Patent Publication Number: US-2023147663-A1

Title: Method for predicting the risk of getting cancer or diagnosing cancer in a female subject

Description:
SEQUENCE LISTING 
     The instant application contains a Sequence Listing which has been submitted electronically in XML format and is hereby incorporated by reference in its entirety. Said XML copy, created on Dec. 14, 2022, is named BOEHMERP-0221-C02_SL.xml and is 30,740 bytes in size. 
     Subject matter of the present invention is a method for predicting the risk of getting cancer in a female subject that does not suffer from cancer or alternatively diagnosing cancer in a female subject comprising: 
     determining the level of Pro-Enkephalin (PENK) or fragments thereof including Leu-Enkephalin and Met-Enkephalin of at least 5 amino acids in a bodily fluid obtained from said female subject; and   correlating said level of Pro-Enkephalin or fragments thereof with a risk for getting cancer, wherein a reduced level is predictive for an enhanced risk of getting cancer or alternatively diagnosing cancer wherein an reduced level is correlated with the diagnosis of cancer.   

     Met-Enkephalin, a 5 amino acid peptide derived from the Enkephalin precursor (PreProEnkephalin), also named “Opioid Growth Factor” (OGF) is released together with ProEnkephalin-fragments. The mature peptide binds to different opioid receptors (Koneru et al., 2009). Enkephalin (OGF) was found to have a number of physiological functions. In the CNS it down regulates Substance P associated pain signalling, it plays roles as cytokine (Plotnikoff et al., 1997). Proenkephalin related peptides exhibiting antibiotic actions (Goumon et al., 1998). Proenkephalin and Enkephalin exhibits anti tumor action and acting as pro-apoptotic agents (Tavish et al., 2007, Donahue et al., 2011, Zagon et al., 2009). 
     The use of vasoactive peptides for prediction of cancer risks in males has been reported by Belting et al., Cancer, Epidemiology, Biomarkes &amp; Prevention. MR-pro-ANP, MR-pro-ADM and copeptin was measured in the fasting plasma from participants of the Malmö Diet and Cancer Study that were free from cancer prior to the baseline exam in 1991 to 1994 (1768 males and 2293 females). The authors stated that among females, there was no relationship between biomarkers and cancer incidence. 
     A subject of the present invention was to investigate the prognostic and diagnostic power of PENK for the prediction of cancer incidence and the prediction of the risk of reoccurrence of cancer. To address this issue, stable fragments of Pro-Enkephalin (Ernst et al., 2006) in fasting plasma were measured in said Swedish prospective cohort study (Malmö Diet and Cancer Study) and related baseline level of this biomarker to breast-cancer incidence during 15 years of follow-up. 
     Surprisingly, it has been shown that Pro-Enkephalin is a powerful and highly significant biomarker for woman for predicting the risk of getting cancer in a female subject that does not suffer from cancer or alternatively diagnosing cancer in a female subject. 
     Thus, subject matter of the present invention is a method for predicting the risk of getting cancer in a female subject that does not suffer from cancer or alternatively diagnosing cancer in a female subject comprising:
     determining the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject; and   correlating said level of Pro-Enkephalin or fragments thereof with a risk for getting cancer, wherein an reduced level is predictive for an enhanced risk of getting cancer or alternatively diagnosing cancer wherein an reduced level is correlated with the diagnosis of cancer.   

     Examples of cancers may be selected from the group comprising breast cancer, lung cancer, pancreatic cancer and colon cancer. 
     Throughout the specification it should be understood that the term fragments of Pro-Enkephalin also include Leu-Enkephalin and Met-Enkephalin. 
     In a specific embodiment of the invention said cancer is breast cancer. In another specific embodiment of the invention said cancer is lung cancer. 
     Thus, subject matter of the present invention is the determination of susceptibility of a woman to aquire cancer, e.g. breast cancer, lung cancer etc 
     Data obtained in the present study revealed also a correlation between the risk of getting cancer in male subjects with the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said male subject; this correlation however, was not that statistically significant for the present data set although there was a clear trend for an increased cancer risk at reduced levels of PENK also in males. Thus, there is a value for the method according to the invention also for male subjects but in the present study the observed effect was not as strong for males as compared to females. This may be primarily due to the low number of cancer incidents in the male population. 
     Further, data obtained in the present study revealed also a correlation between the risk of getting cancer in female subjects with the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject, wherein said cancer was not lung cancer or breast cancer. Due to the small number of incidents in this particular population this correlation however, was not that statistically significant for the present data set. Although it was not significant there was a clear trend. It is furthermore credible that the present data suggest such a correlation also in other cancers due to the known proapoptotic effect of Enkephalin, a fragment of PENK. Starting from the prior art it is surprising that Pro-Enkephalin or fragments thereof may be predictive for cancer. Starting from the present data that are statistically highly relevant for breast cancer and lung cancer it is to be expected and credible that it may be prognostic for other types of cancer as well. 
    
    
     The term “subject” as used herein refers to a living human or non-human organism. Preferably herein the subject is a human subject. 
     The term “reduced level” means a level below a certain threshold level. 
     A bodily fluid may be selected from the group comprising blood, serum, plasma, urine, cerebro spinal liquid (csf), and saliva. 
     In one embodiment of the invention said female subject has never had a diagnosed cancer at the time the sample of bodily fluid is taken from said female subject. 
     In another embodiment said female subject has been diagnosed before with having cancer and has been cured at the time the sample of bodily fluid is taken from said female subject and the risk of reoccurrence of getting cancer is determined or alternatively the re-occurrence of cancer is predicted. 
     Pro-Enkephalin has the following sequence: 
     SEQ ID NO. 1 (Pro-Enkephalin (1-243)  
     
       
         
           
               
            
               
                 ECSQDCATCSYRLVRPADINFLACVMECEGKLPSLKIWETCKELLQLSKPELPQDGTSTL 
               
               
                 RENSKPEESHLLAKRYGGFMKRYGGFMKKMDELYPMEPEEEANGSEILAKRYGGFMK 
               
               
                 KDAEEDDSLANSSDLLKELLETGDNRERSHHQDGSDNEEEVSKRYGGFMRGLKRSPQL 
               
               
                 EDEAKELQKRYGGFMRRVGRPEWWMDYQKRYGGFLKRFAEALPSDEEGESYSKEVPE 
               
               
                 MEKRYGGF MRF 
               
            
           
         
       
     
     Fragments of Pro-Enkephalin that may be determined in a bodily fluid may be e.g. selected from the group of the following fragments: 
     SEQ ID NO. 2 (Synenkephalin, Pro-Enkephalin 1-73)  
     
       
         
           
               
            
               
