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Li X, Zhang Y, Zhang T, Zhao L, Lin CG, Hu H, Zheng H. Tafazzin mediates tamoxifen resistance by regulating cellular phospholipid composition in ER-positive breast cancer. Cancer Gene Ther 2024; 31:69-81. [PMID: 37935981 DOI: 10.1038/s41417-023-00683-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/29/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
Tamoxifen is the frontline therapeutic agent for the estrogen receptor-positive (ER + ) subtype of breast cancer patients, which accounts for 70-80% of total breast cancer incidents. However, clinical resistance to tamoxifen has become increasingly common, highlighting the need to identify the underlying cellular mechanisms. In our study, we employed a genome-scale CRISPR-Cas9 loss-of-function screen and validation experiments to discover that Tafazzin (TAZ), a mitochondrial transacylase, is crucial for maintaining the cellular sensitivity of ER+ breast cancer cells to tamoxifen and other chemotherapies. Mechanistically, we found that cardiolipin, whose synthesis and maturation rely on TAZ, is required to maintain cellular sensitivity to tamoxifen. Loss of metabolic enzymatic activity of TAZ causes ERα downregulation and therapy resistance. Interestingly, we observed that TAZ deficiency also led to the upregulation of lysophosphatidylcholine (LPC), which in turn suppressed ERα expression and nuclear localization, thereby contributing to tamoxifen resistance. LPC is further metabolized to lysophosphatidic acid (LPA), a bioactive molecule that supports cell survival. Thus, our findings suggest that the depletion of TAZ promotes tamoxifen resistance through an LPC-LPA phospholipid synthesis axis, and targeting this lipid metabolic pathway could restore cell susceptibility to tamoxifen treatment.
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Affiliation(s)
- Xuan Li
- State Key Laboratory of Molecular Oncology and Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Beijing, China
| | - Yuan Zhang
- Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Tengjiang Zhang
- Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Luyang Zhao
- State Key Laboratory of Molecular Oncology and Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Christopher G Lin
- State Key Laboratory of Molecular Oncology and Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Haitian Hu
- State Key Laboratory of Molecular Oncology and Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Hanqiu Zheng
- State Key Laboratory of Molecular Oncology and Department of Basic Medical Sciences, School of Medicine, Tsinghua University, 100084, Beijing, China.
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2
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Jayaraman S, Reid JM, Hawse JR, Goetz MP. Endoxifen, an Estrogen Receptor Targeted Therapy: From Bench to Bedside. Endocrinology 2021; 162:6364076. [PMID: 34480554 PMCID: PMC8787422 DOI: 10.1210/endocr/bqab191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Indexed: 11/19/2022]
Abstract
The selective estrogen receptor (ER) modulator, tamoxifen, is the only endocrine agent with approvals for both the prevention and treatment of premenopausal and postmenopausal estrogen-receptor positive breast cancer as well as for the treatment of male breast cancer. Endoxifen, a secondary metabolite resulting from CYP2D6-dependent biotransformation of the primary tamoxifen metabolite, N-desmethyltamoxifen (NDT), is a more potent antiestrogen than either NDT or the parent drug, tamoxifen. However, endoxifen's antitumor effects may be related to additional molecular mechanisms of action, apart from its effects on ER. In phase 1/2 clinical studies, the efficacy of Z-endoxifen, the active isomer of endoxifen, was evaluated in patients with endocrine-refractory metastatic breast cancer as well as in patients with gynecologic, desmoid, and hormone-receptor positive solid tumors, and demonstrated substantial oral bioavailability and promising antitumor activity. Apart from its potent anticancer effects, Z-endoxifen appears to result in similar or even greater bone agonistic effects while resulting in little or no endometrial proliferative effects compared with tamoxifen. In this review, we summarize the preclinical and clinical studies evaluating endoxifen in the context of breast and other solid tumors, the potential benefits of endoxifen in bone, as well as its emerging role as an antimanic agent in bipolar disorder. In total, the summarized body of literature provides compelling arguments for the ongoing development of Z-endoxifen as a novel drug for multiple indications.
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Affiliation(s)
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - John R Hawse
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew P Goetz
- Correspondence: Matthew P. Goetz, MD, Department of Medical Oncology and Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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3
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Ahmed NS, Samec M, Liskova A, Kubatka P, Saso L. Tamoxifen and oxidative stress: an overlooked connection. Discov Oncol 2021; 12:17. [PMID: 35201439 PMCID: PMC8777555 DOI: 10.1007/s12672-021-00411-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
Tamoxifen is the gold standard drug for the treatment of breast cancer in pre and post-menopausal women. Its journey from a failing contraceptive to a blockbuster is an example of pharmaceutical innovation challenges. Tamoxifen has a wide range of pharmacological activities; a drug that was initially thought to work via a simple Estrogen receptor (ER) mechanism was proven to mediate its activity through several non-ER mechanisms. Here in we review the previous literature describing ER and non-ER targets of tamoxifen, we highlighted the overlooked connection between tamoxifen, tamoxifen apoptotic effects and oxidative stress.
