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Use of autoantibodies in breast

cancer screening and diagnosis
Sarah J Storr, Jayeta Chakrabarti, Anthony Barnes, Andrea Murray,
Caroline J Chapman and John FR Robertson

CONTENTS
Overview of disease
Autoantibodies in
breast cancer
Assessing an
autoantibody response
Detection of tumor-associated
antigens
Mutated tumor-
associated antigens
Overexpressed tumor-
associated antigens
Altered expression of tumor-
associated antigens
Mucin tumor-
associated antigens
Autoantibodies to monitor
disease & predict clinical
outcome in breast cancer
Autoantibodies & breast
cancer prognosis
Autoantibodies for breast
cancer screening & diagnosis
Conclusions
Expert commentary
Five-year view
Key issues
References
Affiliations
Breast cancer is the most common cancer among women and accounts for 6% of all
cancer deaths. Current screening modalities for breast cancer diagnosis include
mammography, digital mammography and magnetic resonance imaging; however, there
is still an urgent need to develop an alternative modality of screening for earlier diagnosis.
Autoantibodies to tumor-associated autoantigens can be elicited in breast cancer
patients. Tumor-associated antigens vary between cancers and can be the result of a
number of different events, including mutation, overexpression or altered expression
patterns. The inherent amplification of signals provided by the hosts own immune system
to low levels of tumor-associated antigens in early disease provides a potential route to the
early diagnosis of cancer. In addition, autoantibody responses in breast cancer have been
correlated with patient survival and their response to treatment.
Expert Rev. Anticancer Ther. 6(8), 12151223 (2006)
Overview of disease not routinely offered to females under the age
Breast cancer is the second most common can- of 50 years as mammography is less sensitive
cer in the world and the most common cancer in that age group.
in women, accounting for 22% of female can- The use of other imaging modalities such
cers [1]. Although the incidence rate of breast as magnetic resonance imaging (MRI), digital
cancer has risen, mortality from breast cancer mammography and breast ultrasound has
is decreasing in most locations, which is the been investigated and can provide effective
result of increased awareness, earlier detection early diagnosis in subsets of patients [1011]. In
and improved treatment regimens [2]. addition, the measurement of serum-based
For many decades, the early detection of tumor markers as early markers of disease has
breast cancer has been aided by worldwide been examined, but sensitivity is low during
mammography screening and in the UK, the early stages of disease [12]. There is an
women are invited to participate in breast urgent need to develop a screening tool that is
screening from the age of 50 years. Clinical sensitive, specific, simple and cost efficient
trials to evaluate the benefits of mammogra- for the early detection of breast cancer, espe-

Author for correspondence
Division of Breast Surgery,
University of Nottingham,
Nottingham City Hospital,
Hucknall Road, Nottingham ,
NG5 1PB, UK
Tel.: +44 115 823 1876
Fax: +44 115 823 1877
mszjfr@gwmail.nottingham.ac.uk.
KEYWORDS:
antigen panel,
autoantibodies, breast cancer,
diagnosis, prognosis, tumor-
associated antigen
phy in Sweden, Scotland and Canada have
shown a significant decrease in mortality from
breast cancer of approximately 2035% for
women aged 5069 years [38]. Mammo-
graphically detected tumors are usually of a
smaller size and are associated with a better
prognosis [9]. However, there are a number of
factors that reduce the sensitivity of mammo-
graphy as a screening modality, including
breast density, lobular cancers, ductal carci-
noma in situ (DCIS) without associated calci-
fications and multifocal cancers. Screening is
cially in high-risk patient groups or in
younger premenopausal women, where
screening is less effective.
Autoantibodies in breast cancer
Autoantibodies are produced by the immune
system when the body fails to distinguish the
autologous host from foreign particulates. The
manifestation of autoantibodies in a healthy
host may be indicative of an autoimmune dis-
order, such as systemic lupus erythematosus
(lupus) or rheumatic autoimmune disease.

www.future-drugs.com 10.1586/14737140.6.8.1215 2006 Future Drugs Ltd ISSN 1473-7140 1215

