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Gu L, Pillay RP, Aronson R, Kaur M. Cholesteryl ester transfer protein knock-down in conjunction with a cholesterol-depleting agent decreases tamoxifen resistance in breast cancer cells. IUBMB Life 2024; 76:712-730. [PMID: 38733508 DOI: 10.1002/iub.2823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/25/2024] [Indexed: 05/13/2024]
Abstract
The cholesterogenic phenotype, encompassing de novo biosynthesis and accumulation of cholesterol, aids cancer cell proliferation and survival. Previously, the role of cholesteryl ester (CE) transfer protein (CETP) has been implicated in breast cancer aggressiveness, but the molecular basis of this observation is not clearly understood, which this study aims to elucidate. CETP knock-down resulted in a >50% decrease in cell proliferation in both 'estrogen receptor-positive' (ER+; Michigan Cancer Foundation-7 (MCF7) breast cancer cells) and 'triple-negative' breast cancer (TNBC; MDA-MB-231) cell lines. Intriguingly, the abrogation of CETP together with the combination treatment of tamoxifen (5 μM) and acetyl plumbagin (a cholesterol-depleting agent) (5 μM) resulted in twofold to threefold increase in apoptosis in both cell lines. CETP knockdown also showed decreased intracellular CE levels, lipid raft and lipid droplets in both cell lines. In addition, RT2 Profiler PCR array (Qiagen, Germany)-based gene expression analysis revealed an overall downregulation of genes associated in cholesterol biosynthesis, lipid signalling and drug resistance in MCF7 cells post-CETP knock-down. On the contrary, resistance in MDA-MB-231 cells was reduced through increased expression in cholesterol efflux genes and the expression of targetable surface receptors by endocrine therapy. The pilot xenograft mice study substantiated CETP's role as a cancer survival gene as knock-down of CETP stunted the growth of TNBC tumour by 86%. The principal findings of this study potentiate CETP as a driver in breast cancer growth and aggressiveness and thus targeting CETP could limit drug resistance via the reduction in cholesterol accumulation in breast cancer cells, thereby reducing cancer aggressiveness.
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Affiliation(s)
- Liang Gu
- Department of School of Molecular and Cell Biology, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruvesh Pascal Pillay
- Department of School of Molecular and Cell Biology, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruth Aronson
- Department of School of Molecular and Cell Biology, University of the Witwatersrand, Johannesburg, South Africa
| | - Mandeep Kaur
- Department of School of Molecular and Cell Biology, University of the Witwatersrand, Johannesburg, South Africa
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Nthontho KC, Ndlovu AK, Sharma K, Kasvosve I, Hertz DL, Paganotti GM. Pharmacogenetics of Breast Cancer Treatments: A Sub-Saharan Africa Perspective. Pharmgenomics Pers Med 2022; 15:613-652. [PMID: 35761855 PMCID: PMC9233488 DOI: 10.2147/pgpm.s308531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Breast cancer is the most frequent cause of cancer death in low- and middle-income countries, in particular among sub-Saharan African women, where response to available anticancer treatment therapy is often limited by the recurrent breast tumours and metastasis, ultimately resulting in decreased overall survival rate. This can also be attributed to African genomes that contain more variation than those from other parts of the world. The purpose of this review is to summarize published evidence on pharmacogenetic and pharmacokinetic aspects related to specific available treatments and the known genetic variabilities associated with metabolism and/or transport of breast cancer drugs, and treatment outcomes when possible. The emphasis is on the African genetic variation and focuses on the genes with the highest strength of evidence, with a close look on CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A4/5, CYP19A1, UGT1A4, UGT2B7, UGT2B15, SLC22A16, SLC38A7, FcγR, DPYD, ABCB1, and SULT1A1, which are the genes known to play major roles in the metabolism and/or elimination of the respective anti-breast cancer drugs given to the patients. The genetic variability of their metabolism could be associated with different metabolic phenotypes that may cause reduced patients' adherence because of toxicity or sub-therapeutic doses. Finally, this knowledge enhances possible personalized treatment approaches, with the possibility of improving survival outcomes in patients with breast cancer.