                 ECSQDCATCSYRLVRPADINFLACVMECEGKLPSLKIWETCKELLQLSKPELPQDGTSTL 
               
               
                 RENSKPEESHLLA 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 3 (Met-Enkephalin)  
     
       
         
           
               
            
               
                 YGGFM 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 4 (Leu-Enkephalin)  
     
       
         
           
               
            
               
                 YGGFL 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 5 (ProEnkephalin 90-109)  
     
       
         
           
               
            
               
                 MDELYPMEPEEEANGSEILA 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 6 (Pro Enkephalin 119-159, Mid regional Pro-Enkephalin-fragment, MRPENK)  
     
       
         
           
               
            
               
                 DAEEDDSLANSSDLLKELLETGDNRERSHHQDGSDNEEEVS 
               
            
           
         
       
     
     SEQ ID NO. 7 (Met-Enkephalin-Arg-Gly-Leu)  
     
       
         
           
               
            
               
                 YGGFMRGL 
               
            
           
         
       
     
     SEQ ID NO. 8 (Pro-Enkephalin 172-183)  
     
       
         
           
               
            
               
                 SPQLEDEAKELQ 
               
            
           
         
       
     
     SEQ ID NO. 9 (Pro-Enkephalin 193-203)  
     
       
         
           
               
            
               
                 VGRPEWWMDYQ 
               
            
           
         
       
     
     SEQ ID NO. 10 (Pro-Enkephalin 213-234)  
     
       
         
           
               
            
               
                 FAEALPSDEEGESYSKEVPEME 
               
            
           
         
       
     
     SEQ ID NO. 11 (Pro-Enkephalin 213-241)  
     
       
         
           
               
            
               
                 FAEALPSDEEGESYSKEVPEMEKRYGGF M 
               
            
           
         
       
     
     SEQ ID NO. 12 (Met-Enkephalin-Arg-Phe)  
     
       
         
           
               
            
               
                 YGGFMRF 
               
            
           
         
       
     
     Determining the level of Pro-Enkephalin including Leu-Enkephalin and Met-Enkephalin or fragments thereof may mean that the immunoreactivity towards Pro-Enkephalin or fragments thereof including Leu-Enkephalin and Met-Enkephalin is determined. A binder used for determination of Pro-Enkephalin including Leu-Enkephalin and Met-Enkephalin or fragments thereof depending of the region of binding may bind to more than one of the above displayed molecules. This is clear to a person skilled in the art. 
     Thus, according to the present invention the level of immunoreactive analyte by using at least one binder that binds to a region within the amino acid sequence of any of the above peptide and peptide fragments, (i.e. Pro-Enkephalin (PENK) and fragments according to any of the sequences 1 to 12), is determined in a bodily fluid obtained from said subject; and correlated to the specific embodiments of clinical relevance. 
     In a more specific embodiment of the method according to the present invention the level of MRPENK is determined (SEQ ID NO. 6: Pro-Enkephalin 119-159, Mid regional Pro-Enkephalin-fragment, MRPENK). In a more specific embodiment the level of immunoreactive analyte by using at least one binder that binds to MR-PENK is determined and is correlated to the specific embodiments of clinical relevance according to the invention. 
     Determining the level of Pro-Enkephalin or fragments thereof including Leu-Enkephalin and Met-Enkephalin or fragments thereof may mean that the immunoreactivity towards Pro-Enkephalin or fragments thereof including Leu-Enkephalin and Met-Enkephalin is determined. A binder used for determination of Pro-Enkephalin including Leu-Enkephalin and Met-Enkephalin or fragments thereof depending of the region of binding may bind to more than one of the above displayed molecules. This is clear to a person skilled in the art. In another embodiment of the invention the fragment is not Leu-Enkephalin or Met-Enkephalin, In another embodiment of the invention the immunoreactivity towards Pro-Enkephalin or fragments thereof not including Leu-Enkephalin and Met-Enkephalin is determined. 
     In a more specific embodiment of the method according to the present invention the level of MRPENK. (SEQ ID NO. 6 (Pro Enkephalin 119-159, Mid regional Pro-Enkephalin-fragment, MRPENK, DAEEDDSLANSSDLLKELLETGDNRERSHHQDGSDNEEEVS) is determined. 
     Alternatively the level of any of the above analytes may be determined by other analytical methods e.g. mass spectroscopy. 
     In a specific embodiment the level of Pro-Enkephalin or fragments thereof are measured with an immunoassay using antibodies or fragments of antibodies binding to Pro-Enkephalin or fragments thereof. An immunoassay that may be useful for determining the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids may comprise the steps as outlined in Example 2. All thresholds and values have to be seen in correlation to the test and the calibration used according to Example 2. A person skilled in the art may know that the absolute value of a threshold might be influenced by the calibration used. This means that all values and thresholds given herein are to be understood in context of the calibration used in herein (Example 2). According to the invention the diagnostic binder to Pro-Enkephalin is selected from the group consisting of antibodies e.g. IgG, a typical full-length immunoglobulin, or antibody fragments containing at least the F-variable domain of heavy and/or light chain as e.g. chemically coupled antibodies (fragment antigen binding) including but not limited to Fab-fragments including Fab minibodies, single chain Fab antibody, monovalent Fab antibody with epitope tags, e.g. Fab-V5Sx2; bivalent Fab (mini-antibody) dimerized with the CH3 domain; bivalent Fab or multivalent Fab, e.g. formed via multimerization with the aid of a heterologous domain, e.g. via dimerization of dHLX domains, e.g. Fab-dHLX-FSx2; F(ab′)2-fragments, scFv-fragments, multimerized multivalent or/and multispecific scFv-fragments, bivalent and/or bispecific diabodies, BITE® (bispecific T-cell engager), trifunctional antibodies, polyvalent antibodies, e.g. from a different class than G; single-domain antibodies, e.g. nanobodies derived from camelid or fish immunoglobulines. 
     In a specific embodiment the level of Pro-Enkephalin or fragments thereof are measured with an assay using binders selected from the group comprising aptamers, non-Ig scaffolds as described in greater detail below binding to Pro-Enkephalin or fragments thereof. 
     Binder that may be used for determining the level of Pro-Enkephalin or fragments thereof exhibit an affinity constant to Pro-Enkephalin of at least 10 7  M -1 , preferred 10 8  M -1 , preferred affinity constant is greater than 10 9  M -1 , most preferred greater than 10 10  M -1 . A person skilled in the art knows that it may be considered to compensate lower affinity by applying a higher dose of compounds and this measure would not lead out-of-the-scope of the invention. Binding affinity may be determined using the Biacore method, offered as service analysis e.g. at Biaffin, Kassel, Germany (http://www.biaffin.com/de/). 
     A human Pro-Enkephalin-control sample is available by ICI-Diagnostics, Berlin, Germany http://www.ici-diagnostics.com/. The assay may also be calibrated by synthetic (for our experiments we used synthetic MRPENK, SEQ ID NO. 6) or recombinant Pro-Enkephalin or fragments thereof. 
     The threshold for determining the risk of getting breast cancer in a female subject or diagnosing breast cancer in a female subject according to the methods of the present invention is below 100 pmol/l PENK, preferred below 50 pmol/l, more preferred below 40.4 pmol/l. In a specific embodiment said threshold is about 40.4 pmol/l. These thresholds are related to the above mentioned calibration method. A PENK value below said threshold means that the subject has an enhanced risk of getting cancer or has already cancer. 
     In one embodiment of the invention said method is performed more than once in order to monitor the risk of getting breast cancer in a female subject or in order to monitor the course of treatment. In one specific embodiment said monitoring is performed in order to evaluate the response of said female subject to preventive and/or therapeutic measures taken. 
     In one embodiment of the invention the method is used in order to stratify said female subjects into risk groups. 
     Subject of the present invention is also a method for predicting the risk of getting cancer in a female or identifying a female subject having an enhanced risk for getting cancer according to any of the preceding embodiments, wherein the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject either alone or in conjunction with other prognostically useful laboratory or clinical parameters is used for the prediction of a subject’s risk for getting an adverse event by a method which may be selected from the following alternatives:
     Comparison with the median of the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject in an ensemble of predetermined samples in a population of “healthy” or “apparently healthy” subjects,   Comparison with a quantile of the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject in an ensemble of predetermined samples in a population of “healthy” or “apparently healthy” subjects,   Calculation based on Cox Proportional Hazards analysis or by using Risk index calculations such as the NRI (Net Reclassification Index) or the IDI (Integrated Discrimination Index).   