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Affiliation(s)
- Nermin S Ahmed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy and Biotechnology, German University in Cairo, Cairo, 11835, Egypt.
| | - Marek Samec
- Department of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 03601, Martin, Slovakia
| | - Alena Liskova
- Department of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 03601, Martin, Slovakia
| | - Peter Kubatka
- Department of Medical Biology, Department of Experimental Carcinogenesis (Biomedical Center Martin, Division of Oncology), Jessenius Faculty of Medicine, Comenius University in Bratislava, Malá Hora 4, 03601, Martin, Slovak Republic
| | - Luciano Saso
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University, P.le Aldo Moro 5, 00185, Rome, Italy
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4
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Rawat RR, Ruderman D, Macklin P, Rimm DL, Agus DB. Correlating nuclear morphometric patterns with estrogen receptor status in breast cancer pathologic specimens. NPJ Breast Cancer 2018; 4:32. [PMID: 30211313 PMCID: PMC6123433 DOI: 10.1038/s41523-018-0084-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022] Open
Abstract
In this pilot study, we introduce a machine learning framework to identify relationships between cancer tissue morphology and hormone receptor pathway activation in breast cancer pathology hematoxylin and eosin (H&E)-stained samples. As a proof-of-concept, we focus on predicting clinical estrogen receptor (ER) status-defined as greater than one percent of cells positive for estrogen receptor by immunohistochemistry staining-from spatial arrangement of nuclear features. Our learning pipeline segments nuclei from H&E images, extracts their position, shape and orientation descriptors, and then passes them to a deep neural network to predict ER status. After training on 57 tissue cores of invasive ductal carcinoma (IDC), our pipeline predicted ER status in an independent test set of patient samples (AUC ROC = 0.72, 95%CI = 0.55-0.89, n = 56). This proof of concept shows that machine-derived descriptors of morphologic histology patterns can be correlated to signaling pathway status. Unlike other deep learning approaches to pathology, our system uses deep neural networks to learn spatial relationships between pre-defined biological features, which improves the interpretability of the system and sheds light on the features the neural network uses to predict ER status. Future studies will correlate morphometry to quantitative measures of estrogen receptor status and, ultimately response to hormonal therapy.
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Affiliation(s)
- Rishi R Rawat
- 1Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California, 2250 Alcazar Street, CSC 240, Los Angeles, CA 90089-9075 USA
| | - Daniel Ruderman
- 1Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California, 2250 Alcazar Street, CSC 240, Los Angeles, CA 90089-9075 USA
| | - Paul Macklin
- 2Intelligent Systems Engineering, Indiana University, 700N. Woodlawn Ave., Bloomington, IN 47408 USA
| | - David L Rimm
- 3Department of Pathology, BML 116, Yale University School of Medicine, 310 Cedar St, PO Box 208023, New Haven, CT 06520-8023 USA
| | - David B Agus
- 1Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California, 2250 Alcazar Street, CSC 240, Los Angeles, CA 90089-9075 USA
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5
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Lin CH, Chuang PY, You SL, Chiang CJ, Huang CS, Wang MY, Chao M, Lu YS, Cheng AL, Tang CH. Effect of glucocorticoid use on survival in patients with stage I-III breast cancer. Breast Cancer Res Treat 2018; 171:225-234. [PMID: 29761323 DOI: 10.1007/s10549-018-4787-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/09/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE Glucocorticoids (GCs) are commonly used in breast cancer patients to ameliorate emesis induced by chemotherapy. Some preclinical studies have suggested that systemic GCs might promote survival of estrogen receptor (ER)-negative breast cancer cells. This study aims to clarify their clinical effect on patient survival. METHODS A total of 18,596 women with newly diagnosed stage I-III breast cancer in 2002-2006 were identified from the Taiwan Cancer Database and drug treatment was examined from the Taiwan National Health Insurance Claims Database. Of these, 3989 who did not receive adjuvant chemotherapy (non-chemotherapy cohort) and 3237 patients who received six cycles of adjuvant anthracycline-based chemotherapy (anthracycline cohort) were included. The impact of GC use on survival was analyzed separately in these two cohorts using Cox proportional hazards models. RESULTS In the non-chemotherapy cohort, GC use was associated with aggressive clinicopathological features of breast cancer. High-dose GC was associated with shorter overall survival in univariate analysis but not in multivariate analysis. In the anthracycline cohort, multivariate analysis showed that GC use at each dose level was significantly associated with longer breast cancer-specific survival (HR 0.65, 0.70, and 0.70 for low-dose, median-dose, and high-dose GC, respectively) and overall survival (HR 0.72, 0.76, and 0.73, respectively) when compared with those receiving no GC. The associations were significant in both ER-positive and ER-negative subgroups for breast cancer-specific survival, and in ER-negative subgroup for overall survival. CONCLUSION Concomitant use of GC improved survival in patients receiving adjuvant anthracycline-based chemotherapy for stage I-III breast cancer.
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Affiliation(s)
- Ching-Hung Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Oncology Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, No. 172-1, Keelung Road, Section 2, Taipei, 106, Taiwan
| | - San-Lin You
- Department of Public Health, College of Medicine, National Taiwan University, Taipei, Taiwan.,Big Data Research Centre, Fu-Jen Catholic University, New Taipei City, Taiwan.,Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Chun-Ju Chiang
- Taiwan Cancer Registry and Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chiun-Sheng Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Yang Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming Chao
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yen-Shen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, No. 172-1, Keelung Road, Section 2, Taipei, 106, Taiwan.