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Affiliation(s)
- Keneuoe Cecilia Nthontho
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Andrew Khulekani Ndlovu
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | - Ishmael Kasvosve
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Daniel Louis Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Giacomo Maria Paganotti
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana
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Helland T, Alsomairy S, Lin C, Søiland H, Mellgren G, Hertz DL. Generating a Precision Endoxifen Prediction Algorithm to Advance Personalized Tamoxifen Treatment in Patients with Breast Cancer. J Pers Med 2021; 11:jpm11030201. [PMID: 33805613 PMCID: PMC8000933 DOI: 10.3390/jpm11030201] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Tamoxifen is an endocrine treatment for hormone receptor positive breast cancer. The effectiveness of tamoxifen may be compromised in patients with metabolic resistance, who have insufficient metabolic generation of the active metabolites endoxifen and 4-hydroxy-tamoxifen. This has been challenging to validate due to the lack of measured metabolite concentrations in tamoxifen clinical trials. CYP2D6 activity is the primary determinant of endoxifen concentration. Inconclusive results from studies investigating whether CYP2D6 genotype is associated with tamoxifen efficacy may be due to the imprecision in using CYP2D6 genotype as a surrogate of endoxifen concentration without incorporating the influence of other genetic and clinical variables. This review summarizes the evidence that active metabolite concentrations determine tamoxifen efficacy. We then introduce a novel approach to validate this relationship by generating a precision endoxifen prediction algorithm and comprehensively review the factors that must be incorporated into the algorithm, including genetics of CYP2D6 and other pharmacogenes. A precision endoxifen algorithm could be used to validate metabolic resistance in existing tamoxifen clinical trial cohorts and could then be used to select personalized tamoxifen doses to ensure all patients achieve adequate endoxifen concentrations and maximum benefit from tamoxifen treatment.
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Affiliation(s)
- Thomas Helland
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway;
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Correspondence: ; Tel.: +47-92847793
| | - Sarah Alsomairy
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
| | - Chenchia Lin
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway;
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
| | - Daniel Louis Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
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Mulder TAM, de With M, del Re M, Danesi R, Mathijssen RHJ, van Schaik RHN. Clinical CYP2D6 Genotyping to Personalize Adjuvant Tamoxifen Treatment in ER-Positive Breast Cancer Patients: Current Status of a Controversy. Cancers (Basel) 2021; 13:cancers13040771. [PMID: 33673305 PMCID: PMC7917604 DOI: 10.3390/cancers13040771] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Tamoxifen is an important adjuvant endocrine therapy in estrogen receptor (ER)-positive breast cancer patients. It is mainly catalyzed by the enzyme CYP2D6 into the most active metabolite endoxifen. Genetic variation in the CYP2D6 gene influences endoxifen formation and thereby potentially therapy outcome. However, the association between CYP2D6 genotype and clinical outcome on tamoxifen is still under debate, as contradictory outcomes have been published. This review describes the latest insights in both CYP2D6 genotype and endoxifen concentrations, as well CYP2D6 genotype and clinical outcome, from 2018 to 2020. Abstract Tamoxifen is a major option for adjuvant endocrine treatment in estrogen receptor (ER) positive breast cancer patients. The conversion of the prodrug tamoxifen into the most active metabolite endoxifen is mainly catalyzed by the enzyme cytochrome P450 2D6 (CYP2D6). Genetic variation in the CYP2D6 gene leads to altered enzyme activity, which influences endoxifen formation and thereby potentially therapy outcome. The association between genetically compromised CYP2D6 activity and low endoxifen plasma concentrations is generally accepted, and it was shown that tamoxifen dose increments in compromised patients resulted in higher endoxifen concentrations. However, the correlation between CYP2D6 genotype and clinical outcome is still under debate. This has led to genotype-based tamoxifen dosing recommendations by the Clinical Pharmacogenetic Implementation Consortium (CPIC) in 2018, whereas in 2019, the European Society of Medical Oncology (ESMO) discouraged the use of CYP2D6 genotyping in clinical practice for tamoxifen therapy. This paper describes the latest developments on CYP2D6 genotyping in relation to endoxifen plasma concentrations and tamoxifen-related clinical outcome. Therefore, we focused on Pharmacogenetic publications from 2018 (CPIC publication) to 2021 in order to shed a light on the current status of this debate.
