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Estrogen receptor degradation: a CUE for endocrine resistance?


Despite the undoubted success of adjuvant endocrine therapies that target the estrogen receptor pathway, not all women with estrogen receptor-positive breast cancer respond to these therapies, and many who initially respond will subsequently relapse. Deregulation of various aspects of estrogen receptor signaling has been highlighted as a mechanism of resistance and as a basis for alternative therapeutic approaches. However, a recent publication refocuses attention on the estrogen receptor itself by showing that the ubiquitin-binding CUE domain-containing protein 2 is a regulator of estrogen receptor protein degradation and a marker of endocrine resistance in breast cancer.


Endocrine therapies that impair estrogen synthesis or interfere with estrogen receptor (ER) signaling are central to the standard of care for the 75% of breast cancers that are ER-positive, and these therapies, particularly the selective ER modulator tamoxifen, have made a significant contribution to the recent reduction in breast cancer mortality [1]. Many women treated with endocrine therapy will experience disease progression during therapy or subsequent recurrence of their disease, however, and so understanding the molecular basis of endocrine resistance is a priority for improving the survival of breast cancer patients [1, 2].

ERα expression is a major determinant of the success of endocrine therapy: immunohistochemically detectable ERα expression in >1% of cells is sufficient to predict clinical benefit, and patients with the highest levels of ERα expression have the longest survival following endocrine therapy [3, 4]. ERα levels are under complex regulation by transcription factors including multiple Forkhead family members, as well as ligand-mediated downregulation of ERα transcription and proteasomal degradation of the ERα protein [58]. However, the determinants of ERα levels in breast cancer are not completely understood. A recent publication identifies CUE domain-containing protein 2 (CUEDC2) as a new, and probably important, piece in this puzzle [9]. The CUE domain is a ubiquitin-binding motif, which initiates proteolytic degradation of specific targets [10].


Zhang and colleagues have shown that CUEDC2 binds both the progesterone receptor (PR) and ERα, resulting in degradation of these receptors and reduction of ligand-activated gene transcription [9, 11]. CUEDC2 binds PR through an interaction between the CUE domain and the N-terminal inhibitory function domain of PR, but binds ERα through an interaction between the N-terminal domain of CUEDC2 and the DNA binding domain of ERα [9, 11]. The CUE domain is not necessary for ERα binding, but is necessary for ubiquitination and degradation of ERα [9].

To investigate the potential role of CUEDC2 in breast cancer, immunohistochemistry of a panel of markers including CUEDC2, ERα, PR, Ki67 and HER2 was used [9]. CUEDC2 was significantly overexpressed in breast cancer compared with adjacent normal tissue, and breast cancers with the highest CUEDC2 staining (that is, strong staining in >50% of cells) were predominantly ERα-negative and PR-negative. Both overall and in the ERα-positive subgroup, CUEDC2 expression was inversely related to ERα expression, although >20% of ERα-positive cancers had low ERα levels despite low CUEDC2 expression, or high levels of both proteins. High CUEDC2 expression was associated with reduced survival of ERα-positive patients following endocrine therapy (tamoxifen), but had no significant relationship with patient outcome in ERα-positive patients who did not receive tamoxifen therapy or in ERα-negative patients. In breast cancer cells in culture, CUEDC2 overexpression led to tamoxifen resistance. This could be reversed by co-expression of ERα, suggesting that although CUEDC2 binds multiple targets, its effects on tamoxifen sensitivity are predominately mediated through ERα.


Collectively the findings of Zhang and colleagues indicate that CUEDC2 is an important regulator of ERα expression in breast cancer, and is a mechanistically-based biomarker of response to endocrine therapy. Importantly, unlike many other biomarkers that are correlated with patient outcome following tamoxifen treatment [2], CUEDC2 appears to be specifically associated with response to therapy, rather than with an inherently poor-outcome phenotype [9]. One significant implication of this work is that ERα mRNA levels may not necessarily be a good surrogate measure of ERα protein. Overall, ERα mRNA and protein are correlated in large breast cancer series, but determination of ER status by these measures is discordant in ~10% of cases, some of which are immunohistochemically ERα-negative despite expressing readily detectable levels of ERα mRNA [12, 13]. Overexpression of CUEDC2 could contribute to this discordance.