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6
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Knutson TP, Truong TH, Ma S, Brady NJ, Sullivan ME, Raj G, Schwertfeger KL, Lange CA. Posttranslationally modified progesterone receptors direct ligand-specific expression of breast cancer stem cell-associated gene programs. J Hematol Oncol 2017; 10:89. [PMID: 28412963 PMCID: PMC5392969 DOI: 10.1186/s13045-017-0462-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/03/2017] [Indexed: 12/18/2022] Open
Abstract
Background Estrogen and progesterone are potent breast mitogens. In addition to steroid hormones, multiple signaling pathways input to estrogen receptor (ER) and progesterone receptor (PR) actions via posttranslational events. Protein kinases commonly activated in breast cancers phosphorylate steroid hormone receptors (SRs) and profoundly impact their activities. Methods To better understand the role of modified PRs in breast cancer, we measured total and phospho-Ser294 PRs in 209 human breast tumors represented on 2754 individual tissue spots within a tissue microarray and assayed the regulation of this site in human tumor explants cultured ex vivo. To complement this analysis, we assayed PR target gene regulation in T47D luminal breast cancer models following treatment with progestin (promegestone; R5020) and antiprogestins (mifepristone, onapristone, or aglepristone) in conditions under which the receptor is regulated by Lys388 SUMOylation (K388 intact) or is SUMO-deficient (via K388R mutation to mimic persistent Ser294 phosphorylation). Selected phospho-PR-driven target genes were validated by qRT-PCR and following RUNX2 shRNA knockdown in breast cancer cell lines. Primary and secondary mammosphere assays were performed to implicate phospho-Ser294 PRs, epidermal growth factor signaling, and RUNX2 in breast cancer stem cell biology. Results Phospho-Ser294 PR species were abundant in a majority (54%) of luminal breast tumors, and PR promoter selectivity was exquisitely sensitive to posttranslational modifications. Phospho-PR expression and target gene programs were significantly associated with invasive lobular carcinoma (ILC). Consistent with our finding that activated phospho-PRs undergo rapid ligand-dependent turnover, unique phospho-PR gene signatures were most prevalent in breast tumors clinically designated as PR-low to PR-null (luminal B) and included gene sets associated with cancer stem cell biology (HER2, PAX2, AHR, AR, RUNX). Validation studies demonstrated a requirement for RUNX2 in the regulation of selected phospho-PR target genes (SLC37A2). In vitro mammosphere formation assays support a role for phospho-Ser294-PRs via growth factor (EGF) signaling as well as RUNX2 as potent drivers of breast cancer stem cell fate. Conclusions We conclude that PR Ser294 phosphorylation is a common event in breast cancer progression that is required to maintain breast cancer stem cell fate, in part via cooperation with growth factor-initiated signaling pathways and key phospho-PR target genes including SLC37A2 and RUNX2. Clinical measurement of phosphorylated PRs should be considered a useful marker of breast tumor stem cell potential. Alternatively, unique phospho-PR target gene sets may provide useful tools with which to identify patients likely to respond to selective PR modulators that block PR Ser294 phosphorylation as part of rational combination (i.e., with antiestrogens) endocrine therapies designed to durably block breast cancer recurrence. Electronic supplementary material The online version of this article (doi:10.1186/s13045-017-0462-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Todd P Knutson
- Departments of Medicine (Division of Hematology, Oncology, and Transplantation) and Pharmacology, Masonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer and Cardiovascular Research Building, 2231 6th St SE, Minneapolis, MN, 55455, USA
| | - Thu H Truong
- Departments of Medicine (Division of Hematology, Oncology, and Transplantation) and Pharmacology, Masonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer and Cardiovascular Research Building, 2231 6th St SE, Minneapolis, MN, 55455, USA
| | - Shihong Ma
- Department of Urology, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, J8.130C, Dallas, TX, 75390-9110, USA
| | - Nicholas J Brady
- Microbiology, Immunology, and Cancer Biology Graduate Program, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Megan E Sullivan
- Department of Pathology, Evanston Hospital, University of Chicago, NorthShore University HealthSystem, Evanston, IL, 60201, USA
| | - Ganesh Raj
- Department of Urology, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, J8.130C, Dallas, TX, 75390-9110, USA
| | - Kathryn L Schwertfeger
- Department of Laboratory Medicine and Pathology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Carol A Lange
- Departments of Medicine (Division of Hematology, Oncology, and Transplantation) and Pharmacology, Masonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer and Cardiovascular Research Building, 2231 6th St SE, Minneapolis, MN, 55455, USA.
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7
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Chang M. Tamoxifen resistance in breast cancer. Biomol Ther (Seoul) 2014; 20:256-67. [PMID: 24130921 PMCID: PMC3794521 DOI: 10.4062/biomolther.2012.20.3.256] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 05/29/2012] [Accepted: 04/02/2012] [Indexed: 12/21/2022] Open
Abstract
Tamoxifen is a central component of the treatment of estrogen receptor (ER)-positive breast cancer as a partial agonist of ER. It has been clinically used for the last 30 years and is currently available as a chemopreventive agent in women with high risk for breast cancer. The most challenging issue with tamoxifen use is the development of resistance in an initially responsive breast tumor. This review summarizes the roles of ER as the therapeutic target of tamoxifen in cancer treatment, clinical values and issues of tamoxifen use, and molecular mechanisms of tamoxifen resistance. Emerging knowledge on the molecular mechanisms of tamoxifen resistance will provide insight into the design of regimens to overcome tamoxifen resistance and discovery of novel therapeutic agents with a decreased chance of developing resistance as well as establishing more efficient treatment strategies.