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Affiliation(s)
- Tessa A. M. Mulder
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
| | - Mirjam de With
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus MC, Wytemaweg 80, 3015CN Rotterdam, The Netherlands;
| | - Marzia del Re
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 55, Via Roma, 56126 Pisa, Italy
| | - Romano Danesi
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 55, Via Roma, 56126 Pisa, Italy
| | - Ron H. J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus MC, Wytemaweg 80, 3015CN Rotterdam, The Netherlands;
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Correspondence: ; Tel.: +31-10-703-3119
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Slanař O, Hronová K, Bartošová O, Šíma M. Recent advances in the personalized treatment of estrogen receptor-positive breast cancer with tamoxifen: a focus on pharmacogenomics. Expert Opin Drug Metab Toxicol 2020; 17:307-321. [PMID: 33320718 DOI: 10.1080/17425255.2021.1865310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Tamoxifen is still an important drug in hormone-dependent breast cancer therapy. Personalization of its clinical use beyond hormone receptor positivity could improve the substantial variability of the treatment response.Areas covered: The overview of the current evidence for the treatment personalization using therapeutic drug monitoring, or using genetic biomarkers including CYP2D6 is provided. Although many studies focused on the PK aspects or the impact of CYP2D6 variability the translation into clinical routine is not clearly defined due to the inconsistent clinical outcome data.Expert opinion: We believe that at least the main candidate factors, i.e. CYP2D6 polymorphism, CYP2D6 inhibition, endoxifen serum levels may become important predictors of clinical relevance for tamoxifen treatment personalization in the future. To achieve this aim, however, further research should take into consideration more precise characterization of the disease, epigenetic factors and also utilize an appropriately powered multifactorial approach instead of a single gene evaluating studies.
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Affiliation(s)
- Ondřej Slanař
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolína Hronová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Olga Bartošová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
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6
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Optimization of tamoxifen-induced Cre activity and its effect on immune cell populations. Sci Rep 2020; 10:15244. [PMID: 32943672 PMCID: PMC7499195 DOI: 10.1038/s41598-020-72179-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/28/2020] [Indexed: 11/08/2022] Open
Abstract
Tamoxifen (TAM) inducible Cre recombinase system is an essential tool to study gene function when early ablation or overexpression can cause developmental defects or embryonic lethality. However, there remains a lack of consensus on the optimal route and dosage of TAM administration in vivo. Here, we assessed dosage and delivery of TAM for activation of Cre in immune cell subsets assessed longitudinally and spatially using transgenic mice with ubiquitously expressed Cre/ER and the Cre-inducible fluorescent reporter YFP. After comparing two TAM delivery methods (intraperitoneal versus oral gavage) and different doses, we found that 3 mg of TAM administered orally for five consecutive days provides maximal reporter induction with minimal adverse effects in vivo. Serum levels of TAM peaked 1 week after initiating treatment then slowly decreased, regardless of dosing and delivery methods. TAM concentration in specific tissues (liver, spleen, lymph nodes, and thymus) was also dependent on delivery method and dose. Cre induction was highest in myeloid cells and B cells and substantially lower in T cells, and double-positive thymocytes had a notably higher response to TAM. In addition to establishing optimal dose and administration of TAM, our study reveals a disparate activity of Cre in different cell immune populations when using Cre/ER models.
