An ERα-Dependent Hypoxia Response Defines EMT-Adjacent Tumour Regions and Suppresses the Pro-survival Effects of Amiloride in Estrogen Receptor-Positive Breast Cancer

Estrogen receptor-positive (ER+) breast cancer carries a lifelong risk of recurrence and disease progression, with hypoxia-associated transcriptional signatures linked to poor prognosis and therapy resistance. While the effects of hypoxia on tumour progression are well studied, the impact on ER epigenomic regulation remains poorly characterised. Here, we demonstrate that activation of hypoxia-inducible factors (HIFs) dramatically remodels ER chromatin localisation in ER+ breast cancer cells. Transcripts of genes located near hypoxia-induced ER binding sites are significantly associated with reduced recurrence-free survival in breast cancer patients. Transcriptomic profiling under hypoxic conditions (1% oxygen), with and without ER depletion by fulvestrant, revealed a hypoxia-induced, ER-dependent gene expression programme, including upregulation of epithelial sodium channel (ENaC) regulatory subunits that results in acquired sensitivity to the ENaC inhibitor amiloride. Notably, this transcriptional response is spatially correlated with the epithelial-to-mesenchymal hallmark in patient tumours. Our findings establish an interdependence between ER signalling and the hypoxic response, and present functional evidence that ER reprogramming offers novel therapeutic opportunities that bypass the need to directly target the hypoxic response.