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Affiliation(s)
- Minsun Chang
- Department of Medical and Pharmaceutical Science, College of Science, Sookmyung Women's University, Seoul 140-742, Republic of Korea
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8
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Knutson TP, Lange CA. Tracking progesterone receptor-mediated actions in breast cancer. Pharmacol Ther 2014; 142:114-25. [PMID: 24291072 PMCID: PMC3943696 DOI: 10.1016/j.pharmthera.2013.11.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 11/15/2013] [Indexed: 12/13/2022]
Abstract
Ovarian steroid hormones contribute to breast cancer initiation and progression primarily through the actions of their nuclear transcription factors, the estrogen receptor alpha (ERα) and progesterone receptors (PRs). These receptors are important drivers of the luminal A and B subtypes of breast cancer, where estrogen-blocking drugs have been effective endocrine therapies for patients with these tumors. However, many patients do not respond, or become resistant to treatment. When endocrine therapies fail, the luminal subtypes of breast cancer are more difficult to treat because these subtypes are among the most heterogeneous in terms of mutation diversity and gene expression profiles. Recent evidence suggests that progestin and PR actions may be important drivers of luminal breast cancers. Clinical trial data has demonstrated that hormone replacement therapy with progestins drives invasive breast cancer and results in greater mortality. PR transcriptional activity is dependent upon cross-talk with growth factor signaling pathways that alter PR phosphorylation, acetylation, or SUMOylation as mechanisms for regulating PR target gene selection required for increased cell proliferation and survival. Site-specific PR phosphorylation is the primary driver of gene-selective PR transcriptional activity. However, PR phosphorylation and heightened transcriptional activity is coupled to rapid PR protein degradation; the range of active PR detected in tumors is likely to be dynamic. Thus, PR target gene signatures may provide a more accurate means of tracking PR's contribution to tumor progression rather than standard clinical protein-based (IHC) assays. Further development of antiprogestin therapies should be considered alongside antiestrogens and aromatase inhibitors.
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Affiliation(s)
- Todd P Knutson
- Departments of Medicine, Division of Hematology, Oncology, and Transplantation and Pharmacology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Carol A Lange
- Departments of Medicine, Division of Hematology, Oncology, and Transplantation and Pharmacology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA.
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9
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Activation of NFkB is a novel mechanism of pro-survival activity of glucocorticoids in breast cancer cells. Cancer Lett 2013; 337:90-5. [DOI: 10.1016/j.canlet.2013.05.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 05/10/2013] [Accepted: 05/14/2013] [Indexed: 02/07/2023]
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10
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Contopoulos-Ioannidis DG, Ioannidis JPA. Claims for improved survival from systemic corticosteroids in diverse conditions: an umbrella review. Eur J Clin Invest 2012; 42:233-44. [PMID: 21880039 DOI: 10.1111/j.1365-2362.2011.02584.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Systemic corticosteroids have been proposed for numerous indications and there are many claims that corticosteroids can reduce mortality in diverse conditions. METHODS We performed an umbrella, agenda-wide review of the evidence on systemic corticosteroids and mortality, focusing primarily on large trials (defined as those with > 100 deaths) and meta-analyses. Searches were performed in PubMed and Cochrane Central Register of Controlled Trials (last update February 2011). We also examined whether spurious subset analyses may be responsible for claims of survival benefits in indications where only small trials had been available. RESULTS Among 257 identified randomized trials with mortality data in their abstract, we found 14 large trials pertaining to 10 different indications. Although 10 of these 14 trials have reported statistically significant survival differences in subset analyses, none shows a nominally statistically significant (P < 0·05) decrease in death risk for any of the tested conditions when all deaths on all randomized patients are analysed. Meta-analyses for these conditions show statistically significant reductions in mortality only with antenatal corticosteroids for preterm labour (relative risk 0·77, 95% CI, 0·67-0·89) and in tuberculous meningitis (relative risk 0·78, 95% CI, 0·67-0·91). For conditions without any large trials, statistically significant reductions in mortality in meta-analyses were noted for Pneumocystis pneumonia (relative risk 0·54, 95% CI, 0·38-0·79) and alcoholic hepatitis (relative risk 0·63, 95% CI, 0·50-0·80). Many small trials that claim significant benefits, even those for classic indications such as typhoid fever and tetanus, have shown these benefits only in subset analyses. CONCLUSIONS Corticosteroids have been documented to decrease mortality in some indications, in particular, antenatal use for preterm labour, tuberculous meningitis, Pneumocystis pneumonia, and alcoholic hepatitis. Many postulated benefits of corticosteroids on mortality may reflect 'vibration of treatment effects' leading to false-positive claims from spurious subset analyses and even for standard indications, such biases may have inflated the treatment effect estimates. More large trials are needed for serious, common conditions where use of corticosteroids is proposed.
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11
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Keith BD. Systematic review of the clinical effect of glucocorticoids on nonhematologic malignancy. BMC Cancer 2008; 8:84. [PMID: 18373855 PMCID: PMC2330150 DOI: 10.1186/1471-2407-8-84] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 03/28/2008] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Glucocorticoids are often used in the treatment of nonhematologic malignancy. This review summarizes the clinical evidence of the effect of glucocorticoid therapy on nonhematologic malignancy. METHODS A systematic review of clinical studies of glucocorticoid therapy in patients with nonhematologic malignancy was undertaken. Only studies having endpoints of tumor response or tumor control or survival were included. PubMed, EMBASE, the Cochrane Register/Databases, conference proceedings (ASCO, AACR, ASTRO/ASTR, ESMO, ECCO) and other resources were used. Data was extracted using a standard form. There was quality assessment of each study. There was a narrative synthesis of information, with presentation of results in tables. Where appropriate, meta-analyses were performed using data from published reports and a fixed effect model. RESULTS Fifty four randomized controlled trials (RCTs), one meta-analysis, four phase l/ll trials and four case series met the eligibility criteria. Clinical trials of glucocorticoid monotherapy in breast and prostate cancer showed modest response rates. In advanced breast cancer meta-analyses, the addition of glucocorticoids to either chemotherapy or other endocrine therapy resulted in increased response rate, but not increased survival. In GI cancer, there was one RCT each of glucocorticoids vs. supportive care and chemotherapy +/- glucocorticoids; glucocorticoid effect was neutral. The only RCT found of chemotherapy +/- glucocorticoids, in which the glucocorticoid arm did worse, was in lung cancer. In glucocorticoid monotherapy, meta-analysis found that continuous high dose glucocorticoids had a detrimental effect on survival. The only other evidence, for a detrimental effect of glucocorticoid monotherapy, was in one of the two trials in lung cancer. CONCLUSION Glucocorticoid monotherapy has some benefit in breast and prostate cancer. In advanced breast cancer, the addition of glucocorticoids to other therapy does not change the long term outcome. In GI cancer, glucocorticoids most likely have a neutral effect. High dose continuous glucocorticoids have a detrimental effect in nonhematologic malignancy. Glucocorticoid therapy might have a deleterious impact in lung cancer.