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7
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Ahmed JH, Makonnen E, Fotoohi A, Aseffa A, Howe R, Aklillu E. CYP2D6 Genotype Predicts Plasma Concentrations of Tamoxifen Metabolites in Ethiopian Breast Cancer Patients. Cancers (Basel) 2019; 11:cancers11091353. [PMID: 31547390 PMCID: PMC6770728 DOI: 10.3390/cancers11091353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 12/15/2022] Open
Abstract
Tamoxifen displays wide inter-individual variability (IIV) in its pharmacokinetics and treatment outcome. Data on tamoxifen pharmacokinetics and pharmacogenetics from black African breast cancer patient populations is lacking. We investigated the pharmacokinetic and pharmacogenetic profile of tamoxifen and its major active metabolite, endoxifen, in Ethiopian breast cancer patients. A total of 81 female breast cancer patients on adjuvant tamoxifen therapy were enrolled. Tamoxifen (Tam) and its major metabolites, N-desmethyltamoxifen (NDM), 4-hydroxy-tamoxifen (4-HT), and (Z)-endoxifen (E) were quantified using LC-MS/MS. Genotyping for CYP2D6, CYP2C9, CYP2C19, CYP3A5, POR, and ABCB1 and UGT2B15 and copy number variation for CYP2D6 were done. The proportion of patients with low endoxifen level (<5.9 ng/mL) was 35.8% (median concentration 7.94 ng/mL). The allele frequency of CYP2D6 gene deletion (*5) and duplication (*1×N or *2×N) was 4.3% and 14.8%, respectively. Twenty-six percent of the patients carried duplicated or multiplicated CYP2D6 gene. An increase in CYP2D6 activity score was associated with increased endoxifen concentration and MRE/NDM (p < 0.001). The IIV in endoxifen concentration and MRE/NDM was 74.6% and 59%, respectively. CYP2D6 diplotype explained 28.2% and 44% of the variability in absolute endoxifen concentration and MRE/NDM, respectively. The explanatory power of CYP2D6 diplotype was improved among ABCB1c.4036G carriers (43% and 65.2%, respectively for endoxifen concentration and MRE/NDM) compared to A/A genotype. CYP2C9, CYP2C19, and CYP3A5 genotypes had no significant influence on endoxifen concentration or MRE/NDM. In conclusion, we report a high rate of low endoxifen level as well as large IIV in tamoxifen and its metabolite concentrations. CYP2D6 is significant predictor of plasma endoxifen level in a gene-dose dependent manner.
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Affiliation(s)
- Jemal Hussien Ahmed
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia.
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm 141 86, Sweden.
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia.
- Center for Innovative Drug Development and Therapeutic Trials, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia.
| | - Alan Fotoohi
- Division of Clinical Pharmacology, Department of Medicine, Karolinska Institutet, Solna Stockholm 171 76, Sweden.
| | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa P.O. Box 1005, Ethiopia.
| | - Rawleigh Howe
- Armauer Hansen Research Institute, Addis Ababa P.O. Box 1005, Ethiopia.
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm 141 86, Sweden.
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Abstract
Tamoxifen is a prodrug, and most of the therapeutic effect in treating breast cancer stems from its metabolite, endoxifen. Since cytochrome P450 (CYP) 2D6 is the most important enzyme in the production of endoxifen, drugs that inhibit CYP2D6 would be expected to reduce tamoxifen efficacy. In addition to drug–drug interactions (DDI) involving CYP2D6, there is growing evidence that enzyme inducers can substantially alter the disposition of endoxifen, reducing tamoxifen efficacy. Although the clinical evidence on the impact of CYP2D6 inhibitors on tamoxifen efficacy is mixed, there were serious flaws in many of the studies. Thus, there is a reasonable chance that CYP2D6 inhibitors do in fact inhibit tamoxifen efficacy. Tamoxifen has extraordinarily complex pharmacokinetics, with more than a dozen drug-metabolizing enzymes and transporters involved in its disposition. Enzyme inducers may increase the activity of several of these pathways, including phase II enzymes, ABC transporters, and various CYP enzymes other than CYP2D6. Based on current clinical evidence, one could argue that enzyme inducers are potentially more dangerous than CYP2D6 inhibitors in patients taking tamoxifen. Moreover, early evidence suggests that the combination of CYP2D6 inhibitors plus enzyme inducers may produce catastrophic inhibition of tamoxifen efficacy. One could argue that, given the available evidence, an agnostic “wait and see” position on tamoxifen DDI is ethically untenable, and that many women with breast cancer are currently being subjected to an unnecessary risk of cancer recurrence. Specific recommendations to reduce the risk of adverse tamoxifen DDI are offered for consideration.
