WO2023172891A2 - Biomarkers for combination therapy for er+ breast cancer - Google Patents

Abstract

Embodiments of the disclosure concern methods and compositions that facilitate determination of a suitable therapy for an individual in need thereof. In specific embodiments, the individual has ER+ breast cancer of a specific subtype that renders them suitable for a particular therapy and/or renders them unsuitable for a particular therapy. In specific cases, gene expression analysis determines that an individual is of Luminal B subtype and the individual is suited for combination therapy of one or more aromatase inhibitors and one or more selective estrogen receptor degraders (SERDs) and/or is not suitable for chemotherapy.

Description

BIOMARKERS FOR COMBINATION THERAPY FOR ER+ BREAST CANCER [0001] This application claims priority to U.S. Provisional Patent Application Serial No. 63/317,411, filed March 7, 2022, which is incorporated by reference herein in its entirety. BACKGROUND [0002] This invention was made with government support under Grant Number CA186784 awarded by the National Institutes of Health. The government has certain rights in the invention. I. Technical Field [0003] Embodiments of this disclosure relate at least to the fields of cell biology, molecular biology, and medicine, including cancer medicine. II. Background [0004] Neoadjuvant endocrine therapy (NET) for postmenopausal women with ER-rich clinical stage 2 and 3 breast cancer (BC) improves surgical outcomes 1-3. Importantly on- treatment Ki67 values as early as 2-4 weeks on NET are prognostic for recurrence risk 4,5. Additionally, in several retrospective studies, surgical sample Ki67 levels after NET (natural log intervals, lowest group Ki67 ≤2.7%) contribute prognostic information that is independent from pathological stage 6,7. This finding led to a points-based system to predict risk of relapse after NET called the preoperative endocrine prognostic index (PEPI). While NET rarely induced pathologic complete response (pCR), when the PEPI=0 (pathological stage T1, T2, N0 and the surgical Ki67 ≤27% and ER persistently positive) the 5-year relapse risk has been shown to be <5%. 6-8. Thus, PEPI=0 identifies a favorable outcome population with endocrine sensitive disease (ESD), where adjuvant chemotherapy is likely unnecessary 6-8. Furthermore Ki67-based biomarker endpoints in NET trials have shown to predict the efficacy of different endocrine approaches.9-13. [0005] The primary objective of the ALTERNATE trial (FIG.1) was to examine the efficacy of the selective estrogen receptor degrader (SERD) fulvestrant (FULV), as monotherapy or in combination with the aromatase inhibitor (AI) anastrozole (FULV+ANA), versus the standard of care anastrozole (ANA) in terms of inducing ESD, defined by pCR or PEPI (mPEPI)=0 (pT1- 2/pN0-1mic/surgical Ki67≤2·7%) following 24 weeks of NET. mPEPI excludes the ER component in PEPI because a lower ER level is expected following FULV-containing treatments. Findings from the FIRST14,15 and FALCON16 studies indicated that FULV 500 mg monthly is more effective than ANA as a first-line therapy for advanced BC. Furthermore, FULV+ANA was found to be superior to ANA for survival outcomes in the treatment of endocrine-naïve advanced disease in the SWOG 0226 study,17,18, however the FULV dose was 250mg monthly, justifying an examination of the combination of FULV 500mg and ANA in early stage disease. Secondary objectives included assessment of pCR rate and residual cancer burden (RCB) among those with Ki67 >10% following 4 weeks (Wk4) or Wk12 of NET and switched to neoadjuvant chemotherapy (NCT). Correlative objectives included assessments of Ki67-based endpoints including rate of Ki67 >10% and degree of Ki67 suppression at Wk4 and complete cell cycle arrest (CCCA) rate, mPEPI categories and ER levels at surgery, by treatment arm and to examine PAM50 intrinsic subtype in relation to sensitivity to NET and chemotherapy. A second primary objective of ALTERNATE trial is to prospectively validate mPEPI=0 as a surrogate endpoint of ET success with low risks of recurrence. [0006] The present disclosure satisfies a need in the art of ER-positive breast cancer therapy to improve treatment regimens and avoid unnecessary treatments when applicable. SUMMARY [0007] The present disclosure concerns methods and compositions for ER+ cancer treatment, including ER+ breast cancer treatment. In specific embodiments, samples from an individual with ER+ cancer are analyzed or measured to determine suitability for a particular treatment regimen. In certain cases, the samples are analyzed for a particular set of biomarkers that can determine whether or not a certain one or more therapies (including a combination therapy, and such as adjuvant endocrine therapy) may be effective for the individual and/or whether or not a certain one or more therapies may be avoided for the individual. In some embodiments, upon measuring that an individual has a particular set of biomarkers, a combination of one or more aromatase inhibitors and one or more selective estrogen receptor degraders (SERDs) would be efficacious for the individual, such as in comparison to either one alone that may not necessarily be efficacious for the individual, in some embodiments. In some embodiments, upon measuring that an individual has a particular set of biomarkers it is determined that chemotherapy may be avoided because of lack of efficacy for the individual. In embodiments of the disclosure, an individual having the particular set of biomarkers is of the subtype Luminal B as determined by PAM50 classifier that is known in the art, and this individual is suitable for administering one or more aromatase inhibitors and one or more selective estrogen receptor degraders (SERDs) and/or is not suitable for administering chemotherapy. [0008] The neoadjuvant endocrine treatment of Luminal B clinical stage 2 or 3 breast cancers in postmenopausal women should include both Fulvestrant (F) and Anastrozole (A) The benefits of F+A combination therapy include at least reduced exposure to ineffective neoadjuvant chemotherapy. Non-Luminal ER+ breast cancers (HER2-E or Basal-like) should not receive neoaduvant endocrine therapy, as it is ineffective. Luminal A breast cancers can be treated with standard of care A as in this subset there was no significant difference between A and A+F. Luminal A, Luminal B and non-Luminal breast cancer is defined using the PAM50 model. [0009] It is contemplated that any embodiment discussed in this specification can be implemented with respect to any method or composition of the invention, and vice versa. Furthermore, compositions of the invention can be used to achieve methods of the invention. [0010] Other objects, features and advantages of the present invention will become apparent from the following detailed description. It should be understood, however, that the detailed description and the specific examples, while indicating specific embodiments of the invention, are given by way of illustration only, since various changes and modifications within the spirit and scope of the invention will become apparent to those skilled in the art from this detailed description. BRIEF DESCRIPTION OF THE DRAWINGS [0011] The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present disclosure. The disclosure may be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein. [0012] FIG.1. Study Schema [0013] ANA, anastrozole; FULV, fulvestrant; CT, chemotherapy; ET, endocrine therapy; NeoAdj, neoadjuvant; Adj, adjuvant [0014] FIG. 2. Consort Diagram for the Neoadjuvant Randomized Population in ALTERNATE [0015] NET, neoadjuvant endocrine therapy; NCT, neoadjuvant chemotherapy; ESDR, endocrine sensitive disease rate [0016] FIG.3. Scatter Plot of Paired Pre-treatment and Week-4 Ki67 levels by Treatment Arm and by PAM50 Intrinsic Subtype [0017] FIG.4. Endocrine Response Category Distribution in All Patients and by Luminal Subtypes ESD is defined by pCR + mPEPI 0. ERD includes mPEPI 1-3, mPEPI 4-8, week-4 or 12 K67>10% or PD confirmed by imaging, mPEPI indeterminate, and discontinued neoadjuvant endocrine therapy early due to other reasons. FULV, fulvestrant; ANA, anastrozole. In the triplet bars, Ana+Fulv is on top, FULV is in the middle, and ANA is on the bottom. [0018] FIG.5. Patient and disease characteristics for the overall population. DETAILED DESCRIPTION [0019] Throughout this application, the term “about” is used to indicate that a value includes the inherent variation of error for the measurement or quantitation method. [0020] The use of the word “a” or “an” when used in conjunction with the term “comprising” may mean “one,” but it is also consistent with the meaning of “one or more,” “at least one,” and “one or more than one.” [0021] As used herein, the terms “or” and “and/or” are utilized to describe multiple components in combination or exclusive of one another. For example, “x, y, and/or z” can refer to “x” alone, “y” alone, “z” alone, “x, y, and z,” “(x and y) or z,” “x or (y and z),” or “x or y or z.” It is specifically contemplated that x, y, or z may be specifically excluded from an embodiment. [0022] Throughout this application, the term “about” is used according to its plain and ordinary meaning in the area of cell and molecular biology to indicate that a value includes the standard deviation of error for the device or method being employed to determine the value. [0023] The words “comprising” (and any form of comprising, such as “comprise” and “comprises”), “having” (and any form of having, such as “have” and “has”), “including” (and any form of including, such as “includes” and “include”) or “containing” (and any form of containing, such as “contains” and “contain”) are inclusive or open-ended and do not exclude additional, unrecited elements or method steps. [0024] The term “comprising,” which is synonymous with “including,” “containing,” or “characterized by,” is inclusive or open-ended and does not exclude additional, unrecited elements or method steps. The phrase “consisting of” excludes any element, step, or ingredient not specified. The phrase “consisting essentially of” limits the scope of described subject matter to the specified materials or steps and those that do not materially affect its basic and novel characteristics. It is contemplated that embodiments described in the context of the term “comprising” may also be implemented in the context of the term “consisting of” or “consisting essentially of.” [0025] In keeping with long-standing patent law convention, the words “a” and “an” when used in the present specification in concert with the word comprising, including the claims, denote “one or more.” Some embodiments of the disclosure may consist of or consist essentially of one or more elements, method steps, and/or methods of the disclosure. It is contemplated that any method or composition described herein can be implemented with respect to any other method or composition described herein and that different embodiments may be combined. [0026] Throughout this specification, unless the context requires otherwise, the words “comprise”, “comprises” and “comprising” will be understood to imply the inclusion of a stated step or element or group of steps or elements but not the exclusion of any other step or element or group of steps or elements. By “consisting of” is meant including, and limited to, whatever follows the phrase “consisting of.” Thus, the phrase “consisting of” indicates that the listed elements are required or mandatory, and that no other elements may be present. By “consisting essentially of” is meant including any elements listed after the phrase, and limited to other elements that do not interfere with or contribute to the activity or action specified in the disclosure for the listed elements. Thus, the phrase “consisting essentially of” indicates that the listed elements are required or mandatory, but that no other elements are optional and may or may not be present depending upon whether or not they affect the activity or action of the listed elements. [0027] Reference throughout this specification to “one embodiment,” “an embodiment,” “a particular embodiment,” “a related embodiment,” “a certain embodiment,” “an additional embodiment,” or “a further embodiment” or combinations thereof means that a particular feature, structure or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the foregoing phrases in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, the particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments. [0028] The term “sample,” as used herein, generally refers to a biological sample. The sample may be taken from tissue and/or cells and/or from the environment of tissue or cells. In specific cases the cells and/or tissues are cancer cells or suspected cancer cells, including from a tumor or suspected tumor or tumor microenvironment or suspected tumor microenvironment, including in a mammalian breast. The sample may be fresh or frozen prior to analysis. Non-limiting examples include breast biopsy, nipple aspirate, and the like. The sample may or may not be purified or otherwise enriched from its primary source. In some cases the primary source is homogenized prior to further processing. The sample may be filtered or centrifuged to remove undesired matter. The sample may also be purified or enriched for nucleic acids. The sample may contain tissues or cells that are intact, fragmented, or partially degraded. The sample may be separated for further analysis, including into different vessels for analysis. [0029] The term “subject” or “individual” as used herein generally refers to a person having a biological sample that is undergoing processing or analysis and, in specific cases, has cancer or is suspected of having cancer. The subject can be any organism or animal subject that is an object of a method or material, including mammals, e.g., humans, laboratory animals (e.g., primates, rats, mice, rabbits), livestock (e.g., cows, sheep, goats, pigs, turkeys, and chickens), household pets (e.g., dogs, cats, and rodents), horses, and transgenic non-human animals. The subject can be a patient, e.g., has or be suspected of having a disease (that may be referred to as a medical condition), such as one or more one or more cancers, or any combination thereof. The subject may being undergoing or having undergone treatment. The subject may be asymptomatic. The subject may be in need of cancer treatment. The “subject” or “individual”, as used herein, may or may not be housed in a medical facility and may be treated as an outpatient of a medical facility. The individual may be receiving one or more medical compositions via the internet. An individual may comprise any age of a human or non-human animal. It is not intended that the term connote a need for medical treatment, therefore, an individual may voluntarily or involuntarily be part of experimentation whether clinical or in support of basic science studies. * * * [0030] Embodiments of the present disclosure include methods for treating an individual with ER+ breast cancer based on the outcome of analysis of a sample from the individual, wherein the outcome determines the therapy. In some embodiments, an individual is analyzed for a subtype of ER+ cancer (Luminal A, Luminal B, and so forth) and the determination of the subtype will dictate whether or not a particular therapy would be effective for the individual and/or whether or not a particular therapy would not be effective for the individual. As a result, the effective therapy would be administered to the individual and the non-effective therapy would not be administered to the individual. In specific embodiments, the individual is analyzed for a subtype of ER+ cancer and the determination of the subtype determines whether or not one or more hormonal therapies would be effective for the individual and/or whether or not one or more chemotherapies would not be effective for the individual. As a result, the determination of a particular subtype dictates that the individual should receive one or more hormonal therapies and/or should not receive chemotherapy. [0031] In particular embodiments, a sample from an individual known to have, or suspected of having, ER+ breast cancer is analyzed for a particular expression pattern that determines if the individual is of a particular subtype. Without determination of the particular subtype of the ER+ cancer, the individual may be given a therapy that is ineffective. In specific embodiments, a sample from an individual known to have, or suspected of having, ER+ breast cancer is analyzed for a particular expression pattern that determines if the individual is of the Luminal B subtype. In cases wherein the individual is of the Luminal B subtype, the individual is determined to be suitable for one or more hormonal therapies but not suitable for chemotherapy; therefore, the individual is administered one or more hormonal therapies but is not administered chemotherapy. In specific embodiments, the one or more hormonal therapies are a combination of therapies, including one or more SERDS and/or one or more aromatase inhibitors. In specific cases, the SERD is fulvestrant and the aromatase inhibitor is anastrozole, and their combination is provided to an individual determined to be Luminal B subtype. [0032] As used herein herein, the term “Luminal B subtype” and similar terms, including “of the cancer type Luminal B,” refers to those individuals that have a certain gene expression pattern profile utilized with mRNA expression of 50 genes (PAM50), such as defined by Parker et al., 2009, J. Clin. Oncol.27(8): 1160-1167, which is incorporated by reference herein. The subtype may be defined by U.S. Patent Publications US 2009/0199640; US 2011/0145176; US 2014/0087959; and/or US 2016/0153051, all of which are incorporated by reference herein in their entirety. Use of PAM50 encompasses a Centroid Predictor that considers expression of all 50 genes at once, and a sample is classified into one subtype or another based upon its correlation for the Training Set Centroids (and the Centroid feature is all 50 genes). [0033] The present disclosure concerns a neoadjuvant endocrine therapy trial that compares treatment with a SERD, an aromatase inhibitor, or their combination in postmenopausal women with ER+ breast cancer. Specifically, the disclosure concerns a neoadjuvant endocrine therapy trial that compares 24 weeks of anastrozole, fulvestrant and their combination in postmenopausal women with estrogen receptor rich HER2-negative breast cancer. The disclosure provides clinical and biomarker results and analysis by PAM50-based intrinsic subtypes. In particular embodiments, the disclosure provides information for effective treatment regimens in specific subtypes of ER+ cancer, including at least for Luminal B subtype of ER+ cancer. I. Examples of Methods [0034] Embodiments of the present disclosure include methods of treatment, methods of diagnosis, methods of determining a treatment regimen, methods of administering effective therapies to an individual in need thereof, methods of refraining from treatment with ineffective therapies, and so forth. The treatment and diagnosis methods are suitable for an ER+ individual. Method steps may be of any kind, including administering one or more therapies, administering one or more SERDs, administering one or more aromatase inhibitors, analyzing a sample from the individual, determining a subtype of a cancer from an individual, not administering a therapy to the individual, given an additional cancer therapy, measuring a sample from an individual, detecting whether or not an individual is of the cancer type Luminal B, administering to an individual that is of the cancer type Luminal B an effective amount of one or more aromatase inhibitors and one or more SERDs, not administering chemotherapy, determining a treatment regimen for an individual that has ER-positive HER2-negative cancer, measuring a sample from an individual that has cancer or is suspected of having cancer for a Luminal B gene signature, determining a treatment regimen as being an effective amount of one or more aromatase inhibitors and one or more SERDs and/or not being chemotherapy for an individual that has a Luminal B gene signature, and so forth. [0035] In one embodiment, an individual is known to have ER+ cancer (and may be HER2- negative) or is suspected of having it. A suitable sample is obtained, such as from one or both breasts of the individual, and nucleic acid from the sample is analyzed. In specific cases RNA from the sample is analyzed for a particular expression pattern that signifies a particular treatment outcome. When the individual is determined to be a Luminal B subtype, the individual is given an effective amount of one or more aromatase inhibitors and one or more SERDs and/or not is not given chemotherapy (including a neoadjuvant chemotherapy, for example). When the individual is not a Luminal B subtype, another course of action may be taken. The party that analyzes the sample is not necessarily the party that provides a treatment regimen. When the individual is determined to be a Luminal B subtype, the individual may or may not also receive surgery and/or radiation and/or other non-chemotherapeutic cancer treatments. [0036] Embodiments of the disclosure include methods of treating an individual having estrogen receptor (ER)-positive human epidermal growth factor receptor 2 (HER2)-negative cancer, comprising the step of administering an effective amount of one or more aromatase inhibitors and one or more selective estrogen receptor degraders (SERDs) to an individual that is of the cancer type Luminal B; and/or not administering chemotherapy to the individual. In specific embodiments, the aromatase inhibitor is selected from the group consisting of anastrozole, exemestane, letrozole, testolactone, and a combination thereof. In specific embodiments, the SERD is selected from the group consisting of fulvestrant, G1T48, AZD9496, LSZ102, elacestrant, SAR439859, and a combination thereof. In certain cases, the aromatase inhibitor and the SERD are administered at substantially the same time. The aromatase inhibitor and the SERD may or may not be in the same formulation. The aromatase inhibitor and the SERD may or may not be administered at different times. When they are administered at different times, the order may or may not be considered. In some embodiments, when they are administered at different times, the aromatase inhibitor(s) is administered prior to the SERD(s), whereas in other embodiments the aromatase inhibitor(s) is administered after the SERD(s). [0037] Embodiments of the disclosure include methods for treating ER-positive HER2- negative cancer in an individual, comprising detecting whether or not an individual is of the cancer type Luminal B; and administering to an individual that is of the cancer type Luminal B an effective amount of one or more aromatase inhibitors and one or more SERDs; and/or not administering chemotherapy to the individual. [0038] Embodiments of the disclosure include methods of determining a treatment regimen for an individual that has ER-positive HER2-negative cancer, comprising the steps of: measuring a sample from an individual that has cancer or is suspected of having cancer for a Luminal B gene signature; and determining a treatment regimen as being an effective amount of one or more aromatase inhibitors and one or more SERDs and/or not being chemotherapy for an individual that has a Luminal B gene signature. The method may further comprising the step of administering the treatment regimen to the individual that has a Luminal B gene signature. [0039] Also encompassed herein are methods that include diagnosing and treating an individual having a particular subtype of ER+ cancer, the method comprising: (a) optionally obtaining a tissue sample from the individual; (b) measuring or assaying for the expression of one or more genes in the sample; (c) identifying the subtype of the individual based on the measured or assayed expression levels; and (d) administering to the individual an appropriate therapy based on the subtype identified in step (c). [0040] Any method encompassed herein may include method steps for obtaining a sample and/or analyzing a sample, including analyzing RNA and/or protein from a sample. II. Samples and Collection [0041] In the present disclosure, breast cancer subtype is assessed through the evaluation of expression patterns, or profiles, of the intrinsic genes from the PAM50 classifier in one or more subject samples. A subject can be a subject, a study participant, a control subject, a screening subject, or any other class of individual from whom a sample is obtained and assessed in the context of the disclosure. Accordingly, a subject can be diagnosed with breast cancer, can present with one or more symptoms of breast cancer (such as a new lump in the breast or