Open Access Open Badges Research article

Quantitative measures of estrogen receptor expression in relation to breast cancer-specific mortality risk among white women and black women

Huiyan Ma1*, Yani Lu1, Polly A Marchbanks2, Suzanne G Folger2, Brian L Strom3, Jill A McDonald2, Michael S Simon4, Linda K Weiss5, Kathleen E Malone6, Ronald T Burkman7, Jane Sullivan-Halley1, Dennis M Deapen8, Michael F Press9 and Leslie Bernstein1

Author Affiliations

1 Division of Cancer Etiology, Department of Population Sciences, Beckman Research Institute, City of Hope, Duarte, CA 91010, USA

2 Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA

3 Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA

4 Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI 48201, USA

5 Cancer Centers Branch, National Cancer Institute, Bethesda, MD 20892, USA

6 Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA

7 Department of Obstetrics and Gynecology, Baystate Medical Center, Springfield, MA 01199, USA

8 Department of Preventive Medicine, University of Southern California, Los Angeles, CA 90033, USA

9 Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA

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Breast Cancer Research 2013, 15:R90  doi:10.1186/bcr3486

Published: 27 September 2013



The association of breast cancer patients’ mortality with estrogen receptor (ER) status (ER + versus ER-) has been well studied. However, little attention has been paid to the relationship between the quantitative measures of ER expression and mortality.


We evaluated the association between semi-quantitative, immunohistochemical staining of ER in formalin-fixed paraffin-embedded breast carcinomas and breast cancer-specific mortality risk in an observational cohort of invasive breast cancer in 681 white women and 523 black women ages 35-64 years at first diagnosis of invasive breast cancer, who were followed for a median of 10 years. The quantitative measures of ER examined here included the percentage of tumor cell nuclei positively stained for ER, ER Histo (H)-score, and a score based on an adaptation of an equation presented by Cuzick and colleagues, which combines weighted values of ER H-score, percentage of tumor cell nuclei positively stained for the progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) results. This is referred to as the ER/PR/HER2 score.


After controlling for age at diagnosis, race, study site, tumor stage, and histologic grade in multivariable Cox proportional hazards regression models, both percentage of tumor cell nuclei positively stained for ER (Ptrend = 0.0003) and the ER H-score (Ptrend = 0.0004) were inversely associated with breast cancer-specific mortality risk. The ER/PR/HER2 score was positively associated with breast cancer-specific mortality risk in women with ER + tumor (Ptrend = 0.001). Analyses by race revealed that ER positivity was associated with reduced risk of breast cancer-specific mortality in white women and black women. The two quantitative measures for ER alone provided additional discrimination in breast cancer-specific mortality risk only among white women with ER + tumors (both Ptrend ≤ 0.01) while the ER/PR/HER2 score provided additional discrimination for both white women (Ptrend = 0.01) and black women (Ptrend = 0.03) with ER + tumors.


Our data support quantitative immunohistochemical measures of ER, especially the ER/PR/HER2 score, as a more precise predictor for breast cancer-specific mortality risk than a simple determination of ER positivity.