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Lim DW, Li WW, Giannakeas V, Cil TD, Narod SA. Survival of Filipino women with breast cancer in the United States. Cancer Med 2023; 12:19921-19934. [PMID: 37755311 PMCID: PMC10587940 DOI: 10.1002/cam4.6403] [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: 12/03/2022] [Revised: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The survival of women with early-stage breast cancer varies by racial group. Filipino women with breast cancer are an understudied group and are often combined with other Asian groups. We compared clinical presentations and survival rates for Filipino and White women with breast cancer diagnosed in the United States. METHODS We conducted a retrospective cohort study of women with breast cancer diagnosed between 2004 and 2015 in the SEER18 registries database. We compared crude survival between Filipino and White women. We then calculated adjusted hazard ratios (HR) in a propensity-matched design using the Cox proportional hazards model. RESULTS There were 10,834 Filipino (2.5%) and 414,618 White women (97.5%) with Stage I-IV breast cancer in the SEER database. The mean age at diagnosis was 57.5 years for Filipino women and 60.8 years for White women (p < 0.0001). Filipino women had more high-grade and larger tumors than White women and were more likely to have node-positive disease. Among women with Stage I-IIIC breast cancer, the crude 10-year breast cancer-specific survival rate was 91.0% for Filipino and 88.9% for White women (HR 0.81, 95% CI 0.74-0.88, p < 0.01). In a propensity-matched analysis, the HR was 0.73 (95% CI 0.66-0.81). The survival advantage for Filipino women was present in subgroups defined by age of diagnosis, nodal status, estrogen receptor status, and HER2 receptor status. CONCLUSION In the United States, Filipino women often present with more advanced breast cancers than White women, but experience better breast cancer-specific survival.
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Affiliation(s)
- David W. Lim
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Women's College Research Institute, Women's College HospitalTorontoOntarioCanada
- Department of SurgeryWomen's College HospitalTorontoOntarioCanada
- Division of General Surgery, Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Winston W. Li
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Vasily Giannakeas
- Women's College Research Institute, Women's College HospitalTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Tulin D. Cil
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Department of SurgeryWomen's College HospitalTorontoOntarioCanada
- Division of General Surgery, Department of SurgeryUniversity of TorontoTorontoOntarioCanada
- Division of General SurgeryUniversity Health Network (Princess Margaret Cancer Centre)TorontoOntarioCanada
| | - Steven A. Narod
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Women's College Research Institute, Women's College HospitalTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Institute of Medical Science, University of TorontoTorontoOntarioCanada
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Keller DN, Medwid SJ, Ross CD, Wigle TJ, Kim RB. Impact of organic anion transporting polypeptide, P-glycoprotein, and breast cancer resistance protein transporters on observed tamoxifen and endoxifen concentration and adverse effects. Pharmacogenet Genomics 2023; 33:10-18. [PMID: 36373739 DOI: 10.1097/fpc.0000000000000486] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Drug transporters are important determinants of drug disposition and response. Tamoxifen is an antiestrogen for breast cancer therapy known for adverse drug reactions (ADRs). In this study, the involvement of OATP transporters in tamoxifen and endoxifen transport was studied in vitro while the impact of single nucleotide variation (SNV) in OATP and efflux transporters P-glycoprotein ( ABCB1 ) and Breast Cancer Resistance Protein ( ABCG2 ) on ADRs during tamoxifen therapy were assessed. METHODS Patients receiving tamoxifen for breast cancer, who were CYP2D6 normal metabolizers were enrolled ( n = 296). Patients completed a survey that captured ADRs and a blood sample was collected. Tamoxifen and endoxifen plasma concentration were measured, while DNA was genotyped for SNVs in ABCB1, ABCG2, SLCO1A2, SLCO1B1 , and SLCO2B1 . HEK293T cells were used to determine the extent of OATP-mediated transport of tamoxifen and endoxifen. RESULTS Common SNVs of ABCB1, ABCG2, SLCO1A2 , and SLCO1B1 were not associated with tamoxifen or endoxifen concentration. However, tamoxifen concentration was significantly higher in carriers of SLCO2B1 c.935G>A (129.8 ng/mL) compared to wildtype (114.9 ng/mL; P = 0.036). Interestingly, subjects who carried SLCO1A2 c.38A>G reported significantly less dizziness ( P = 0.016). In-vitro analysis demonstrated increased cellular accumulation of tamoxifen in cells overexpressing OATP1A2 and 1B1, but endoxifen uptake was not effected in OATP overexpressing cells. CONCLUSIONS We showed that OATP1A2 , a transporter known to be expressed at the blood-brain barrier, is capable of tamoxifen transport. Additionally, OATP1A2 c.38A>G was associated with reduced ADRs. Taken together, our findings suggest genetic variation in OATP transporters may be an important predictor of tamoxifen ADRs.