underarm (armpit); thickening or swelling of part of the breast; irritation or dimpling of breast skin; redness or flaky skin in the nipple area or the breast; pulling in of the nipple or pain in the nipple area; nipple discharge other than breast milk, including blood; any change in the size or the shape of the breast; pain in any area of the breast; or a combination thereof), or a predisposing factor, such as a family (genetic) or medical history (medical) factor, for breast cancer, can be undergoing treatment or therapy for breast cancer, or the like. Alternatively, a subject can be healthy with respect to any of the aforementioned factors or criteria. It will be appreciated that the term "healthy" as used herein, is relative to breast cancer status, as the term "healthy" cannot be defined to correspond to any absolute evaluation or status. Thus, an individual defined as healthy with reference to any specified disease or disease criterion, can in fact be diagnosed with any other one or more diseases, or exhibit any other one or more disease criterion, including one or more cancers other than breast cancer. However, healthy controls are preferably free of any cancer. [0042] In particular embodiments, the methods for analyzing breast cancer intrinsic subtypes for determination of a treatment include collecting a biological sample comprising a cancer cell or tissue, such as a breast tissue sample or a primary breast tumor tissue sample or a sample from a lump in the breast. By "biological sample" is intended any sampling of cells, tissues, or bodily fluids in which expression of an intrinsic gene can be detected. Examples of such biological samples include, but are not limited to, biopsies and smears. Bodily fluids useful in the present invention include blood, lymph, urine, saliva, nipple aspirates, gynecological fluids, or any other bodily secretion or derivative thereof. Blood can include whole blood, plasma, serum, or any derivative of blood. In some embodiments, the biological sample includes breast cells, particularly breast tissue from a biopsy, such as a breast tumor tissue sample. Biological samples may be obtained from a subject by a variety of techniques including, for example, by scraping or swabbing an area, by using a needle to aspirate cells or bodily fluids, or by removing a tissue sample (i.e., biopsy). Methods for collecting various biological samples are well known in the art. In some embodiments, a breast tissue sample is obtained by, for example, fine needle aspiration biopsy, core needle biopsy, or excisional biopsy. Fixative and staining solutions may be applied to the cells or tissues for preserving the specimen and for facilitating examination. Biological samples, particularly breast tissue samples, may be transferred to a glass slide for viewing under magnification. In one embodiment, the biological sample is a formalin-fixed, paraffin-embedded breast tissue sample, particularly a primary breast tumor sample. III. Expression Profiling and Detection Methods [0043] In various embodiments, the present disclosure provides methods for determining a treatment for breast cancer in subjects. In this embodiment, data obtained from analysis of intrinsic gene expression is evaluated for an individual, and the evaluation step may be of any kind that includes determining the gene expression, for example by using one or more pattern recognition algorithms. [0044] The PAM50 classification model is based on the gene expression profile for a plurality of subject samples using a set of intrinsic genes. Any methods available in the art for detecting expression of the intrinsic genes in PAM50 are encompassed herein. By "detecting expression" is intended determining the quantity or presence of an RNA transcript or its expression product of an intrinsic gene. Methods for detecting expression may include methods based on hybridization analysis of polynucleotides, methods based on sequencing of polynucleotides, immunohistochemistry methods, and proteomics-based methods. In some embodiments, PCR- based methods, such as reverse transcription PCR (RT-PCR) (Weis et al., TIG 8:263-64, 1992), and array-based methods such as microarray (Schena et al., Science 270:467-70, 1995) are used. By "microarray" is intended an ordered arrangement of hybridizable array elements, such as, for example, polynucleotide probes, on a substrate. The term "probe" refers to any molecule that is capable of selectively binding to a specifically intended target biomolecule, for example, a nucleotide transcript or a protein encoded by or corresponding to an intrinsic gene. Probes can be synthesized by one of skill in the art, or derived from appropriate biological preparations. Probes may be specifically designed to be labeled. Examples of molecules that can be utilized as probes include, but are not limited to, RNA, DNA, proteins, antibodies, and organic molecules. [0045] Many expression detection methods use isolated RNA. The starting material is typically total RNA isolated from a biological sample, such as a tumor or tumor cell line, and corresponding normal tissue or cell line, respectively. If the source of RNA is a primary tumor, RNA (e.g., mRNA) can be extracted, for example, from frozen or archived paraffin-embedded and fixed (e.g., formalin-fixed) tissue samples (e.g., pathologist-guided tissue core samples). [0046] General methods for RNA extraction are well known in the art and are disclosed in standard textbooks of molecular biology, including Ausubel et al., ed., Current Protocols in Molecular Biology, John Wiley & Sons, New York 1987-1999. Methods for RNA extraction from paraffin embedded tissues are disclosed, for example, in Rupp and Locker (Lab Invest.56:A67, 1987) and De Andres et al. (Biotechniques 18:42-44, 1995). In particular, RNA isolation can be performed using a purification kit, a buffer set and protease from commercial manufacturers, such as Qiagen (Valencia, Calif.), according to the manufacturer's instructions. For example, total RNA from cells in culture can be isolated using Qiagen RNeasy mini-columns. Other commercially available RNA isolation kits include MASTERPURE.RTM. Complete DNA and RNA Purification Kit (Epicentre, Madison, Wis.) and Paraffin Block RNA Isolation Kit (Ambion, Austin, Tex.). Total RNA from tissue samples can be isolated, for example, using RNA Stat-60 (Tel-Test, Friendswood, Tex.). RNA prepared from a tumor can be isolated, for example, by cesium chloride density gradient centrifugation. Additionally, large numbers of tissue samples can readily be processed using techniques well known to those of skill in the art, such as, for example, the single-step RNA isolation process of Chomczynski (U.S. Pat. No.4,843,155). [0047] Isolated RNA can be used in hybridization or amplification assays that include, but are not limited to, PCR analyses and probe arrays. One method for the detection of RNA levels involves contacting the isolated RNA with a nucleic acid molecule (probe) that can hybridize to the mRNA encoded by the gene being detected. The nucleic acid probe can be, for example, a full- length cDNA, or a portion thereof, such as an oligonucleotide of at least 7, 15, 30, 60, 100, 250, or 500 nucleotides in length and sufficient to specifically hybridize under stringent conditions to a gene of the present disclosure, or any derivative DNA or RNA. Hybridization of an mRNA with the probe indicates that the gene in question is being expressed. [0048] In one embodiment, the mRNA is immobilized on a solid surface and contacted with a probe, for example by running the isolated mRNA on an agarose gel and transferring the mRNA from the gel to a membrane, such as nitrocellulose. In an alternative embodiment, the probes are immobilized on a solid surface and the mRNA is contacted with the probes, for example, in an Agilent gene chip array. A skilled artisan can readily adapt known mRNA detection methods for use in detecting the level of expression of the genes of the present disclosure. [0049] An alternative method for determining the level of gene expression product in a sample involves the process of nucleic acid amplification, for example, by RT-PCR (U.S. Pat. No. 4,683,202), ligase chain reaction (Barany, Proc. Natl. Acad. Sci. USA 88:189-93, 1991), self- sustained sequence replication (Guatelli et al., Proc. Natl. Acad. Sci. USA 87:1874-78, 1990), transcriptional amplification system (Kwoh et al., Proc. Natl. Acad. Sci. USA 86:1173-77, 1989), Q-Beta Replicase (Lizardi et al., Bio/Technology 6:1197, 1988), rolling circle replication (U.S. Pat. No.5,854,033), or any other nucleic acid amplification method, followed by the detection of the amplified molecules using techniques well known to those of skill in the art. These detection schemes are especially useful for the detection of nucleic acid molecules if such molecules are present in very low numbers. [0050] In particular aspects of the disclosure, gene expression is assessed by quantitative RT- PCR. Numerous different PCR or QPCR protocols are known in the art and exemplified herein below and can be directly applied or adapted for the detection and/or quantification of the PAM50 genes associated with Luminal B subtype. Generally, in PCR, a target polynucleotide sequence is amplified by reaction with at least one oligonucleotide primer or pair of oligonucleotide primers. The primer(s) hybridize to a complementary region of the target nucleic acid and a DNA polymerase extends the primer(s) to amplify the target sequence. Under conditions sufficient to provide polymerase-based nucleic acid amplification products, a nucleic acid fragment of one size dominates the reaction products (the target polynucleotide sequence which is the amplification product). The amplification cycle is repeated to increase the concentration of the single target polynucleotide sequence. The reaction can be performed in any thermocycler commonly used for PCR. However, preferred are cyclers with real-time fluorescence measurement capabilities, for example, SMARTCYCLER.RTM. (Cepheid, Sunnyvale, Calif.), ABI PRISM 7700.RTM. (Applied Biosystems, Foster City, Calif.), ROTOR-GENE.RTM. (Corbett Research, Sydney, Australia), LIGHTCYCLER.RTM. (Roche Diagnostics Corp, Indianapolis, Ind.), ICYCLER.RTM. (Biorad Laboratories, Hercules, Calif.) and MX4000.RTM. (Stratagene, La Jolla, Calif.). [0051] Quantitative PCR (QPCR) (also referred as real-time PCR) is preferred under some circumstances because it provides not only a quantitative measurement, but also reduced time and contamination. In some instances, the availability of full gene expression profiling techniques is limited due to requirements for fresh frozen tissue and specialized laboratory equipment, making the routine use of such technologies difficult in a clinical setting. However, QPCR gene measurement can be applied to standard formalin-fixed paraffin-embedded clinical tumor blocks, such as those used in archival tissue banks and routine surgical pathology specimens (Cronin et al. (2007) Clin Chem 53:1084-91)[Mullins 2007] [Paik 2004]. As used herein, "quantitative PCR (or "real time QPCR") refers to the direct monitoring of the progress of PCR amplification as it is occurring without the need for repeated sampling of the reaction products. In quantitative PCR, the reaction products may be monitored via a signaling mechanism (e.g., fluorescence) as they are generated and are tracked after the signal rises above a background level but before the reaction reaches a plateau. The number of cycles required to achieve a detectable or "threshold" level of fluorescence varies directly with the concentration of amplifiable targets at the beginning of the PCR process, enabling a measure of signal intensity to provide a measure of the amount of target nucleic acid in a sample in real time. [0052] In another embodiment of the disclosure, microarrays are used for expression profiling. Microarrays are particularly well suited for this purpose because of the reproducibility between different experiments. DNA microarrays provide one method for the simultaneous measurement of the expression levels of large numbers of genes. Each array consists of a reproducible pattern of capture probes attached to a solid support. Labeled RNA or DNA is hybridized to complementary probes on the array and then detected by laser scanning. Hybridization intensities for each probe on the array are determined and converted to a quantitative value representing relative gene expression