Storr, Chakrabarti, Barnes, Murray, Chapman & Robertson
Cancer patients are able to elicit an autoimmune response not
associated with autoimmune disorders in response to the pres-
entation of tumor-associated antigens. Tumor-associated anti-
gens can elicit an autoimmune response by the presentation of
proteins at the cell surface that may not be usually located
there, or expression of cryptic epitopes not usually visible to the
hosts immune system [13,14]. Autoantibodies against tumor-
associated antigens can be detected in the sera of cancer
patients as part of an in vivo amplification of an early carcino-
genesis signal. The subsequent detection of an autoantibody
response may be able to provide a mechanism for the early
detection of breast cancer by noninvasive methodology and
earlier treatment intervention.
Assessing an autoantibody response
Current methods available for the detection of autoantibodies
in the sera of cancer patients include western blotting (WB),
immunoprecipitation (IP), immunoflorescence (IF), flow
cytometry (FC) and enzyme-linked immunosorbent assays
(ELISA). More recently, miniature autoantigen arrays have
been used for the characterization of autoantibody responses in
autoimmune diseases and, in addition, allow screening for
autoantibodies against many breast cancer antigens [15]. The
most prevalent methodology for autoantibody screening is
recombinant antigen ELISA, where a microtiter plate is coated
with antigen to which autoantibodies present in patient sera
bind. Studies are conducted on cancer patients at various stages
of disease and a positive autoantibody response is usually
assigned as 2 or 3 standard deviations above the mean of
healthy donor sera (2 standard deviations above the mean gives
a 95% confidence interval).
Detection of tumor-associated antigens
Tumor-associated antigens that are able to elicit an autoanti-
body response can be characterized by numerous methods.
Serological identification of antigens by recombinant expres-
sion cloning (SEREX) is a rapid method of profiling patient
tissue and is identifying many new antigens for autoantibody
analysis [16]. SEREX involves the screening of cancer tissue
complementary DNA libraries with autoantibodies that are
present in patient sera. As a result, many tumor-associated
antigens have been identified, such as NY-ESO-1, a cancer-
testis antigen [17]. In addition, it is now understood that pro-
teins such as heat-shock protein (Hsp)90 are able to generate
an autoantibody response in cancer [18]. Although SEREX has
led to the identification of many tumor-associated antigens,
few have been incorporated into the clinical setting, partly due
to the patient-specific nature of identified antigens [19]. In
addition to SEREX, the phage display of cDNA libraries from
cancer cell lines or peptides can be screened using patient
serum to allow the identification of tumor-associated
antigens [20,21]. Many of the classical tumor-associated anti-
gens were originally identified by alteration/altered expression
of the antigen, followed by the observation of a corresponding
autoantibody response.
1216
Mutated tumor-associated antigens
The tumor-suppressor protein p53 was one of the first tumor-
associated antigens identified to elicit autoantibodies in cancer
patients [22]. In response to cellular stress, p53 is able to arrest cell-
cycle development, allowing DNA damage to be repaired, or is
able to induce apoptosis [23,24]. Missense mutations to the highly
conserved domains of p53 are the most prevalent changes in can-
cer and it has been demonstrated that these mutations correlate
with the presence of p53 autoantibodies [25,26]. However, the p53
epitopes to which autoantibodies bind do not lie in the mutated
hot spot regions of p53, but in the carboxy and amino terminal
region of the protein [27,28]. Autoantibodies against p53 are found
in many malignancies and the published frequency of p53-spe-
cific autoantibodies in breast cancer ranges from 3 to 48% [29].
The p53 mutation is found in approximately 30% of breast can-
cer patients; however, only half of these patients are able to elicit a
p53-specific autoantibody response [29]. In addition, patients with
p53 autoantibodies demonstrate a complex of p53 protein and
Hsp70 in breast cancer, which may be involved in the antigenic
presentation of p53 [30]. The absence of p53 autoantibodies in
patients with p53 mutations indicates the importance of antigen
load, protein stability and protein localization.
Overexpressed tumor-associated antigens
Brass and colleagues were able to demonstrate a relationship
between expressed immunogenic antigens and amplified genes
in squamous cell lung carcinoma, showing a correlation
between gene amplification, overexpression and the production
of autoantibodies in cancer [31].
There are a number of tumor-associated antigens that are
overexpressed in breast cancer, such as the transmembrane recep-
tor P185HER-2. P185HER-2 is overexpressed in 2530% of breast
cancers due to amplification of the HER-2/neu gene and its
overexpression is associated with cancers that have a poor prog-
nosis [3235]. The HER-2/neu gene product is a human growth
factor receptor, related to but distinct from the epidermal growth
factor receptor (EGFR), and functions as a tyrosine kinase in the
specific activation of signal transduction pathways [3638]. A sin-
gle-point mutation changing valine to glutamic acid in the trans-
membrane domain is responsible for P185HER-2 protein activa-
tion [39]. Monitoring the expression of P185HER-2 has been
implicated as a predictive measure for projecting response to
cancer therapy [40]. The HER-2/neu gene product is able to elicit
autoantibodies in breast cancer, which is probably due to the
increased expression level of the P185HER-2 protein. It has been
demonstrated that in early stage breast cancer, P185HER-2-spe-
cific autoantibodies correlate with P185HER-2-positive cancers
(20%; 9 out of 44) compared with P185HER-2-negative tumors
(5% 3 out of 63), with an 11% (12 out of 107) overall detection
of autoantibody presence in breast cancer sera [41].
Altered expression of tumor-associated antigens
Survivin is an apoptosis inhibitor whose expression is limited to
embryonic and fetal development. Survivin is not found in nor-
mal, terminally differentiated adult tissues, but its expression
Expert Rev. Anticancer Ther. 6(8), (2006)
 Autoantibodies in breast cancer screening and diagnosis