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Affiliation(s)
| | | | - Cameron D Ross
- Department of Medicine, University of Western Ontario, Canada
| | | | - Richard B Kim
- Department of Medicine, University of Western Ontario, Canada
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Anabtawi N, Drabison T, Hu S, Sparreboom A, Talebi Z. The role of OATP1B1 and OATP1B3 transporter polymorphisms in drug disposition and response to anticancer drugs: a review of the recent literature. Expert Opin Drug Metab Toxicol 2022; 18:459-468. [PMID: 35983889 DOI: 10.1080/17425255.2022.2113380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Members of the solute carrier family of organic anion transporting polypeptides are responsible for the cellular uptake of a broad range of endogenous compounds and xenobiotics in multiple tissues. In particular, the polymorphic transporters OATP1B1 and OATP1B3 are highly expressed in the liver and have been identified as critical regulators of hepatic eliminaton. As these transporters are also expressed in cancer cells, the function alteration of these proteins have important consequences for an individual's susceptibility to certain drug-induced side effects, drug-drug interactions, and treatment efficacy. AREAS COVERED In this mini-review, we provide an update of this rapidly emerging field, with specific emphasis on the direct contribution of genetic variants in OATP1B1 and OATP1B3 to the transport of anticancer drugs, the role of these carriers in regulation of their disposition and toxicity profiles, and recent advances in attempts to integrate information on transport function in patients to derive individualized treatment strategies. EXPERT OPINION Based on currently available data, it appears imperative that different aspects of disease, physiology, and drugs of relevance should be evaluated along with an individual's genetic signature, and that tools such as biomarker levels can be implemented to achieve the most reliable prediction of clinically relevant pharmacodynamic endpoints.
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Affiliation(s)
- Nadeen Anabtawi
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Thomas Drabison
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Shuiying Hu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio.,Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Zahra Talebi
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
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Ravindranath KJ, Mohaideen NSMH, Srinivasan H. Phytocompounds of Onion Target Heat Shock Proteins (HSP70s) to Control Breast Cancer Malignancy. Appl Biochem Biotechnol 2022; 194:4836-4851. [PMID: 35666379 DOI: 10.1007/s12010-022-04016-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 12/16/2022]
Abstract
Globally, breast cancer is one of the leading invasive cancers in women. Moreover, the use of chemotherapeutic drugs for treating cancer produces toxic side effects and has even led to drug resistance. This research paper focuses on targeting three heat shock proteins belonging to 70 kDa subfamily (HSP70s), predominantly, Mortalin, Binding Immunoglobulin Protein (BiP), and Stress Inducible HSP70 (Stress Inducible Heat Shock Protein 70) involved in breast cancer malignancy using different phytocompounds of onion. Phytocompounds of onion (ligands) obtained from different literature sources and the conventional drug, Tamoxifen (standard ligand), used for treating breast cancer are docked against three HSP70s (target proteins) through molecular docking. Molecular docking helps to determine protein-ligand interactions with minimum binding affinity. A comparative analysis revealed that fourteen phytocompounds of onion have lesser binding affinity and formed more stable complexes with the target proteins compared to that of the conventional drug. This evidence can be used and confirmed further through in vitro (cell culture) and in vivo (animal models) studies, and then, these phytocompounds can be modulated efficiently as potential therapeutics for treating breast cancer with less or nearly no side effects. In Silico work represented here targets three heat shock proteins belonging to 70 kDa subfamily (HSP70s)-Mortalin, Binding Immunoglobulin Protein (BiP), and Stress Inducible HSP70 involved in breast cancer malignancy using different phytocompounds of onion to identify potential phytocompounds that can treat breast cancer with nearly no side effects.
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Affiliation(s)
- Karunya Jenin Ravindranath
- School of Life Sciences, B. S. Abdur Rahman Crescent Institute of Science & Technology, Vandalur, Chennai, 600048, India
| | | | - Hemalatha Srinivasan
- School of Life Sciences, B. S. Abdur Rahman Crescent Institute of Science & Technology, Vandalur, Chennai, 600048, India.