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Affiliation(s)
- Bruce D Keith
- Northern Ontario School of Medicine, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada.
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12
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Mouridsen HT. Letrozole in advanced breast cancer: the PO25 trial. Breast Cancer Res Treat 2007; 105 Suppl 1:19-29. [PMID: 17333340 PMCID: PMC2001219 DOI: 10.1007/s10549-007-9527-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 01/16/2007] [Indexed: 11/25/2022]
Abstract
Tamoxifen has been a standard first-line endocrine therapy for post-menopausal women with hormone-responsive advanced breast cancer, but more than half of patients fail to respond and time to progression is less than 12 months in responders. The third-generation aromatase inhibitors were developed to provide more effective alternatives to tamoxifen. In the Femara Study PO25, post-menopausal women with advanced breast cancer were randomized to receive letrozole 2.5 mg (n=453) or tamoxifen 20 mg (n=454) given orally daily until progressive disease occurred. Patients were permitted to cross over to the other treatment at progression. In the primary efficacy analysis, median time to progression (TTP) was significantly longer with letrozole than with tamoxifen (9.4 months vs. 6.0 months, respectively; P<0.0001). The objective response rate (ORR) was significantly higher for letrozole than for tamoxifen (32% vs. 21%; P=0.0002). Prospectively planned analyses of the intent-to-treat population showed that letrozole significantly improved overall survival (OS) compared with tamoxifen over the first 24 months of the trial. An exploratory analysis of patients, who did not cross over, indicated a median OS benefit of 14 months for letrozole compared with tamoxifen. Letrozole is the only third-generation aromatase inhibitor that has demonstrated significant improvements in ORR, TTP, and early OS.
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Affiliation(s)
- Henning T Mouridsen
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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13
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Ring A, Dowsett M. Human epidermal growth factor receptor-2 and hormonal therapies: clinical implications. Clin Breast Cancer 2003; 4 Suppl 1:S34-41. [PMID: 12756077 DOI: 10.3816/cbc.2003.s.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Estrogen-targeted therapies such as administration of tamoxifen or aromatase inhibitors are among the most important treatment strategies in the modern management of breast cancer. Despite initial responses in the metastatic setting and prolonged disease-free intervals in the adjuvant setting, many patients subsequently become resistant to these agents. Human epidermal growth factor receptor-2 (HER2) is a transmembrane glycoprotein receptor that is overexpressed in 13%-30% of human breast cancers. There are experimental data suggesting an important role for HER2 in de novo and acquired resistance to endocrine therapies. These experimental data are discussed in this article, as are clinical data addressing the role of HER2 in resistance to endocrine therapy in the adjuvant, neoadjuvant, and metastatic settings. Responses and benefit from tamoxifen appear to be impaired in patients in whom HER2 is overexpressed. In contrast, early data from the neoadjuvant setting suggest that responses to aromatase inhibitors may be maintained in patients with HER2 overexpression.
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Affiliation(s)
- Alistair Ring
- Department of Academic Biochemistry, Wallace Wing, Royal Marsden Hospital, London, United Kingdom
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14
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Abstract
Tamoxifen has been used in the management of breast cancer for over 30 years. Since its introduction for the treatment of advanced breast cancer, its indications have increased to include the treatment of early breast cancer, ductal carcinoma in situ, and more recently for breast cancer chemoprevention. Tamoxifen has a good tolerability profile and moreover, unlike many other endocrine therapies, it is efficacious in both pre- and postmenopausal women. It is the combination of efficacy and tolerability that allows tamoxifen to maintain its position as the hormonal treatment of choice for most patients with oestrogen-receptor positive breast cancer. Ongoing studies will provide further information about the optimal duration of tamoxifen therapy and how it compares with the newer aromatase inhibitors.
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Affiliation(s)
- M Clemons
- Division of Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.
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15
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Abstract
Randomized controlled trials are generally regarded as the gold standard of study designs to determine causality. The inclusion of a placebo group in these trials, when appropriate, is critical to access the efficacy of a drug or supplement. The placebo response itself has received some attention in the medical literature over the past fifty years. The recent increasing utilization of dietary supplements and herbal medications by patients makes it imperative to reevaluate the placebo response in conventional and alternative medicine. This article will review a whole series of unique conditions (allergies/asthma, alopecia, BPH, erectile dysfunction, osteoporosis, weight loss...) and the placebo response associated with them from conventional medical randomized trials.
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Affiliation(s)
- Mark A Moyad
- Department of Urology (Complementary and Alternative Medicine), University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0330, USA.
