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Harborg S, Cronin-Fenton D, Jensen MBR, Ahern TP, Ewertz M, Borgquist S. Obesity and Risk of Recurrence in Patients With Breast Cancer Treated With Aromatase Inhibitors. JAMA Netw Open 2023; 6:e2337780. [PMID: 37831449 PMCID: PMC10576219 DOI: 10.1001/jamanetworkopen.2023.37780] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023] Open
Abstract
Importance Clinical studies confirm that obesity is a risk factor for recurrence in postmenopausal women with hormone receptor-positive (HR+) breast cancer. Evidence suggests that women with obesity do not obtain similar protection from aromatase inhibitors as women with healthy weight. Objective To examine the associations of body mass index (BMI) with recurrence. Design, Setting, and Participants The cohort study was conducted using data from the Danish Breast Cancer Group and enrolled postmenopausal women diagnosed with stage I to III HR+ breast cancer from 1998 through 2016. Data analysis was conducted from November 2022 to April 2023. Exposures BMI was classified as (1) healthy weight (18.5-24.9), (2) overweight (25.0-29.9), (3) obesity (30.0-34.9), and (4) severe obesity (≥35.0) using the World Health Organization guidelines. Healthy weight was considered the reference group in statistical analyses. Main Outcomes and Measures Follow-up began 6 months after breast cancer surgery and continued until the first event of recurrence, contralateral breast cancer, new primary malignant neoplasm, death, emigration, end of clinical follow-up at 10 years, or September 25, 2018. Cox regression was used to estimate crude and adjusted hazard ratios with 95% CIs, adjusting for patient, tumor, and treatment characteristics. Results A total of 13 230 patients (median [IQR] age at diagnosis, 64.4 [58.6-70.2] years) with information on BMI were enrolled. There were 1587 recurrences with a median (IQR) potential estimated follow-up of 6.2 (3.6-8.5) years. Multivariable analyses revealed increased recurrence hazards associated with obesity (adjusted hazard ratio, 1.18 [95% CI, 1.01-1.37]) and severe obesity (adjusted hazard ratio, 1.32 [95% CI, 1.08-1.62]) vs patients with healthy weight. Patients with overweight had a greater risk, but the results were not statistically significant (adjusted hazard ratio, 1.10 [95% CI, 0.97-1.24]). Conclusions and Relevance In this study, obesity was associated with an increased risk of breast cancer recurrence among postmenopausal patients with HR+ early-stage breast cancer treated with aromatase inhibitors. Physicians should be aware of the significance of obesity on breast cancer outcomes to secure optimal treatment benefit in all patients.
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Affiliation(s)
- Sixten Harborg
- Department of Oncology, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University, Aarhus N, Denmark
| | | | | | - Thomas P. Ahern
- Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Marianne Ewertz
- Oncology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Signe Borgquist
- Department of Oncology, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
- Department of Clinical Sciences, Lund, Oncology, Lund University, Sweden
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2
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Sankofi BM, Valencia-Rincón E, Sekhri M, Ponton-Almodovar AL, Bernard JJ, Wellberg EA. The impact of poor metabolic health on aggressive breast cancer: adipose tissue and tumor metabolism. Front Endocrinol (Lausanne) 2023; 14:1217875. [PMID: 37800138 PMCID: PMC10548218 DOI: 10.3389/fendo.2023.1217875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023] Open
Abstract
Obesity and type 2 diabetes are chronic metabolic diseases that impact tens to hundreds of millions of adults, especially in developed countries. Each condition is associated with an elevated risk of breast cancer and with a poor prognosis after treatment. The mechanisms connecting poor metabolic health to breast cancer are numerous and include hyperinsulinemia, inflammation, excess nutrient availability, and adipose tissue dysfunction. Here, we focus on adipose tissue, highlighting important roles for both adipocytes and fibroblasts in breast cancer progression. One potentially important mediator of adipose tissue effects on breast cancer is the fibroblast growth factor receptor (FGFR) signaling network. Among the many roles of FGFR signaling, we postulate that key mechanisms driving aggressive breast cancer include epithelial-to-mesenchymal transition and cellular metabolic reprogramming. We also pose existing questions that may help better understand breast cancer biology in people with obesity, type 2 diabetes, and poor metabolic health.
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Affiliation(s)
- Barbara Mensah Sankofi
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Estefania Valencia-Rincón
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Malika Sekhri
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adriana L. Ponton-Almodovar
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI, United States
- Nicolas V. Perricone Division of Dermatology, Michigan State University, East Lansing, MI, United States
- Department of Medicine, Michigan State University, East Lansing, MI, United States
| | - Jamie J. Bernard
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI, United States
- Nicolas V. Perricone Division of Dermatology, Michigan State University, East Lansing, MI, United States
- Department of Medicine, Michigan State University, East Lansing, MI, United States
| | - Elizabeth A. Wellberg
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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3
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Barone I, Caruso A, Gelsomino L, Giordano C, Bonofiglio D, Catalano S, Andò S. Obesity and endocrine therapy resistance in breast cancer: Mechanistic insights and perspectives. Obes Rev 2022; 23:e13358. [PMID: 34559450 PMCID: PMC9285685 DOI: 10.1111/obr.13358] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/07/2021] [Accepted: 08/13/2021] [Indexed: 12/24/2022]
Abstract
The incidence of obesity, a recognized risk factor for various metabolic and chronic diseases, including numerous types of cancers, has risen dramatically over the recent decades worldwide. To date, convincing research in this area has painted a complex picture about the adverse impact of high body adiposity on breast cancer onset and progression. However, an emerging but overlooked issue of clinical significance is the limited efficacy of the conventional endocrine therapies with selective estrogen receptor modulators (SERMs) or degraders (SERDs) and aromatase inhibitors (AIs) in patients affected by breast cancer and obesity. The mechanisms behind the interplay between obesity and endocrine therapy resistance are likely to be multifactorial. Therefore, what have we actually learned during these years and which are the main challenges in the field? In this review, we will critically discuss the epidemiological evidence linking obesity to endocrine therapeutic responses and we will outline the molecular players involved in this harmful connection. Given the escalating global epidemic of obesity, advances in understanding this critical node will offer new precision medicine-based therapeutic interventions and more appropriate dosing schedule for treating patients affected by obesity and with breast tumors resistant to endocrine therapies.
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Affiliation(s)
- Ines Barone
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Amanda Caruso
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Luca Gelsomino
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Cinzia Giordano
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Daniela Bonofiglio
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Stefania Catalano
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
| | - Sebastiano Andò
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, Cosenza, Italy
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Soulières D, Gelmon KA. Sotorasib: Is Maximum Tolerated Dose Really the Issue at Hand? J Clin Oncol 2021; 39:3427-3429. [PMID: 34543060 DOI: 10.1200/jco.21.02072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Denis Soulières
- Section of Hematology/Oncology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Karen A Gelmon
- Department of Medical Oncology, British-Columbia Cancer Agency, Vancouver, BC, Canada
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5
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Kumar S, Freelander A, Lim E. Type 1 Nuclear Receptor Activity in Breast Cancer: Translating Preclinical Insights to the Clinic. Cancers (Basel) 2021; 13:4972. [PMID: 34638457 PMCID: PMC8507977 DOI: 10.3390/cancers13194972] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/30/2022] Open
Abstract
The nuclear receptor (NR) family of transcription factors is intimately associated with the development, progression and treatment of breast cancer. They are used diagnostically and prognostically, and crosstalk between nuclear receptor pathways and growth factor signalling has been demonstrated in all major subtypes of breast cancer. The majority of breast cancers are driven by estrogen receptor α (ER), and anti-estrogenic therapies remain the backbone of treatment, leading to clinically impactful improvements in patient outcomes. This serves as a blueprint for the development of therapies targeting other nuclear receptors. More recently, pivotal findings into modulating the progesterone (PR) and androgen receptors (AR), with accompanying mechanistic insights into NR crosstalk and interactions with other proliferative pathways, have led to clinical trials in all of the major breast cancer subtypes. A growing body of evidence now supports targeting other Type 1 nuclear receptors such as the glucocorticoid receptor (GR), as well as Type 2 NRs such as the vitamin D receptor (VDR). Here, we reviewed the existing preclinical insights into nuclear receptor activity in breast cancer, with a focus on Type 1 NRs. We also discussed the potential to translate these findings into improving patient outcomes.
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Affiliation(s)
- Sanjeev Kumar
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, Darlinghurst 2010, Australia; (A.F.); (E.L.)
- Garvan Institute of Medical Research, University of New South Wales, Darlinghurst 2010, Australia
| | - Allegra Freelander
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, Darlinghurst 2010, Australia; (A.F.); (E.L.)
- Garvan Institute of Medical Research, University of New South Wales, Darlinghurst 2010, Australia
| | - Elgene Lim
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, Darlinghurst 2010, Australia; (A.F.); (E.L.)