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5
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Pharmacogenetics of Drugs Used in the Treatment of Cancers. Genes (Basel) 2022; 13:genes13020311. [PMID: 35205356 PMCID: PMC8871547 DOI: 10.3390/genes13020311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/01/2023] Open
Abstract
Pharmacogenomics is based on the understanding of the individual differences in drug use, the response to drug therapy (efficacy and toxicity), and the mechanisms underlying variable drug responses. The identification of DNA variants which markedly contribute to inter-individual variations in drug responses would improve the efficacy of treatments and decrease the rate of the adverse side effects of drugs. This review focuses only on the impact of polymorphisms within drug-metabolizing enzymes on drug responses. Anticancer drugs usually have a very narrow therapeutic index; therefore, it is very important to use appropriate doses in order to achieve the maximum benefits without putting the patient at risk of life-threatening toxicities. However, the adjustment of the appropriate dose is not so easy, due to the inheritance of specific polymorphisms in the genes encoding the target proteins and drug-metabolizing enzymes. This review presents just a few examples of such polymorphisms and their impact on the response to therapy.
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6
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Cacabelos R, Naidoo V, Corzo L, Cacabelos N, Carril JC. Genophenotypic Factors and Pharmacogenomics in Adverse Drug Reactions. Int J Mol Sci 2021; 22:ijms222413302. [PMID: 34948113 PMCID: PMC8704264 DOI: 10.3390/ijms222413302] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
Adverse drug reactions (ADRs) rank as one of the top 10 leading causes of death and illness in developed countries. ADRs show differential features depending upon genotype, age, sex, race, pathology, drug category, route of administration, and drug–drug interactions. Pharmacogenomics (PGx) provides the physician effective clues for optimizing drug efficacy and safety in major problems of health such as cardiovascular disease and associated disorders, cancer and brain disorders. Important aspects to be considered are also the impact of immunopharmacogenomics in cutaneous ADRs as well as the influence of genomic factors associated with COVID-19 and vaccination strategies. Major limitations for the routine use of PGx procedures for ADRs prevention are the lack of education and training in physicians and pharmacists, poor characterization of drug-related PGx, unspecific biomarkers of drug efficacy and toxicity, cost-effectiveness, administrative problems in health organizations, and insufficient regulation for the generalized use of PGx in the clinical setting. The implementation of PGx requires: (i) education of physicians and all other parties involved in the use and benefits of PGx; (ii) prospective studies to demonstrate the benefits of PGx genotyping; (iii) standardization of PGx procedures and development of clinical guidelines; (iv) NGS and microarrays to cover genes with high PGx potential; and (v) new regulations for PGx-related drug development and PGx drug labelling.
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Affiliation(s)
- Ramón Cacabelos
- Department of Genomic Medicine, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain
- Correspondence: ; Tel.: +34-981-780-505
| | - Vinogran Naidoo
- Department of Neuroscience, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Lola Corzo
- Department of Medical Biochemistry, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Natalia Cacabelos
- Department of Medical Documentation, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
| | - Juan C. Carril
- Departments of Genomics and Pharmacogenomics, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, 15165 Corunna, Spain;
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7
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Braal CL, Jager A, Hoop EOD, Westenberg JD, Lommen KMWT, de Bruijn P, Vastbinder MB, van Rossum-Schornagel QC, Thijs-Visser MF, van Alphen RJ, Struik LEM, Zuetenhorst HJM, Mathijssen RHJ, Koolen SLW. Therapeutic Drug Monitoring of Endoxifen for Tamoxifen Precision Dosing: Feasible in Patients with Hormone-Sensitive Breast Cancer. Clin Pharmacokinet 2021; 61:527-537. [PMID: 34786650 PMCID: PMC8975771 DOI: 10.1007/s40262-021-01077-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 02/08/2023]
Abstract
Background Endoxifen is the most important active metabolite of tamoxifen. Several retrospective studies have suggested a minimal or threshold endoxifen systemic concentration of 14–16 nM is required for a lower recurrence rate. The aim of this study was to investigate the feasibility of reaching a predefined endoxifen level of ≥ 16 nM (5.97 ng/mL) over time using therapeutic drug monitoring (TDM). Methods This prospective open-label intervention study enrolled patients who started treatment with a standard dose of tamoxifen 20 mg once daily for early breast cancer. An outpatient visit was combined with a TDM sample at 3, 4.5, and 6 months after initiation of the tamoxifen treatment. The tamoxifen dose was escalated to a maximum of 40 mg if patients had an endoxifen concentration < 16 nM. The primary endpoint of the study was the percentage of patients with an endoxifen level ≥ 16 nM at 6 months after the start of therapy compared with historical data, in other words, 80% of patients with endoxifen levels ≥ 16 nM with standard therapy. Results In total, 145 patients were included. After 6 months, 89% of the patients had endoxifen levels ≥ 16 nM, compared with a literature-based 80% of patients with endoxifen levels ≥ 16 nM at baseline (95% confidence interval 82–94; P = 0.007). In patients with an affected CYP2D6 allele, it was not always feasible to reach the predefined endoxifen level of ≥ 16 nM. No increase in tamoxifen-related adverse events was reported after dose escalation. Conclusion This study demonstrated that it is feasible to increase the percentage of patients with endoxifen levels ≥ 16 nM using TDM. TDM is a safe strategy that offers the possibility of nearly halving the number of patients with endoxifen levels < 16 nM.