levels. See, for example, U.S. Pat. Nos. 6,040,138, 5,800,992 and 6,020,135, 6,033,860, and 6,344,316. High-density oligonucleotide arrays are particularly useful for determining the gene expression profile for a large number of RNAs in a sample. [0053] Techniques for the synthesis of these arrays using mechanical synthesis methods are described in, for example, U.S. Pat. No. 5,384,261. Although a planar array surface is generally used, the array can be fabricated on a surface of virtually any shape or even a multiplicity of surfaces. Arrays can be nucleic acids (or peptides) on beads, gels, polymeric surfaces, fibers (such as fiber optics), glass, or any other appropriate substrate. See, for example, U.S. Pat. Nos. 5,770,358, 5,789,162, 5,708,153, 6,040,193 and 5,800,992. Arrays can be packaged in such a manner as to allow for diagnostics or other manipulation of an all-inclusive device. See, for example, U.S. Pat. Nos.5,856,174 and 5,922,591. [0054] In a specific embodiment of the microarray technique, PCR amplified inserts of cDNA clones are applied to a substrate in a dense array. The microarrayed genes, immobilized on the microchip, are suitable for hybridization under stringent conditions. Fluorescently labeled cDNA probes can be generated through incorporation of fluorescent nucleotides by reverse transcription of RNA extracted from tissues of interest. Labeled cDNA probes applied to the chip hybridize with specificity to each spot of DNA on the array. After stringent washing to remove non- specifically bound probes, the chip is scanned by confocal laser microscopy or by another detection method, such as a CCD camera. Quantitation of hybridization of each arrayed element allows for assessment of corresponding mRNA abundance. [0055] With dual color fluorescence, separately labeled cDNA probes generated from two sources of RNA are hybridized pairwise to the array. The relative abundance of the transcripts from the two sources corresponding to each specified gene is thus determined simultaneously. The miniaturized scale of the hybridization affords a convenient and rapid evaluation of the expression pattern for large numbers of genes. Such methods have been shown to have the sensitivity required to detect rare transcripts, which are expressed at a few copies per cell, and to reproducibly detect at least approximately two-fold differences in the expression levels (Schena et al., Proc. Natl. Acad. Sci. USA 93:106-49, 1996). Microarray analysis can be performed by commercially available equipment, following manufacturer's protocols, such as by using the Affymetrix GenChip technology, or Agilent ink jet microarray technology. The development of microarray methods for large-scale analysis of gene expression makes it possible to search systematically for molecular markers of cancer classification and outcome prediction in a variety of tumor types. IV. Administration of Therapeutic Compositions [0056] Embodiments of a therapy provided herein comprise administration of a combination of therapeutic agents, such as a first cancer therapy and a second cancer therapy, including one or more SERDs and one or more aromatase inhibitors. The therapies may be administered in any suitable manner known in the art. For example, the two treatments may be administered sequentially (at different times) or concurrently (at the same time). In some embodiments, the first and second cancer treatments are administered in a separate composition that may or may not be the same administration route. In some embodiments, the first and second cancer treatments are in the same composition. [0057] Embodiments of the disclosure relate to compositions and methods comprising therapeutic compositions. The different therapies may be administered in one composition or in more than one composition, such as 2 compositions, 3 compositions, or 4 compositions. Various combinations of the agents may be employed. [0058] The SERD and aromatase inhibitor agents of the disclosure may be administered by the same route of administration or by different routes of administration. In some embodiments, the cancer therapy is administered intravenously, intramuscularly, subcutaneously, topically, orally, transdermally, intraperitoneally, intraorbitally, by implantation, by inhalation, intrathecally, intraventricularly, or intranasally. In some embodiments, an antibiotic is administered intravenously, intramuscularly, subcutaneously, topically, orally, transdermally, intraperitoneally, intraorbitally, by implantation, by inhalation, intrathecally, intraventricularly, or intranasally. The appropriate dosage may be determined based on the type of disease to be treated, severity and course of the disease, the clinical condition of the individual, the individual's clinical history and response to the treatment, and the discretion of the attending physician. [0059] The treatments may include various “unit doses.” Unit dose is defined as containing a predetermined-quantity of the therapeutic composition. The quantity to be administered, and the particular route and formulation, is within the skill of determination of those in the clinical arts. A unit dose need not be administered as a single injection but may comprise continuous infusion over a set period of time. In some embodiments, a unit dose comprises a single administrable dose. [0060] The quantity to be administered, both according to number of treatments and unit dose, depends on the treatment effect desired. An effective dose is understood to refer to an amount necessary to achieve a particular effect. In the practice in certain embodiments, it is contemplated that doses in the range from 10 mg/kg to 200 mg/kg can affect the protective capability of these agents. Thus, it is contemplated that doses include doses of about 0.1, 0.5, 1, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, and 200, 300, 400, 500, 1000 µg/kg, mg/kg, µg/day, or mg/day or any range derivable therein. Furthermore, such doses can be administered at multiple times during a day, and/or on multiple days, weeks, or months. [0061] In certain embodiments, the effective dose of the pharmaceutical composition is one which can provide a blood level of about 1 µM to 150 µM. In another embodiment, the effective dose provides a blood level of about 4 µM to 100 µM.; or about 1 µM to 100 µM; or about 1 µM to 50 µM; or about 1 µM to 40 µM; or about 1 µM to 30 µM; or about 1 µM to 20 µM; or about 1 µM to 10 µM; or about 10 µM to 150 µM; or about 10 µM to 100 µM; or about 10 µM to 50 µM; or about 25 µM to 150 µM; or about 25 µM to 100 µM; or about 25 µM to 50 µM; or about 50 µM to 150 µM; or about 50 µM to 100 µM (or any range derivable therein). In other embodiments, the dose can provide the following blood level of the agent that results from a therapeutic agent being administered to a subject: about, at least about, or at most about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100 μM or any range derivable therein. In certain embodiments, the therapeutic agent that is administered to a subject is metabolized in the body to a metabolized therapeutic agent, in which case the blood levels may refer to the amount of that agent. Alternatively, to the extent the therapeutic agent is not metabolized by a subject, the blood levels discussed herein may refer to the unmetabolized therapeutic agent. [0062] Precise amounts of the therapeutic composition also depend on the judgment of the practitioner and are peculiar to each individual. Factors affecting dose include physical and clinical state of the patient, the route of administration, the intended goal of treatment (alleviation of symptoms versus cure) and the potency, stability and toxicity of the particular therapeutic substance or other therapies a subject may be undergoing. [0063] It will be understood by those skilled in the art and made aware that dosage units of µg/kg or mg/kg of body weight can be converted and expressed in comparable concentration units of µg/ml or mM (blood levels), such as 4 µM to 100 µM. It is also understood that uptake is species and organ/tissue dependent. The applicable conversion factors and physiological assumptions to be made concerning uptake and concentration measurement are well-known and would permit those of skill in the art to convert one concentration measurement to another and make reasonable comparisons and conclusions regarding the doses, efficacies and results described herein. V. Kits [0064] Certain aspects of the present disclosure also concern kits containing compositions of the disclosure or compositions to implement methods of the disclosure. In some embodiments, kits can be used to evaluate one or more biomarkers and/or to provide one or more therapies to an individual. In certain embodiments, a kit contains, contains at least or contains at most 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 100, 500, 1,000 or more probes, primers or primer sets, synthetic molecules or inhibitors, or any value or range and combination derivable therein. In some embodiments, there are kits for evaluating biomarker activity in a cell. In some embodiments, kits may include one or more SERDs and/or one or more aromatase inhibitors. [0065] Kits may comprise components, which may be individually packaged or placed in a container, such as a tube, bottle, vial, syringe, or other suitable container means. [0066] Individual components may also be provided in a kit in concentrated amounts; in some embodiments, a component is provided individually in the same concentration as it would be in a solution with other components. Concentrations of components may be provided as 1x, 2x, 5x, 10x, or 20x or more. [0067] Kits for using probes, synthetic nucleic acids, nonsynthetic nucleic acids, and/or inhibitors of the disclosure for prognostic or diagnostic applications are included as part of the disclosure. Specifically contemplated are any such molecules corresponding to any biomarker identified herein, which includes nucleic acid primers/primer sets and probes that are identical to or complementary to all or part of a biomarker, which may include noncoding sequences of the biomarker, as well as coding sequences of the biomarker. [0068] In certain aspects, negative and/or positive control nucleic acids, probes, and inhibitors are included in some kit embodiments. In addition, a kit may include a sample that is a negative or positive control for methylation of one or more biomarkers. [0069] It is contemplated that any method or composition described herein can be implemented with respect to any other method or composition described herein and that different embodiments may be combined. The claims originally filed are contemplated to cover claims that are multiply dependent on any filed claim or combination of filed claims. [0070] Embodiments of the disclosure include kits for analysis of a pathological sample by assessing biomarker profile for a sample comprising, in suitable container means, two or more biomarker probes, wherein the biomarker probes detect one or more of the biomarkers identified herein. The kit can further comprise reagents for labeling nucleic acids in the sample. The kit may also include labeling reagents, including at least one of amine-modified nucleotide, poly(A) polymerase, and poly(A) polymerase buffer. Labeling reagents can include an amine-reactive dye. Examples [0071] The following examples are included to demonstrate certain embodiments of the disclosure. It should be appreciated by those of skill in the art that the techniques disclosed in the examples which follow represent techniques discovered to function well in the practice of the invention, and thus can be considered to constitute particular modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments that are disclosed and still obtain a like or similar result without departing from the spirit and scope of the embodiments of the disclosure. EXAMPLE 1 THE EFFECT OF INTRINSIC SUBTYPE ON INHIBITION OF TUMOR GROWTH BY ANASTROZOLE VS. FULVESTRANT VS. THE COMBINATION:RESULTS FROM THE ALLIANCE NEOADJUVANT ENDOCRINE THERAPY (NET) ALTERNATE TRIAL. [0072] Introduction. The ALTERNATE trial randomized postmenopausal women with ER Allred 6-8 HER2- breast cancer to either 6 months of NET with anastrozole (A), fulvestrant (F) or the combination (A+F). Biopsies were taken preNET and after 4-weeks(wks). Patients with Ki67 values >10% at 4-wks were offered triage to neoadjuvant chemotherapy. Patients with on- treatment Ki67 ≤ 10% who completed NET underwent surgery and Ki67 was reassessed. The primary endpoint was endocrine-sensitive disease rate (ESDR). ESD was defined as pCR or PEPI- 0 residual disease (pT1-2, pN0, Ki67 ≤ 2.7%). It was previously reported that the ESDR difference between the F-containing arms and the A arm was not >10% (ASCO 2020) and that RNA-seq- based intrinsic subtype did not significantly interact with ESDR by treatment arm (SABCS 2021). This disclosure describes relationships between PAM50 intrinsic subtype and Ki67 values on each arm because comparative drug effectiveness in adjuvant endocrine therapy studies in ER+ HER2- breast cancer can be predicted by the degree of Ki67 suppression (PMC3518447). [0073] Methods. 