- Garvan Institute of Medical Research, University of New South Wales, Darlinghurst 2010, Australia
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6
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The Tumor Promotional Role of Adipocytes in the Breast Cancer Microenvironment and Macroenvironment. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:1342-1352. [PMID: 33639102 DOI: 10.1016/j.ajpath.2021.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
The role of the adipocyte in the tumor microenvironment has received significant attention as a critical mediator of the obesity-cancer relationship. Current estimates indicate that 650 million adults have obesity, and thirteen cancers, including breast cancer, are estimated to be associated with obesity. Even in people with a normal body mass index, adipocytes are key players in breast cancer progression because of the proximity of tumors to mammary adipose tissue. Outside the breast microenvironment, adipocytes influence metabolic and immune function and produce numerous signaling molecules, all of which affect breast cancer development and progression. The current epidemiologic data linking obesity, and importantly adipose tissue, to breast cancer risk and prognosis, focusing on metabolic health, weight gain, and adipose distribution as underlying drivers of obesity-associated breast cancer is presented here. Bioactive factors produced by adipocytes, both normal and cancer associated, such as cytokines, growth factors, and metabolites, and the potential mechanisms through which adipocytes influence different breast cancer subtypes are highlighted.
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7
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Aromatase and CDK4/6 Inhibitor-Induced Musculoskeletal Symptoms: A Systematic Review. Cancers (Basel) 2021; 13:cancers13030465. [PMID: 33530456 PMCID: PMC7865932 DOI: 10.3390/cancers13030465] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Treatment with aromatase inhibitors (AIs) is fundamental in women with hormone receptor-positive breast cancer in the adjuvant as well as the metastatic setting. Even though it is considered to be a well-tolerated therapy, aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) is the most common adverse event encountered by breast cancer patients. CDK4/6 inhibitors have emerged as a new treatment strategy in metastatic hormone receptor-positive breast cancer. However, the impact of CDK4/6 inhibitors on musculoskeletal symptoms caused by AIs is not well-defined. OBJECTIVES This systematic review aims to identify the frequency of joint symptoms induced by treatment with AIs and CDK4/6 inhibitors in the metastatic setting. SEARCH STRATEGY Eligible articles were identified by a search of existing literature for the period 2005/01/01-2021/01/01; The algorithm consisted of a predefined combination of the following keywords "breast", "cancer", "aromatase inhibitors", "CDK4/6", "phase III". SELECTION CRITERIA This study was performed in accordance with PRISMA guidelines. All randomized controlled Phase III trials (RCTs) evaluating the administration of third-generation aromatase inhibitors (AIs) and CDK4/6 inhibitors in postmenopausal women in the metastatic setting were considered eligible for this review. DATA COLLECTION Overall, 16 randomized control trials (RCTs) were retrieved, of which nine studies explored the administration of AIs in the metastatic setting and seven studies investigated the combination of CDK4/6 inhibitors and AIs. Arthralgia was reported in 1-47% of patients treated with AIs and 5.8-33.3% of patients treated with CDK4/6 inhibitors. Myalgias occurred in 2-23.7% of patients receiving AIs compared with 4.8-11.9% of patients treated with CDK4/6 inhibitors. The incidence of back pain was 7-32.9% vs. 2.9-8.5% in postmenopausal women with metastatic disease treated with AIs and CDK4/6 inhibitors, respectively. Bone pain was reported in 7-32.9% of postmenopausal women treated with AIs and 2.9-8.5% of women treated with CDK4/6 inhibitors. CONCLUSIONS AI treatment-induced musculoskeletal syndrome is an adverse event affecting over one-third (20-47%) of postmenopausal patients treated with AIs that often leads to treatment discontinuation. Data from RCTs provide evidence that the incidence of musculoskeletal symptoms is relatively decreased upon CDK4/6 inhibitor administration. CDK4/6 inhibitors may provide a protective role against AIMSS development.
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8
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Giles ED, Wellberg EA. Preclinical Models to Study Obesity and Breast Cancer in Females: Considerations, Caveats, and Tools. J Mammary Gland Biol Neoplasia 2020; 25:237-253. [PMID: 33146844 PMCID: PMC8197449 DOI: 10.1007/s10911-020-09463-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/09/2020] [Indexed: 12/28/2022] Open
Abstract
Obesity increases the risk for breast cancer and is associated with poor outcomes for cancer patients. A variety of rodent models have been used to investigate these relationships; however, key differences in experimental approaches, as well as unique aspects of rodent physiology lead to variability in how these valuable models are implemented. We combine expertise in the development and implementation of preclinical models of obesity and breast cancer to disseminate effective practices for studies that integrate these fields. In this review, we share, based on our experience, key considerations for model selection, highlighting important technical nuances and tips for use of preclinical models in studies that integrate obesity with breast cancer risk and progression. We describe relevant mouse and rat paradigms, specifically highlighting differences in breast tumor subtypes, estrogen production, and strategies to manipulate hormone levels. We also outline options for diet composition and housing environments to promote obesity in female rodents. While we have applied our experience to understanding obesity-associated breast cancer, the experimental variables we incorporate have relevance to multiple fields that investigate women's health.
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Affiliation(s)
- Erin D Giles
- Department of Nutrition, Texas A&M University, College Station, TX, USA.
| | - Elizabeth A Wellberg
- Department of Pathology, University of Oklahoma Health Science Center, Stephenson Cancer Center, Harold Hamm Diabetes Center, Oklahoma City, OK, USA
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9
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Ratre P, Mishra K, Dubey A, Vyas A, Jain A, Thareja S. Aromatase Inhibitors for the Treatment of Breast Cancer: A Journey from the Scratch. Anticancer Agents Med Chem 2020; 20:1994-2004. [DOI: 10.2174/1871520620666200627204105] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 03/15/2020] [Indexed: 01/08/2023]
Abstract
Background:
Estrogens are essential for the growth of breast cancer in the case of premenopausal as
well as in postmenopausal women. However, most of the breast cancer incidences are reported in postmenopausal
women and the concurrent risk surges with an increase in age. Since the enzyme aromatase catalyses
essential steps in estrogen biosynthesis, Aromatase Inhibitors (AIs) are effective targeted therapy in patients
with Estrogen Receptor positive (ER+) breast cancer. AIs are more effective than Selective Estrogen Receptor
Modulators (SERMs) because they block both the genomic and nongenomic activities of ER. Till date, first,
second and third-generation AIs have been approved by the FDA. The third-generation AIs, viz. Letrozole,
Anastrozole, Exemestane, are currently used in the standard treatment for postmenopausal breast cancer.
Methods:
Data were collected from Medline, PubMed, Google Scholar, Science Direct through searching of
keywords: ‘aromatase’, ‘aromatase inhibitors’, ‘breast cancer’, ‘steroidal aromatase inhibitors’, ‘non-steroidal
inhibitors’ and ‘generations of aromatase inhibitors’.
Results:
In the current scenario of breast cancer chemotherapy, AIs are the most widely used agents which reveal
optimum efficacy along with the least side effects. Keeping in view the prominence of AIs in breast cancer
therapy, this review covered the detailed description of aromatase including its role in the biosynthesis of estrogen,
biochemistry, gene expression, 3D-structure, and information of reported AIs along with their role in breast
cancer treatment.
Conclusion:
AIs are the mainstream solution of the ER+ breast cancer treatment regimen with the continuous
improvement of human understanding of the importance of a healthy life of women suffering from breast cancer.
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Affiliation(s)
- Pooja Ratre
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Keerti Mishra
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Amit Dubey
- Chhattisgarh Council of Science and Technology, Raipur-492 014 (C.G.), India
| | - Amber Vyas
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur-492 010 (C.G.), India
| | - Akhlesh Jain
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Suresh Thareja
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
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10
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McAndrew NP, Finn RS. Management of ER positive metastatic breast cancer. Semin Oncol 2020; 47:270-277. [PMID: 32958261 DOI: 10.1053/j.seminoncol.2020.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 12/29/2022]
Abstract
There are over 2 million cases a year of breast cancer, leading to over 600,000 deaths globally [1]. Despite these large numbers, increasingly more women are being cured with early stage disease and women with advanced disease are living longer [2]. The appreciation for molecular subtypes of the disease has led to significant therapeutic advances and estrogen receptor positive (ER+) breast cancer represents the largest of these subgroups. An appreciation for the importance of estrogen signaling in ER+ dates back to 1896 when Dr. George Thomas Beatson observed impressive disease responses after performing bilateral oophorectomy in 3 women at Glasgow Cancer Hospital [3]. The evolution of treatment for advanced disease from progestins, to the selective estrogen receptor modulator tamoxifen, and subsequently the aromatase inhibitors and the selective estrogen receptor degrader fulvestrant, has been accompanied by improved efficacy and decreased side effects. While the use of these drugs has changed the natural history of both early and advanced disease, it has been long recognized that many patients will develop resistance to this approach. After many years of trying to improve on single-agent endocrine treatment, since 2012 there has been an explosion of new drugs that have shown improved efficacy in combination with endocrine approaches. The first of these to receive FDA approval was the mTOR inhibitor everolimus (2012) [4], followed by the approval of 3 cyclin-dependent kinase 4 and 6 (CDK 4/6) inhibitors [palbociclib (2015) [5], ribociclib (2018) [6], and abemaciclib (2018) [7]], and more recently the PI3-kinase inhibitor alpelisib (2019) [8]. In addition, chemotherapy is still used frequently when endocrine manipulations have been exhausted. Like other incurable malignancies, the goal in advanced ER+ breast cancer is to prolong survival and maintain quality of life. Currently, we have more tools available to achieve this than ever before and we will review the efficacy and side effect data with these agents that are driving physician choices for individual patients.
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Affiliation(s)
- Nicholas P McAndrew
- Division of Hematology Oncology, Department of Medicine, Geffen School of Medicine at UCLA, Santa Monica, CA 90404, United States
| | - Richard S Finn
- Division of Hematology Oncology, Department of Medicine, Geffen School of Medicine at UCLA, Santa Monica, CA 90404, United States.