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16
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Krishnan AV, Swami S, Feldman D. Estradiol inhibits glucocorticoid receptor expression and induces glucocorticoid resistance in MCF-7 human breast cancer cells. J Steroid Biochem Mol Biol 2001; 77:29-37. [PMID: 11358672 DOI: 10.1016/s0960-0760(01)00030-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Our study has shown that treatment of MCF-7 human breast cancer cells with 17-beta estradiol (E(2)) produced significant decreases in glucocorticoid receptor (GR) concentrations and GR mRNA levels. E(2) pre-treatment of MCF-7 cells stably transfected with the GR responsive pMTV-CAT reporter (MCF-7-MTV cells), caused significant attenuation of dexamethasone (DEX)-induced chloramphenicol acetyl transferase (CAT). In MCF-7 cells transiently transfected with [(GRE)(3)-Luc] reporter plasmid, E(2) pre-treatment significantly suppressed DEX-induced luciferase, which was abolished by the estrogen receptor antagonist ICI 182,780. We examined the effect of chronic E(2) treatment as well as E(2) withdrawal on GR function and abundance. MCF-7-MTV cells were treated with vehicle (control) or E(2) for up to 16 days. A third group received E(2) for 5 days followed by E(2) withdrawal from day 6 to 16. Chronic E(2) treatment almost totally abrogated DEX-induced CAT and reduced GR to very low levels. Interestingly, in the group subjected to E(2) withdrawal, neither the DEX response nor GR abundance recovered and reached control values suggesting that the estrogen mediated suppression is long lasting and could not be easily reversed. The E(2) induced resistance to glucocorticoid action may be of potential clinical significance in a number of settings including breast cancer, neuroendocrine response to stress and osteoporosis and could possibly contribute to the differences in glucocorticoid responsiveness among patients.
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Affiliation(s)
- A V Krishnan
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 95305-5103, USA
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17
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Stein KD, Jacobsen PB, Hann DM, Greenberg H, Lyman G. Impact of hot flashes on quality of life among postmenopausal women being treated for breast cancer. J Pain Symptom Manage 2000; 19:436-45. [PMID: 10908824 DOI: 10.1016/s0885-3924(00)00142-1] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hot flashes are among the most commonly reported symptoms among women who have completed treatment for breast cancer. Relatively little is known, however, about hot flashes among women while they are undergoing breast cancer treatment. The present study investigated the prevalence and severity of hot flashes of women during chemotherapy and radiotherapy for breast cancer. We also sought to identify the medical, demographic, and treatment correlates of hot flashes during treatment and to document the impact of hot flashes on quality of life. Seventy postmenopausal women with breast cancer completed a self-report questionnaire packet during chemotherapy and radiotherapy. Forty percent (n = 28) reported hot flashes during the week prior to assessment. Of the 28 women endorsing hot flashes, 25% (n = 7) rated them as severe, 39% (n = 11) rated them as moderate, and 36% (n = 10) rated them as mild. Women with hot flashes were significantly (p < 0.05) younger and reported significantly (p < 0.001) more fatigue, poorer sleep quality, and poorer physical health compared to women without hot flashes. Multivariate analyses revealed that, even after controlling for relevant medical, demographic, and treatment variables, the prevalence of hot flashes significantly (p < 0.05) predicted poorer sleep quality, more fatigue, and worse physical health. The results indicate that hot flashes are experienced by a sizable percentage of postmenopausal breast cancer patients as they undergo treatment. Hot flashes during cancer treatment appear to have a negative impact upon patient quality of life that may be due, in part, to fatigue and interference with sleep. Future research should seek to evaluate interventions to relieve hot flashes during breast cancer treatment as a means of improving patient quality of life.
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Affiliation(s)
- K D Stein
- Psychosocial Oncology, Programs, University of South Florida H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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18
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Abstract
Estrogens are the most effective therapy for women with postmenopausal problems. However, relatively few women use estrogen and then often for a limited time because of the fear of its carcinogenic effects on the uterus and breast; in addition, estrogen is not advised for women who have had breast cancer. Selective estrogen receptor modulators (SERMs) are agents with antagonist action on the uterus and breast and agonist action on the bones, cardiovascular system, and brain. Unlike estrogens, however, existing SERMs do not help alleviate the vasomotor and urogenital problems associated with menopause. A comprehensive review of the literature published from January 1995 to June 1999 was conducted. Reports were identified using Medline and Cancer Lit. The effect of menopausal problems on the health of women and the socioeconomic effects of menopause are discussed. All currently available and investigational SERMs are reviewed and discussed, including their mechanism of action, metabolism, dose scheduling, antitumor activity, and potential role in maintaining the health of menopausal women and in preventing breast cancer.
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Affiliation(s)
- N K Ibrahim
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, USA.