743 of the 1297 eligible patients (A: 264; F: 231; A+F: 248) had RNA extracted from preNET frozen tumor biopsies with >50% tumor content and subjected to RNA seq. Intrinsic subtypes were then assigned as LumA, LumB, and NonLum (Basal or HER2-E) using open-source PAM50-based informatics. Differences in the proportion with wk4 Ki67 > 10%, % change in wk4 ki67, and surgical CCCA (Ki67 ≤ 2.7%) rate (sxCCCA) between treatments and by intrinsic subtype was assessed using stratified logistic regression, Wilcoxon rank sum test, and Fisher’s exact test, respectively. Analysis of sxCCCA excluded those who failed to complete NET for reasons other than disease progression or early Ki67 >10%. [0074] Results. Amongst the 358 LumA cases there were no significant differences in Ki67- based endpoints between treatments. Among the 292 LumB cases, the wk4 ki67 > 10% rate was lower with A+F (19.4%) than A (43%) (P=0.0002) and was somewhat lower in F (31%) versus A (P=0.076). The % change in wk4 Ki67 in LumB cases, adjusted for baseline Ki67, showed markedly superior suppression for A+F versus A (-90% vs. -77%; P=<0.0001) and versus F (-90% vs. -80%; P=0.0026). Furthermore sxCCCA rates were significantly higher with A+F than A (53% vs.25% P = <0.0001) and somewhat higher for F (37%) than A (p=0.068), indicating that superior antiproliferative effects persist after 6 months on therapy. Lack of Ki67 suppression in response to treatment was observed in the majority of 43 NonLum samples regardless of treatment and timepoint. [0075] Conclusion. The combination of A+F was significantly more effective than either drug alone for the control of LumB breast cancer cell proliferation. This indicates that A+F is a more effective adjuvant endocrine therapy than A alone in LumB disease. The lower Ki67 suppression with A alone also suggests that poorer outcome in some LumB tumors may be due to insufficient ER targeting rather than ER-independent tumor growth. EXAMPLE 2 A RANDOMIZED PHASE 3 NEOADJUVANT ENDOCRINE THERAPY TRIAL COMPARING 24 WEEKS OF ANASTROZOLE, FULVESTRANT AND THE COMBINATION IN POSTMENOPAUSAL WOMEN WITH ESTROGEN RECEPTOR RICH HER2-NEGATIVE BREAST CANCER: CLINICAL AND BIOMARKER RESULTS AND OUTCOMES ACCORDING TO PAM50-BASED INTRINSIC SUBTYPES [0076] Background. Comparative assessment of Ki67-based endpoints in neoadjuvant endocrine therapy (NET) trials has the potential to identify more effective ET. PAM50-based gene- expression analysis segregates ER-positive breast cancer (BC) into distinctive biological subtypes. [0077] Methods. The ALTERNATE trial randomized postmenopausal women with ER- positive (Allred 6-8)/HER2-negative BC 1:1:1 to 24 weeks of NET with anastrozole (ANA), fulvestrant (FULV) or ANA+FULV. Patients with Ki67 >10% on week 4 (Wk4) biopsies were recommended switching to neoadjuvant chemotherapy. The primary endpoint was endocrine- sensitive disease rate (ESDR: pathologic complete response [pCR] plus modified preoperative endocrine prognostic index [mPEPI]-0 rate). RNA-sequencing based PAM50 analysis was performed on tumor-rich pre-treatment biopsies. ClinicalTrials.gov Identifier: NCT01953588. [0078] Findings. [0079] Among the 1,297 evaluable patients, the ESDR (95%CI) was 22·8% (18·9-27·1%) on FULV and 20·6% (16·8-24·7%) on ANA+FULV, neither being more than 10% different from that on ANA (18·7% [15·1-22·7%]). Intrinsic subtyping was possible for 743 patients. The 358 luminal A (LumA) cases showed no differences in Ki67-based endpoints between arms. Among the 292 LumB cases, compared to ANA, ANA+FULV resulted in a significantly lower rate of Ki67>10% (19·4% vs.43%; p=0·0002) and superior Ki67 suppression (-90% vs. -77%; p≤0·0001) at Wk4, and higher rate of complete cell cycle arrest at surgery (53% vs.25% p≤0·0001). The 43 NonLum cases lacked Ki67 response regardless of NET. Following switching to chemotherapy, the pCR rate was 4·8% (95%CI: ), but reached 18.8% (95%CI: ) in NonLum subtype, compared to 0% (95%CI: ) in LumA and 5.2% (95%CI: ) in LumB) (p). [0080] Interpretation. ANA+FULV inhibited proliferation more potently than either drug alone in LumB BC, suggesting benefits in maximizing ET for LumB disease. NonLum BC was unresponsive to ET, but higher sensitivity to chemotherapy. [0081] Patients and Methods [0082] Eligibility [0083] Eligible patients included post-menopausal women, with an untreated palpable clinical T2-T4c, any N, M0, invasive BC, ER-positive (Allred score 6-8 or >66%), HER2-negative (0 or 1+ by immunohistochemistry or ISH ratio (HER2 gene copy/chromosome 17 < 2), Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) 0-2, and adequate organ function. Key exclusion criteria included excisional biopsy of this BC, surgical axillary staging procedure, inflammatory BC, and a prior history of BC. [0084] Protocol therapy [0085] In the first phase (neoadjuvant comparison phase) of the trial which is reported herein, eligible patients were randomized 1:1:1 ratio to receive ANA (1mg PO daily), or FULV (500mg IM on days (D)1 and D15 of cycle 1 (C1), then 500mg IM on D1 of subsequent cycles), or ANA+FULV for 6 cycles (each cycle is 28 days) followed by surgery. Research biopsies of the BC were required pre-treatment, Wk4, and at surgery, and optional at Wk12 if clinical response to NET was less than optimal as judged by treating physician, or in patients whose Wk4 biopsy was non-informative for Ki67 analysis. At each time point, four cores (14-G) were collected, with two immediately frozen in OCT, and two in formalin fixation for paraffin embedding (FFPE). Patients with Ki67 >10% at Wk4 or Wk12 were recommended to switch to NCT with either paclitaxel (80mg/m² IV, days 1, 8, 15, and 22, every 28-day cycle x 3 cycles) or a taxane and/or anthracycline or CMF (cyclophosphamide, methotrexate and 5-FU) regimen per NCCN guidelines, of physician choice, or on to surgery if not a chemotherapy candidate. Mammograms and ultrasounds were required at baseline and completion of neoadjuvant therapy. Evidence of clinical progression during treatment was confirmed by mammogram or ultrasound. Surgery of the breast and lymph nodes was per institutional standard of care and occurred on days 7-28 during NET cycle 6, or 3- 6 weeks following the last dose chemotherapy. mPEPI was calculated post-surgery in patients who completed the assigned NET per protocol. In the NCT group, RCB was calculated post-surgery using the Residual Cancer Burden Calculator at the M.D. Anderson Cancer Center website. [0086] Central Ki67 and ER immunohistochemistry (IHC) analysis and Scoring [0087] Central assessment of ER, and Ki67 were performed by IHC on sections from FFPE cores using the Ventana Medical System platform at the CAP/CLIA certified AMP core lab at Washington University in St. Louis, using the CONFIRM anti-Ki67 antibody (clone 30-9) for Ki67 and SP1 for ER. To quantify Ki67 index (% tumor cells positive for Ki67 staining), immunostained whole-slide sections were scanned on the VENTANA iScan Coreo Au slide scanner, followed by pathologist-guided imaging analysis using VIRTUOSO software as previously described.⁷ At least 200 tumor cells were counted. Cases with less than 200 tumor cells on the slide were considered non-informative for Ki67, unless pCR. ER staining and scoring were performed per ASCO/CAP guidelines.^19,20 [0088] RNA Preparation, RNA sequencing data generation and analysis [0089] Pre-treatment frozen biopsy cores with tumor cellularity of at least 50% were subjected to further processing, RNA extraction, then RNA-sequencing (RNASeq) data generation and analysis as described previously.²¹ PAM50 intrinsic subtype and ROR-P values were generated from RNASeq data using open-source informatics.²² [0090] Statistics [0091] The primary endpoint of the neoadjuvant comparison phase of the ALTERNATE trial is ESD rate (ESDR), with the primary objectives to examine whether the ESDR with FULV or FULV+ANA is at least 10% higher than that with ANA. Randomization was stratified by clinical tumor stage (T2 vs T3 vs T4a-c), lymph node status (positive vs negative), ECOG PS (0-1 vs 2). With 425 patients per treatment arm, a one-tailed alpha=0·025, chi-square test of two independent proportions, has 84% power to detect an increase of at least 10% in ESDR for a given FULV- containing arm relative to that in the ANA arm (assuming ESDR is ≤30%). Differences in the proportion with Wk4 Ki67 >10%, % change in Wk4 Ki67, and surgical complete cell cycle arrest (sxCCCA: Ki67 ≤2·7%) rate between treatments and by intrinsic subtype were assessed using stratified logistic regression, Wilcoxon rank sum test, and Fisher’s exact test, respectively. Analysis of sxCCCA excluded those failed to complete NET for reasons other than disease progression or early Ki67 >10%. [0092] [0093] Patient and Tumor Characteristics [0094] From February 2014 to November 2018, 1,362 women were registered onto this trial, with 39 found to be ineligible on review and 26 withdrew consent prior to starting protocol treatment. The remaining 1,297 women compose the analysis cohort (figure 2), in which tumor rich pre-NET biopsies were available for RNASeq based determination of PAM50 subtype in 753 (ANA: n=265; FULV: n=234; and ANA+FULV: n=254) (FIG. 5. Patient and disease characteristics are presented in Table 1 for the overall population and Suppl. Table S1 for the PAM50 analyzed cohort. [0095] Endocrine Sensitive Determination [0096] Arm 1: ANA [0097] As shown in Table 2 and figure 2, among the 434 eligible women randomized to ANA alone, 145 (33·4%) were considered to have endocrine resistant disease (ERD) based on neoadjuvant treatment course, namely, Wk4 Ki67 >10% (n=106), Wk12 Ki67 >10% (n=3), disease progression (PD) confirmed by imaging (n=7), failure to complete protocol treatment due to refusal (n=19), intolerability (n=4), and other reasons (n=6). The ERD status of the remaining 289 (66·6%) women depended upon the pathologic staging and the Ki67 level in the invasive residual disease found at surgery. Of these 289 women, 81 had ESD as a result of no invasive residual disease in the breast or nodes (pCR or pT0-Tis/pN0: n=5) or mPEPI=0 residual disease (pT1- T2/pN0-1mic/Ki67≤2·7%: n=76) and 208 patients had ERD due to either mPEPI>0 residual disease (n=203) or insufficient information to determine their mPEPI score (n=5). Thus, among the 434 eligible patients randomized to ANA the ESD (pCR+mPEPI 0) rate was 18·7% (81/434; 97·5%CI: 14.6-23.2%; 95%CI: 15·1-22·7%). [0098] Arm 2: FULV [0099] As shown in Table 2, among the 430 eligible women randomized to FULV alone, 110 (25·6%) had ERD due to: Wk4 Ki67 >10% (n=97), Wk12 Ki67 >10% (n=7), PD confirmed by imaging (n=6), and failure to complete protocol treatment due to refusal (n=9), intolerability (n=1), and other reasons (n=4). Of the remaining 306 patients, 98 were considered to have ESD, having had a pCR or mPEPI=0 residual disease, and 208 patients were considered to have ERD due to either mPEPI>0 residual disease (n=206) or insufficient information to determine their mPEPI score (n=2). Thus, among the 430 eligible patients randomized to FULV the ESD (pCR+mPEPI 0) rate was 22·8% (98/430; 97·5% CI: 18·4-27·6%; 95%CI: 18·9-27·1%). [0100] Arm 3: ANA+FULV [0101] As shown in Table 2, among the 433 eligible women randomized to ANA+FULV, 75 (17·3%) had ERD due to: Wk4 Ki67 >10% (n=61), Wk12 Ki67 >10% (n=7), PD confirmed by imaging (n=7), and failure to complete protocol treatment due to refusal (n=13), intolerability (n=1), and other reasons (n=7). Of the remaining 337 women, 89 were considered to have ESD (pCR+mPEPI 0) and 248 patients had ERD either due to mPEPI>0 residual disease (n=236) or insufficient information to determine their mPEPI score (n=12). Thus, among the 433 eligible patients randomized to ANA+FULV the ESD (pCR+mPEPI 0) rate was 