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Küpeli Akkol E, Genç Y, Karpuz B, Sobarzo-Sánchez E, Capasso R. Coumarins and Coumarin-Related Compounds in Pharmacotherapy of Cancer. Cancers (Basel) 2020; 12:cancers12071959. [PMID: 32707666 PMCID: PMC7409047 DOI: 10.3390/cancers12071959] [Citation(s) in RCA: 173] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 12/19/2022] Open
Abstract
Cancer is one of the most common causes of disease-related deaths worldwide. Despite the discovery of many chemotherapeutic drugs that inhibit uncontrolled cell division processes for the treatment of various cancers, serious side effects of these drugs are a crucial disadvantage. In addition, multi-drug resistance is another important problem in anticancer treatment. Due to problems such as cytotoxicity and drug resistance, many investigations are being conducted to discover and develop effective anticancer drugs. In recent years, researchers have focused on the anticancer activity coumarins, due to their high biological activity and low toxicity. Coumarins are commonly used in the treatment of prostate cancer, renal cell carcinoma and leukemia, and they also have the ability to counteract the side effects caused by radiotherapy. Both natural and synthetic coumarin derivatives draw attention due to their photochemotherapy and therapeutic applications in cancer. In this review, a compilation of various research reports on coumarins with anticancer activity and investigation and a review of structure-activity relationship studies on coumarin core are presented. Determination of important structural features around the coumarin core may help researchers to design and develop new analogues with a strong anticancer effect and reduce the potential side effects of existing therapeutics.
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Affiliation(s)
- Esra Küpeli Akkol
- Department of Pharmacognosy, Faculty of Pharmacy, Gazi University, Etiler 06330, Ankara, Turkey;
- Correspondence: (E.K.A.); (R.C.); Tel.: +90-312-2023185 (E.K.A); +39-081-678664 (R.C.)
| | - Yasin Genç
- Department of Pharmacognosy, Faculty of Pharmacy, Hacettepe University, Sıhhiye 06100, Ankara, Turkey;
| | - Büşra Karpuz
- Department of Pharmacognosy, Faculty of Pharmacy, Gazi University, Etiler 06330, Ankara, Turkey;
| | - Eduardo Sobarzo-Sánchez
- Instituto de Investigación e Innovación en Salud, Facultad de Ciencias de la Salud, Universidad Central de Chile, 8330507 Santiago, Chile;
- Department of Organic Chemistry, Faculty of Pharmacy, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
| | - Raffaele Capasso
- Department of Agricultural Sciences, University of Naples Federico II, 80055 Portici (Naples), Italy
- Correspondence: (E.K.A.); (R.C.); Tel.: +90-312-2023185 (E.K.A); +39-081-678664 (R.C.)
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12
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Snell CE, Gough M, Liu C, Middleton K, Pyke C, Shannon C, Woodward N, Hickey TE, Armes JE, Tilley WD. Improved relapse-free survival on aromatase inhibitors in breast cancer is associated with interaction between oestrogen receptor-α and progesterone receptor-b. Br J Cancer 2018; 119:1316-1325. [PMID: 30410061 PMCID: PMC6265321 DOI: 10.1038/s41416-018-0331-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/14/2018] [Accepted: 10/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Recent pre-clinical studies indicate that activated progesterone receptor (PR) (particularly the PR-B isoform) binds to oestrogen receptor-α (ER) and reprogrammes transcription toward better breast cancer outcomes. We investigated whether ER and PR-B interactions were present in breast tumours and associated with clinical parameters including response to aromatase inhibitors. METHODS We developed a proximity ligation assay to detect ER and PR-B (ER:PR-B) interactions in formalin-fixed paraffin-embedded tissues. The assay was validated in a cell line and patient-derived breast cancer explants and applied to a cohort of 229 patients with ER-positive and HER2-negative breast cancer with axillary nodal disease. RESULTS Higher frequency of ER:PR-B interaction correlated with increasing patient age, lower tumour grade and mitotic index. A low frequency of ER:PR-B interaction was associated with higher risk of relapse. In multivariate analysis, ER:PR-B interaction frequency was an independent predictive factor for relapse, whereas PR expression was not. In subset analysis, low frequency of ER:PR-B interaction was predictive of relapse on adjuvant aromatase inhibitor (HR 4.831, p = 0.001), but not on tamoxifen (HR 1.043, p = 0.939). CONCLUSIONS This study demonstrates that ER:PR-B interactions have utility in predicting patient response to adjuvant AI therapy.
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Affiliation(s)
- Cameron E Snell
- Cancer Pathology Research Group, Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia.
- Department of Anatomical Pathology, Mater Pathology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia.
| | - Madeline Gough
- Cancer Pathology Research Group, Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia
- Department of Anatomical Pathology, Mater Pathology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
| | - Cheng Liu
- Department of Anatomical Pathology, Mater Pathology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
| | - Kathryn Middleton
- Department of Medical Oncology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
- Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia
| | - Christopher Pyke
- Department of Breast and Endocrine Surgery, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
- Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia
| | - Catherine Shannon
- Department of Medical Oncology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
- Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia
| | - Natasha Woodward
- Department of Medical Oncology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
- Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, QLD, 4102, Australia
| | - Theresa E Hickey
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Jane E Armes
- Department of Anatomical Pathology, Mater Pathology, Mater Hospital Brisbane, South Brisbane, QLD, 4101, Australia
| | - Wayne D Tilley
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
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Siersbæk R, Kumar S, Carroll JS. Signaling pathways and steroid receptors modulating estrogen receptor α function in breast cancer. Genes Dev 2018; 32:1141-1154. [PMID: 30181360 PMCID: PMC6120708 DOI: 10.1101/gad.316646.118] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Estrogen receptor α (ER) is the major driver of ∼75% of breast cancers, and multiple ER targeting drugs are routinely used clinically to treat patients with ER+ breast cancer. However, many patients relapse on these targeted therapies and ultimately develop metastatic and incurable disease, and understanding the mechanisms leading to drug resistance is consequently of utmost importance. It is now clear that, in addition to estrogens, ER function is modulated by other steroid receptors and multiple signaling pathways (e.g., growth factor and cytokine signaling), and many of these pathways affect drug resistance and patient outcome. Here, we review the mechanisms through which these pathways impact ER function and drug resistance as well as discuss the clinical implications.
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Affiliation(s)
- Rasmus Siersbæk
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 0RE, United Kingdom
| | - Sanjeev Kumar
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 0RE, United Kingdom
- Addenbrookes Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Jason S Carroll
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 0RE, United Kingdom
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Jameera Begam A, Jubie S, Nanjan MJ. Estrogen receptor agonists/antagonists in breast cancer therapy: A critical review. Bioorg Chem 2017; 71:257-274. [PMID: 28274582 DOI: 10.1016/j.bioorg.2017.02.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/15/2017] [Accepted: 02/18/2017] [Indexed: 01/25/2023]
Abstract
Estrogens display intriguing tissue selective action that is of great biomedical importance in the development of optimal therapeutics for the prevention and treatment of breast cancer. There are also strong evidences to show that both endogenous and exogenous estrogens are involved in the pathogenesis of breast cancer. Tamoxifen has been the only drug of choice for more than 30years to treat patients with estrogen related (ER) positive breast tumors. There is a need therefore, for identifying newer, potential and novel candidates for breast cancer. Keeping this in view, the present review focuses on selective estrogen receptor modulators and estrogen antagonists such as sulfatase and aromatase inhibitors involved in breast cancer therapy. A succinct and critical overview of the structure of estrogen receptors, their signaling and involvement in breast carcinogenesis are herein described.
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Affiliation(s)
- A Jameera Begam
- Department of Pharmaceutical Chemistry, JSS College of Pharmacy, Udhagamandalam, India; A Constituent College of JSS University, Mysore, India
| | - S Jubie
- Department of Pharmaceutical Chemistry, JSS College of Pharmacy, Udhagamandalam, India; A Constituent College of JSS University, Mysore, India.
| | - M J Nanjan
- TIFAC CORE HD, JSS University, Mysore, India
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Carroll JS, Hickey TE, Tarulli GA, Williams M, Tilley WD. Deciphering the divergent roles of progestogens in breast cancer. Nat Rev Cancer 2017; 17:54-64. [PMID: 27885264 DOI: 10.1038/nrc.2016.116] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Most breast cancers are driven by oestrogen receptor-α. Anti-oestrogenic drugs are the standard treatment for these breast cancers; however, treatment resistance is common, necessitating new therapeutic strategies. Recent preclinical and historical clinical studies support the use of progestogens to activate the progesterone receptor (PR) in breast cancers. However, widespread controversy exists regarding the role of progestogens in this disease, hindering the clinical implementation of PR-targeted therapies. Herein, we present and discuss data at the root of this controversy and clarify the confusion and misinterpretations that have consequently arisen. We then present our view on how progestogens may be safely and effectively used in treating breast cancer.