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Affiliation(s)
- Philip D Hansten
- Professor Emeritus, School of Pharmacy, University of Washington, Seattle, WA, 98195, USA.
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Cronin-Fenton DP, Damkier P. Tamoxifen and CYP2D6: A Controversy in Pharmacogenetics. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:65-91. [PMID: 29801584 DOI: 10.1016/bs.apha.2018.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tamoxifen reduces the rate of breast cancer recurrence by about one-half. It is converted to more active metabolites by enzymes encoded by polymorphic genes, including cytochrome P450 2D6 (CYP2D6) and transported by ATP-binding cassette transporters. Genetic polymorphisms that confer reduced CYP2D6 activity or concurrent use of CYP2D6-inhibiting drugs may reduce the clinical efficacy of tamoxifen. The issue of the clinical utility of CYP2D6 genotype testing is subject to considerable and ongoing academic and clinical controversy. In this chapter, we outline tamoxifen's clinical pharmacology and give an overview of the research to date on the association between CYP2D6 inhibition and tamoxifen effectiveness. Based on the evidence to date, the impact of drug-induced and/or gene-induced inhibition of CYP2D6 activity is likely to be null or small, or at most moderate in subjects carrying two reduced function alleles. Future research should examine the effect of polymorphisms in genes encoding enzymes in tamoxifen's complete metabolic pathway, should comprehensively evaluate other biomarkers that affect tamoxifen effectiveness, such as the transport enzymes, and focus on subgroups of patients, such as premenopausal breast cancer patients, for whom tamoxifen is the only guideline approved endocrine therapy.
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Affiliation(s)
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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10
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Goetz MP, Sangkuhl K, Guchelaar HJ, Schwab M, Province M, Whirl-Carrillo M, Symmans WF, McLeod HL, Ratain MJ, Zembutsu H, Gaedigk A, van Schaik RH, Ingle JN, Caudle KE, Klein TE. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and Tamoxifen Therapy. Clin Pharmacol Ther 2018; 103:770-777. [PMID: 29385237 PMCID: PMC5931215 DOI: 10.1002/cpt.1007] [Citation(s) in RCA: 207] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/14/2017] [Accepted: 12/23/2017] [Indexed: 12/15/2022]
Abstract
Tamoxifen is biotransformed by CYP2D6 to 4-hydroxytamoxifen and 4-hydroxy N-desmethyl tamoxifen (endoxifen), both with greater antiestrogenic potency than the parent drug. Patients with certain CYP2D6 genetic polymorphisms and patients who receive strong CYP2D6 inhibitors exhibit lower endoxifen concentrations and a higher risk of disease recurrence in some studies of tamoxifen adjuvant therapy of early breast cancer. We summarize evidence from the literature and provide therapeutic recommendations for tamoxifen based on CYP2D6 genotype.