20·6% (89/433; 97·5%CI: 16·4-25·3%; 95%CI: 16·8-24·7%). [0102] Primary Objective (Comparing ESDR between FULV-containing arms and ANA) [0103] The difference in ESDR was 4·1% (one-sided 97·5% UCB=9·1%) between the FULV and ANA arms and 1·9% (one-sided 97·5% UCB=7·2%) between the FULV+ANA and ANA arms. Neither of these differences were ≥10% (Wald test: p=0·9835 and p=0·9984, respectively) (Table 2). Stratified multivariate logistic regression modeling (with treatment arm as stratification factor) found that the likelihood of ERD was increased for women with cT3/4 (adjOR=2·49; 95%CI: 1·66-3·73; p<0·0001), cN1-3 (adjOR=17·88; 95%CI: 10·06-31·77; p<0.0001), grade 3 (adjOR=1·80; 95%CI: 1·09-2.96; p=0·0212) and pre-NET Ki67 >20% (adjOR=1·50; 95%CI: 1·09-2·07; p=0·0132). These results were stronger after excluding those who went off NET early for reasons other than Wk4/12 Ki67 >10% or radiographically confirmed PD. [0104] [0105] Examination of pre-NET and Wk4 Ki67 on NET and by PAM50 subtype [0106] There were 176 (13·6%) among the 1,297 eligible patients without a Ki67 determination prior to NET and/or at Wk4 on NET. pre-NET tumor specimens were available for RNASeq based determination of PAM50 subtype in 753 of the 1,297 eligible patients enrolled (FIG.5). [0107] Pairwise comparisons between treatment arms of the percent decrease in Ki67 after 4 weeks of treatment found only the ANA+FULV arm had a significantly greater Wk4 Ki67 suppression than that on the FULV arm (p=0·015) (Suppl. Table S2). However, when considering molecular subtypes, differences in the percent decrease in Wk4 Ki67 between each single agent and combination arms were observed among LumB tumors (ANA vs. ANA+FULV: p<0·0001; FULV vs. ANA+FULV: p=0·0026), but not among LumA tumors (Suppl. Table S2). Figure 3 shows the scatter plot of paired pre-treatment and Wk4 Ki67, demonstrating ANA+FULV more potently reducing Wk4 Ki67 than ANA or FULV in LumB tumors only (p=0·0002). Moreover, stratified multivariate logistic regression modeling found that: the likelihood of Ki67 >10% at Wk 4 on NET, which did not differ significantly with respect to treatment arms among LumA tumors, was significantly lower in the ANA+FULV arm than ANA arm (43% vs 19·4%, OR[Ana+Fulv/Ana]=0·279, 95%CI: 0·141-0·550; p=0·0002) among LumB tumors (Table 3) or PAM50 ROR high subgroup (34·9% vs 52·7%, adjOR[Ana+Fulv/Ana]=0·36, 95%CI: 0·168- 0·770; p=0·0085) (Suppl. Table S3). [0108] Surgery outcome and Residual disease ER and Ki67 after completion of NET [0109] Table 4 shows surgery outcomes and residual disease path stage among patients with Wk4 Ki67 ≤10% or unable to be determined who completed protocol NET and surgery. Notably, 69·6% (201/289), 69·3% (212/306), and 70·6% (238/337) underwent breast conserving surgery in the ANA, FULV, and ANA+FULV arms, respectively. The distributions of surgery ER Allred Scores (AS) are also presented in Table 4. Missing category includes those who had a pCR and those for whom an AS could not be obtained. Compared to ANA arm, the proportion of patients with AS 6-8 was significantly lower in those randomized to FULV (74·8% vs 96.5%, p<0.0001) or ANA+FULV (71·8% vs 96.5%, p<0.0001). However, complete ER degradation (AS 0-2) was rare, 2·6% (8/306) and 4·5% (15/337) in the FULV and ANA+FULV arms, respectively. pCR rate was low (1·7% in ANA, 1·3% in FULV, and 0·6% in ANA+FULV) following NET, but CCCA rate reached 57·8% in ANA, 61·8% in FULV, and 62·6% in ANA+FULV. Among these patients, the likelihood of a pCR or CCCA (Ki67≤2.7%) in the residual surgical specimen did not differ between either of the FULV-containing regimens and ANA in the overall population or in the subgroup of LumA tumors, however, a higher rate of pCR+CCCA was observed on ANA+FULV than ANA among those with LumB tumors (63·0% vs 41·9%; OR[ANA+FULV/ANA]=2·533, 95%CI: 1·243-5·164; p=0·0105) (Table 3), with a similar trend favoring the combination in the PAM50 ROR high subgroup (58·1% vs 37·1%, adjOR[Ana+Fulv/Ana]=2·35, 95%CI: 0·941- 5·868; p=0·0672) (Suppl. Table S3). [0110] Summary Distribution of Endocrine Response Category by treatment arm and by PAM50 subtype [0111] Figure 4 and Suppl. Table S4 show that the ANA+FULV am is significant different from the ANA arm in the distribution of endocrine response categories, with a significant shift towards lower PEPI scores favoring ANA+FULV, by treatment arm in the overall patient population and in the LumB subgroup, but not in LumA subgroup. Overall, ESDR was significantly higher in LumA (% ) compared to LumB (% ), or NonLum (%) (p ) (Suppl. Table S4). [0112] Outcomes for those who switched to NCT [0113] There were 167 patients (ANA: n=65; FULV: n=58; ANA+FULV: n=44) who switched to NCT based on ki67 >10% at Wk4 (n=157) or Wk12 (n=10). Common NCT regimens included: doxorubicin cyclophosphamide followed by paclitaxel (n=60; 35·9%), single agent paclitaxel (n=56; 33·5%), and docetaxel with cyclophosphamide (n=33; 19·8%). [0114] There were 34 patients who did not complete their planned course of NCT due to intolerability (n=26) or refusal (n=8). Of the remaining 133 patients who completed their planned course of NCT, 6 patients did not undergo surgery due to: desire for additional NET (n=1), radiographic evidence of disease progression (n=3), second primary cancer diagnosis (n=1), and death due to unknown causes (n=1). Surgical procedures and pathologic findings for the 127 women who completed surgery are presented in Table 4. Thus, among the 167 women who switched to NCT after Wk4/12 Ki67 >10% on NET, there were 8 pCRs (4·8%; 95%CI: 2·1% to 9·2%), 16 (9·6%) RCB-1, 80 (47·9%) RCB-2, 43 (25·8%) RCB-3, and 20 cases (12·0%) whose RCB class could not be determined due to missing data elements or surgery not performed. When analyzed by intrinsic subtype, the NonLum cases had a much higher rate of pCR (18.8%), compared to 0% in LumA or 5.2% in LumB (Suppl. Table S5). [0115] [0116] Significance of Certain Embodiments [0117] The ALTERNATE trial demonstrated, for the first time, that the combination of an AI (ANA) plus a SERD (FULV) was superior to either drug alone in inhibiting proliferation in early stage LumB BC in postmenopausal women. This finding is in contrast to previous efforts that assessed the combination of AI and tamoxifen. The Anastrozole (A), Tamoxifen (T) And Combination (C) (ATAC) trial was the largest adjuvant study that examined dual targeting of ER¹⁰. The decision to include the ANA+T combination arm was largely speculative, without strong clinical evidence from the advanced disease setting. Subsequently the IMPACT neoadjuvant endocrine therapy study demonstrated that, in terms of Ki67 suppression, ANA+T was not more effective than T alone, whereas ANA was more effective than T.¹³ These data thus predicted the outcome of the ATAC trial where the combination arm was terminated early due to lack of efficacy and that ANA was found to be superior to tamoxifen in disease free survival outcomes.¹⁰ In contrast, evidence supporting the potential superior efficacy of ANA+FULV versus ANA exists in advanced disease setting, although it is somewhat contradictory. The SWOG 0226 trial found that the combination of ANA+FULV produced both a progression-free and overall survival advantage versus ANA alone.^17,18 Since this study used FULV 250mg dose these findings were countered by the subsequent approval of FULV 500mg monthly. This raised the question of whether ANA was only necessary in SWOG 0226 because the patients were under-dosed with FULV. Furthermore, the absence of an FULV alone arm means that the combination hypothesis was only partially addressed. Two other trials, FACT²³ and SoFEA,²⁴ failed to demonstrate an advantage for FULV+ANA but these studies had many fewer patients with de novo (untreated) metastatic disease, suggesting the importance of addressing the ANA+FULV combination hypothesis in previously untreated ER+ BC. The ALTERNATE trial is the only investigation that studed each drug alone and in combination, at the 500mg dose of FULV, in the setting of ET naïve disease, thus addressing all three caveats raised by trials in the advanced disease setting. [0118] The lack of difference in the primary endpoint (ESDR) across treatment arms, even when the intrinsic subtype was taken into account, reveals, in retrospect, a limitation of this endpoint. The degree of surgical down-staging with 24 weeks of NET must be very modest since 57% of patients were N+ at surgery versus 42% clinically node positive (N+) at baseline. This is consistent with a previous report by Kantor et al that nodal pCR among cN1 stage II-III HR+/HER2- BC in response to NET was low (10.4% with a median duration of 122 days of therapy, in the National Cancer Data Base cohort).²⁵ Thus, the biological effect of NET on Ki67 suppression in N+ disease could not be discerned using the ESDR endpoint, since the mPEPI=0 endpoint requires node negative disease. Indeed, if differences in PEPI scores are considered across all three PEPI categories (0, 1-3 and 4-6) and Wk4 Ki67 response, there was clearly a significant shift towards lower PEPI scores favoring the combination in the LumB disease. [0119] The strong interaction between the efficacy of ANA+FULV versus ANA and intrinsic subtype comes with the caveat that RNA-sequencing based PAM50 analysis was only available on 52% of the ALTERNATE trial population. However the baseline characteristics were not different between cases in the PAM50 analysis cohort and the rest ALTERNATE trial population, and the statistics are highly robust. Certain findings should be treated with caution, however, given the short, six-month treatment period, particularly in the LumA population. Previous studies in the metastatic setting suggested that acquired ESR1 mutations could be enriched in LumA population.²⁶ If relapses in LumA are driven by acquired somatic ESR1 mutations on the ANA arm, these events might be prevented by FULV-containing regimens.²⁷ Such an advantage would take years to be clinically evident, although molecular evidence for suppression of ESR1 mutations in the surgical samples or in the peripheral blood could be observed at an earlier time point. The markedly reduced sensitivity of non-luminal tumors to NET reproduces our earlier findings in the Z1031 trial.²⁸ In terms of adjuvant trial design, our data supports that ER+ non-luminal tumors should ideally be excluded or at least identified, as these tumors are likely to generate early events that are not sensitive to intervention with an endocrine agent. [0120] The activity of ANA+FULV in LumB BC suggests that while many LumB tumors are insensitive to AI, the requirement of ER for tumor growth has not been bypassed, but rather due to development of ligand-independent ER activity which could be addressed with a SERD. Furthermore, by removing endogenous estradiol, AIs may increase FULV binding and therefore ER inhibition and/or degradation, although the ER AS categories did not appear different between FULV and ANA+FULV arms on surgical residual tumor samples. The superiority of ANA+FULV is also consistent with the preclinical observation that FULV in combination with estrogen deprivation was more effective than either treatment alone in an MCF7-based model of aromatase- dependent ER+ breast cancer xenograft growth.^29,30 In these experiments, the combination of AI+FULV was associated with lower ER levels than either treatment alone, and both anastrozole and letrozole added significant benefit to fulvestrant in delaying tumor growth. In addition to ER, greater degrees of down-regulation of IGF-IR, and downstream MAPK and PI3K pathways were also observed compared to single agent therapy³¹. Overall, these results suggest that intrinsic subtype will be a useful tool in the design and interpretation of adjuvant endocrine therapy trials. [0121] A coprimary endpoint for ALTERNATE clinical is a prospective validation of mPEPI=0 status as a marker of excellent outcomes after NET. Patients with mPEPI=0 status therefore completed treatment that included a total of two years of FULV or ANA+FULV for those assigned to the FULV-containing arms. The mPEPI=0 endpoint will be validated for the ANA arm as the primary objective, but also for the FULV-containing arms, which will be useful for future trial design. Since FULV was not continued for patients without ESD, the value of ANA+FULV or FULV as adjuvant therapy will not be directly assessable in this study. [0122] TABLES [0123] Table 1. Baseline Patient and Tumor Characteristics