     In one embodiment of the invention subject of the present invention is also a method for predicting the risk of getting cancer in a female or identifying a female subject having an enhanced risk for getting cancer according to any of the preceding embodiments, wherein the level of Pro-Enkephalin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject either alone or in conjunction with other prognostically useful biomarker. Such a useful biomarker may be Pro-Neurotensin and fragments thereof of at least 5 amino acids. 
     In a more specific embodiment of the method according to the present invention the level of Pro-Neurotensin 1-117 is determined in addition to the determination of Pro-Enkephalin an fragments thereof. 
     Thus, subject matter of the present invention is also a method for predicting the risk of getting cancer in a female subject that does not suffer from cancer or alternatively diagnosing cancer in a female subject comprising:
     determining the level of Pro-Enkephalin or fragments thereof including Leu-Enkephalin and Met-Enkephalin of at least 5 amino acids in a bodily fluid obtained from said female subject; and   determining the level of Pro-Neurotensin or fragments thereof of at least 5 amino acids in a bodily fluid obtained from said female subject; and   correlating said level of Pro-Enkephalin or fragments thereof and Pro-Neurotensin or fragments thereof of at least 5 amino acids with a risk for getting cancer, wherein an reduced level of Pro-Enkephalin is predictive for an enhanced risk of getting cancer or alternatively diagnosing cancer wherein an reduced level is correlated with the diagnosis of cancer and wherein an increased level of Pro-Neurotensin is predictive for an enhanced risk of getting cancer or alternatively diagnosing cancer wherein an increased level is correlated with the diagnosis of cancer.   

     SEQ ID NO. 13 (Pro-Neurotensin 1-147)  
     
       
         
           
               
            
               
                 SDSEEEMKAL EADFLTNMHT SKISKAHVPS WKMTLLNVCS LVNNLNSPAE 
               
               
                 ETGEVHEEEL VARRKLPTAL DGFSLEAMLT IYQLHKICHS RAFQHWELIQ 
               
               
                 EDILDTGNDK NGKEEVIKRK IPYILKRQLY ENKPRRPYIL KRDSYYY 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 14 (Pro-Neurotensin 1-125 (large neuromedin N))  
     
       
         
           
               
            
               
                 SDSEEEMKAL EADFLTNMHT SKISKAHVPS WKMTLLNVCS LVNNLNSPAE 
               
               
                 ETGEVHEEEL VARRKLPTAL DGFSLEAMLT IYQLHKICHS RAFQHWELIQ 
               
               
                 EDILDTGNDK NGKEEVI KR KIPYIL 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 15 (neuromedin N)  
     
       
         
           
               
            
               
                 KIPYIL 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 16 (neurotensin)  
     
       
         
           
               
            
               
                 pyroQLYENKPRRP YIL 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 17 (Pro-Neurotensin 1-117)  
     
       
         
           
               
            
               
                 SDSEEEMKAL EADFLTNMHT SKISKAHVPS WKMTLLNVCS LVNNLNSPAE 
               
               
                 ETGEVHEEEL VARRKLPTAL DGFSLEAMLT IYQLHKICHS RAFQHWELIQ 
               
               
                 EDILDTGNDK NGKEEVI 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 18 (Pro-Neurotensin 1-132)  
     
       
         
           
               
            
               
                 SDSEEEMKAL EADFLTNMHT SKISKAHVPS WKMTLLNVCS LVNNLNSPAE 
               
               
                 ETGEVHEEEL VARRKLPTAL DGFSLEAMLT IYQLHKICHS RAFQHWELIQ 
               
               
                 EDILDTGNDK NGKEEVIKRK IPYILKRQLY EN 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 19 (Pro-Neurotensin 120-140)  
     
       
         
           
               
            
               
                 KIPYILKRQL YENKPRRPYI L 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 20 (Pro-Neurotensin 120-147)  
     
       
         
           
               
            
               
                 KIPYILKRQL YENKPRRPYIL KRDSYYY 
               
               
                   
               
            
           
         
       
     
     SEQ ID NO. 21 (Pro-Neurotensin 128-147)  
     
       
         
           
               
            
               
                 QLYENKPRRP YILKRDSYYY 
               
               
                   
               
            
           
         
       
     