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Affiliation(s)
- Jason S Carroll
- Cancer Research UK Cambridge Institute, University of Cambridge, Robinson Way, Cambridge CB2 0RE, UK
| | - Theresa E Hickey
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
| | - Gerard A Tarulli
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
| | - Michael Williams
- Division of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239-3098, USA
| | - Wayne D Tilley
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
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Kümler I, Knoop AS, Jessing CAR, Ejlertsen B, Nielsen DL. Review of hormone-based treatments in postmenopausal patients with advanced breast cancer focusing on aromatase inhibitors and fulvestrant. ESMO Open 2016; 1:e000062. [PMID: 27843622 PMCID: PMC5070302 DOI: 10.1136/esmoopen-2016-000062] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/12/2016] [Accepted: 05/13/2016] [Indexed: 12/14/2022] Open
Abstract
Background Endocrine therapy constitutes a central modality in the treatment of oestrogen receptor (ER)-positive advanced breast cancer. Purpose To evaluate the evidence for endocrine treatment in postmenopausal patients with advanced breast cancer focusing on the aromatase inhibitors, letrozole, anastrozole, exemestane and fulvestrant. Methods A review was carried out using PubMed. Randomised phase II and III trials reporting on ≥100 patients were included. Results 35 trials met the inclusion criteria. If not used in the adjuvant setting, a non-steroid aromatase inhibitor was the optimal first-line option. In general, the efficacy of the different aromatase inhibitors and fulvestrant was similar in tamoxifen-refractory patients. A randomised phase II trial of palbociclib plus letrozole versus letrozole alone showed significantly increased progression-free survival (PFS) when compared with endocrine therapy alone in the first-line setting (20.2 vs 10.2 months). Furthermore, the addition of everolimus to exemestane in the Breast Cancer Trials of OraL EveROlimus-2 (BOLERO-2) study resulted in an extension of median PFS by 4.5 months after recurrence/progression on a non-steroid aromatase inhibitor. However, overall survival was not significantly increased. Conclusion Conventional treatment with an aromatase inhibitor or fulvestrant may be an adequate treatment option for most patients with hormone receptor-positive advanced breast cancer. Mammalian target of rapamycin (mTOR) inhibition and cyclin-dependent kinase 4/6 (CDK4/6) inhibition might represent substantial advances for selected patients in some specific settings. However, there is an urgent need for prospective biomarker-driven trials to identify patients for whom these treatments are cost-effective.
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Affiliation(s)
- Iben Kümler
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
| | - Ann S Knoop
- Department of Oncology , Finsen Centre, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Christina A R Jessing
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
| | - Bent Ejlertsen
- Department of Oncology , Finsen Centre, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Dorte L Nielsen
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
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Heterogeneous estrogen receptor expression in circulating tumor cells suggests diverse mechanisms of fulvestrant resistance. Mol Oncol 2016; 10:1078-85. [PMID: 27178224 DOI: 10.1016/j.molonc.2016.04.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/01/2016] [Accepted: 04/20/2016] [Indexed: 01/13/2023] Open
Abstract
Fulvestrant is a dose dependent selective estrogen receptor (ER) down-regulator (SERD) used in ER-positive metastatic breast cancer (MBC). Nearly all patients develop resistance. We performed molecular analysis of circulating tumor cells (CTC) to gain insight into fulvestrant resistance. Preclinical studies were performed with cultured breast cancer cells spiked into human blood and analyzed on the CellSearch(®) system. Clinical data are limited to a subset of patients with ER-positive MBC from a previously reported pilot trial whose disease was progressing on fulvestrant (N = 7) or aromatase inhibitors (AIs) (N = 10). CTCs were enumerated and phenotyped for ER and B-cell lymphoma (BCL2) using the CellSearch(®) CXC kit. In preclinical modeling, tamoxifen and AIs resulted in stabilized ER expression, whereas fulvestrant eliminated it. Five of seven patients progressing on fulvestrant had ≥5CTC/7.5 ml WB. Two of these five, treated with 500 mg/month fulvestrant, had no detectable CTC-expression of ER and BCL2 (an ER regulated gene). Three patients had heterogeneous CTC-ER and BCL2 expression indicating incomplete degradation of the ER target by fulvestrant. Two of these patients received 250 mg/month whereas the third patient received 500 mg/month fulvestrant. Her cancer harbored a mutation (Y537S) in the estrogen receptor alpha gene (ESR1). All seven ER positive patients progressing on AIs had heterogeneous CTC-ER expression. These results suggest heterogeneous mechanisms of resistance to fulvestrant, including insufficient dosage, ESR1 mutation, or conversion to dependence on non-ER pathways. CTC enumeration, phenotyping, and genotyping might identify patients who would benefit from fulvestrant dose escalation versus switching to alternative therapies.
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Sini V, Cinieri S, Conte P, De Laurentiis M, Leo AD, Tondini C, Marchetti P. Endocrine therapy in post-menopausal women with metastatic breast cancer: From literature and guidelines to clinical practice. Crit Rev Oncol Hematol 2016; 100:57-68. [PMID: 26944782 DOI: 10.1016/j.critrevonc.2016.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/15/2016] [Indexed: 12/22/2022] Open
Abstract
Current international guidelines recommend endocrine therapy as the initial treatment of choice in hormone receptor positive advanced breast cancer. Endocrine therapy has been a mainstay of hormone responsive breast cancer treatment for more than a century. To date it is based on different approaches,such as blocking the estrogen receptor through selective receptor estrogen modulators, depleting extragonadal peripheral estrogen synthesis by aromatase inhibitors or inducing estrogen receptor degradation using selective down-regulators. Despite estrogen and/or progesterone receptor positive status, up to a quarter of patients could be either primarily resistant to hormone therapies or will develop hormone resistance during the course of their disease. Different mechanisms, either intrinsic or acquired, could be implicated in endocrine resistance. In the present work available endocrine therapies and their appropriate sequences have been reviewed, and the most promising strategies to overcome endocrine resistance have been highlighted.
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Affiliation(s)
- Valentina Sini
- Surgical and Medical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, "Sapienza" University of Rome, Italy; Oncology Department, Santo Spirito Hospital, Rome, Italy
| | - Saverio Cinieri
- Medical Oncology Department & Breast Unit-Hospital of Brindisi and Medical Oncology Department-European Institute of Oncology, Milan, Italy
| | - Pierfranco Conte
- Medical Oncology 2, Venetian Oncological Institute, Padova, Italy; Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Michelino De Laurentiis
- Department of Breast Oncology, National Cancer Institute "Fondazione Pascale", Naples, Italy
| | - Angelo Di Leo
- Medical Oncology Department, "Sandro Pitigliani" Hospital of Prato, Istituto Toscano Tumori, Prato, Italy
| | - Carlo Tondini
- USC Oncologia Medica, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, Medical Oncology Division, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy; IDI-IRCCS, Rome, Italy.
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Liedtke C, Kolberg HC. Current Medical Treatment of Patients with Non-Colorectal Liver Metastases: Primary Tumor Breast Cancer. VISZERALMEDIZIN 2015; 31:424-32. [PMID: 26889146 PMCID: PMC4748775 DOI: 10.1159/000441961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND (Metastatic) breast cancer is a heterogeneous entity in which every disease subtype requires an individualized systemic treatment approach. METHODS We reviewed the currently available data regarding systemic therapy of breast cancer and present a review of historical and current treatment approaches, with the publications cited covering a time span from 1896 to the last ASCO 2015. RESULTS Systemic therapy of metastatic breast cancer may include chemotherapy, endocrine therapy, and targeted therapies (e.g. antibody-based approaches). Based on the patient's breast cancer subtype, these agents may be employed alone or in combination. Therefore, characterization of the phenotype of the disease is necessary and may include biopsy of the metastatic site. Novel therapeutic approaches include immunologic therapies as well as PARP, PI3K and CDK 4/6 inhibitors, which are currently under investigation in clinical trials. CONCLUSION Systemic therapy of metastatic breast cancer requires complex and individualized treatment approaches that are best offered in an interdisciplinary setting.
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Affiliation(s)
- Cornelia Liedtke
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein – Campus Lübeck, Lübeck, Germany
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20
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Quinn EM, Fleming C, O'Sullivan MJ. Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy. Ir J Med Sci 2015; 185:383-92. [PMID: 25971465 DOI: 10.1007/s11845-015-1307-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND/AIMS Adjuvant endocrine therapy for at least 5 years improves oncological outcomes in oestrogen receptor-positive breast cancer. Adherence rates to prescribed endocrine therapy are low and the search for modifiable causes of this continues. The aim of this study was to assess adherence rates in an Irish cohort of breast cancer patients prescribed adjuvant endocrine therapy and to assess modifiable factors associated with suboptimal adherence. METHODS A cross-sectional anonymous survey was performed on 261 patients currently prescribed endocrine therapy. Data were collected regarding demographics, treatment, social and emotional factors and medication side effects. Each patient completed a medication adherence score and provided information about discontinuation of therapy and reasons for same. RESULTS Only 67.8 % of patients assessed demonstrated complete medication adherence on the medication adherence scale. Twenty-nine patients (10.9 %) permanently stopped taking their prescribed endocrine therapy. Suboptimal adherence was more likely in younger patients (p < 0.001), those in employment (p = 0.005), those who experienced side effects (p = 0.006), those who perceived themselves to have low levels of emotional support (p < 0.001) and those who use the internet to read about their illness (p = 0.003). CONCLUSIONS Endocrine therapy adherence is suboptimal in almost one-third of patients in our cohort. Appropriate assessment and management of side effects and negative emotions, combined with direction of patients to accurate internet sources of information, could help improve endocrine therapy adherence in women with early-stage breast cancer.