Table 2: Endocrine Responsiveness by Treatment Arm

Table 3: Likelihood of Week-4 Ki67 > 10% (recommendation to triage to chemotherapy) and likelihood of a pCR or complete cell cycle arrest (Ki67 < 2.7%) in residual specimen by treatment arm and by PAM50-based intrinsic subtype

Table 4: Surgical Outcomes Anastrozole Fulvestrant Anastrozole + Neo-adjuvant n=289 n=306 Fulvestrant chemotherapy n=337 n=153 Extent of Breast Surgery 62 (40.5%) Mastectomy 88 (30.4%) 94 (30.7%) 99 (29.4%) 91 (59.5%) Breast Conserving 201 (69.6%) 212 (69.3%) 238 (70.6%) Extent of Axilla Surgery 2 (0.7%) 2 (0.7%) 3 (0.9%) 5 (3.3%) Not done 175 (60.6%) 199 (65.0%) 219 (65.0%) 74 (48.4%) SLN 52 (18.0%) 39 (12.7%) 45 (13.4%) 28 (18.3%) ALND 60 (20.8%) 66 (21.6%) 70 (20.8%) 46 (30.1%) SLN+ALND pTstage T0/Tis 6 (2.1%) 6 (2.0%) 3 (0.9%) 10 (6.54%) T1-T2 232 (80.3%) 253 (82.7%) 289 (85.8%) 122 (79.7%) T3-T4 51 (17.6%) 47 (15.4%) 45 (13.4%) 21 (13.7%) pNstage pNX 3 (1.0%) 2 (0.7%) 5 (1.5%) 1 (0.7%) pN0 116 (40.1%) 143 (46.7%) 145 (43.0%) 65 (42.5%) pN1 112 (38.8%) 102 (33.3%) 131 (38.9%) 57 (37.3%) pN2 35 (12.1%) 38 (12.4%) 38 (11.3%) 23 (15.0%) pN3 23 (8.0%) 21 (6.9%) 18 (5.3%) 7 (4.6%) ER Allred Score 0-2 2 (0.7%) 8 (2.6%) 15 (4.5%) 3-5 5 (1.7%) 61 (19.9%) 69 (20.5%) ---- 6-8 279 (96.5%) 229 (74.8%) 242 (71.8%) Not reported 3 (1.0%) 8 (2.6%) 11 (3.3%) Ki67 of residual tumor 5 (1.7%) 4 (1.3%) 2 (0.6%) pCR 167 (57.8%) 189 (61.8%) 211 (62.6%) 0-2.7% 86 (29.8%) 94 (30.7%) 91 (27.0%) ---- 2.8-19.7% 21 (7.3%) 11 (3.6%) 12 (3.6%) 19.8-53.1% 1 (0.3%) 2 (0.7%) 0 53.2-100% 9 (3.1%) 6 (2.0%) 21 (6.2%) Not obtained RCB ----- pCR 8 (5.2%) I ---- ---- 16 (10.5%) II 80 (52.2%) III 43 (28.1%) Not reported 6 (3.9%) Supplementary Table S1. Patient and Tumor Characteristics for the PAM50 Analysis Cohort

Supplementary Table S2. Pairwise Comparison of the degrees of Ki67 suppression at week- 4 compared to pre-treatment Ki67 by treatment arm and by intrinsic subtype

Supplementary Table S3. Likelihood of week-4 Ki67 >10% (recommendation to switch to chemotherapy) and likelihood of a pCR or complete cell cycle arrest (Ki67 ≤ 2.7%) in residual specimen by PAM50 ROR

a: Patients who had insufficient cells to ascertain week-4 Ki67 or withdrew prior to week-4 biopsy are excluded (ANA: n=44;FULV: n=48; ANA+FULV: n=46) Supplementary Table S4. Endocrine Response Categories by Treatment Arm and by Intrinsic Subtype

Supplementary Table S5. Rate of Pathologic Complete Response and Residual Cancer Burden by Intrinsic Subtype