     In a specific embodiment the level of Pro-Neurotensin is measured with an immunoassay. More specifically an immunoassay is used as described in Ernst et al. (Peptides (2006), (27) 1787-1793). An immunoassay that may be useful for determining the level of Pro-Neurotensin or fragments thereof of at least 5 amino acids may comprise the steps as outlined in Example 2. All thresholds and values have to be seen in correlation to the test and the calibration used according to Example 2. A person skilled in the art may know that the absolute value of a threshold might be influenced by the calibration used. This means that all values and thresholds given herein are to be understood in context of the calibration used in herein (Example 2). A human Pro-Neurotensin-calibrator is available by ICI-Diagnostics, Berlin, Germany. Alternatively, the assay may also be calibrated by synthetic or recombinant P—NT 1-117 or fragments thereof (see also Ernst et al, 2006). 
     Binder that may be used for determining the level of Pro-Neurotensin or fragments thereof exhibit an affinity constant to Pro-Neurotensin of at least 10 7  M -1 , preferred 10 8  M -1 , preferred affinity constant is greater than 10 9  M -1 , most preferred greater than 10 10  M -1 . A person skilled in the art knows that it may be considered to compensate lower affinity by applying a higher dose of compounds and this measure would not lead out-of-the-scope of the invention. Binding affinity may be determined using the Biacore method, offered as service analysis e.g. at Biaffin, Kassel, Germany (http://www.biaffin.com/de/).The threshold for determining the risk of getting breast cancer in a female subject or diagnosing breast cancer in a female subject according to the methods of the present invention is above 78 pmol/l PNT, preferred 100 pmol/l, more preferred 150 pmol/l. In a specific embodiment said threshold is about 100 pmol/l. These thresholds are related to the above mentioned calibration method. A P-NT value above said threshold means that the subject has an enhanced risk of getting cancer or has already cancer. 
     In one embodiment of the invention said method is performed more than once in order to monitor the risk of getting breast cancer in a female subject or in order to monitor the course of treatment. In one specific embodiment said monitoring is performed in order to evaluate the response of said female subject to preventive and/or therapeutic measures taken. 
     In one embodiment of the invention the method is used in order to stratify said female subjects into risk groups. 
     In one embodiment of the invention the cancer is selected from the group comprising breast cancer, and lung cancer. Subject matter of the invention is further an assay for determining Pro-Enkephalin and Pro-Enkephalin fragments in a sample comprising two binders that bind to two different regions within the region of Pro-Enkephalin that is aminoacid 133-140 (LKELLETG, SEQ ID NO. 22) and aminoacid 152-159 (SDNEEEVS, SEQ ID NO. 23) wherein each of said regions comprises at least 4 or 5 amino acids. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention the assay sensitivity of said assay is able to quantify the Pro-Enkephalin or Pro-Enkephalin fragments of healthy subjects and is &lt; 15 pmol/, preferably &lt; 10 pmol/l and more preferably L &lt; 6 pmol/L. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention said binder exhibits an binding affinity to its binding partner of at least 10 7  M -1 , preferred 10 8  M -1 , preferred affinity constant is lower than 10 9  M -1 , most preferred lower than 10 10  M -1 . A person skilled  [K1]  in the art knows that it may be considered to compensate lower affinity by applying a higher dose of compounds and this measure would not lead out-of-the-scope of the invention binding affinity may be determined as described above. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention such assay is a sandwich assay, preferably a fully automated assay. It may be an ELISA fully automated or manual. It may be a so-called POC-test (point -of-care). Examples of automated or fully automated assay comprise assays that may be used for one of the following systems: Roche Elecsys®, Abbott Architect®, Siemens Centauer®, Brahms Kryptor®, Biomerieux Vidas®, Alere Triage®. Examples of test formats are provided above. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention at least one of said two binders is labeled in order to be detected. Examples of labels are provided above. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention at least one of said two binders is bound to a solid phase. Examples of solid phases are provided above. 
     In one embodiment of the assays for determining Pro-Enkephalin or Pro-Enkephalin fragments in a sample according to the present invention said label is selected from the group comprising chemiluminescent label, enzyme label, fluorescence label, radioiodine label. 
     A further subject of the present invention is a kit comprising an assay according to the present invention wherein the components of said assay may be comprised in one or more container. 
     EXAMPLES 
     Example 1 
     Development of Antibodies 
     Peptides 
     Peptides were synthesized (JPT Technologies, Berlin, Germany). 
     Peptides/Conjugates for Immunization 
     Peptides for immunization were synthesized (JPT Technologies, Berlin, Germany) with an additional N-terminal Cystein residue for conjugation of the peptides to bovine serum albumin (BSA). The peptides were covalently linked to BSA by using Sulfo-SMCC (Perbio-science, Bonn, Germany). The coupling procedure was performed according to the manual of Perbio.  
     
       
         
          TABLE 1
           
               
               
             
               
                 Peptide for immunization 
                 Pro-Enkephalin sequence 
               
             
            
               
                 (C)DAEEDD (SEQ ID NO: 26) 
                 119-125 
               
               
                 (C)EEDDSLANSSDLLK (SEQ ID NO: 27) 
                 121-134 
               
               
                 (C)LKELLETG (SEQ ID NO: 28) 
                 133-140 
               
               
                 (C)TGDNRERSHHQDGSDNE (SEQ ID NO: 29) 
                 139-155 
               
               
                 (C)SDNEEEVS (SEQ ID NO: 30) 
                 152-159 
               
            
           
         
       
     
     The antibodies were generated according to the following method: 
     A BALB/c mouse was immunized with 100 µg peptide-BSA-conjugate at day 0 and 14 (emulsified in 100 µl complete Freund’s adjuvant) and 50 µg at day 21 and 28 (in 100 µl incomplete Freund’s adjuvant). Three days before the fusion experiment was performed, the animal received 50 µg of the conjugate dissolved in 100 µl saline, given as one intraperitonal and one intravenous injection. 
     Spenocytes from the immunized mouse and cells of the myeloma cell line SP2/0 were fused with 1 ml 50% polyethylene glycol for 30 s at 37° C. After washing, the cells were seeded in 96-well cell culture plates. Hybrid clones were selected by growing in HAT medium [RPMI 1640 culture medium supplemented with 20% fetal calf serum and HAT-supplement]. After two weeks the HAT medium is replaced with HT Medium for three passages followed by returning to the normal cell culture medium. 
     The cell culture supernatants were primary screened for antigen specific IgG antibodies three weeks after fusion. The positive tested microcultures were transferred into 24-well plates for propagation. After retesting the selected cultures were cloned and recloned using the limiting-dilution technique and the isotypes were determined. 
     (Lane, R.D. “A short-duration polyethylene glycol fusiontechnique for increasing production of monoclonal antibody-secreting hybridomas”, J. Immunol. Meth. 81: 223-228; (1985), Ziegler, B. et al. “Glutamate decarboxylase (GAD) is not detectable on the surface of rat islet cells examined by cytofluorometry and complement-dependent antibody-mediated cytotoxicity of monoclonal GAD antibodies”, Horm. Metab. Res. 28: 11-15, (1996)). 
     Monoclonal Antibody Production 
     Antibodies were produced via standard antibody production methods (Marx et al., Monoclonal Antibody Production (1997), ATLA 25, 121) and purified via Protein A-chromatography. The antibody purities were &gt; 95% based on SDS gel electrophoresis analysis. 
     Labelling and Coating of Antibodies 
     All antibodies were labelled with acridinium ester according the following procedure: 
     Labelled compound (tracer): 100 µg (100 µl) antibody (1 mg/ml in PBS, pH 7.4, was mixed with 10 µl Acridinium NHS-ester (1 mg/ml in acetonitrile, InVent GmbH, Germany) (EP 0353971) and incubated for 20 min at room temperature. Labelled antibody was purified by gel-filtration HPLC on Bio-Sil SEC 400-5 (Bio-Rad Laboratories, Inc., USA) The purified labelled antibody was diluted in (300 mmol/l potassiumphosphate, 100 mmol/l NaCl, 10 mmol/l Na-EDTA, 5 g/l bovine serum albumin, pH 7.0). The final concentration was approx. 800.000 relative light units (RLU) of labelled compound (approx. 20 ng labeled antibody) per 200 µl. Acridiniumester chemiluminescence was measured by using an AutoLumat LB 953 (Berthold Technologies GmbH &amp; Co. KG). 
     Solid Phase Antibody (Coated Antibody) 
     Solid phase: Polystyrene tubes (Greiner Bio-One International AG, Austria) were coated (18 h at room temperature) with antibody (1.5 µg antibody/0.3 ml 100 mmol/l NaCl, 50 mmol/l Tris/HCl, pH 7.8). After blocking with 5% bovine serum albumine, the tubes were washed with PBS, pH 7.4 and vacuum dried. 
     Antibody Specificity 
     The crossreactivities of the different antibodies are listed in table 2.  
     