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Affiliation(s)
- Matthew P. Goetz
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Department of Clinical Pharmacology, University Hospital, Tuebingen, Germany
- Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
| | - Michael Province
- Division of Statistical Genomics, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - W. Fraser Symmans
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mark J. Ratain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL
| | - Hitoshi Zembutsu
- Division of Human Genetics, National Cancer Center, Research Institute, Tokyo, Japan
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ron H. van Schaik
- International Expertcenter Pharmacogenetics, Dept Clinical Chemistry, Erasmus MC, Rotterdam, The Netherlands
- LKCH UMC Utrecht, The Netherlands
| | - James N Ingle
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly E. Caudle
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
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Khan BA, Robinson R, Fohner AE, Muzquiz LI, Schilling BD, Beans JA, Olnes MJ, Trawicki L, Frydenlund H, Laukes C, Beatty P, Phillips B, Nickerson D, Howlett K, Dillard DA, Thornton TA, Thummel KE, Woodahl EL. Cytochrome P450 Genetic Variation Associated with Tamoxifen Biotransformation in American Indian and Alaska Native People. Clin Transl Sci 2018; 11:312-321. [PMID: 29436156 PMCID: PMC5944577 DOI: 10.1111/cts.12542] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/12/2017] [Accepted: 01/15/2017] [Indexed: 01/24/2023] Open
Abstract
Despite evidence that pharmacogenetics can improve tamoxifen pharmacotherapy, there are few studies with American Indian and Alaska Native (AIAN) people. We examined variation in cytochrome P450 (CYP) genes (CYP2D6, CYP3A4, CYP3A5, and CYP2C9) and tamoxifen biotransformation in AIAN patients with breast cancer (n = 42) from the Southcentral Foundation in Alaska and the Confederated Salish and Kootenai Tribes in Montana. We tested for associations between CYP diplotypes and plasma concentrations of tamoxifen and metabolites. Only the CYP2D6 variation was significantly associated with concentrations of endoxifen (P = 0.0008) and 4-hydroxytamoxifen (P = 0.0074), tamoxifen's principal active metabolites, as well as key metabolic ratios. The CYP2D6 was also the most significant predictor of active metabolites and metabolic ratios in a multivariate regression model, including all four genes as predictors, with minor roles for other CYP genes. In AIAN populations, CYP2D6 is the largest contributor to tamoxifen bioactivation, illustrating the importance of validating pharmacogenetic testing for therapy optimization in an understudied population.
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Affiliation(s)
- Burhan A. Khan
- Department of Biomedical and Pharmaceutical SciencesUniversity of MontanaMissoulaMontanaUSA
- Southcentral FoundationAnchorageAlaskaUSA
| | | | - Alison E. Fohner
- Institute for Public Health GeneticsUniversity of WashingtonSeattleWashingtonUSA
| | - LeeAnna I. Muzquiz
- Tribal Health DepartmentConfederated Salish and Kootenai TribesMontanaUSA
| | | | | | | | - Laura Trawicki
- Alaska Native Tribal Health ConsortiumAnchorageAlaskaUSA
| | | | - Cindi Laukes
- Department of Biomedical and Pharmaceutical SciencesUniversity of MontanaMissoulaMontanaUSA
- Montana Cancer Institute FoundationMissoulaMontanaUSA
| | - Patrick Beatty
- Montana Cancer Institute FoundationMissoulaMontanaUSA
- Montana Cancer SpecialistsMissoulaMontanaUSA
| | - Brian Phillips
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Deborah Nickerson
- Department of Genome SciencesUniversity of WashingtonSeattleWashingtonUSA
| | - Kevin Howlett
- Tribal Health DepartmentConfederated Salish and Kootenai TribesMontanaUSA
| | | | | | | | - Erica L. Woodahl
- Department of Biomedical and Pharmaceutical SciencesUniversity of MontanaMissoulaMontanaUSA
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Pharmacogenomics Guided-Personalization of Warfarin and Tamoxifen. J Pers Med 2017; 7:jpm7040020. [PMID: 29236081 PMCID: PMC5748632 DOI: 10.3390/jpm7040020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/23/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023] Open
Abstract
The use of pharmacogenomics to personalize drug therapy has been a long-sought goal for warfarin and tamoxifen. However, conflicting evidence has created reason for hesitation in recommending pharmacogenomics-guided care for both drugs. This review will provide a summary of the evidence to date on the association between cytochrome P450 enzymes and the clinical end points of warfarin and tamoxifen therapy. Further, highlighting the clinical experiences that we have gained over the past ten years of running a personalized medicine program, we will offer our perspectives on the utility and the limitations of pharmacogenomics-guided care for warfarin and tamoxifen therapy.
