cells, myeloid cells, PD-1+ cells, and PD-L1+ cells) and epithelial content.RESULTSPositive associations with LTS compared with STS were seen for 9 of 10 immune-cell subsets. In particular, the combination of intraepithelial CD8+ T cells and intrastromal B cells showed near 5-fold increased odds of LTS compared with STS. All of these associations were stronger in tumors with high epithelial content and/or the C4/Differentiated molecular subtype, despite immune-cell densities generally being higher in tumors with low epithelial content and/or the C2/Immunoreactive molecular subtype.CONCLUSIONThe tumor microenvironment of HGSC LTS is distinguished by the intersection of T and B cell coinfiltration, high epithelial content, and C4/differentiated molecular subtype, features which may inspire new approaches to immunotherapy.FUNDINGOvarian Cancer Research Program (OCRP) of the Congressionally Directed Medical Research Program (CDMRP), U.S. Department of Defense (DOD); American Cancer Society; BC Cancer Foundation; Canada's Networks of Centres of Excellence; Canadian Cancer Society; Canadian Institutes of Health Research; Cancer Councils of New South Wales, Victoria, Queensland, South Australia, and Tasmania, Cancer Foundation of Western Australia; Cancer Institute NSW; Cancer Research UK; Deutsche Forschungsgesellschaft; ELAN Funds of the University of Erlangen-Nuremberg; Fred C. and Katherine B. Andersen Foundation; Genome BC; German Cancer Research Center; German Federal Ministry of Education and Research, Programme of Clinical Biomedical Research; Instituto de Salud Carlos III; Mayo Foundation; Minnesota Ovarian Cancer Alliance; Ministerio de Economía y Competitividad; Medical Research Council (MRC); National Center for Advancing Translational Sciences; National Health and Medical Research Council of Australia (NHMRC); Ovarian Cancer Australia; Peter MacCallum Foundation; Sydney West Translational Cancer Research Centre; Terry Fox Research Institute; The Eve Appeal (The Oak Foundation); UK National Institute for Health Research Biomedical Research Centres at the University of Cambridge; University of Pittsburgh School of Medicine; U.S. National Cancer Institute of the National Institutes of Health; VGH & UBC Hospital Foundation; Victorian Cancer Agency.

Supplementary Figure S3. Overall survival by combined RB1 and p53 expression in ENOC, and RB1 protein expression and BRCA status in HGSC.