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19
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Quella SK, Loprinzi CL, Sloan JA, Vaught NL, DeKrey WL, Fischer T, Finck G, Pierson N, Pisansky T. Long term use of megestrol acetate by cancer survivors for the treatment of hot flashes. Cancer 1998. [DOI: 10.1002/(sici)1097-0142(19980501)82:9<1789::aid-cncr27>3.0.co;2-#] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Jeff A. Sloan
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | | | | | | | - Gwen Finck
- Iowa Oncology Research Association CCOP, Des Moines, Iowa
| | - Nancy Pierson
- Sioux Community Cancer Consortium, Sioux Falls, South Dakota
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20
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Abstract
The nonsteroidal antiestrogen tamoxifen is the most widely used anticancer drug. In women with breast cancer, adjuvant therapy with tamoxifen reduces relapse and improves overall survival. In advanced breast cancer, the response rate is more than 50% in hormonal dependent disease. In women treated with adjuvant tamoxifen the incidence of new primary breast cancers is decreased. This latter observation has led to the initiation of prevention trials. In 1989 the first report from a large prospective randomised trial showed a significant increase of endometrial carcinoma among women treated with adjuvant tamoxifen. This effect may be linked to the somewhat paradoxical estrogenic properties of tamoxifen. The endometrial effects should be considered in the long term use of tamoxifen, and should also be taken into account in the evaluation of the prevention trials. Animal data indicate that tamoxifen can induce tumours in other organ systems, for example the liver, but no increase in primary liver cancer has been reported from the randomised trials. In some of these trials an increase in other gastrointestinal cancers (e.g. colon and gastric carcinoma) has been observed. The mechanism behind this may be different from that of the endometrium. In animal systems, tamoxifen has shown to induce DNA damage, with formation of DNA adducts. The risk of secondary gastrointestinal cancer needs to be further evaluated. The adverse effects of tamoxifen have led to the development of new anti-estrogenic drugs and other estrogen reducing agents (e.g. aromatase inhibitors).
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Affiliation(s)
- N Wilking
- Department of Oncology, Radiumhemmet, Karolinska Hospital, Stockholm, Sweden.
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21
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Law TM, Hesketh PJ, Porter KA, Lawn-Tsao L, McAnaw R, Lopez MJ. Breast cancer in elderly women: presentation, survival, and treatment options. Surg Clin North Am 1996; 76:289-308. [PMID: 8610265 DOI: 10.1016/s0039-6109(05)70440-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Recent data suggest that breast cancer in elderly women does not present as more advanced disease, nor is survival significantly inferior to that in younger women. Unfortunately, until recently, older women have been excluded from clinical trials that have determined survival benefit in both screening and treatment modalities. Unless co-morbid conditions adversely affect one's life expectancy or tolerance to therapy, older women should be treated with standard surgical procedures (including breast conservation, if so desired) for early-stage disease, as outcome is comparable to that in younger patients. Adjuvant tamoxifen therapy has proven survival benefit in women over 70 years of age with estrogen receptor-positive tumors and should be considered in all women with tumors greater than 1 cm in size. Older women may experience more chemotherapy-related toxicities. However, for those with a significant risk of recurrence due to tumor size or lymph node status, chemotherapy can be safely administered when factors such as age-related decline in creatinine clearance and co-morbid conditions are considered. Hormonal therapy (tamoxifen) is usually the first-line treatment option over chemotherapy for metastatic disease in the elderly unless the patient has an estrogen receptor-negative tumor, visceral-dominant disease, or significant disease-related symptoms. In the latter settings, chemotherapy can provide improved or more rapid response proportions but does not affect long-term survival.
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Affiliation(s)
- T M Law
- St. Elizabeth's Medical Center, Boston, USA
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22
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Dhodapkar MV, Ingle JN, Cha SS, Mailliard JA, Wieand HS. Prognostic factors in elderly women with metastatic breast cancer treated with tamoxifen: an analysis of patients entered on four prospective clinical trials. Cancer 1996; 77:683-90. [PMID: 8616760 DOI: 10.1002/(sici)1097-0142(19960215)77:4<683::aid-cncr14>3.0.co;2-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Information regarding prognostic factors and survival in elderly women with metastatic breast cancer treated with tamoxifen is limited. METHODS The data from 4 prospective clinical trials were analyzed, including information on 396 postmenopausal women with advanced breast cancer who received tamoxifen as initial therapy for metastatic disease. Emphasis was placed on 184 elderly patients (age greater than 65 years) to characterize the response to therapy, time to progression TTP), overall survival (OS), prognostic factors, and treatment-related toxicity. RESULTS Among 363 patients with measurable or evaluable disease, the objective response rates were higher in the elderly patients (46% versus 33%, P = 0.06); but age did not achieve significance in a logistic regression analysis (P= 0. 1). The median TTP (10.5 months versus 6.2 months, log rank P = 0.002) and OS (35.7 months versus 28.8 months, log rank P = 0.02) were superior in the elderly cohort. In multivariate analysis, age at diagnosis approached statistical significance (P = 0.055) for TTP but was not significant for OS (P = 0.17). Among elderly patients, disease free interval (DFI) (greater than 5 years), dominant disease site (soft tissue), prior adjuvant chemotherapy, positive estrogen/progesterone receptor (ER/PgR) and performance status (PS) were independent prognostic factors. Hot flashes were common in both younger and older cohorts (25% versus 33%, P = 0.14), while anorexia (14% versus 22%, P = 0.04) and mood changes (2% versus 6%, P = 0.03) were more common in the elderly patients. CONCLUSIONS There was no indication that elderly women with metastatic breast cancer treated with tamoxifen have a poorer outcome with regard to response rate, TTP or OS; in fact, they appeared to have a slightly better prognosis although this was not significant after adjustment for other prognostic factors. In elderly patients, DFI, PS, positive ER or PGR, and dominant disease site are independent prognostic factors.
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Affiliation(s)
- M V Dhodapkar
- Division of Medical Oncology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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23
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Abstract
Endocrine treatment plays an important role in the therapy of breast cancer. While the basic mechanisms are understood, additional mechanisms may be of importance to their action and they may also contribute to the mechanism(s) of acquired resistance. Currently, several novel drugs are entering into clinical trials. Observations of the absence or presence of cross resistance to novel 'pure' steroidal antiestrogens and the non-steroidal tamoxifen may add important information to our understanding of the mechanisms of action of both classes of drugs. Similarly, exploration of different aromatase inhibitors in sequence or concert, as well as the combining of different endocrine treatment options may be warranted. Additionally, alterations in different biochemical parameters such as growth factors should not only be carefully explored in relation to treatment options but should also be followed during the course of treatment to asess alterations over time and in relation to the development of drug resistance.