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Marcath LA, Deal AM, Van Wieren E, Danko W, Walko CM, Ibrahim JG, Weck KE, Jones DR, Desta Z, McLeod HL, Carey LA, Irvin WJ, Hertz DL. Comprehensive assessment of cytochromes P450 and transporter genetics with endoxifen concentration during tamoxifen treatment. Pharmacogenet Genomics 2017; 27:402-409. [PMID: 28877533 PMCID: PMC5659294 DOI: 10.1097/fpc.0000000000000311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Tamoxifen bioactivation to endoxifen is mediated primarily by CYP2D6; however, considerable variability remains unexplained. Our aim was to perform a comprehensive assessment of the effect of genetic variation in tamoxifen-relevant enzymes and transporters on steady-state endoxifen concentrations. PATIENTS AND METHODS Comprehensive genotyping of CYP enzymes and transporters was performed using the iPLEX ADME PGx Pro Panel in 302 tamoxifen-treated breast cancer patients. Predicted activity phenotype for 19 enzymes and transporters were analyzed for univariate association with endoxifen concentration, and then adjusted for CYP2D6 and clinical covariates. RESULTS In univariate analysis, higher activity of CYP2C8 (regression β=0.22, P=0.020) and CYP2C9 (β=0.20, P=0.04), lower body weight (β=-0.014, P<0.0001), and endoxifen measurement during winter (each β<-0.39, P=0.002) were associated with higher endoxifen concentrations. After adjustment for the CYP2D6 diplotype, weight, and season, CYP2C9 remained significantly associated with higher concentrations (P=0.02), but only increased the overall model R by 1.3%. CONCLUSION Our results further support a minor contribution of CYP2C9 genetic variability toward steady-state endoxifen concentrations. Integration of clinician and genetic variables into individualized tamoxifen dosing algorithms would marginally improve their accuracy and potentially enhance tamoxifen treatment outcomes.
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Affiliation(s)
- Lauren A Marcath
- aDepartment of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan bUNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina cDeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida dDepartment of Clinical Pharmacology, Indiana University, Indianapolis, Indiana eBon Secours Cancer Institute, Richmond, Virginia, USA
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Damkier P, Kjærsgaard A, Barker KA, Cronin-Fenton D, Crawford A, Hellberg Y, Janssen EAM, Langefeld C, Ahern TP, Lash TL. CYP2C19*2 and CYP2C19*17 variants and effect of tamoxifen on breast cancer recurrence: Analysis of the International Tamoxifen Pharmacogenomics Consortium dataset. Sci Rep 2017; 7:7727. [PMID: 28798474 PMCID: PMC5552748 DOI: 10.1038/s41598-017-08091-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/06/2017] [Indexed: 12/13/2022] Open
Abstract
The role of cytochrome P450 drug metabolizing enzymes in the efficacy of tamoxifen treatment of breast cancer is subject to substantial interest and controversy. CYP2D6 have been intensively studied, but the role of CYP2C19 is less elucidated, and we studied the association of CYPC19 genotype and recurrence of breast cancer. We used outcome and genotyping data from the large publicly available International Tamoxifen Pharmacogenomics Consortium (ITPC) dataset. Cox regression was used to compute the hazard ratios (HRs) for recurrence. CYP2C19 genotype data was available for 2 423 patients and the final sample cohort comprised 2 102 patients. CYP2C19*2 or *19 alleles did not influence DFS. For the CYP2C19*2 allele, the HR was 1.05 (CI 0.78–1.42) and 0.79 (CI 0.32–1.94) for hetero- and homozygote carriers, respectively. The corresponding HR for hetero- and homozygote carriers of the CYP2C19*17 allele were 1.02 (CI 0.71–1.46) and 0.57 (CI 0.26–1.24), respectively. Accounting for CYP2D6 genotype status did not change these estimates. We found no evidence to support a clinically meaningful role of CYP2C19 polymorphisms and response to tamoxifen in breast cancer patients and, consequently, CYP2C19 genotype status should not be included in clinical decisions on tamoxifen treatment.
