The importance of estrogen-related receptors (ERRs) in human breast cancer was assessed by comparing their mRNA profiles with established clinicopathological indicators and mRNA profiles of estrogen receptors (ERs) and ErbB family members. Using real-time quantitative PCR assays, mRNA levels of ERalpha, ERbeta, epidermal growth factor receptor, ErbB2, ErbB3, ErbB4, ERRalpha, ERRbeta, and ERRgamma were determined in unselected primary breast tumors (n = 38) and normal mammary epithelial cells enriched from reduction mammoplasties (n = 9). ERRalpha showed potential as a biomarker of unfavorable clinical outcome and, possibly, hormonal insensitivity. ERRalpha mRNA was expressed at levels greater than or similar to ERalpha mRNA in 24% of unselected breast tumors, and generally at higher levels than ERalpha in the progesterone receptor (PgR)-negative tumor subgroup (1-way ANOVA with repeated measures, P = 0.030). Increased ERRalpha levels associated with ER-negative (Fisher's exact, P = 0.003) and PgR-negative tumor status (Fisher's exact, P = 0.006; Kruskal-Wallis ANOVA, P = 0.021). ERRalpha levels also correlated with expression of ErbB2 (Spearman's rho, P = 0.005), an indicator of aggressive tumor behavior. Thus, ERRalpha was the most abundant nuclear receptor in a subset of tumors that tended to lack functional ERalpha and expressed ErbB2 at high levels. Consequently, ERRalpha may potentiate constitutive transcription of estrogen response element-containing genes independently of ERalpha and antiestrogens in ErbB2-positive tumors. ERRbeta's potential as a biomarker remains unclear; it showed a direct relationship with ERbeta (Spearman's rho, P = 0.0002) and an inverse correlation with S-phase fraction (Spearman's rho, P = 0.026). Unlike ERRalpha, ERRgamma showed potential as a biomarker of favorable clinical course and, possibly, hormonal sensitivity. ERRgamma was overexpressed in 75% of the tumors, resulting in the median ERRgamma level being elevated in breast tumors compared with normal mammary epithelial cells (Kruskal-Wallis ANOVA, P = 0.001). ERRgamma overexpression associated with hormonally responsive ER- and PgR-positive status (Fisher's exact, P = 0.054 and P = 0.045, respectively). Additionally, ERRgamma expression correlated with levels of ErbB4 (Spearman's rho, P = 0.052), a likely indicator of preferred clinical course, and associated with diploid-typed tumors (Fisher's exact, P = 0.042). Hence, ERRalpha and ERRgamma status may be predictive of sensitivity to hormonal blockade therapy, and ERRalpha status may also be predictive of ErbB2-based therapy such as Herceptin. Moreover, ERRalpha and ERRgamma are candidate targets for therapeutic development.