       
         
          TABLE 2
           
               
               
               
             
               
                 Peptide for immunization 
                 Pre-Pro-Enkephalin-sequence 
                 Antibody name 
               
             
            
               
                 (C)DAEEDD (SEQ ID NO: 26) 
                 119-125 
                 NT-MRPENK 
               
               
                 (C)EEDDSLANSSDLLK (SEQ ID NO: 27) 
                 121-134 
                 NM-MRPENK 
               
               
                 (C)LKELLETG (SEQ ID NO: 28) 
                 133-140 
                 MR-MRPENK 
               
               
                 (C)TGDNRERSHHQDGSDNE (SEQ ID NO: 29) 
                 139-155 
                 MC-MRPENK 
               
               
                 (C)SDNEEEVS (SEQ ID NO: 30) 
                 152-159 
                 CT-MRPENK 
               
            
           
         
       
     
     Antibody cross-reactivities were determined as follows: 
     1ug peptide in 300 µl PBS, pH 7.4 was pipetted into Polystyrene tubes and incubated for 1 h at room temperature. After incubation the tubes were washed 5 times (each 1 ml) using 5% BSA in PBS, pH 7.4. Each of the labelled antibodies were added (300 µl in PBS, pH 7.4, 800.000 RLU/ 300 µl) an incubated for 2 h at room temperature, After washing 5 times (each 1 ml of washing solution (20 mmol/l PBS, pH 7.4, 0.1 % Triton X 100), the remaining luminescence (labelled antibody) was quantified using the AutoLumat LB 953. MRPENK-peptide was used as reference substance (100%).  
     
       
         
          TABLE 3
           
               
               
               
               
               
               
               
             
               
                 antibody peptide 
                 DAEEDD (SEQ ID NO: 31) 
                 EEDDSLANSSD LLK (SEQ ID NO: 32) 
                 LKELLETG (SEQ ID NO: 22) 
                 TGDNRERSH HQDGSDNE (SEQ ID NO: 33) 
                 SDNEEEVS (SEQ ID NO: 23) 
                 MRPENK (SEQ ID NO. 6) 
               
             
            
               
                 NT-MRPENK 
                 121 
                 10 
                 &lt;1 
                 &lt;1 
                 &lt;1 
                 100 
               
               
                 NM-MRPENK 
                 &lt;1 
                 98 
                 &lt;1 
                 &lt;1 
                 &lt;1 
                 100 
               
               
                 MR-MRPENK 
                 &lt;1 
                 &lt;1 
                 105 
                 &lt;1 
                 &lt;1 
                 100 
               
               
                 MC-MRPENK 
                 &lt;1 
                 &lt;1 
                 &lt;1 
                 115 
                 &lt;1 
                 100 
               
               
                 CT-MRPENK 
                 &lt;1 
                 &lt;1 
                 &lt;1 
                 &lt;1 
                 95 
                 100 
               
            
           
         
       
     
     All antibodies bound the MRPENK peptide, compareable to the peptides which were used for immunization. Except for NT-MRPENK-antibody (10% cross reaction with EEDDSLANSSDLLK (SEQ ID NO: 32)) no antibody showed a cross reaction with MR-PENK peptides not used for immunization of the antibody. 
     Pro-Enkephalin Immunoassay 
     50 µl of sample (or calibrator) was pipetted into coated tubes, after adding labeled antibody (200 ul), the tubes were incubated for 2 h at 18-25° C. Unbound tracer was removed by washing 5 times (each 1 ml) with washing solution (20 mmol/l PBS, pH 7.4, 0.1% Triton X-100). Tube-bound labelled antibody was measured by using the Luminumeter LB 953 and a fixed concentration of 1000 pmol/l of MRPENK. The signal (RLU at 1000 pmol MRPENK/l) to noise (RLU without MRPENK) ratio of different antibody combinations is given in table 4. All antibodies were able to generate a sandwich complex with any other antibody. Surprisingly, the strongest signal to noise ratio (best sensitivity) was generated by combining the MR-MRPENK and CT-MRPENK antibody. Subsequently, we used this antibody combination to perform the MRPENK-immunoassay for further investigations. MR-MRPENK antibody was used as coated tube antibody and CT-MRPENK antibody was used as labelled antibody.  
     