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Affiliation(s)
- Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Kimberly A Barker
- Department of Microbiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Anatasha Crawford
- Department of Epidemiology, Rollins School of Public Health and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Ylva Hellberg
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Carl Langefeld
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Thomas P Ahern
- Departments of Surgery and Biochemistry, The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, Vermont, USA
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health and Winship Cancer Institute, Emory University, Atlanta, GA, USA
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15
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Lefranc F, Tabanca N, Kiss R. Assessing the anticancer effects associated with food products and/or nutraceuticals using in vitro and in vivo preclinical development-related pharmacological tests. Semin Cancer Biol 2017; 46:14-32. [PMID: 28602819 DOI: 10.1016/j.semcancer.2017.06.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/02/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
Abstract
This review is part of a special issue entitled "Role of dietary pattern, foods, nutrients and nutraceuticals in supporting cancer prevention and treatment" and describes a pharmacological strategy to determine the potential contribution of food-related components as anticancer agents against established cancer. Therefore, this review does not relate to chemoprevention, which is analysed in several other reviews in the current special issue, but rather focuses on the following: i) the biological events that currently represent barriers against the treatment of certain types of cancers, primarily metastatic cancers; ii) the in vitro and in vivo pharmacological pre-clinical tests that can be used to analyse the potential anticancer effects of food-related components; and iii) several examples of food-related components with anticancer effects. This review does not represent a catalogue-based listing of food-related components with more or less anticancer activity. By contrast, this review proposes an original pharmacological strategy that researchers can use to analyse the potential anticancer activity of any food-related component-e.g., by considering the crucial characteristics of cancer biological aggressiveness. This review also highlights that cancer patients undergoing chemotherapy should restrict the use of "food complements" without supervision by a medical nutritionist. By contrast, an equilibrated diet that includes the food-related components listed herein would be beneficial for cancer patients who are not undergoing chemotherapy.
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Affiliation(s)
- Florence Lefranc
- Service de Neurochirurgie, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070 Brussels, Belgium.
| | - Nurhayat Tabanca
- U.S Department of Agriculture-Agricultural Research Service, Subtropical Horticulture Research Station,13601 Old Cutler Rd., Miami, FL 33158, USA.
| | - Robert Kiss
- Retired-formerly at the Fonds National de la Recherche Scientifique (FRS-FNRS, Brussels, Belgium), 5 rue d'Egmont, 1000 Brussels, Belgium.
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Mikelman S, Mardirossian N, Gnegy ME. Tamoxifen and amphetamine abuse: Are there therapeutic possibilities? J Chem Neuroanat 2016; 83-84:50-58. [PMID: 27585851 DOI: 10.1016/j.jchemneu.2016.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/05/2016] [Accepted: 08/14/2016] [Indexed: 12/11/2022]
Abstract
Although best known as a selective estrogen receptor modulator (SERM), tamoxifen is a drug with a wide range of activities. Tamoxifen has demonstrated some efficacy has a therapeutic for bipolar mania and is believed to exert these effects through inhibition of protein kinase C (PKC). As the symptoms of amphetamine treatment in rodents are believed to mimic the symptoms of a manic episode, many of the preclinical studies for this indication have demonstrated that tamoxifen inhibits amphetamine action. The amphetamine-induced increase in extracellular dopamine which gives rise to the 'manic' effects is due to interaction of amphetamine with the dopamine transporter. We and others have demonstrated that PKC reduces amphetamine-induced reverse transport through the dopamine transporter. In this review, we will outline the actions of tamoxifen as a SERM and further detail another known action of tamoxifen-inhibition of PKC. We will summarize the literature showing how tamoxifen affects amphetamine action. Finally, we will present our hypothesis that tamoxifen, or an analog, could be used therapeutically to reduce amphetamine abuse in addition to treating mania.
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Affiliation(s)
- Sarah Mikelman
- Department of Pharmacology, 2220E MSRB III, 1150 West Medical Center Drive, University of Michigan Medical School, Ann Arbor, MI 28109-5632, United States
| | - Natalie Mardirossian
- Department of Pharmacology, 2220E MSRB III, 1150 West Medical Center Drive, University of Michigan Medical School, Ann Arbor, MI 28109-5632, United States
| | - Margaret E Gnegy
- Department of Pharmacology, 2220E MSRB III, 1150 West Medical Center Drive, University of Michigan Medical School, Ann Arbor, MI 28109-5632, United States.
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