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Affiliation(s)
- E M Quinn
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland.
| | - C Fleming
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - M J O'Sullivan
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
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Bowers LW, deGraffenried LA. Targeting the COX-2 Pathway to Improve Therapeutic Response in the Obese Breast Cancer Patient Population. ACTA ACUST UNITED AC 2015; 1:336-345. [PMID: 26442202 DOI: 10.1007/s40495-015-0041-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple studies have demonstrated that obesity is associated with a worse outcome for all breast cancer subtypes and that obese breast cancer patients do not respond as well as normal weight patients to aromatase inhibitor treatment and chemotherapy. While a number of mechanisms have been proposed to explain this link, recent studies have provided evidence that elevated local cyclooxygenase-2 (COX-2) expression and the resulting increase in prostaglandin E2 (PGE2) production may play an important role. COX-2 upregulation in breast tumors is associated with a poor prognosis, a connection generally attributed to PGE2's direct effects on apoptosis and invasion as well as its stimulation of pre-adipocyte aromatase expression and subsequent estrogen production. Research in this area has provided a strong foundation for the hypothesis that COX-2 signaling is involved in the obesity-breast cancer link, and further study regarding the role of COX-2 in this link is warranted.
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Affiliation(s)
- Laura W Bowers
- Department of Nutritional Sciences, University of Texas at Austin, 1400 Barbara Jordan Boulevard, R1800, Austin, TX 78723
| | - Linda A deGraffenried
- Department of Nutritional Sciences, University of Texas at Austin, 1400 Barbara Jordan Boulevard, R1800, Austin, TX 78723
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22
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Bowers LW, Maximo IXF, Brenner AJ, Beeram M, Hursting SD, Price RS, Tekmal RR, Jolly CA, deGraffenried LA. NSAID use reduces breast cancer recurrence in overweight and obese women: role of prostaglandin-aromatase interactions. Cancer Res 2014; 74:4446-57. [PMID: 25125682 DOI: 10.1158/0008-5472.can-13-3603] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Obesity is associated with a worse breast cancer prognosis and elevated levels of inflammation, including greater cyclooxygenase-2 (COX-2) expression and activity in adipose-infiltrating macrophages. The product of this enzyme, the proinflammatory eicosanoid prostaglandin E2 (PGE2), stimulates adipose tissue aromatase expression and subsequent estrogen production, which could promote breast cancer progression. This study demonstrates that daily use of a nonsteroidal anti-inflammatory drug (NSAID), which inhibits COX-2 activity, is associated with reduced estrogen receptor α (ERα)-positive breast cancer recurrence in obese and overweight women. Retrospective review of data from ERα-positive patients with an average body mass index of >30 revealed that NSAID users had a 52% lower recurrence rate and a 28-month delay in time to recurrence. To examine the mechanisms that may be mediating this effect, we conducted in vitro studies that utilized sera from obese and normal-weight patients with breast cancer. Exposure to sera from obese patients stimulated greater macrophage COX-2 expression and PGE2 production. This was correlated with enhanced preadipocyte aromatase expression following incubation in conditioned media (CM) collected from the obese-patient, sera-exposed macrophages, an effect neutralized by COX-2 inhibition with celecoxib. In addition, CM from macrophage/preadipocyte cocultures exposed to sera from obese patients stimulated greater breast cancer cell ERα activity, proliferation, and migration compared with sera from normal-weight patients, and these differences were eliminated or reduced by the addition of an aromatase inhibitor during CM generation. Prospective studies designed to examine the clinical benefit of NSAID use in obese patients with breast cancer are warranted.
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Affiliation(s)
- Laura W Bowers
- Department of Nutritional Sciences, University of Texas at Austin, Austin, Texas
| | - Ilane X F Maximo
- Department of Nutritional Sciences, University of Texas at Austin, Austin, Texas
| | - Andrew J Brenner
- Division of Hematology and Medical Oncology, University of Texas Health Science Center, San Antonio, Texas
| | | | - Stephen D Hursting
- Department of Nutritional Sciences, University of Texas at Austin, Austin, Texas
| | - Ramona S Price
- Department of Nutritional Sciences, University of Texas at Austin, Austin, Texas
| | - Rajeshwar R Tekmal
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas
| | - Christopher A Jolly
- Department of Nutritional Sciences, University of Texas at Austin, Austin, Texas
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Bowers LW, Cavazos DA, Maximo IXF, Brenner AJ, Hursting SD, deGraffenried LA. Obesity enhances nongenomic estrogen receptor crosstalk with the PI3K/Akt and MAPK pathways to promote in vitro measures of breast cancer progression. Breast Cancer Res 2014; 15:R59. [PMID: 23880059 PMCID: PMC3978844 DOI: 10.1186/bcr3453] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 05/18/2013] [Accepted: 07/23/2013] [Indexed: 02/03/2023] Open
Abstract
Introduction Epidemiological and clinical studies indicate that obesity is associated with a worse postmenopausal breast cancer prognosis and an increased risk of endocrine therapy resistance. However, the mechanisms mediating these effects remain poorly understood. Here we investigate the molecular pathways by which obesity-associated circulating factors in the blood enhance estrogen receptor alpha (ERα) positive breast cancer cell viability and growth. Methods Blood serum was collected from postmenopausal breast cancer patients and pooled by body mass index (BMI) category (Control: 18.5 to 24.9 kg/m2; Obese: ≥30.0 kg/m2). The effects of patient sera on MCF-7 and T47D breast cancer cell viability and growth were examined by MTT and colony formation assays, respectively. Insulin-like growth factor receptor 1(IGF-1R), Akt, and ERK1/2 activation and genomic ERα activity were assessed to determine their possible contribution to obese patient sera-induced cell viability and growth. To further define the relative contribution of these signaling pathways, cells grown in patient sera were treated with various combinations of ERα, PI3K/Akt and MAPK targeted therapies. Comparisons between cells exposed to different experimental conditions were made using one-way analysis of variance (ANOVA) and Student's t test. Results Cells grown in media supplemented with obese patient sera displayed greater cell viability and growth as well as IGF-1R, Akt and ERK1/2 activation relative to control sera. Despite the lack of a significant difference in genomic ERα activity following growth in obese versus control patient sera, we observed a dramatic reduction in cell viability and growth after concurrent inhibition of the ERα and PI3K/Akt signaling pathways. Further, we demonstrated that ERα inhibition was sufficient to attenuate obese serum-induced Akt and ERK1/2 activation. Together, these data suggest that obesity promotes greater ERα positive breast cancer cell viability and growth through enhanced crosstalk between nongenomic ERα signaling and the PI3K/Akt and MAPK pathways. Conclusions Circulating factors in the serum of obese postmenopausal women stimulate ERα positive breast cancer cell viability and growth by facilitating non-genomic ERα crosstalk with the PI3K/Akt and MAPK signaling pathways. These findings provide valuable insight into one mechanism by which obesity may promote ERα positive postmenopausal breast cancer progression and endocrine therapy resistance.
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Ioannides SJ, Barlow PL, Elwood JM, Porter D. Effect of obesity on aromatase inhibitor efficacy in postmenopausal, hormone receptor-positive breast cancer: a systematic review. Breast Cancer Res Treat 2014; 147:237-48. [PMID: 25119728 DOI: 10.1007/s10549-014-3091-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
Aromatase inhibitors (AIs) decrease the production of oestrogen, decreasing stimulation of hormone receptor-positive breast cancer. Theoretically, AIs may be less effective in obese women, due to the greater quantity of aromatase in peripheral fatty tissue. We performed a systematic review to assess the effect of obesity on AI efficacy in breast cancer treatment. The review followed PRISMA guidelines. Studies included were interventional or observational studies with comparison groups, of postmenopausal women with hormone receptor-positive breast cancer on treatment with an AI, alone or in combination with other drugs, in which body mass index or another measure of obesity was recorded. Studies in all languages were included; if published as an abstract only, authors were contacted for further information. Outcome measures included overall survival, disease-free survival or time to progressive disease, survival from the start of therapy, mortality measures, local or distant recurrence of primary cancer and time to recurrence. Of 2,344 citations identified from five databases, eight studies met the criteria for inclusion; three randomised controlled trials and five retrospective cohort studies. Due to variability in study factors, it was not possible to perform a quantitative meta-analysis. However, the systematic review showed a trend towards a negative effect of obesity on AI efficacy. There is evidence of a negative effect of obesity on AI efficacy in postmenopausal hormone receptor-positive breast cancer, but the size of the effect cannot be assessed. More information is needed before clinical recommendations are made.
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Affiliation(s)
- S J Ioannides
- Cancer Epidemiology, FMHS School of Population Health, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand,
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25
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Ratain MJ. Targeted therapies: redefining the primary objective of phase I oncology trials. Nat Rev Clin Oncol 2014; 11:503-4. [PMID: 25091610 DOI: 10.1038/nrclinonc.2014.135] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cytotoxic agents are conventionally dosed on the basis of the maximum tolerated dose defined in phase I trials. A study assessing adverse events in over 2,000 patients treated with molecularly targeted agents suggests a need to redefine criteria for dosing of molecularly targeted agents, which should be based on randomized, dose-ranging phase II trials.