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MESH Headings
- Adrenal Cortex/drug effects
- Adrenal Cortex/physiopathology
- Adult
- Aged
- Animals
- Antineoplastic Agents, Hormonal/classification
- Antineoplastic Agents, Hormonal/pharmacology
- Antineoplastic Agents, Hormonal/therapeutic use
- Aromatase Inhibitors
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/physiopathology
- Breast Neoplasms/therapy
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Drug Resistance, Multiple
- Enzyme Inhibitors/pharmacology
- Enzyme Inhibitors/therapeutic use
- Estrogen Antagonists/adverse effects
- Estrogen Antagonists/pharmacology
- Estrogen Antagonists/therapeutic use
- Estrogens/blood
- Estrogens/physiology
- Female
- Gene Expression Regulation, Neoplastic/drug effects
- Gonadotropin-Releasing Hormone/agonists
- Humans
- Insulin-Like Growth Factor I/antagonists & inhibitors
- Insulin-Like Growth Factor I/physiology
- Mammary Neoplasms, Experimental/drug therapy
- Mammary Neoplasms, Experimental/physiopathology
- Menopause
- Mice
- Middle Aged
- Neoplasm Proteins/antagonists & inhibitors
- Neoplasms, Hormone-Dependent/drug therapy
- Neoplasms, Hormone-Dependent/genetics
- Neoplasms, Hormone-Dependent/physiopathology
- Neoplasms, Hormone-Dependent/therapy
- Progesterone/antagonists & inhibitors
- Progesterone/physiology
- Progestins/antagonists & inhibitors
- Progestins/pharmacology
- Progestins/therapeutic use
- Receptors, Estrogen/drug effects
- Receptors, Estrogen/physiology
- Signal Transduction/drug effects
- Steroids/metabolism
- Tamoxifen/adverse effects
- Tamoxifen/pharmacology
- Tamoxifen/therapeutic use
- Tumor Cells, Cultured/drug effects
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Affiliation(s)
- E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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24
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Fentiman IS, Howell A, Hamed H, Lee SM, Ranson M, Wall J, Chaudary MA, Ash CM, Gregory WM, Sellwood RA. A controlled trial of adjuvant tamoxifen, with or without prednisolone, in post-menopausal women with operable breast cancer. Br J Cancer 1994; 70:729-31. [PMID: 7917929 PMCID: PMC2033384 DOI: 10.1038/bjc.1994.384] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A randomised clinical trial has been conducted to compare adjuvant tamoxifen, 20 mg daily, with tamoxifen and prednisolone, 7.5 mg daily, in post-menopausal women with operable breast cancer. There were 254 evaluable patients, of whom 128 were given tamoxifen alone and 126 received tamoxifen and prednisolone. After a median follow-up of 48 months there was no significant difference in relapse-free or overall survival of the two groups. Furthermore, with survival slightly favouring tamoxifen, confidence intervals on the hazard ratio established that a difference in favour of tamoxifen plus prednisolone of even 5% at 5 years was very unlikely (P < 0.02). Thus, despite the relatively small number of patients in this trial, the data clearly establish that prednisolone is not of value as an additional adjuvant agent.
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Affiliation(s)
- I S Fentiman
- ICRF Clinical Oncology Unit, Guy's Hospital, London, UK
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25
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Kristensen B, Ejlertsen B, Holmegaard SN, Krarup-Hansen A, Transbøl I, Mouridsen H. Prednisolone in the treatment of severe malignant hypercalcaemia in metastatic breast cancer: a randomized study. J Intern Med 1992; 232:237-45. [PMID: 1402620 DOI: 10.1111/j.1365-2796.1992.tb00578.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To determine the effect of prednisolone on severe hypercalcaemia in women with metastatic breast cancer, 30 patients with serum ionized calcium above 1.60 mmol l-1 (reference range 1.15-1.35 mmol l-1) entered a randomized trial. Performance status before entry to the trial and survival time after hypercalcaemia were also noted. All patients received 4 l of isotonic saline daily and 80 mg intravenous furosemide three times daily for 2 d; thereafter they received 3 l of isotonic saline daily and 80 mg furosemide twice daily for 6 d. Fifteen patients were randomized to receive prednisolone, 25 mg orally, three times daily for 8 d. Serum ionized calcium decreased significantly in both groups, but most markedly in the prednisolone group. The median difference was 0.28 mmol l-1 (95% confidence interval (CI), 0.09-0.52) on day 4 and 0.21 mmol l-1 (95% CI, 0.12-0.44) on day 8. In seven prednisolone-treated patients serum ionized calcium normalized, compared to none in the control group (Fisher's exact test; P = 0.028). No severe adverse effects were observed. Prior to detection of hypercalcaemia all patients were severely immobilized, primarily due to bone pain. Only 10 patients were still living after 3 months. Prednisolone, furosemide and rehydration is superior to furosemide and rehydration alone in severely hypercalcaemic patients with metastatic breast cancer in whom immobilization appears to be an early warning sign of life-threatening hypercalcaemia. The short survival time was not influenced by prednisolone.
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Affiliation(s)
- B Kristensen
- Department of Oncology ONK, Rigshospitalet, Copenhagen, Denmark
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