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Purpose: This study was undertaken to conduct a comprehensive investigation of the role of DNA damage repair (DDR) defects in poor outcome ER + disease. Experimental Design: Expression and mutational status of DDR genes in ER + breast tumors were correlated with proliferative response in neoadjuvant aromatase inhibitor therapy trials (discovery dataset), with outcomes in METABRIC, TCGA, and Loi datasets (validation datasets), and in patient-derived xenografts. A causal relationship between candidate DDR genes and endocrine treatment response, and the underlying mechanism, was then tested in ER + breast cancer cell lines. Results: Correlations between loss of expression of three genes: CETN2 ( P &lt; 0.001) and ERCC1 ( P = 0.01) from the nucleotide excision repair (NER) and NEIL2 ( P = 0.04) from the base excision repair (BER) pathways were associated with endocrine treatment resistance in discovery dataset, and subsequently validated in independent patient cohorts. Complementary mutation analysis supported associations between mutations in NER and BER genes and reduced endocrine treatment response. A causal role for CETN2, NEIL2 , and ERCC1 loss in intrinsic endocrine resistance was experimentally validated in ER + breast cancer cell lines, and in ER + patient-derived xenograft models. Loss of CETN2, NEIL2 , or ERCC1 induced endocrine treatment resistance by dysregulating G 1 -S transition, and therefore, increased sensitivity to CDK4/6 inhibitors. A combined DDR signature score was developed that predicted poor outcome in multiple patient cohorts. Conclusions: This report identifies DDR defects as a new class of endocrine treatment resistance drivers and indicates new avenues for predicting efficacy of CDK4/6 inhibition in the adjuvant treatment setting. Clin Cancer Res; 24(19); 4887-99. ©2018 AACR .

Comprehensive Profiling of DNA Repair Defects in Breast Cancer Identifies a Novel Class of Endocrine Therapy Resistance Drivers