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Affiliation(s)
- Mark J Ratain
- Department of Medicine, Comprehensive Cancer Center, and Center for Personalized Therapeutics, The University of Chicago, 5841 South Maryland Avenue, MC2115, Chicago, IL 60637, USA
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Glück S. Extending the Clinical Benefit of Endocrine Therapy for Women With Hormone Receptor–Positive Metastatic Breast Cancer: Differentiating Mechanisms of Action. Clin Breast Cancer 2014; 14:75-84. [DOI: 10.1016/j.clbc.2013.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/04/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
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Hussain SA, Palmer DH, Moon S, Rea DW. Endocrine therapy and other targeted therapies for metastatic breast cancer. Expert Rev Anticancer Ther 2014; 4:1179-95. [PMID: 15606341 DOI: 10.1586/14737140.4.6.1179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The most important change in the treatment of advanced breast cancer that will emerge over the next 10 years is the shift from adjuvant tamoxifen to adjuvant aromatase inhibitors. This will mean an increasing proportion of tamoxifen-naive aromatase inhibitor-resistant breast cancer. Research of the most appropriate methods of optimizing remaining endocrine sensitivity in these patients is needed. The rapid expansion in the understanding of the molecular basis of breast cancer biology provides potential targets for novel therapies. Despite these pivotal developments, resistance to endocrine therapy remains a key limitation in the management of advanced breast cancer. Until recently, the only option following the development of resistance to an endocrine agent was to change endocrine therapy and, on exhaustion of endocrine sensitivity, to move to cytotoxic chemotherapy. Understanding of at least some of the mechanisms underlying the development of endocrine resistance is now emerging. We now have the tools that may allow us to both overcome resistance and restore sensitivity, or to pre-empt certain types of resistance from developing. These tools include the increasing array of signal transduction inhibitors in combination with standard endocrine agents. Correct clinical management strategy can be guided by preclinical modeling but can only be validated by carefully designed clinical trials. These will, at the very least, need to be conducted with correlative translational research elements that will track changes in tumors as resistance emerges and will allow us to select the most appropriate treatment strategy for individual patients. Amongst the myriad of promising drugs there will undoubtedly be some that fail to meet current hopes, but we can be optimistic that a handful will find a useful place in keeping advanced breast cancer at bay for longer than can be achieved at present. However, the holy grail of a cure is likely, in the medium term, to remain elusively at the end of the rainbow for most of these patients. Several other methods for the management of these patients are in development. These include strategies to overcome endocrine resistance and methods to target deregulated endocrine and growth factor signaling pathways using gene and immunotherapy approaches.
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Affiliation(s)
- Syed A Hussain
- Cancer Research UK, Institute for Cancer Studies and The Cancer Centre, Queen Elizabeth Hospital, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
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Ballazhi L, Imeri F, Dimovski A, Jashari A, Popovski E, Breznica-Selmani P, Mikhova B, Dräger G, Alili-Idrizi E, Mladenovska K. Synergy of novel coumarin derivatives and tamoxifen in blocking growth and inducing apoptosis of breast cancer cells. ACTA ACUST UNITED AC 2014. [DOI: 10.33320/maced.pharm.bull.2014.60.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Possible synergistic effect of tamoxifen (2 μM) and hydrazinyldiene-chroman-2,4-diones (10-100 μM) was examined with an aim to create more effective treatment for ER+ breast cancer. Anti-breast cancer effect has been evaluated on the proliferation of MCF-7 breast adenocarcinoma cells using MTT and alamarBlue assays. Cell viability was evaluated after 48h-treatment and the ICs50 of the coumarin derivatives were determined. The apoptotic effect was evaluated by detection of PARP cleavage and reduced activity of the survival kinase Akt. The results demonstrated dose-dependent activity, with a percent of growth inhibition after combination treatment being significantly higher (53% to 79%, 10 μM and 100 μM, respectively) than the one in the cell lines treated with tamoxifen (29% to 37%) and the synthesized coumarin derivatives alone (11% to 68%, 10 μM and 100 μM, respectively). The ICs50 of the synthesized compounds significantly decreased in synergy with tamoxifen (33% to 51%). Coumarin derivative having thiazole moiety with additional methyl groups attached
to the carbons at positions 5 and 4 in the thiazole ring showed to be the most potent, with IC50 20 µM when administered alone and 10 µM in synergy with tamoxifen. The levels of phospho-Thr308 Akt were down-regulated by the combination treatment, pointing to tyrosine kinase phosphorylation inhibition. In conclusion, the novel coumarin derivatives enhance the activity of tamoxifen and this combination may
be suitable for prevention of ER+ breast cancer or development of related compounds. Further studies are needed to elucidate precisely the type of receptor involved in the activity and the mechanism of action.
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Development of new estrogen receptor-targeting therapeutic agents for tamoxifen-resistant breast cancer. Future Med Chem 2013; 5:1023-35. [PMID: 23734685 DOI: 10.4155/fmc.13.63] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Despite our deepening understanding of the mechanisms of resistance and intensive efforts to develop therapeutic solutions to combat resistance, de novo and acquired tamoxifen resistance remains a clinical challenge, and few effective regimens exist to treat tamoxifen-resistant breast cancer. The complexity of tamoxifen resistance calls for diverse therapeutic approaches. This review presents several therapeutic strategies and lead compounds targeting the estrogen receptor signaling pathways for treatment of tamoxifen-resistant breast cancer, with a critical assessment of challenges and potentials regarding clinical outcome. Medicinal chemistry holds the key to effective, personalized combination therapy for tamoxifen-resistant breast cancer by making available a diverse arsenal of small-molecule drugs that specifically target signaling pathways modulating hormone resistance. These combination therapy candidates should have the desired specificity, selectivity and low toxicity to resensitize tumor response to tamoxifen and/or inhibit the growth and proliferation of resistant breast cancer cells.
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Li F, Zou XJ, Zheng H, Xiang Y. LC-MS/MS method for determination of megestrol in human plasma and its application in bioequivalence study. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2013; 33:912-916. [PMID: 24337858 DOI: 10.1007/s11596-013-1221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/10/2013] [Indexed: 06/03/2023]
Abstract
A rapid and highly selective liquid chromatography-tandem mass spectrometric (LC-MS/MS) method for the determination of megestrol in human plasma was described using medrysone as internal standard (IS). Blood samples were collected from 20 healthy volunteers after oral administration of 160 mg megestrol acetate dispersible tablets. The analytes were extracted by liquid-liquid extraction procedure and separated on a hanbon lichrospher column with the mobile phase of methanol and water containing 0.1% formic acid and 20 mmol/L ammonium acetate (5:1, v/v). Positive ion electrospray ionization with multiple reaction-monitoring mode (MRM) was employed by monitoring the transitions m/z 385.5-325.4 and m/z 387.5-327.4 for megestrol and medrysone, respectively. Under the isocratic separation conditions, the chromatographic run time was approximately 2.54 min for megestrol and 2.59 min for medrysone. The calibration curve range was from 0.5 to 200.0 ng/mL. The inter-batch and intra-batch precision and accuracy were less than 5.2% relative standard deviation (RSD) and 6.4% relative error (RE). The proposed method was successfully applied in the bioequivalence study of megestrol acetate dispersible tablets.
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Affiliation(s)
- Fan Li
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiao-Juan Zou
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Heng Zheng
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yi Xiang
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Jonat W, Bachelot T, Ruhstaller T, Kuss I, Reimann U, Robertson J. Randomized phase II study of lonaprisan as second-line therapy for progesterone receptor-positive breast cancer. Ann Oncol 2013; 24:2543-2548. [DOI: 10.1093/annonc/mdt216] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Schiavon G, Smith IE. Endocrine therapy for advanced/metastatic breast cancer. Hematol Oncol Clin North Am 2013; 27:715-36, viii. [PMID: 23915741 DOI: 10.1016/j.hoc.2013.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
First-line endocrine therapy by estrogen antagonism or suppression of estrogen achieves objective responses (ORs) and clinical benefit (CB) in around 30% and 50% of estrogen receptor-positive metastatic breast cancer patients, respectively. Aromatase inhibitors (AIs) are the most effective treatment in previously untreated postmenopausal women. Tamoxifen is an effective alternative. The optimal endocrine therapy on relapse remains uncertain. Tamoxifen and fulvestrant achieve CB in around 50% of patients and ORs of 10%. CB of exemestane after nonsteroidal AIs is 30% to 50% but ORs are rare. Targeted agents (eg, everolimus) plus endocrine therapy are likely to become increasingly important in overcoming endocrine resistance.
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Affiliation(s)
- Gaia Schiavon
- Breast Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK.
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Aromatase inhibitors in the treatment of elderly women with metastatic breast cancer. Breast 2013; 22:142-149. [PMID: 23321585 DOI: 10.1016/j.breast.2012.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 10/26/2012] [Accepted: 12/17/2012] [Indexed: 11/22/2022] Open
Abstract
The proportion of elderly women in the population is rising, and in tandem, the incidence of breast cancer rises with age. Because of health and tolerability concerns, as well as life expectancy, physicians may be reluctant to advise a standard treatment regimen for elderly patients with metastatic breast cancer. To elucidate this issue, we performed a literature review of clinical studies that included women with metastatic breast cancer who were over the age of 65. Our results show that although little clinical evidence exists, what is available suggests that standard treatment is tolerated and beneficial for patients meeting certain criteria. A geriatric assessment may identify specific patient groups (independent, dependent, or frail) and thereby guide treatment. Treatment recommendations for elderly patients with metastatic breast cancer are sparse, although first-line endocrine treatment, usually aromatase inhibitors or tamoxifen, is recommended for hormone-sensitive disease. In general, the evidence from clinical studies suggests that aromatase inhibitors are more effective than either tamoxifen or megestrol acetate as first- or second-line treatment in postmenopausal women with metastatic breast cancer. Ultimately, quality of life, treatment effects, and comorbidities are important aspects in this population and may guide treatment choice. To provide evidence-based treatment guidance, future clinical trials should include more patients over the age of 65 years.