Table 1. The frequency of autoantibodies found in breast cancer against certain tumor-associated antigens and their
correlation with clinico-pathological variables and survival.
Antigen Assay Antigen Frequency of ELISA cut off (n) Comment Ref.
autoantibodies
p53 Various Various 348% Various See TABLE 2 [29]
HER-2
P185 ELISA SKBR-3 cell lysate 11% (12/107) >Mean + 4 SD (200) Not reported [41]

NY-ESO-1 FC Recombinant 4% (4/100) N/A Not reported [72]

ELISA Recombinant 8% (2/26) >Mean + 3 SD (70) [56]

Survivin ELISA Recombinant 8% (5/64) >Mean + 3 SD (82) Not reported [51]

ELISA Recombinant 24% (11/46) >Mean + 3 SD (10) [50]
ELISA Recombinant 12% (11/105) >Mean + 3 SD (82) [73]

Annexin XI-A Autoantigen Phage-displayed 19% (17/90) N/A Higher frequency [74]
microarray antigen in DCIS
Endostatin WB Recombinant 51% (49/95) N/A Improved survival [71]

Hsp90 ELISA Purified from HeLa 37% (46/125) >Mean + 3 SD* Association with [70]
cell line the development
of metastases
Cyclin B1 ELISA Recombinant 5% (3/64) >Mean + 3 SD (82) Not reported [51]

p62 ELISA Recombinant 8% (5/64) >Mean + 3 SD (82) Not reported [51]

ELISA Recombinant 5% (5/98) >Mean + 3 SD (82) [75]

Koc ELISA Recombinant 14% (9/64) >Mean + 3 SD (82) Not reported [51]
ELISA Recombinant 12% (12/98) >Mean + 3 SD (82) [75]

MUC1 ELISA 60-mer peptide- 24% (37/154) Value equal or above the Improved disease- [64]
BSA conjugate median value obtained for the specific survival
total breast cancer group
RPA32 ELISA Recombinant 11% (87/801) >Mean + 3 SD (65) No correlation [76]

Cut off describes how a positive autoantibody response was determined in ELISA.
*Number not given; BSA: Bovine serum albumin; DCIS: Ductal carcinoma in situ; ELISA: Enzyme-linked immunosorbent assay; FC: Flow cytometry; Hsp: Heat-shock protein;
N/A: Not applicable; n: Number of healthy donor sera used to generate the mean; RPA32: 32,000 Mr subunit of replication protein A; SD: Standard deviation;
WB: Western blotting.