Several priorities for further investigation arise from these findings. Although regulation of ERα protein levels was necessary for the ability of CUEDC2 overexpression to confer tamoxifen resistance in vitro, in multivariate analysis CUEDC2 was predictive of the outcome of tamoxifen therapy independent of ERα expression [9]. ERα may thus not be the only relevant target of CUEDC2 in clinical breast cancer. Whether CUEDC2 regulates the degradation of steroid hormone receptors other than ERα and PR, and whether its expression is correlated with steroid receptor expression in hormone-dependent cancers other than breast cancer, are not known. However, CUEDC2 expression is reduced in castrate-recurrent prostate cancer, which is characterized by increased androgen receptor activity [14], suggesting CUEDC2 may also act to dampen androgen receptor signaling. In addition, there are no published data addressing regulation of CUEDC2 so it will be of significant interest to determine how the protein's expression and function are regulated in normal physiology, and to determine the mechanisms for the significant overexpression of CUEDC2 in breast cancer. Finally, it will be important to dissect the functional interrelationships between CUEDC2 and the kinase LMTK3, recently identified as a negative regulator of ERα protein degradation that is also necessary for transcription of ERα mRNA and is correlated with endocrine resistance [15].



CUE domain-containing protein 2


estrogen receptor


progesterone receptor.


  1. Early Breast Cancer Triallists' Collaborative Group: Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005, 365: 1687-1717.

    Article  Google Scholar 

  2. Musgrove EA, Sutherland RL: Biological determinants of endocrine resistance in breast cancer. Nat Rev Cancer. 2009, 9: 631-643. 10.1038/nrc2713.

    Article  CAS  PubMed  Google Scholar 

  3. Harvey JM, Clark GM, Osborne CK, Allred DC: Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol. 1999, 17: 1474-1481.

    CAS  PubMed  Google Scholar 

  4. Viale G, Regan MM, Maiorano E, Mastropasqua MG, Dell'Orto P, Rasmussen BB, Raffoul J, Neven P, Orosz Z, Braye S, Ohlschlegel C, Thurlimann B, Gelber RD, Castiglione-Gertsch M, Price KN, Goldhirsch A, Gusterson BA, Coates AS: Prognostic and predictive value of centrally reviewed expression of estrogen and progesterone receptors in a randomized trial comparing letrozole and tamoxifen adjuvant therapy for postmenopausal early breast cancer: BIG 1-98. J Clin Oncol. 2007, 25: 3846-3852. 10.1200/JCO.2007.11.9453.

    Article  PubMed  Google Scholar 

  5. Pinzone JJ, Stevenson H, Strobl JS, Berg PE: Molecular and cellular determinants of estrogen receptor alpha expression. Mol Cell Biol. 2004, 24: 4605-4612. 10.1128/MCB.24.11.4605-4612.2004.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Madureira PA, Varshochi R, Constantinidou D, Francis RE, Coombes RC, Yao KM, Lam EW: The Forkhead box M1 protein regulates the transcription of the estrogen receptor alpha in breast cancer cells. J Biol Chem. 2006, 281: 25167-25176. 10.1074/jbc.M603906200.

    Article  CAS  PubMed  Google Scholar 

  7. Lonard DM, O'Malley BW: Emerging roles of the ubiquitin proteasome system in nuclear hormone receptor signaling. Prog Mol Biol Transl Sci. 2009, 87: 117-135.