       
         
          TABLE 4
           
               
               
               
               
               
               
               
             
               
                   
                 Solid phase antibody 
                 NT-MRPENK 
                 NM-MRPENK 
                 MR-MRPENK 
                 MC-MRPENK 
                 CT-MRPENK 
               
             
            
               
                 Labelled antibody 
                   
                   
                   
                   
                   
                   
               
               
                 NT-MRPENK 
                   
                 / 
                 27 
                 212 
                 232 
                 &lt;1 
               
               
                 NM-MRPENK 
                   
                 36 
                 / 
                 451 
                 487 
                 &lt;1 
               
               
                 MR-MRPENK 
                   
                 175 
                 306 
                 / 
                 536 
                 1050 
               
               
                 MC-MRPENK 
                   
                 329 
                 577 
                 542 
                 / 
                 &lt;1 
               
               
                 CT-MRPENK 
                   
                 &lt;1 
                 615 
                 1117 
                 516 
                 / 
               
            
           
         
       
     
     Calibration 
     The assay was calibrated, using dilutions of synthetic MRPENK, diluted in 20 mM K2PO4, 6 mM EDTA, 0.5% BSA, 50 µM Amastatin, 100 µM Leupeptin, pH 8.0. Pro-Enkephalin control plasma is available at ICI-diagnostics, Berlin, Germany. 
       FIG.  1    shows a typical Pro-Enkephalin dose/ signal curve. Standard curve Pro-Enkephalin. 
     The assay sensitivity was 20 determinations of 0-calibrator (no addition of MRPENK) + 2SD) 5.5 pmol/L. 
     Population Study 
     Methods 
     We measured Pro-Enkephalin in fasting plasma from 2559 female participants of the population based Malmö Diet and Cancer Study baseline exam in 1991-1994 (age 58 ± 6 years and 59% females). We used multivariable adjusted (all traditional cardiovascular risk factors, diabetes risk factors and in analyses of cancer also heredity for cancer) Cox proportional hazards models to relate baseline PENK (hazard ratio per each standard deviation increase of log-transformed PENK) to the time to the first event of each of the studied endpoints during a median follow-up time of more than 12 years. Endpoints were retrieved through the Swedish National Hospital Discharge Registry, the Swedish Myocardial Infarction Registry, the Stroke in Malmö Registry and the Swedish Cancer Registry. Retrieval of endpoints through these registries has been validated and found to be accurate (see also Belting et al. Cancer Epidemiol Biomarkers Prev; 1-10. 2012 AACR). 
     Clinical characteristics of females in the study  
     
       
         
          TABLE 5
           
               
               
               
               
             
               
                 Descriptive Statistics 
               
               
                   
                 N 
                 Mean 
                 Std. Deviation 
               
             
            
               
                 Age at MDCS screening 
                 2559 
                 57.554 
                 5.9403 
               
               
                 Systolic blood pressure (mmHg) 
                 2559 
                 140.50 
                 19.311 
               
               
                 Diastolic blood pressure (mmHg) 
                 2559 
                 85.65 
                 9.117 
               
               
                 body-mass-index (weight/kg x kg) 
                 2559 
                 25.5196 
                 4.19083 
               
               
                 WAIST (cm) 
                 2559 
                 76.99 
                 10.245 
               
               
                 Glucose (mmol/l) 
                 2559 
                 5.0418 
                 1.21798 
               
               
                 Triglycerides (mmol/l) 
                 2559 
                 1.2245 
                 0.58404 
               
               
                 High density lipoprotein (mmol/l) 
                 2559 
                 1.5123 
                 0.36949 
               
               
                 Low density lipoprotein (mmol/l) 
                 2559 
                 4.2016 
                 1.04762 
               
               
                 P-INSULIN 
                 2512 
                 7.223 
                 5.4223 
               
            
           
         
       
     
       FIG.  2   : frequence distribution of Pro Enkephalin in the females population: 
     The mean value was 47.2 pmol/L, standard deviation= 1.2 pmol/L. The x axis is the Logarithmus Naturalis (LN) of the PENK concentration. All results were within the measurement of the assay, the lowest PENK concentration was 9 pmol/L. These results indicating the suitability of the used assay (assay sensitivity 5.5 pmol/L). 
     PENK and Prediction of Breast Cancer 
     We assessed the relationship between Pro-Enkephalin and breast cancer (Table 6). There was a strong relationship between Pro-Enkephalin and breast cancer in females. In a fully adjusted model each SD increase of Pro-Enkephalin was associated with a 28.6% risk reduction or each SD of decrease of Pro-Enkephalin (revPENK) was associated with a 40% increased risk of future breast cancer (table 5) and the top versus bottom quartile of Pro-Enkephalin identified a more than 3-fold difference in risk of breast cancer (see table 7 and  FIG.  3   ).  
     
       
         
          TABLE 6
           
               
               
               
               
               
               
               
               
               
             
               
                 Variables in the Equation° 
               
               
                   
                 B 
                 SE 
                 Wald 
                 df 
                 Sig. 
                 Exp(B) 
                 95.0% Cl for Exp(B) 
               
               
                 Lower 
                 Upper 
               
             
            
               
                 AGE 
                 0.007 
                 0.016 
                 0.228 
                 1 
                 0.633 
                 1.007 
                 0.977 
                 1.039 
               
               
                 SEX 
                   
                   
                   
                 0 a 
 
                   
                   
                   
                   
               
               
                 BMI_B 
                 0.026 
                 0.025 
                 1.139 
                 1 
                 0.286 
                 1.027 
                 0.978 
                 1.077 
               
               
                 DM_B 
                 -0.242 
                 0.407 
                 0.352 
                 1 
                 0.553 
                 0.785 
                 0.354 
                 1.744 
               
               
                 HDL_B 
                 0.044 
                 0.252 
                 0.031 
                 1 
                 0.860 
                 1.045 
                 0.638 
                 1.714 
               
               
                 LDL_B 
                 -0.001 
                 0.090 
                 0.000 
                 1 
                 0.988 
                 0.999 
                 0.837 
                 1.191 
               
               
                 current_smoker 
                 0.330 
                 0.195 
                 2.886 
                 1 
                 0.089 
                 1.392 
                 0.950 
                 2.037 
               
               
                 HER_CANCER_0 
                 0.034 
                 0.176 
                 0.038 
                 1 
                 0.846 
                 1.035 
                 0.733 
                 1.461 
               
               
                 LNINS 
                 -0.288 
                 0.197 
                 2.127 
                 1 
                 0.145 
                 0.750 
                 0.509 
                 1.104 
               
               
                 ZscoreLNPENK_ females_noCa 
                 -0.337 
                 0.082 
                 16.858 
                 1 
                 0.000 
                 0.714 
                 0.608 
                 0.839 
               
            
           
         
       
     
     
       
         
          TABLE 7
           
               
               
               
               
               
               
               
               
             
               
                 BREAST CANCER 
               
               
                   
                 HR per 1 SD 
                 P-value 
                 Quartile 4 
                 Quartile 3 
                 Quartile 2 
                 Quartile 1 
                 P for trend 
               
             
            
               
                 Women (2140 / 135) 
                 1.40 (13-1.6) 
                 &lt;0.001 
                 1.0 (ref) 
                 1.50 (0.81-2.1) 
                 2.7(1.7-3.4) 
                 3.6 (2.7-4.9) 
                 &lt;0.001 
               
               
                 Multivariate Cox proportional Hazards models for baseline Pro-Enkephalin versus incidence of breast cancer. 
               