has been described in lung, colon, pancreas, prostate, gastric and
breast cancer [4245]. Inhibition of survivin decreases cell viability
and cell death can be initiated by either classic apoptosis path-
ways or a caspase-independent mechanism [43,46]. In breast can-
cer, survivin messenger RNA expression can be detected in
7090% of tissue and correlates with bcl-2 expression [45,47,48].
In ELISA experiments using recombinant survivin protein,
22% (11 out of 51) of lung cancer patients and 8% (4 out of
49) of colorectal cancer patients were found to express survivin
autoantibodies [49]. Autoantibodies to survivin have been
detected in breast cancer patient sera against recombinant anti-
gen in ELISA, although the frequency of positives detected dif-
fers. Yagihashi and colleagues detected autoantibodies in 24%
(11 out of 46) of breast cancer sera [50], whereas Zhang and col-
leagues detected autoantibodies to survivin in 8% (5 out of 64)
of breast cancer sera [51].
NY-ESO-1 is an immunogenic testicular antigen that dem-
onstrates a restricted expression pattern, with expression in nor-
mal tissues being restricted to testis and ovary [17,52]. NY-ESO-1
mRNA has been detected in various cancers, such as
melanoma, bladder, prostate and hepatocellular cancer [53].
Reports on the number of breast cancers that express
NY-ESO-1 mRNA vary between 10 [54], 30 [53] and 42% [55].
In addition, low levels of NY-ESO-1 mRNA can be detected in
68% of benign breast conditions [55]. Using recombinant NY-
ESO-1 antigen in an ELISA, autoantibodies against NY-ESO-1
are observed in 8% (2 out of 26) of breast cancers, increasing to
13% (4 out of 32) in ovarian cancer [56].
Mucin tumor-associated antigens
There are a number of tumor-associated mucin autoantigens
that demonstrate both altered and overexpression and are sub-
ject to aberrant posttranslational modifications. MUC1 is a
high-molecular-weight glycoprotein overexpressed in breast
cancer and is a prime example of a protein that is able to over-
ride immune tolerance. During breast cancer, an atypical
expression pattern is exhibited, changing from the apical border
of epithelial cells to apolar cell-surface distribution. In addition
to altered cell-surface location, MUC1 can be found in the
cytoplasm and at higher levels in the circulation of
patients [57,58]. MUC1 also shows a shift in the complexity of
its O-linked glycosylation on the variable number of tandem

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Storr, Chakrabarti, Barnes, Murray, Chapman & Robertson