    Article  CAS  PubMed  Google Scholar 

  8. Bernardo GM, Lozada KL, Miedler JD, Harburg G, Hewitt SC, Mosley JD, Godwin AK, Korach KS, Visvader JE, Kaestner KH, Abdul-Karim FW, Montano MM, Keri RA: FOXA1 is an essential determinant of ERα expression and mammary ductal morphogenesis. Development. 2010, 137: 2045-2054. 10.1242/dev.043299.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Pan X, Zhou T, Tai YH, Wang C, Zhao J, Cao Y, Chen Y, Zhang PJ, Yu M, Zhen C, Mu R, Bai ZF, Li HY, Li AL, Liang B, Jian Z, Zhang WN, Man JH, Gao YF, Gong WL, Wei LX, Zhang XM: Elevated expression of CUEDC2 protein confers endocrine resistance in breast cancer. Nat Med. 2011, 17: 708-714. 10.1038/nm.2369.

    Article  CAS  PubMed  Google Scholar 

  10. Hicke L, Schubert HL, Hill CP: Ubiquitin-binding domains. Nat Rev Mol Cell Biol. 2005, 6: 610-621. 10.1038/nrm1701.

    Article  CAS  PubMed  Google Scholar 

  11. Zhang PJ, Zhao J, Li HY, Man JH, He K, Zhou T, Pan X, Li AL, Gong WL, Jin BF, Xia Q, Yu M, Shen BF, Zhang XM: CUE domain containing 2 regulates degradation of progesterone receptor by ubiquitin-proteasome. EMBO J. 2007, 26: 1831-1842. 10.1038/sj.emboj.7601602.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Gong Y, Yan K, Lin F, Anderson K, Sotiriou C, Andre F, Holmes FA, Valero V, Booser D, Pippen JE, Vukelja S, Gomez H, Mejia J, Barajas LJ, Hess KR, Sneige N, Hortobagyi GN, Pusztai L, Symmans WF: Determination of oestrogen-receptor status and ERBB2 status of breast carcinoma: a geneexpression profiling study. Lancet Oncol. 2007, 8: 203-211. 10.1016/S1470-2045(07)70042-6.

    Article  CAS  PubMed  Google Scholar 

  13. Badve SS, Baehner FL, Gray RP, Childs BH, Maddala T, Liu ML, Rowley SC, Shak S, Perez EA, Shulman LJ, Martino S, Davidson NE, Sledge GW, Goldstein LJ, Sparano JA: Estrogen- and progesterone-receptor status in ECOG 2197: comparison of immunohistochemistry by local and central laboratories and quantitative reverse transcription polymerase chain reaction by central laboratory. J Clin Oncol. 2008, 26: 2473-2481. 10.1200/JCO.2007.13.6424.

    Article  PubMed  Google Scholar 

  14. Romanuik TL, Wang G, Morozova O, Delaney A, Marra MA, Sadar MD: LNCaP Atlas: gene expression associated with in vivo progression to castrationrecurrent prostate cancer. BMC Med Genomics. 2010, 3: 43-10.1186/1755-8794-3-43.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Giamas G, Filipovic A, Jacob J, Messier W, Zhang H, Yang D, Zhang W, Shifa BA, Photiou A, Tralau-Stewart C, Castellano L, Green AR, Coombes RC, Ellis IO, Ali S, Lenz HJ, Stebbing J: Kinome screening for regulators of the estrogen receptor identifies LMTK3 as a new therapeutic target in breast cancer. Nat Med. 2011, 17: 715-719. 10.1038/nm.2351.

    Article  CAS  PubMed  Google Scholar 

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Research in the author's laboratory is supported by the National Health and Medical Research Council of Australia, the Cancer Institute NSW, and the Australian Cancer Research Foundation.

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Correspondence to Elizabeth A Musgrove.

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The authors declare that they have no competing interests.

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Musgrove, E.A. Estrogen receptor degradation: a CUE for endocrine resistance?. Breast Cancer Res 13, 312 (2011).

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