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Howell A. Anastrozole: a new gold standard of hormonal treatment for breast cancer? ACTA ACUST UNITED AC 2012; 1:309-22. [PMID: 19803873 DOI: 10.2217/17455057.1.3.309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tamoxifen has long been the standard endocrine therapy for postmenopausal women with hormone-sensitive breast cancer. However, data now suggest that the third-generation aromatase inhibitors have emerged as superior alternatives for advanced disease. In early disease evaluation of initial adjuvant therapy, data from the Arimidex((R)), Tamoxifen, Alone and in Combination trial has shown that anastrozole is more effective than tamoxifen with a better risk-benefit profile. This trial provides the most mature data of any aromatase inhibitor study and suggests that anastrozole should be considered the preferred initial adjuvant therapy for postmenopausal women with hormone-responsive early breast cancer. The emergence of aromatase inhibitors as an alternative to tamoxifen for the treatment of breast cancer is challenging the management of the disease and influencing the change of regulatory guidelines.
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Affiliation(s)
- Anthony Howell
- CRUK Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Withington, Manchester, M20 4BX, UK.
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Barrios C, Forbes JF, Jonat W, Conte P, Gradishar W, Buzdar A, Gelmon K, Gnant M, Bonneterre J, Toi M, Hudis C, Robertson JFR. The sequential use of endocrine treatment for advanced breast cancer: where are we? Ann Oncol 2012; 23:1378-86. [PMID: 22317766 PMCID: PMC6267865 DOI: 10.1093/annonc/mdr593] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 11/23/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hormone receptor-positive advanced breast cancer is an increasing health burden. Although endocrine therapies are recognised as the most beneficial treatments for patients with hormone receptor-positive advanced breast cancer, the optimal sequence of these agents is currently undetermined. METHODS We reviewed the available data on randomised controlled trials (RCTs) of endocrine therapies in this treatment setting with particular focus on RCTs reported over the last 15 years that were designed based on power calculations on primary end points. RESULTS In this paper, data are reviewed in postmenopausal patients for the use of tamoxifen, aromatase inhibitors and fulvestrant. We also consider the available data on endocrine crossover studies and endocrine therapy in combination with chemotherapy or growth factor therapies. Treatment options for premenopausal patients and those with estrogen receptor-/human epidermal growth factor receptor 2-positive tumours are also evaluated. CONCLUSION We present the level of evidence available for each endocrine agent based on its efficacy in advanced breast cancer and a diagram of possible treatment pathways.
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Affiliation(s)
- C. Barrios
- Internal Medicine Department, PUCRS School of Medicine, Porto Alegre,
Brazil
| | - J. F. Forbes
- School of Medicine & Public Health, University of Newcastle, Newcastle,
Australia
| | - W. Jonat
- Department of Obstetrics and Gynaecology, University of Kiel, Kiel,
Germany
| | - P. Conte
- Department of Oncology and Hematology, University of Modena and Reggio
Emilia, Modena, Italy
| | - W. Gradishar
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University
Feinberg School of Medicine, Chicago
| | - A. Buzdar
- Department of Breast Medical Oncology, University of Texas MD Anderson
Cancer Center, Houston, USA
| | - K. Gelmon
- Department of Medical Oncology, University of British Columbia, Vancouver,
Canada
| | - M. Gnant
- Department of Surgery, Comprehensive Cancer Centre Vienna, Medical
University of Vienna, Vienna, Austria
| | - J. Bonneterre
- Integrated Clinical Research Unit, Centre Oscar Lambret, Lille, France
| | - M. Toi
- Breast Surgery Department, Kyoto University, Kyoto, Japan
| | - C. Hudis
- Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New
York, USA
| | - J. F. R. Robertson
- Faculty of Medicine and Health Sciences, Nottingham University, Derby,
UK
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Howell A. Genesis and Outcome of a Breast Cancer Trial to Develop the Aromatase Inhibitor Anastrozole. Clin Chem 2012; 58:782-3. [DOI: 10.1373/clinchem.2011.181206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anthony Howell
- Manchester Breast Centre, The Christie NHS Foundation Trust, University of Manchester, Manchester, UK
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Papadatos-Pastos D, Dedes KJ, de Bono JS, Kaye SB. Revisiting the role of antiandrogen strategies in ovarian cancer. Oncologist 2011; 16:1413-21. [PMID: 21948654 DOI: 10.1634/theoncologist.2011-0164] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Androgen receptors are frequently expressed in epithelial ovarian cancer (EOC). Their role in the development of EOC is not fully understood. In the present review we first discuss the epidemiological data linking a hyperandrogen state to a higher risk for ovarian cancer, second describe in vitro studies of the role of androgens in influencing the growth of EOC, and finally review the completed clinical trials with compounds that exploit the androgen axis in patients with ovarian cancer. The therapeutic approaches that inhibit androgen signaling have so far produced only modest response rates. In the light of new data regarding the role of androgen stimulation in the evolution of EOC and the emergence of new compounds used for the treatment of other hormone-driven malignancies, such as prostate and breast cancer, we provide suggestions for new studies of antiandrogen therapeutics in the treatment of EOC. A specific example is the new agent abiraterone. In addition, we propose a panel of molecules that could be assessed as potential biomarkers that may aid patient selection for this approach in the future.
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Adelson K, Germain D, Raptis G, Biran N. Hormonal modulation in the treatment of breast cancer. Endocrinol Metab Clin North Am 2011; 40:519-32, viii. [PMID: 21889718 DOI: 10.1016/j.ecl.2011.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article explores the history of endocrine therapy for the treatment of breast cancer, the clinical evidence behind the current standards of care, and controversies that may change these standards in the future.
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Affiliation(s)
- Kerin Adelson
- Division of Hematology and Medical Oncology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Goodwin PJ, Pritchard KI. Obesity and hormone therapy in breast cancer: an unfinished puzzle. J Clin Oncol 2010; 28:3405-7. [PMID: 20548001 DOI: 10.1200/jco.2010.29.5113] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ingle JN, Buzdar AU, Schaid DJ, Goetz MP, Batzler A, Robson ME, Northfelt DW, Olson JE, Perez EA, Desta Z, Weintraub RA, Williard CV, Flockhart DA, Weinshilboum RM. Variation in anastrozole metabolism and pharmacodynamics in women with early breast cancer. Cancer Res 2010; 70:3278-86. [PMID: 20354183 DOI: 10.1158/0008-5472.can-09-3024] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aromatase inhibitors play a prominent role in the management of postmenopausal women with endocrine-sensitive breast cancer, but there is large variability in both efficacy and tolerability. The purpose of our study was to define interindividual variation in anastrozole metabolism and pharmacodynamics among patients treated with the approved daily dose of 1 mg in a standard practice setting as adjuvant therapy for resected early breast cancer. This study was performed in 191 women in whom pretreatment and during anastrozole plasma concentrations of estrone (E1), estradiol (E2), estrone conjugates, androstenedione, and testosterone were determined and correlated with plasma concentrations of anastrozole and anastrozole metabolites. There were large interindividual variations in plasma anastrozole and anastrozole metabolite concentrations, as well as pretreatment and postdrug plasma E1, E2, and E1 conjugate and estrogen precursor (androstenedione and testosterone) concentrations. E1 and E2 concentrations were below the lower limit of quantitation (LLQ) in most patients after anastrozole therapy (83% for both), but those with detectable concentrations had a broad range (1.58-45.2 and 0.635-97.0 pg/mL, respectively). E1 conjugates after anastrozole therapy were above the LLQ in most patients (93%), with wide interpatient variability (3.50-2,990 pg/mL). Two patients seemed to extensively metabolize anastrozole and failed to display substantial decreases in estrogens. Acknowledging the potential factor of variable compliance, our results showed large interindividual variation in anastrozole metabolism and its effect on circulating estrogens in postmenopausal patients. These findings may have implications with regard to efficacy and adverse events and may indicate the need to "individualize" therapy with this drug.
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Affiliation(s)
- James N Ingle
- Division of Medical Oncology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
Remarkable progress has been made in the treatment of breast cancer over the past 100 years. The ability to probe at the genomic level increased our understanding of the disease but the improved survival outcomes can also be attributed to screening programs, which have altered the pattern of diagnosis and prognosis, and to a number of groundbreaking clinical trials. Indeed, the latter are largely responsible for the most startling paradigm reversals in oncology; namely, that optimal benefit can be achieved with minimal, rather than maximal, intervention. As such, surgical lumpectomy can replace the radical mastectomy, sentinel node biopsy may circumvent the need for complete (axillary) nodal dissection, hormonal therapy--depending on tumor sensitivity to endocrine manipulation--is likely to be beneficial without the addition of chemotherapy, and some targeted therapies can be used selectively in those most likely to benefit. However, despite the advances, controversies remain; patients die; and cure remains elusive.
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Affiliation(s)
- Gerald M Higa
- West Virginia University, Mary Babb Randolph Cancer Center, Schools of Pharmacy and Medicine, Morgantown, WV 26506-9520, USA.