repeats (VNTR) that comprise the majority of the protein. A to osteosarcoma, Hsp90 autoantibodies have been implicated
shift from core-2-based glycans to the simpler primarily sia- as a poor prognostic factor in breast cancer, with Hsp90
lylated core-1-based glycans in breast cancer is observed, and is autoantibodies and the presence of involved nodes correlating
believed to make the protein more accessible to the immune with the development of metastases and poor survival [69,70].
system [59]. The altered location and post-translational modifi-
cations of MUC1 may elicit autoantibodies against the antigen Autoantibodies & breast cancer prognosis
that can be detected within the circulation of breast cancer There are a number of tumor-associated antigens that can elicit
patient serum by ELISA [60,63,64]. In addition, it seems that an autoantibody response, which can be correlated with prog-
MUC1-specific autoantibodies have a certain degree of nosis. Endostatin is an inhibitor of angiogenesis that can elicit
dependency upon the glycosylation state of the core MUC1 an autoantibody response in 66% (24 out of 36) of breast can-
protein and that the circulating autoantibodies to MUC1 can cer patients with localized disease and 42% (25 out of 59) of
be a positive prognostic factor in breast, nonsmall cell lung and breast cancer patients with metastatic disease. However,
pancreatic cancer patients [6164]. autoantibody response to endostatin is not correlated with cir-
culating endostatin. Both the presence of low levels of circulat-
Autoantibodies to monitor disease & predict clinical outcome ing endostatin and the presence of endostatin-specific autoanti-
in breast cancer bodies are associated with an improved prognosis in metastatic
There are limited examples correlating autoantibody frequency breast cancer (mean survival time 20 vs 8 months) (TABLE 1) [71].
and titer fluctuation with the clinical outcome of cancer; how- In addition to endostatin autoantibodies, MUC1-specific
ever, a number of studies have highlighted the potential for autoantibodies are a favorable prognostic indicator for pancre-
autoantibody screening. atic, nonsmall cell lung and breast cancer patients [6164]. How-
Autoantibodies to the tumor-associated antigen p53 have ever, laminin-specific autoantibodies correlate with a reduced
demonstrated a correlation with clinical outcome in breast disease-free interval and survival rate in breast cancer [77]. Poor
cancer. A group of 24 patients with primary nonmetastatic prognostic features in breast cancer can also be associated with
breast cancer had p53-specific autoantibodies measured retro- the presence of p53 autoantibodies (TABLE 2).
spectively by ELISA; 46% (11 out of 24) of the group had ele-
vated p53 autoantibody levels at the time of diagnosis. Of
those 11 patients, seven (64%) showed decreasing p53 auto- Table 2. p53-specific autoantibodies and their
antibody titers in response to therapy and three patients dem- correlation with patient prognosis in breast cancer.
onstrated an autoantibody titer increase prior to relapse [65]. In Frequency of Assay Comment Ref.
addition to p53, nucleophosmin (NPM)-specific autoanti- autoantibodies
body titer has been shown to increase in breast cancer patients
9% (14/155) IP using Association with grade [22]
between diagnosis and 6 months prior to recurrence [66]. cell lysates Increased lung vs
Similarly, in a study of 12 NY-ESO-1-positive tumor bone metastases
patients with melanoma, adenocarcinoma, nonsmall cell lung
8% (8/101) ELISA Association with [78]
cancer or bladder cancer, autoantibodies could be detected in tumor grade
10 out of 12 patients. In four of the patients with a detectable Association with lack of ER
NY-ESO-1 antibody response, a titer increase was observed
26% (48/182) ELISA Association with [79]
with progressive or stable disease. In five of the patients, a
histological grade
decrease in NY-ESO-1 antibody titers was observed with the
reduction of tumor mass, or relapse with a NY-ESO-1-nega- 12% (42/353) ELISA Association with [80]
tive tumor, and one patient showed a stable NY-ESO-1 anti- shortened survival
body titer over 40 months, with gradual regression of tumor 15% (9/61) ELISA Association with [81]
mass [67]. tumor size
Hsp90 autoantibodies can be positively correlated with 48% (39/82) ELISA No clinical correlation [82]
osteosarcoma-patient response to neoadjuvant chemotherapy. A
total of 75% (6 out of 8) of patients who demonstrated an 9% (15/165) ELISA + WB Association with [83]
shortened survival
Hsp90-specific autoantibody response had a good response to
neoadjuvant chemotherapy, with 100% (all eight) of that group 12% (5/43) ELISA No clinical correlation [84]
having no appearance of metastasis. Conversely, patients who
15% (115/1006) ELISA No clinical correlation [85]
had not developed Hsp90-specific autoantibodies had a poor
response to neoadjuvant chemotherapy (75%; 9 out of 12) and 19% (30/158) ELISA Association with stage [86]
a higher appearance of metastases were observed (25%; 3 out Association with lack of ER
Association with Ki-67
of 12) [68]. Hsp90 was originally identified as a tumor antigen
by SEREX and 8% (1 out of 13) of breast cancer patient sera ELISA: Enzyme-linked immunosorbent assay; ER: Estrogen receptor;
IP: Immunoprecipitation; WB: Western blotting.
have a detectable Hsp90 autoantibody response [18]. In addition

1218 Expert Rev. Anticancer Ther. 6(8), (2006)

 Autoantibodies in breast cancer screening and diagnosis

Autoantibodies for breast cancer screening & diagnosis
The detection of autoantibodies as an aid to the diagnosis of
breast cancer may allow for earlier detection than conventional
screening. The detection of autoantibodies in patients with
DCIS has been demonstrated using a library of 938 T7 phages
selected via biopanning of a breast cancer T7 phage cDNA
display library with the sera from ten invasive ductal carci-
noma (IDC) patients. The panel of 938 T7 phages was probed
with DCIS, IDC or control sera to eliminate nonspecific reac-
tions and to reduce the panel to 12 T7 phages. Of 90 breast
cancer sera screened for an autoantibody response to the
12 antigens, 77% demonstrated a response against at least one
of the antigens. Annexin XI-A, part of the tumor-associated
antigen panel, offered a possibility of distinguishing DCIS and
IDC, with 60% (9 out of 15) of DCIS sera demonstrating the
presence of annexin XI-A-specific autoantibodies compared
with 11% (8 out of 75) of IDC sera [74]. Using an alternate
panel of tumor-associated antigens, autoantibodies can be
detected in 82% of 200 primary breast cancer sera using
ELISA (MUC1, p53, c-myc and P185HER-2). Interestingly,
autoantibodies were found in 60% of a group of nine sera
taken from women predating breast cancer diagnosis by at
least 6 months [87], suggesting that an autoantibody response
can be detected in the pre- or early stages of carcinogenesis.
There are a number of other antigens that have a detectable
autoantibody response during the early stages of disease.
Recently, autoantibodies against the 32,000 Mr subunit of
replication protein A (RPA32) have been detected in 11%
(87 out of 801) of breast cancer patients. The antigenic pro-
tein was selected by screening of a HeLa cDNA expression
library by one patients serum, which had been collected prior
to the diagnosis of breast cancer. Using sera samples predating
cancer diagnosis by up to 18 months, RPA32-specific autoan-
tibodies were found to be present in all samples, at the same
titer as at diagnosis [76].
Additional support for the hypothesis that autoantibodies
precede the onset clinical symptoms in cancer is provided by
Trivers and colleagues [88]. The group reported that autoanti-
bodies against p53 could be detected prior to cancer diagnosis
in smokers with chronic obstructive pulmonary disease. There
are a small number of case reports that further indicate the
importance of autoantibodies in the diagnosis of breast cancer

Table 3. Tumor-associated antigen panels and their sensitivity in detecting breast cancer.
Patient cohort Assay Antigen panel Sensitivity Cancer sera ELISA cut off (n) Ref.
Primary breast cancer ELISA Human MUC1 and 82% 200 primary breast >Mean + 2 SD (100) [87]
recombinant antigens cancer patients
p53, c-myc and
P185HER-2
DCIS and IDC Autoantigen 12 phage-displayed 77% 15 DCIS patients N/A [74]
microarray antigens (including 75 IDC patients
annexin XI-A, p80
subunit of Ku antigen
and ribosomal
protein S6).
Breast cancer ELISA Survivin and livin 52% 46 breast cancer >Mean + 2 SD (10) [50]
stages IIV patients (stages IIV)
Breast cancer ELISA c-myc, p53, cyclin B1, 44% 64 breast cancer >Mean + 3 SD (82) [51]
survivin, p62, Koc patients
and IMP1
Initial diagnosis of ELISA c-myc, p53 27% 64 breast cancer >Mean + 3 SD (82) [73]
breast cancer and survivin patients (sera
collected at
diagnosis)
Breast cancer ELISA Koc and p62 16% 98 breast cancer >Mean + 3 SD (82) [75]
patients
Metastatic breast ELISA NY-ESO-1, MAGE-1, 8% 26 metastatic breast >Mean + 3 SD (70) [56]
cancer MAGE-3, SSX2, cancer patients
melan-A, tyrosinase
and carbonic
anhydrase
Cut off describes how a positive autoantibody response was determined in ELISA. All antigens were recombinant proteins unless otherwise stated.
DCIS: Ductal carcinoma in situ; ELISA: Enzyme-linked immunosorbent assay; IDC: Invasive ductal carcinoma; MUC: Mucin; n: Number of normal sera used to generate the
mean; SD: Standard deviation.

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Storr, Chakrabarti, Barnes, Murray, Chapman & Robertson