* * * [0124] All of the methods disclosed and claimed herein can be made and executed without undue experimentation in light of the present disclosure. While the compositions and methods of this invention have been described in terms of preferred embodiments, it will be apparent to those of skill in the art that variations may be applied to the methods and in the steps or in the sequence of steps of the method described herein without departing from the concept, spirit and scope of the invention. More specifically, it will be apparent that certain agents which are both chemically and physiologically related may be substituted for the agents described herein while the same or similar results would be achieved. All such similar substitutes and modifications apparent to those skilled in the art are deemed to be within the spirit, scope and concept of the invention as defined by the appended claims. REFERENCES The following references, to the extent that they provide exemplary procedural or other details supplementary to those set forth herein, are specifically incorporated herein by reference. 1. Korde LA, Somerfield MR, Carey LA, et al. Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2021;39:1485-505. 2. Sella T, Weiss A, Mittendorf EA, et al. Neoadjuvant Endocrine Therapy in Clinical Practice: A Review. JAMA Oncol 2021;7:1700-8. 3. Spring LM, Gupta A, Reynolds KL, et al. Neoadjuvant Endocrine Therapy for Estrogen Receptor-Positive Breast Cancer: A Systematic Review and Meta-analysis. JAMA Oncol 2016;2:1477-86. 4. Dowsett M, Smith IE, Ebbs SR, et al. Prognostic value of Ki67 expression after short-term presurgical endocrine therapy for primary breast cancer. Journal of the National Cancer Institute 2007;99:167-70. 5. Smith I, Robertson J, Kilburn L, et al. Long-term outcome and prognostic value of Ki67 after perioperative endocrine therapy in postmenopausal women with hormone-sensitive early breast cancer (POETIC): an open-label, multicentre, parallel-group, randomised, phase 3 trial. The Lancet Oncology 2020;21:1443-54. 6. Ellis MJ, Tao Y, Luo J, et al. Outcome prediction for estrogen receptor-positive breast cancer based on postneoadjuvant endocrine therapy tumor characteristics. Journal of the National Cancer Institute 2008;100:1380-8. 7. Goncalves R, DeSchryver K, Ma C, et al. Development of a Ki-67-based clinical trial assay for neoadjuvant endocrine therapy response monitoring in breast cancer. Breast Cancer Res Treat 2017;165:355-64. 8. Ellis MJ, Suman VJ, Hoog J, et al. Ki67 Proliferation Index as a Tool for Chemotherapy Decisions During and After Neoadjuvant Aromatase Inhibitor Treatment of Breast Cancer: Results From the American College of Surgeons Oncology Group Z1031 Trial (Alliance). Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2017;35:1061-9. 9. Goncalves R, Ma C, Luo J, Suman V, Ellis MJ. Use of neoadjuvant data to design adjuvant endocrine therapy trials for breast cancer. Nature reviews Clinical oncology 2012;9:223-9. 10. Baum M, Budzar AU, Cuzick J, et al. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet 2002;359:2131-9. 11. Thurlimann B, Keshaviah A, Coates AS, et al. A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med 2005;353:2747-57. 12. Ellis MJ, Coop A, Singh B, et al. Letrozole inhibits tumor proliferation more effectively than tamoxifen independent of HER1/2 expression status. Cancer research 2003;63:6523-31. 13. Dowsett M, Smith IE, Ebbs SR, et al. Short-term changes in Ki-67 during neoadjuvant treatment of primary breast cancer with anastrozole or tamoxifen alone or combined correlate with recurrence-free survival. Clinical cancer research : an official journal of the American Association for Cancer Research 2005;11:951s-8s. 14. Robertson JFR, Llombart-Cussac A, Rolski J, et al. Activity of fulvestrant 500 mg versus anastrozole 1 mg as first-line treatment for advanced breast cancer: Results from the FIRST study. Journal of Clinical Oncology 2009;27:4530-5. 15. Robertson JR, Lindemann JO, Llombart-Cussac A, et al. Fulvestrant 500 mg versus anastrozole 1 mg for the first-line treatment of advanced breast cancer: follow-up analysis from the randomized ‘FIRST’ study. Breast Cancer Research and Treatment 2012;136:503-11. 16. Robertson JFR, Bondarenko IM, Trishkina E, et al. Fulvestrant 500 mg versus anastrozole 1 mg for hormone receptor-positive advanced breast cancer (FALCON): an international, randomised, double-blind, phase 3 trial. The Lancet 2016;388:2997-3005. 17. Mehta RS, Barlow WE, Albain KS, et al. Combination anastrozole and fulvestrant in metastatic breast cancer. The New England journal of medicine 2012;367:435-44. 18. Mehta RS, Barlow WE, Albain KS, et al. Overall Survival with Fulvestrant plus Anastrozole in Metastatic Breast Cancer. New England Journal of Medicine 2019;380:1226-34. 19. Griguolo G, Bottosso M, Vernaci G, Miglietta F, Dieci MV, Guarneri V. Gene-expression signatures to inform neoadjuvant treatment decision in HR+/HER2- breast cancer: Available evidence and clinical implications. Cancer Treat Rev 2022;102:102323. 20. Dowsett M, Ellis MJ, Dixon JM, et al. Evidence-based guidelines for managing patients with primary ER+ HER2- breast cancer deferred from surgery due to the COVID-19 pandemic. NPJ Breast Cancer 2020;6:21. 21. Ellis MJ, Suman VJ, Hoog J, et al. Randomized phase II neoadjuvant comparison between letrozole, anastrozole, and exemestane for postmenopausal women with estrogen receptor-rich stage 2 to 3 breast cancer: clinical and biomarker outcomes and predictive value of the baseline PAM50-based intrinsic subtype--ACOSOG Z1031. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2011;29:2342-9. 22. Prat A, Fan C, Fernández A, et al. Response and survival of breast cancer intrinsic subtypes following multi-agent neoadjuvant chemotherapy. BMC Medicine 2015;13:303. 23. Allison KH, Hammond MEH, Dowsett M, et al. Estrogen and Progesterone Receptor Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Guideline Update. Arch Pathol Lab Med 2020;144:545-63. 24. Allred DC, Harvey JM, Berardo M, Clark GM. Prognostic and predictive factors in breast cancer by immunohistochemical analysis. Mod Pathol 1998;11:155-68. 25. Parker JS, Mullins M, Cheang MC, et al. Supervised risk predictor of breast cancer based on intrinsic subtypes. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2009;27:1160-7. 26. Bergh J, Jönsson P-E, Lidbrink EK, et al. FACT: An Open-Label Randomized Phase III Study of Fulvestrant and Anastrozole in Combination Compared With Anastrozole Alone as First- Line Therapy for Patients With Receptor-Positive Postmenopausal Breast Cancer. Journal of Clinical Oncology 2012. 27. Johnston SR, Kilburn LS, Ellis P, et al. Fulvestrant plus anastrozole or placebo versus exemestane alone after progression on non-steroidal aromatase inhibitors in postmenopausal patients with hormone-receptor-positive locally advanced or metastatic breast cancer (SoFEA): a composite, multicentre, phase 3 randomised trial. The Lancet Oncology 2013;14:989-98. 28. Brett JO, Spring LM, Bardia A, Wander SA. ESR1 mutation as an emerging clinical biomarker in metastatic hormone receptor-positive breast cancer. Breast cancer research : BCR 2021;23:85. 29. Brodie A, Jelovac D, Macedo L, Sabnis G, Tilghman S, Goloubeva O. Therapeutic observations in MCF-7 aromatase xenografts. Clin Cancer Res 2005;11:884s-8s. 30. Jelovac D, Macedo L, Goloubeva OG, Handratta V, Brodie AM. Additive antitumor effect of aromatase inhibitor letrozole and antiestrogen fulvestrant in a postmenopausal breast cancer model. Cancer Res 2005;65:5439-44. 31. Macedo LF, Sabnis GJ, Goloubeva OG, Brodie A. Combination of anastrozole with fulvestrant in the intratumoral aromatase xenograft model. Cancer Res 2008;68:3516-22.

Claims

WHAT IS CLAIMED IS: 1. A method of treating an individual having estrogen receptor (ER)-positive human epidermal growth factor receptor 2 (HER2)-negative cancer, comprising the step of: administering an effective amount of one or more aromatase inhibitors and one or more selective estrogen receptor degraders (SERDs) to an individual that is of the cancer type Luminal B; and/or not administering chemotherapy to the individual.

2. The method of claim 1, wherein the chemotherapy is neoadjuvant chemotherapy.

3. The method of any one of the preceding claims, wherein the individual is given an additional cancer treatment that is not chemotherapy.

4. The method of any one of the preceding claims, wherein the individual is subject to surgery for the cancer.

5. The method of any one of the preceding claims, wherein the aromatase inhibitor is selected from the group consisting of anastrozole, exemestane, letrozole, testolactone, and a combination thereof.

6. The method of any one of the preceding claims, wherein the aromatase inhibitor is anastrozole.

7. The method of any one of the preceding claims, wherein the SERD is selected from the group consisting of fulvestrant, G1T48, AZD9496, LSZ102, elacestrant, SAR439859, and a combination thereof.

8. The method of any one of the preceding claims, wherein the SERD is fulvestrant and the aromatase inhibitor is anastrozole.

9. The method of any one of the preceding claims, wherein the aromatase inhibitor and the SERD are administered at substantially the same time.

10. The method of claim 9, wherein the aromatase inhibitor and the SERD are in the same formulation.

11. The method of claim 9, wherein the aromatase inhibitor and the SERD are not in the same formulation.

12. The method of any one of claims 1-9 and 11, wherein the aromatase inhibitor and the SERD are administered at different times.

13. The method of any one of the preceding claims, wherein the method further comprises measuring a sample from the individual that is a Luminal B-positive sample.

14. A method for treating ER-positive HER2-negative cancer in an individual, comprising detecting whether or not an individual is of the cancer type Luminal B; and administering to an individual that is of the cancer type Luminal B an effective amount of one or more aromatase inhibitors and one or more SERDs; and/or not administering chemotherapy to the individual.

15. A method of determining a treatment regimen for an individual that has ER-positive HER2- negative cancer, comprising the steps of: measuring a sample from an individual that has cancer or is suspected of having cancer for a Luminal B gene signature; and determining a treatment regimen as being an effective amount of one or more aromatase inhibitors and one or more SERDs and/or not being chemotherapy for an individual that has a Luminal B gene signature.

16. The method of claim 15, further comprising the step of administering the treatment regimen to the individual that has a Luminal B gene signature.