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Prediction of outcome of patients with metastatic breast cancer: evaluation with prognostic factors and Nottingham prognostic index. Support Care Cancer 2009; 18:1553-64. [DOI: 10.1007/s00520-009-0778-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 10/28/2009] [Indexed: 11/26/2022]
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Gibson L, Lawrence D, Dawson C, Bliss J. Aromatase inhibitors for treatment of advanced breast cancer in postmenopausal women. Cochrane Database Syst Rev 2009; 2009:CD003370. [PMID: 19821307 PMCID: PMC7154337 DOI: 10.1002/14651858.cd003370.pub3] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Endocrine therapy removes the influence of oestrogen on breast cancer cells and so hormonal treatments such as tamoxifen, megestrol acetate and medroxyprogesterone acetate have been in use for many years for advanced breast cancer. Aromatase inhibitors (AIs) inhibit oestrogen synthesis in the peripheral tissues and have a similar tumour-regressing effect to other endocrine treatments. Aminoglutethimide was the first AI in clinical use and now the third generation AIs, anastrozole, exemestane and letrozole, are in current use. Randomised trial evidence on response rates and side effects of these drugs is still limited. OBJECTIVES To compare AIs to other endocrine therapy in the treatment of advanced breast cancer in postmenopausal women. SEARCH STRATEGY For this update, the Cochrane Breast Cancer Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) and relevant conference proceedings were searched (to 30 June 2008). SELECTION CRITERIA Randomised controlled trials in postmenopausal women comparing the effects of any AI versus other endocrine therapy, no endocrine therapy, or a different AI in the treatment of advanced (metastatic) breast cancer. Non-English language publications, comparisons of the same AI at different doses, AIs used as neoadjuvant treatment, or outcomes not related to tumour response were excluded. DATA COLLECTION AND ANALYSIS Data from published trials were extracted independently by two review authors and cross-checked by a third. Hazard ratios (HR) were derived for analysis of time-to-event outcomes (overall and progression-free survival). Odds ratios (OR) were derived for objective response, clinical benefit, and toxicity. MAIN RESULTS Thirty-seven trials were identified, 31 of which were included in the main analysis of any AI versus any other treatment (11,403 women). No trials were excluded due to inadequate allocation concealment. The pooled estimate showed a significant survival benefit for treatment with an AI over other endocrine therapies (HR 0.90, 95% CI 0.84 to 0.97). A subgroup analysis of the three commonly prescribed AIs (anastrozole, exemestane, letrozole) also showed a similar survival benefit (HR 0.88, 95% CI 0.80 to 0.96). There were very limited data to compare one AI with a different AI, but these suggested an advantage for letrozole over anastrozole.AIs have a different toxicity profile to other endocrine therapies. For those currently prescribed, and for all AIs combined, they had similar levels of hot flushes and arthralgia; increased risks of rash, nausea, diarrhoea and vomiting; but a 71% decreased risk of vaginal bleeding and 47% decrease in thromboembolic events compared with other endocrine therapies. AUTHORS' CONCLUSIONS In women with advanced (metastatic) breast cancer, aromatase inhibitors including those in current clinical use show a survival benefit when compared to other endocrine therapy.
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Affiliation(s)
- Lorna Gibson
- Cancer and Public Health Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, Greater London, UK, WC1E 7HT
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Joensuu H, Ejlertsen B, Lønning PE, Rutqvist LE. Aromatase inhibitors in the treatment of early and advanced breast cancer. Acta Oncol 2009; 44:23-31. [PMID: 15848903 DOI: 10.1080/02841860510007468] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The third generation aromatase inhibitors anastrozole, exemestane, and letrozole have been compared with tamoxifen and other endocrine therapies in several studies in early and advanced breast cancer. These studies are reviewed in this report. Based on the available evidence, the panel recommends that adjuvant treatment with tamoxifen for 5 years should no longer be considered as the sole standard but that a third-generation aromatase inhibitor should be used either alone or in a sequence with tamoxifen in the adjuvant treatment of postmenopausal women with hormone-receptor-positive breast cancer. Third generation aromatase inhibitors may be considered as the first line therapy of hormone-receptor-positive advanced breast cancer in postmenopausal women, and they may also be used for preoperative therapy of breast cancer.
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Affiliation(s)
- Heikki Joensuu
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland.
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Hargis JB, Nakajima ST. Resumption of Menses with Initiation of Letrozole After Five Years of Amenorrhea on Tamoxifen: Caution Needed When Using Tamoxifen Followed by Aromatase Inhibitors. Cancer Invest 2009; 24:174-7. [PMID: 16537187 DOI: 10.1080/07357900500524538] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Randomized trials in postmenopausal women have shown a benefit to substituting aromatase inhibitors for tamoxifen or using them sequentially following a full course of tamoxifen. The aromatase inhibitor letrozole has also been utilized for ovarian induction in premenopausal women. CASE REPORT A premenopausal woman with early stage breast cancer became amenorrheic with adjuvant chemotherapy, and remained so during 5 years of daily tamoxifen. After discontinuing tamoxifen, laboratory studies confirmed an apparent postmenopausal state. Menses resumed following a 2-week course of letrozole. CONCLUSION Aromatase inhibitors need to be used with caution in women who stop menstruating following adjuvant chemotherapy or tamoxifen.
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Affiliation(s)
- Jeffrey B Hargis
- Kentuckiana Cancer Institute PLLC, Louisville, Kentucky 40202, USA
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Campos SM, Guastalla JP, Subar M, Abreu P, Winer EP, Cameron DA. A comparative study of exemestane versus anastrozole in patients with postmenopausal breast cancer with visceral metastases. Clin Breast Cancer 2009; 9:39-44. [PMID: 19299239 DOI: 10.3816/cbc.2009.n.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Patients developing visceral breast cancer metastases generally receive chemotherapy rather than endocrine therapy. Recent aromatase inhibitor studies have reported activity in such patients; therefore, this study formally evaluated anastrozole and exemestane in postmenopausal patients in this setting. PATIENTS AND METHODS Postmenopausal women with advanced breast cancer and > or = 1 visceral (liver or lung) lesion were randomized to anastrozole (1 mg/day orally) or exemestane (25 mg/day orally) for > or = 8 weeks. The primary endpoint was objective response in visceral lesions based on modified Response Evaluation Criteria in Solid Tumors. Secondary endpoints included clinical benefit (objective response plus stable disease > or = 180 days), overall survival, and adverse events. RESULTS A total of 130 patients were enrolled, and 128 patients (64 anastrozole, 64 exemestane) were included in the intent-to-treat analysis. Accrual delays caused study closure before the target enrollment (N = 200) was reached, limiting the statistical power of the study. Objective response in visceral sites was approximately 15% in both groups. Clinical benefit in visceral sites was 32% of the patients treated with anastrozole and 38% of the patients treated with exemestane. Median survival was 33.3 months and 30.5 months in the anastrozole and exemestane groups, respectively. Toxicities were similar to those previously reported; however, treatment-related adverse events were more frequent with anastrozole (41%) than with exemestane (31%). Both treatments were generally well tolerated in patients with postmenopausal breast cancer with visceral metastases. CONCLUSION Efficacy was similar in both treatment groups for all endpoints. Aromatase inhibitors can be considered as a treatment option in postmenopausal patients with hormone receptor-positive visceral breast cancer metastases.
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Abstract
Endocrine therapy plays a crucial and historically important role in the treatment ofwomen with hormone-responsive breast cancer. Tamoxifen has been the standard endocrine treatment for advanced and early-stage breast cancer for almost three decades. However, patients receiving tamoxifen may either fail to respond or develop disease recurrence following completion of therapy. The aromatase inhibitors (Als) have become the new and alternative modalities of endocrine treatment for post-menopausal women with oestrogen receptor-positive breast cancer, as a result of promising data from randomised trials in metastatic and locally advanced breast cancers. Recently, the results from several large, randomised, controlled adjuvant trials have provided further evidence that the use of Als, either as initial treatment or sequentially after tamoxifen, improves disease-free survival and, in certain patients, overall survival. With relatively short-term follow-up, the use of Als has been shown to be safe and welltolerated. Nevertheless, some detrimental adverse effects, particularly skeletal-related events or cardiovascular disease, remain important issues of concern and warrant continued monitoring and follow-up. The optimal use of Als, the appropriate timing of treatment, and the superiority of individual agents are under investigation. Use of Als in women with chemotherapy-induced amenorrhoea should be cautious due to the possibility of return of ovarian function. Cost-effectiveness and quality of life remain issues of interest since the high and ever increasing incidence of breast cancer has contributed to significant healthcare costs and patients with breast cancer following appropriate treatment are living longer but not necessarily being cured of their diseases.
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Abstract
Breast cancer growth and dissemination is regulated by estrogen and different growth factor receptor signalling pathways. The increasing knowledge of the biology of breast cancer regarding the interaction of these signalling pathways provides a tool to understand endocrine therapies response and resistance mechanisms. In patients with slowly progressive disease, no visceral involvement, and minimal symptoms, endocrine therapy could be the strategy of choice, even if the tumor has low estrogen receptor expression. Ovarian suppression and tamoxifen are recommended for premenopausal patients whether aromatase inhibitors are the option for postmenopausal ones. Chemotherapy still remains as the right alternative for hormone unresponsive or resistant patients. This is a review focused on the different strategies and combinations of endocrine therapies for metastatic breast cancer patients considering the potential strategies clinically tested to overcome resistance and the different treatments of choice available for each scenario of disseminated disease.
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