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Affiliation(s)
- C Louwrens Braal
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Justin D Westenberg
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Koen M W T Lommen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mijntje B Vastbinder
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | | | - Martine F Thijs-Visser
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands.,Department of Internal Medicine, Spijkenisse MC, Spijkenisse, The Netherlands
| | - Robbert J van Alphen
- Department of Internal Medicine, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Liesbeth E M Struik
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.
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8
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Mueller-Schoell A, Michelet R, Klopp-Schulze L, van Dyk M, Mürdter TE, Schwab M, Joerger M, Huisinga W, Mikus G, Kloft C. Computational Treatment Simulations to Assess the Need for Personalized Tamoxifen Dosing in Breast Cancer Patients of Different Biogeographical Groups. Cancers (Basel) 2021; 13:cancers13102432. [PMID: 34069810 PMCID: PMC8157244 DOI: 10.3390/cancers13102432] [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] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Tamoxifen is a drug often used to treat the most common type of breast cancer. Its metabolite endoxifen is formed by the liver enzyme CYP2D6, whose activity is variable and depends on a patient’s genetic profile. The frequency of CYP2D6 variants with different functional enzymatic activity varies largely between populations. To ensure sufficient efficacy of tamoxifen, a certain target concentration of endoxifen is needed, and 20% of White breast cancer patients have been shown not to reach this target concentration. However, little is known about the risk of not attaining the endoxifen target amongst other ethnic populations. This study investigated the risk for suboptimal endoxifen concentration in nine different biogeographical populations based on their distinct CYP2D6 genetic profile. The variability between the populations was high (up to three-fold), and East Asian breast cancer patients were identified as the population with the highest need for personalized tamoxifen dosing. Abstract Tamoxifen is used worldwide to treat estrogen receptor-positive breast cancer. It is extensively metabolized, and minimum steady-state concentrations of its metabolite endoxifen (CSS,min ENDX) >5.97 ng/mL have been associated with favorable outcome. Endoxifen formation is mediated by the enzyme CYP2D6, and impaired CYP2D6 function has been associated with lower CSS,min ENDX. In the Women’s Healthy Eating and Living (WHEL) study proposing the target concentration, 20% of patients showed subtarget CSS,min ENDX at tamoxifen standard dosing. CYP2D6 allele frequencies vary largely between populations, and as 87% of the patients in the WHEL study were White, little is known about the risk for subtarget CSS,min ENDX in other populations. Applying pharmacokinetic simulations, this study investigated the risk for subtarget CSS,min ENDX at tamoxifen standard dosing and the need for dose individualization in nine different biogeographical groups with distinct CYP2D6 allele frequencies. The high variability in CYP2D6 allele frequencies amongst the biogeographical groups resulted in an up to three-fold difference in the percentages of patients with subtarget CSS,min ENDX. Based on their CYP2D6 allele frequencies, East Asian breast cancer patients were identified as the population for which personalized, model-informed precision dosing would be most beneficial (28% of patients with subtarget CSS,min ENDX).
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Lena Klopp-Schulze
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia;
| | - Thomas E. Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, and University Tübingen, 70376 Tübingen, Germany;
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany;
- German Cancer Consortium (DKTK), Partner Site Tübingen, German Cancer Research, 69120 Heidelberg, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University Tübingen, 72076 Tübingen, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St. Gallen, Switzerland;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, 53113 Bonn, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Correspondence:
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