patients with autoimmune neurological diseases. In one such
study, autoantibodies against a 128 kDa neuronal protein were
found in three patients suffering from the stiff-man syndrome
and two out of three had breast cancer. Subsequently, a search
for cancer was conducted in the third patient and a small IDC
was identified by ultrasonography [89].
Conclusions
Autoantibodies have the potential for a new blood-based
screening mechanism for breast cancer, ideally allowing the
detection of breast cancer before current established screening
methods. The inherent amplification of signals provided by the
hosts own immune system to low levels of tumor-associated
antigens in early disease provides a potential route to the early
diagnosis of cancer. Since breast cancer is heterogeneous, no
single antigen will demonstrate an autoantibody response in all
patients. By using panels of independent tumor-associated anti-
gens, high cancer detection rates can be observed, even in
DCIS, the earliest clinically recognisable breast cancer. It is
clear that the success of autoantibody assays lies in the selection
of the optimal panel of tumor-associated antigens (TABLE 3).
The selection of antigens for use in autoantibody assays has to
be made upon the suitability of that antigen, both in its appro-
priateness for identifying a specific cancer and the immuno-
genicity of that antigen. The immunogenicity of antigens used,
in addition to the varying techniques, may explain the variation
of autoantibody detection described, such as p53 in breast
cancer [29]. However, there is persuasive evidence available to
suggest that autoantibody assays can be used to predict the out-
come of treatment regimes and in the prognosis of patients.
Autoantibody assays may allow for a sensitive, specific, cost-effi-
cient and noninvasive modality of screening women as an aid to
mammography and, ultimately, if the specificity is high enough,
as a stand-alone test.
Expert commentary
The detection of an elevated autoantibody response in breast
cancer patients is becoming a sensitive tool for the diagnosis and
monitoring of breast cancer owing to the increased use of anti-
gen panels for detection of autoantibodies. The use of panels can
significantly increase the number of cancers detected by auto-
antibody screening and is becoming an increasingly interesting
possibility for use in the clinical setting.
Five-year view
The next 5 years of autoantibody research should see the detec-
tion of autoantibodies progress through the formal structure in
the process of biomarker development [90]. This will hopefully
allow for the transition from the current primarily retrospective
studies to the real-time/prospective analysis of the patient
autoantibody response to assess its efficacy in the clinical setting.
A large-scale evaluation of the use of antigen panels for the detec-
tion of autoantibodies is required to validate the method of early
cancer detection in patients with an elevated risk of breast cancer.

Key issues

Breast cancer is the most common female cancer and accounts for 6% of all cancer deaths.
Autoantibodies can be elicited against tumor-associated antigens by a number of mechanisms, such as overexpression, altered
cellular location and altered post-translational modifications.
The screening of breast cancer patients for autoantibodies against tumor-associated antigens may provide an aid to patient
management and treatment.
The detection of autoantibodies against tumor-associated antigens may allow for the early detection of breast cancer.
A panel of independent tumor-associated antigens has a higher detection rate in cancer than a single antigen measurement, owing
to the heterogeneous nature of the disease.

References
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Autoantibodies in breast cancer screening and diagnosis
Describes the use of an antigen panel Road, Nottingham, NG5 1PB, UK
for the detection of autoantibodies in Tel.: +44 115 823 1876
early breast cancer. Fax: +44 115 823 1877
mszjc3@gwmail.nottingham.ac.uk
88 Trivers GE, De Benedetti VM, Cawley HL
et al. Anti-p53 antibodies in sera from Anthony Barnes, PhD
patients with chronic obstructive Chief Executive Officer, Oncimmune Ltd.,
Biocity Nottingham, Pennyfoot Street,
pulmonary disease can predate a diagnosis
Nottingham, NG1 1GF, UK
of cancer. Clin. Cancer Res. 2, 17671775
Tel.: +1 404 488 5560
(1996).
Fax: +1 770 234 4036
89 Folli F, Solimena M, Cofiell R et al. tbarnes614@aol.com
Autoantibodies to a 128-kD synaptic Andrea Murray, PhD
protein in three women with the stiff man Director of Research, Oncimmune Ltd., Biocity
syndrome and breast cancer. N. Engl. J. Nottingham, Pennyfoot Street, Nottingham,
Med. 328, 546551 (1993). NG1 1GF, UK
Describes a case study in which the Tel.: +44 115 823 1826
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search for breast cancer in one patient. mszam5@gwmail.nottingham.ac.uk
90 Sullivan Pepe M, Etzioni R, Feng Z et al. Caroline J Chapman, PhD
Phases of biomarker development for early University of Nottingham,Tumor Immunology
detection of cancer. J. Natl Cancer Inst. Group, Division of Breast Surgery, Nottingham
93, 10541061 (2001). City Hospital, Hucknall Road, Nottingham,
NG5 1PB, UK
Tel.: +44 115 823 1825
Affiliations Fax: +44 115 823 1877
Sarah J Storr mszcjc@gwmail.nottingham.ac.uk
Research Student, Tumor Immunology Group, John FR Robertson, FRCS, MD
University of Nottingham, Division of Breast University of Nottingham, Division of Breast
Surgery, Nottingham City Hospital, Surgery, Nottingham City Hospital, Hucknall
Hucknall Road, Nottingham, NG5 1PB, UK Road, Nottingham, NG5 1PB, UK
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Jayeta Chakrabarti, MRCS
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Surgery, Nottingham City Hospital, Hucknall
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