            
           
         
       
     
       FIG.  3   : Kaplan Meier graphs, illustrating the cumulative breast cancer diagnosis in women Quartile (Q) 1 (below 40.4 pmol/l) quartile 2 (40.4-47.1 pmol/l), quartile 3 (47.2-54.1 pmol/l), quartile 4 (above 54.1 pmol/l). Decreased PENK indicates a long term increased risk of breast cancer development. Since any women with cancer history at day of baseline (blood sampling) were excluded, Pro-Enkephalin is highly predictive for future breast cancer development. Over all, women from Q 1 have a 3.6 times higher risk to develop breast cancer than women from Q 4. 
     COMBINATION PRO ENKEPHALIN AND PRO NEUROTENSIN 
     Since increasing Pro-Neurotensin recently was shown to be highly predictive for breast cancer, we combined both biomarkers for breast cancer prediction. 
     EXAMPLES 
     Pro-Neurotensin Assay 
     Antibodies were generated as described above. The antibody for labelling (LA) was generated against P—NT 119 (H-CSDSEEEMKALEADFLTNMH (SEQ ID NO: 24)) and the solid phase antibody (SPA) was generated against peptide P—NT 44—62 (CNLNSPAEETGEVHEEELVA (SEQ ID NO: 25)). 
     Immunoassay for the Quantification of Human Pro-Neurotensin 
     The technology used was a sandwich coated tube luminescence immunoassay, based on Acridinium ester labelling. 
     Labelled compound (tracer): 100 µg (100 µl) LA (1 mg/ml in PBS, pH 7.4, was mixed with 10 µl Acridinium NHS-ester (1 mg/ml in acetonitrile, InVent GmbH, Germany) (EP 0353971) and incubated for 20 min at room temperature. Labelled LA was purified by gel-filtration HPLC on Bio-Sil SEC 400-5 (Bio-Rad Laboratories, Inc., USA) The purified LA was diluted in (300 mmol/l potassiumphosphate, 100 mmol/l NaCl, 10 mmol/l Na-EDTA, 5 g/l bovine serum albumin, pH 7.0). The final concentration was approx. 800.000 relative light units (RLU) of labelled compound (approx. 20 ng labeled antibody) per 200 µl. Acridiniumester chemiluminescence was measured by using an AutoLumat LB 953 (Berthold Technologies GmbH &amp; Co. KG). 
     Solid phase: Polystyrene tubes (Greiner Bio-One International AG, Austria) were coated (18 h at room temperature) with SPA (1.5 µg SPA/0.3 ml 100 mmol/l NaCl, 50 mmol/l Tris/HCl, pH 7.8). After blocking with 5 % bovine serum albumine, the tubes were washed with PBS, pH 7.4 and vakuum dried. 
     Calibration 
     The assay was calibrated, using dilutions of Pro-Neurotensin containing human serum. A pool of human sera with high Pro-Neurotensin immunoreactivity (InVent Diagostika, Hennigsdorf, Germany) was diluted with horse serum (Biochrom AG, Deutschland) (assay standards). 
     The standards were calibrated by use of the human Pro-Neurotensin-calibrator (ICI-Diagnostics, Berlin, Germany). Alternatively, the assay may be calibrated by synthetic or recombinant P—NT 1117 or fragments thereof (see also Ernst et al., 2006). 
     ProNT Immunoassay 
     50 µl of sample (or calibrator) was pipetted into SPA coated tubes, after adding labeleld LA (200 ul), the tubes were incubated for 16-22 h at 18-25° C. Unbound tracer was removed by washing 5 times (each 1 ml) with washing solution (20 mmol/l PBS, pH 7.4, 0.1% Triton X-100). Tube-bound LA was measured by using the Luminumeter LB 953. Results were calculated from the calibration curve. 
     Combined analysis of Pro-Enkephalin and PNT in the female population: There was no significant correlation between Pro-Enkephalin and Pro-Neurotensin (p= 0.56). In a combined model using both biomarkers, we found them both independent in breast cancer prediction. 
     In a fully adjusted model each SD increase of PNT was associated with a 49.9% risk increase of future breast cancer. Surprisingly, after adding PNT to the equation, PENK was even stronger than without PNT and showed for each SD increase of Pro-Enkephalin a 30.8 % risk reduction or each SD of decrease of Pro-Enkephalin (revPENK) was associated with a 44.5% increased risk of future breast cancer (table 8).  
     
       
         
          TABLE 8
           
               
               
               
               
               
               
               
               
               
             
               
                 combined analysis of PNT and PENK for breast cancer prediction 
               
               
                 Variables in the Equation 
               
               
                   
                 B 
                 SE 
                 Wald 
                 df 
                 Sig. 
                 Exp(B) 
                 95.0% Cl for Exp(B) 
               
               
                 Lower 
                 Upper 
               
             
            
               
                 AGE 
                 -0.003 
                 0.019 
                 0.020 
                 1 
                 0.888 
                 0.997 
                 0.960 
                 1.036 
               
               
                 current_smoker0 
                 0.434 
                 0.204 
                 4.505 
                 1 
                 0.034 
                 1.543 
                 1.034 
                 2.304 
               
               
                 BMI_B 
                 0.001 
                 0.027 
                 0.001 
                 1 
                 0.979 
                 1.001 
                 0.948 
                 1.056 
               
               
                 GFR_CG_BSAcorr 
                 -0.005 
                 0.008 
                 0.357 
                 1 
                 0.550 
                 0.995 
                 0.979 
                 1.011 
               
               
                 hrt_curr 
                 0.730 
                 0.201 
                 13.146 
                 1 
                 0.000 
                 2.075 
                 1.399 
                 3.079 
               
               
                 PNT 
                 0.405 
                 0.091 
                 19.731 
                 1 
                 0.000 
                 1.499 
                 1.254 
                 1.793 
               
               
                 PENK 
                 -0.368 
                 0.088 
                 17.416 
                 1 
                 0.000 
                 0.692 
                 0.582 
                 0.823 
               
            
           
         
       
     
     Highest vs. lowest quartile PNT indicated a 2.56 fold risk for breast cancer development and Pro Enkephalin on top of PNT lowest vs highest quartile (rev=reversed quartiles Q1=Q4, Q2=Q3, Q3=Q2, Q4=Q1)) an independent 3.6 fold risk (table 9). 
     Combining highest quartile of PNT and lowest Pro-Enkephalin quartile vs. lowest PNT- and highest Pro -Enkephalin quartile showed a combined risk of 6.17 (see  FIG.  3   ). 
     Table 9: combined analysis of PNT and PENK for breast cancer prediction.  
     
       
         
          TABLE 9
           
               
               
               
               
               
               
               
               
             
               
                 Variables in the Equation 
               
               
                   
                   
                 95.0% Cl SE Wald df Sig. Exp(B) Lower 
               
               
                   
                 B 
               
             
            
               
                 AGE 
                 -0.022 
                 0.018 
                 1.468 
                 1 
                 0.226 
                 0.976 
                 0.943 
               
               
                 current_smoker0 
                 0.391 
                 0.200 
                 3.808 
                   
                 1.051 
                 1.478 
                 0.998 
               
               
                 Nt_curr 
                 0.652 
                 0.195 
                 11.145 
                 1 
                 0.001 
                 1.920 
                 1.309 
               
               
                 BMI_B 
                 0.012 
                 0.025 
                 0.247 
                 1 
                 0.619 
                 1.012 
                 0.964 
               
               
                 GFR_CG_BSAcurr 
                 -0.012 
                 0.008 
                 2.279 
                 1 
                 0.131 
                 0.968 
                 0.972 
               
               
                 NLN_PNT 
                   
                   
                 13.898 
                 3 
                 0.003 
                   
                   
               
               
                 NLN_PNT(1) 
                 0.353 
                 0.301 
                 1.378 
                 1 
                 0.241 
                 1.424 
                 0.789 
               
               
                 NLN_PNT(2) 
                 0.604 
                 0.286 
                 4.452 
                 1 
                 0.035 
                 1.630 
                 1.044 
               
               
                 NLN_PNT(3) 
                 0.942 
                 0.269 
                 12.280 
                 1 
                 0.000 
                 2.566 
                 1.514 
               
               
                 Q_PENK_rev 
                   
                   
                 23.381 
                 3 
                 0.000 
                   
                   
               
               
                 Q_PENK_rev(1) 
                 0.410 
                 0.331 
                 1.534 
                 1 
                 0.215 
                 1.507 
                 0.787 
               
               
                 Q_PENK_rev(2) 
                 0.979 
                 0.306 
                 10.299 
                 1 
                 0.001 
                 2.663 
                 1.464 
               
               
                 Q_PENK_rev(3) 
                 1.284 
                 0.300 
                 18.315 
                 1 
                 0.000 
                 3.610 
                 2.005 
               
            
           
         
       
     
       FIG.  4   : Illustration example of combined analysis of Pro-Enkephalin for breast cancer prediction: 
     We combined the women with lowest Pro-Enkephalin (1 st ) quartile and highest (4 th ) Pro-Neurotensin quartile (group 3). Within that high risk group about 19.02% of women developed breast cancer within the following 15 years. 
     Group 2 is a combination of women with 3 nd  quartile of Pro-Neurotensin and 2 nd  quartile of Pro-Enkephalin plus 2 nd  quartile of Pro-Neurotensin and 3th quartile of Pro-Enkephalin. Within that medium risk group about 7.48% of women developed breast cancer within the following 15 years. 
     Group 1 is a combination of women with 1 st  quartile of Pro-Neurotensin and 4 th  quartile of Pro-Enkephalin. Within that low risk group about 3.08% of women developed breast cancer within the following 15 years. The Hazard risk between group 1 and group 3 is about 6.17. 
     LUNG CANCER 
     Pro-Enkephalin also predicts lung cancer in females. 
     40 women developed lung cancer during the observation period. Pro-Enkephalin is not different in smoking and not smoking women (p=0.44). As expected, smoking is a strong risk prediction marker for lung cancer (p&lt;0.0001). Surprisingly, although smoking is part of the equation, low Pro-Enkephalin indicated a 3.2 fold risk of developing lung cancer (table 10 a and 10 b). 
     Table 10 a and 10 b: PENK in the prediction of lung cancer in females. The women were grouped in tertiles (see table 10 a) and than analyzed for lung cancer development (see table 10 b). rev = highest tertile (tertile 3), rev (1)= tertile 2 and rev(2) = lowest tertile (tertile 1).  
     
       
         
          TABLE 10 a
           
               
               
               
               
             
               
                 PENK [pmol/L] 
               
               
                 Percentile Group of PENKpmolL 
                 Median 
                 Minimum 
                 Maximum 
               
             
            
               
                 1 
                 37.80000 
                 9.000 
                 42.800 
               
               
                 2 
                 47.20000 
                 42.900 
                 51.300 
               
               
                 3 
                 58.30000 
                 51.400 
                 518.100 
               
               
                 Total 
                 47.25000 
                 9.000 
                 518.100 
               
            
           
         
       
     
     
       
         
          TABLE 10 b
           
               
               
               
               
               
               
               
             
               
                 Variables in the Equation 
               
               
                   
                 B 
                 SE 
                 Wald 
                 df 
                 Sig. 
                 Exp(B) 
               
             
            
               
                 AGE 
                 0.045 
                 0.040 
                 1.251 
                 1 
                 0.263 
                 1.046 
               
               
                 current_smokerD 
                 1.897 
                 0.427 
                 19.761 
                 1 
                 0.000 
                 6.667 
               
               
                 BMI_B 
                 -0.034 
                 0.063 
                 0.287 
                 1 
                 0.592 
                 0.967 
               
               
                 GFR_CG_BSAcorr 
                 -0.024 
                 0.019 
                 1.592 
                 1 
                 0.207 
                 0.976 
               
               
                 T_PENK_females_rev 
                   
                   
                 6.698 
                 2 
                 0.035 
                   
               
               
                 T_PENK_females_rev(1) 
                 0.208 
                 0.580 
                 0.128 
                 1 
                 0.721 
                 1.231 
               
               
                 T_PENK_females_rev(2) 
                 1.168 
                 0.511 
                 5.220 
                 1 
                 0.022 
                 3.214 
               
            
           
         
       
     
    
    
     
       FIGURE DESCRIPTION 
         FIG.  1   : shows a typical Pro-Enkephalin dose/ signal curve. Standard curve Pro-Enkephalin. 
         FIG.  2   : frequence distribution of Pro-Enkephalin in the females population: 
         FIG.  3   : Kaplan Meier graphs, illustrating the cumulative breast cancer diagnosis in women quartile (Q) 1 (below 40.4 pmol/l) quartile 2 (40.4-47.1 pmol/l), quartile 3 (47.2-54.1 pmol/l), quartile 4 (above 54.1 pmol/l). Decreased PENK indicates a long term increased risk of breast cancer development. Since any women with cancer history at day of baseline (blood sampling) were excluded, Pro-Enkephalin is highly predictive for future breast cancer development. Over all, women from Q 1 have a 3.6 times higher risk to develop breast cancer than women from Q 4. 
         FIG.  4   : Illustration example of combined analysis of Pro-Enkephalin for breast cancer prediction: