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Abudukeremu M, Ayoufu A, Tuerhong A, Paizula X, Ou JH. Distribution of CYP2D6 and CYP2C19 gene polymorphisms in Han and Uygur populations with breast cancer in Xinjiang, China. Open Life Sci 2024; 19:20220728. [PMID: 38681733 PMCID: PMC11049739 DOI: 10.1515/biol-2022-0728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 05/01/2024] Open
Abstract
The aim of this study was to investigate the frequency distribution of the cytochrome P450 (CYP450) enzymes, CYP2D6 and CYP2C19, and the form of tamoxifen metabolisation in premenopausal patients with breast cancer in the Han and Uygur ethnic groups of Xinjiang to guide rational clinical drug use. A total of 125 Han patients and 121 Uygur patients with premenopausal hormone-receptor-positive breast cancer treated at the Xinjiang Uygur Autonomous Region Cancer Hospital between 1 June 2011 and 1 December 2013 were selected. The common mutation sites in CYP450 were analysed using TaqMan® minor groove binder technology. Genetic testing was performed to determine other metabolic types of tamoxifen, and the genotypes and metabolic types were compared using a Chi-squared test. Between the Han and Uygur groups, there were significant differences in the frequencies of the CYP2D6 (*10/*10) and CYP2C19 (*1/*1) genotypes, with P-values of 0.002 and 0.015, respectively. Genotypes of CYP2D6 (*1/*1), CYP2D6 (*1/*5), CYP2D6 (*5/*5), CYP2D6 (*5/*10) and CYP2C19 (*3/*3) were expressed in the two patient groups, and the difference was not statistically significant (P > 0.05). In the Han patients, the proportions of extensive, intermediate and poor metabolisers of tamoxifen were 72, 24 and 4%, respectively, whereas those in the Uygur patients were 76.9, 17.4 and 5.7%, respectively, with no significant difference (P > 0.05). In conclusion, There were partial differences in the CYP2D6 and CYP2C19 gene polymorphisms of CYP450 between the Han and Uygur patients with premenopausal breast cancer, but there was no significant difference between the CYP2D6 and CYP2C19 phenotypes. Further research is needed to determine the relationship between the enzyme genetic differences of CYP450 and the pharmacokinetics and efficacy of tamoxifen. Although there were some differences in genotypes, these did not result in differences in the predicted tamoxifen metabolisation phenotype between the Han and Uygur patients with breast cancer. Therefore, the doses should be adjusted according to the individual genotype data.
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Affiliation(s)
- Muzhapaer Abudukeremu
- Department of Breast and Thyroid Surgery, Affiliated Cancer Hospital of Xinjiang Medical University, Urumqi City, 830000, Xinjiang, China
| | - Aisikaer Ayoufu
- Department of Breast Cancer Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, No. 789, Suzhou Road, Urumqi, Xinjiang, 830011, China
| | - Adila Tuerhong
- Department of Breast Cancer Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, No. 789, Suzhou Road, Urumqi, Xinjiang, 830011, China
| | - Xuelaiti Paizula
- Department of Breast Cancer Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, No. 789, Suzhou Road, Urumqi, Xinjiang, 830011, China
| | - Jiang-Hua Ou
- Department of Breast Cancer Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, No. 789, Suzhou Road, Urumqi, Xinjiang, 830011, China
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Zhuang X, Li M, Xu D, Lin S, Yang Z, Xu T, Yin J. Comprehensive analysis of pain genes in prognosis of kidney renal clear cell carcinoma and tumor immunotherapy: A comprehensive bioinformatic study. Health Sci Rep 2024; 7:e1884. [PMID: 38352696 PMCID: PMC10862147 DOI: 10.1002/hsr2.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/09/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
Background The effect of pain genes (NAV1, EHMT2, SP1, SLC6A4, COMT, OPRM1, OPRD1, CYP2D6, and CYP3A4) have not been reported previously in kidney renal clear cell carcinoma (KIRC) patients and thus we made a comprehensive analysis of pain genes in the prognosis of KIRC and tumor immunotherapy. Methods In this study, TCGA, Kaplan-Meier plotter, Metascape, STRING, Human Protein Atlas, Single Cell Expression Atlas database, LinkedOmics, cBioPortal, MethSurv, CancerSEA, COSMIC database and R package (ggplot2, version 3.3.3) were used for comprehensive analysis of pain genes in KIRC. Pearson and Spearman correlation coefficients were for co-expression analysis. Immunotherapy and TISIDB database were used for tumor Immunotherapy. Results Representative pain genes (SP1, SLC6A4, COMT, OPRD1, CYP2D6, and CYP3A4) were statistically significant (p < 0.0001) in the prognosis of KIRC. Immunotherapy (anti-PD-1 therapy, anti-PD-L1 therapy, and anti-CTLA4 therapy) and immunomodulator (immunoinhibitor, immunostimulator, and MHC molecule) in KIRC were significant associated with pain genes (SP1, SLC6A4, COMT, OPRD1, CYP2D6, and CYP3A4), which were the important addition to clinical decision making for patients. Conclusions Our study uncovered a mechanism for the effect of pain genes on KIRC outcome via the modulation of associated co-expression gene networks, gene variation, and tumor Immunotherapy.
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Affiliation(s)
- Xiao‐Yu Zhuang
- Department of AnesthesiologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Ming Li
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Da‐Ming Xu
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for CancerSun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- Department of UrologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
| | - Shu‐Bin Lin
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Zheng‐Liang Yang
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Teng‐Yu Xu
- Department of UrologySecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
| | - Jun Yin
- Department of Clinical Laboratory MedicineSecond Affiliated Hospital of Shantou University Medical CollegeShantouPeople's Republic of China
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Kellogg CM, Pham K, Ko S, Cox JE, Machalinski AH, Stout MB, Sharpe AL, Beckstead MJ, Chucair-Elliott AJ, Ocañas SR, Freeman WM. Specificity and efficiency of tamoxifen-mediated Cre induction is equivalent regardless of age. iScience 2023; 26:108413. [PMID: 38058312 PMCID: PMC10696116 DOI: 10.1016/j.isci.2023.108413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/15/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023] Open
Abstract
Temporally controlling Cre recombination through tamoxifen (Tam) induction has many advantages for biomedical research. Most studies report early post-natal/juvenile (<2 m.o.) Tam induction, but age-related neurodegeneration and aging studies can require Cre induction in older mice (>12 m.o.). While anecdotally reported as problematic, there are no published comparisons of Tam-mediated Cre induction at early and late ages. Here, microglial-specific Cx3cr1creERT2 mice were crossed to a floxed NuTRAP reporter to compare Cre induction at early (3-6 m.o.) and late (20 m.o.) ages. Specificity and efficiency of microglial labeling at 21-22 m.o. were identical in mice induced with Tam at early and late ages. Age-related microglial translatomic changes were also similar regardless of Tam induction age. Each Cre and flox mouse line should be independently validated, however, these findings demonstrate that Tam-mediated Cre induction can be performed even into older mouse ages and should be generalizable to other inducible Cre models.
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Affiliation(s)
- Collyn M. Kellogg
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Department of Biochemistry & Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kevin Pham
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Sunghwan Ko
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Neuroscience Graduate Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jillian E.J. Cox
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Neuroscience Graduate Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Adeline H. Machalinski
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Michael B. Stout
- Aging & Metabolism Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Amanda L. Sharpe
- Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Neuroscience Graduate Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael J. Beckstead
- Aging & Metabolism Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Ana J. Chucair-Elliott
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Sarah R. Ocañas
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Neuroscience Graduate Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Willard M. Freeman
- Genes & Human Disease Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
- Department of Biochemistry & Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Neuroscience Graduate Program, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Golubenko EO, Savelyeva MI, Sozaeva ZA, Korennaya VV, Poddubnaya IV, Valiev TT, Kondratenko SN, Ilyin MV. Predictive modeling of adverse drug reactions to tamoxifen therapy for breast cancer on base of pharmacogenomic testing. Drug Metab Pers Ther 2023; 38:339-347. [PMID: 37466310 DOI: 10.1515/dmpt-2023-0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/19/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES The present study investigated the analysis of adverse drug reactions (ADRs) to tamoxifen (TAM) in breast cancer patients in relation to the carriage of genetic polymorphisms of genes encoding enzymes of CYP system and transporters of P-glycoprotein (Pg) and predictive models based on it. METHODS A total of 120 women with breast cancer taking adjuvant TAM were examined for the gene polymorphisms such as CYP2D6*4, CYP3A5*3, CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*3 and ABCB1 (C3435T). Allelic variants were determined using the real-time polymerase chain reaction method. The research material was double sampling of buccal epithelium. Medical history data and extracts from case histories were used as sources of medical information, on the basis of which questionnaires specially created by us were filled out. RESULTS An associative analysis showed association with the development of ADRs to TAM indicating their clinical significance from different genetic polymorphisms of CYP2D6, CYP3A5, CYP2C9 and ABCB1. The complex associative analysis performed using mathematical modeling made it possible to build predictive risk models for the development of ADRs such as hot flashes, dyspepsia, bone pain, and asthenia. CONCLUSIONS Models that include both genetic and non-genetic determinants of ADRs of TAM may further improve the prediction of individual response to TAM.
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Affiliation(s)
- Ekaterina Olegovna Golubenko
- Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow, Russia
| | - Marina Ivanovna Savelyeva
- Department of Therapy, Institute of Continuous Professional Education, Yaroslavl State Medical University of the Ministry of Health of Russia, Yaroslavl, Russia
| | - Zhannet Alimovna Sozaeva
- Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow, Russia
| | - Vera Vyacheslavovna Korennaya
- Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow, Russia
| | - Irina Vladimirovna Poddubnaya
- Oncology Department, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow, Russia
| | - Timur Tejmurazovich Valiev
- Department of Pediatric Oncology and Hematology Research Institute, Blokhin' National Medical Research Cancer Center of the Ministry of Health of Russia, Moscow, Russia
| | - Svetlana Nikolaevna Kondratenko
- Department of Clinical Pharmacology and Propaedeutics of Internal Diseases, Sechenov' First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - Mikhail Vitalyevich Ilyin
- Department of Therapy, Institute of Continuous Professional Education, Yaroslavl State Medical University of the Ministry of Health of Russia, Yaroslavl, Russia
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Mbavha BT, Thelingwani RS, Chikwambi Z, Nyakabau AM, Masimirembwa C. Pharmacogenetics and pharmacokinetics of tamoxifen in a Zimbabwean breast cancer cohort. Br J Clin Pharmacol 2023; 89:3209-3216. [PMID: 37337448 PMCID: PMC10529681 DOI: 10.1111/bcp.15827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023] Open
Abstract
Tamoxifen is the most used hormonal therapy for oestrogen receptor-positive breast cancer. CYP2D6 is the main enzyme in the metabolic pathway of tamoxifen to endoxifen. Variations in endoxifen plasma concentrations are associated with CYP2D6 polymorphisms. This study aimed to determine the association between the CYP2D6 polymorphisms and endoxifen plasma concentrations in a cohort of Zimbabwean breast cancer patients (n = 40). TaqMan genotyping and copy number assays were done to determine CYP2D6 genotypes. Tamoxifen and metabolites were quantitated using LC-MS/MS. The population had high frequencies of the CYP2D6 reduced function alleles, *17 (15%) and *29 (18%). The median endoxifen concentration was 4.78 ng/mL, and in 55% of the patients, mostly intermediate metabolizers were below the endoxifen therapeutic threshold of 5.97 ng/mL. The CYP2D6 phenotypes and activity scores were significantly associated with endoxifen plasma concentrations (P = 0.0151) and with endoxifen to N-desmethyl-tamoxifen ratios (P = 0.0006).
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Affiliation(s)
- Bianza Tinotenda Mbavha
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), 911 Boronia Township, Beatrice, Zimbabwe
- Department of Biotechnology, Chinhoyi University of Technology, Private Bag 7724, Chinhoyi, Zimbabwe
| | - Roslyn Stella Thelingwani
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), 911 Boronia Township, Beatrice, Zimbabwe
| | - Zedias Chikwambi
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), 911 Boronia Township, Beatrice, Zimbabwe
- Department of Biotechnology, Chinhoyi University of Technology, Private Bag 7724, Chinhoyi, Zimbabwe
| | - Anna Mary Nyakabau
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | - Collen Masimirembwa
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), 911 Boronia Township, Beatrice, Zimbabwe
- Sydney Brenner Institute for Molecular Bioscience (SBIMB), University of the Witwatersrand, Johannesburg 2000, South Africa
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Kellogg CM, Pham K, Ko S, Cox JEJ, Machalinski AH, Stout MB, Sharpe AL, Beckstead MJ, Chucair-Elliott AJ, Ocañas SR, Freeman WM. Consistent specificity and efficiency of tamoxifen-mediated cre induction across ages. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.19.558482. [PMID: 37781585 PMCID: PMC10541132 DOI: 10.1101/2023.09.19.558482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Temporally controlling cre recombination through tamoxifen (Tam) induction has many advantages for biomedical research. Most studies report Tam induction at early post-natal/juvenile (<2 m.o.) mouse ages, but age-related neurodegeneration and aging studies can require cre induction in older mice (>12 m.o.). While anecdotally reported as problematic, there are no published comparisons of Tam mediated cre induction at early and late ages. Here, microglial-specific Cx3cr1 creERT 2 mice were crossed to a floxed NuTRAP reporter to compare cre induction at early (3-6 m.o.) and late (20 m.o.) ages. Specificity and efficiency of microglial labeling at 21-22 m.o. were identical in mice induced with Tam at 3-6 m.o. or 20 m.o. of age. Age-related microglial translatomic changes were also similar regardless of Tam induction age. Each cre and flox mouse line should be validated independently, however, these findings demonstrate that Tam-mediated cre induction can be performed even into older mouse ages.
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Blancas I, Linares-Rodríguez M, Martínez de Dueñas E, Herrero-Vicent C, Molero-Mir MD, Garrido JM, Rodríguez-Serrano F. Early increase in tamoxifen dose in CYP2D6 poor metaboliser breast cancer patients and survival: A propensity score matching analysis. Breast 2023; 69:342-348. [PMID: 37011481 PMCID: PMC10090803 DOI: 10.1016/j.breast.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023] Open
Abstract
PURPOSE Tamoxifen is a drug used for hormone receptor-positive breast cancers, primarily metabolised by the CYP2D6 enzyme into active metabolites such as endoxifen. CYP2D6 displays varying degrees of activity depending on its genotype. This study aims to analyse the effect of an early increase in tamoxifen dose in poor metabolisers (PM) on survival. METHODS We enrolled 220 patients diagnosed with breast cancer who were treated with tamoxifen. CYP2D6 polymorphisms were determined, and the phenotype was estimated according to the Clinical Pharmacogenetics Implementation Consortium. Disease-free survival (DFS) and overall survival (OS) were analysed considering the entire patient group, and a subgroup of 110 patients selected by Propensity Score Matching (PSM). All women were treated with 20 mg/day of tamoxifen for 5 years, except PM, who initially received 20 mg/day for 4 months, followed by 40 mg/day for 4 months and 60 mg/day for 4 months before returning to the standard dose of 20 mg/day until completing 5 years of treatment. RESULTS The analysis of the influence of CYP2D6 polymorphisms in the complete group and in the PSM subgroup revealed no significant differences for DFS or OS. Furthermore, DFS and OS were analysed in relation to various covariates such as age, histological grade, nodal status, tumour size, HER-2, Ki-67, chemotherapy, and radiotherapy. Only age, histological grade, nodal status, and chemotherapy treatment demonstrated statistical significance. CONCLUSION An early increase in tamoxifen dose in PM patients is not associated with survival differences among CYP2D6 phenotypes.
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Woerdenbag HJ, Olinga P, Kok EA, Brugman DAP, van Ark UF, Ramcharan AS, Lebbink PW, Hoogwater FJH, Knapen DG, de Groot DJA, Nijkamp MW. Potential, Limitations and Risks of Cannabis-Derived Products in Cancer Treatment. Cancers (Basel) 2023; 15:cancers15072119. [PMID: 37046779 PMCID: PMC10093248 DOI: 10.3390/cancers15072119] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
The application of cannabis products in oncology receives interest, especially from patients. Despite the plethora of research data available, the added value in curative or palliative cancer care and the possible risks involved are insufficiently proven and therefore a matter of debate. We aim to give a recommendation on the position of cannabis products in clinical oncology by assessing recent literature. Various types of cannabis products, characteristics, quality and pharmacology are discussed. Standardisation is essential for reliable and reproducible quality. The oromucosal/sublingual route of administration is preferred over inhalation and drinking tea. Cannabinoids may inhibit efflux transporters and drug-metabolising enzymes, possibly inducing pharmacokinetic interactions with anticancer drugs being substrates for these proteins. This may enhance the cytostatic effect and/or drug-related adverse effects. Reversely, it may enable dose reduction. Similar interactions are likely with drugs used for symptom management treating pain, nausea, vomiting and anorexia. Cannabis products are usually well tolerated and may improve the quality of life of patients with cancer (although not unambiguously proven). The combination with immunotherapy seems undesirable because of the immunosuppressive action of cannabinoids. Further clinical research is warranted to scientifically support (refraining from) using cannabis products in patients with cancer.
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Affiliation(s)
- Herman J. Woerdenbag
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Ellen A. Kok
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Donald A. P. Brugman
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Ulrike F. van Ark
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | | | - Paul W. Lebbink
- Transvaal Apotheek, Kempstraat 113, 2572 GC Den Haag, The Netherlands
| | - Frederik J. H. Hoogwater
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan G. Knapen
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Derk Jan A. de Groot
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Manthalkar L, Bhattacharya S. Evidence-based capacity of natural cytochrome enzyme inhibitors to increase the effectivity of antineoplastic drugs. Discov Oncol 2022; 13:142. [PMID: 36571647 PMCID: PMC9792636 DOI: 10.1007/s12672-022-00605-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022] Open
Abstract
Cytochrome (CYP) enzymes catalyze the metabolism of numerous exogenous and endogenous substrates in cancer therapy leading to significant drug interactions due to their metabolizing effect. CYP enzymes play an important role in the metabolism of essential anticancer medications. They are shown to be overexpressed in tumor cells at numerous locations in the body. This overexpression could be a result of lifestyle factors, presence of hereditary variants of CYP (Bio individuality) and multi-drug resistance. This finding has sparked an interest in using CYP inhibitors to lower their metabolizing activity as a result facilitating anti-cancer medications to have a therapeutic impact. As a result of the cytotoxic nature of synthetic enzyme inhibitors and the increased prevalence of herbal medication, natural CYP inhibitors have been identified as an excellent way to inhibit overexpression sighting their tendency to show less cytotoxicity, lesser adverse drug reactions and enhanced bioavailability. Nonetheless, their effect of lowering the hindrance caused in chemotherapy due to CYP enzymes remains unexploited to its fullest. It has been observed that there is a substantial decrease in first pass metabolism and increase in intestinal absorption of chemotherapeutic drugs like paclitaxel when administered along with flavonoids which help suppress certain specific cytochrome enzymes which play a role in paclitaxel metabolism. This review elaborates on the role and scope of phytochemicals in primary, secondary and tertiary care and how targeted prevention of cancer could be a breakthrough in the field of chemotherapy and oncology. This opens up a whole new area of research for delivery of these natural inhibitors along with anticancer drugs with the help of liposomes, micelles, nanoparticles, the usage of liquid biopsy analysis, artificial intelligence in medicine, risk assessment tools, multi-omics and multi-parametric analysis. Further, the site of action, mechanisms, metabolites involved, experimental models, doses and observations of two natural compounds, quercetin & thymoquinone, and two plant extracts, liquorice & garlic on CYP enzymes have been summarized.
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Affiliation(s)
- Laxmi Manthalkar
- Department of Pharmaceutics, School of Pharmacy & Technology Management, SVKM'S NMIMS Deemed-to-be University, Shirpur, 425405, Maharashtra, India
| | - Sankha Bhattacharya
- Department of Pharmaceutics, School of Pharmacy & Technology Management, SVKM'S NMIMS Deemed-to-be University, Shirpur, 425405, Maharashtra, India.
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Savelyeva MI, Golubenko EO, Sozaeva ZA, Poddubnaya IV, Korennaya VV. Analysis of the complications of endocrine therapy with tamoxifen in breast cancer: clinical and pharmacogenetic aspects. Prospective pharmacogenetic cohort study. JOURNAL OF MODERN ONCOLOGY 2022. [DOI: 10.26442/18151434.2022.3.201783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background. Tamoxifen is the drug of choice in ER-positive breast cancer (BC) therapy for perimenopausal women and one of the endocrine therapy options for menopausal patients. The pharmacological effect of tamoxifen can be influenced by the activity of cytochrome P450 (CYP) enzymes and P-glycoprotein transporters (Pg), and the genes encoding them have broad polymorphism, affecting serum concentrations of active metabolites. This article presents the overall results of a prospective population-based study of the clinical significance of genetic polymorphism of tamoxifen metabolic enzymes and transporters in breast cancer patients after radical treatment receiving adjuvant endocrine therapy with tamoxifen in outpatient settings during 2018-2019. The study was approved by the Research Ethics Committee of the Russian Medical Academy of Continuing Professional Education.
Aim. To analyze the clinical presentation of endocrine therapy with tamoxifen in the adjuvant regimen and to assess the association of polymorphisms of genes encoding cytochrome P450 enzymes and drug transporter proteins with adverse events in BC patients.
Materials and methods. One hundred and four women with stage I-III luminal breast cancer receiving adjuvant tamoxifen were examined for the presence of CYP2D6, CYP2C, and the following CYP3A gene polymorphisms: CYP2D6*4, CYP3A5*3, CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*3, as well as the ABCB1 gene polymorphic marker (C3435T) encoding the P-glycoprotein. The allelic variants were identified using the real-time polymerase chain reaction; the test was performed in the Research Center of the Russian Medical Academy of Continuing Professional Education. The study material was buccal epithelium (double sampling) taken after informed consent signing.
Results. Association analysis showed the association of different genetic polymorphisms of CYP2D6, CYP3A5, CYP2C9, and ABCB1 with tamoxifen adverse drug reactions, indicating the clinical significance of these polymorphisms.
Conclusion. With the implementation of genetic testing of the studied polymorphisms into the routine clinical practice of oncologists prescribing tamoxifen and gynecologists involved in the follow-up of breast cancer patients receiving endocrine therapy in the adjuvant mode, there will be an opportunity for more effective and safer pharmacotherapy.
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Boucenna A, Boudaoud K, Hireche A, Rezgoune ML, Abadi N, Filali T, Satta D. Influence of CYP2D6, CYP2C19 and CYP3A5 polymorphisms on plasma levels of tamoxifen metabolites in Algerian women with ER+ breast cancer. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Tamoxifen, a selective estrogen receptor modulator, is indicated for breast cancer developed in response to estrogen.
Findings
In the current study we explored the relationship between the different variants of CYP2D6, CYP2C19, CYP3A5 and plasma Endoxifen levels in Algerian patients with ER + breast cancer. We further conducted the relationship between the candidate genes and the recurrences rate. Endoxifen levels differed significantly (p < .005) between carriers of two functional alleles and patients genotyped as CYP2D6*10, CYP2D6*17, CYP2D6*41 or CYP2D6*5/*5. Patients with elevated Endoxifen concentrations were significantly more likely to not report recurrences than patients with reduced or nul alleles. Such nul/nul, red/red, and red/nul diplotypes have been associated with a higher rate of recurrences than other genotypes during treatment.
Conclusion
Our findings suggest that the CYP2D6 genotype should be considered in tamoxifen-treated women. While quantitatively, CYP2D6 represents only a minor fraction of the total drug metabolizing capacity of the liver, it is polymorphic and, therefore, may alter the balance of metabolism of tamoxifen toward the activation pathways. Breast cancer patients with the CYP2D6 nul/nul or red/nul diplotype may benefit less from Tamoxifen treatment and are more likely to develop recurrences. Comprehensive CYP2D6 genotyping has a good predictive value for CYP2D6 activity. Common variants in CYP2C19 and CYP3A5 did not have a significant impact on the recurrences in this cohort of patients with ER + breast cancer.
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Mbavha BT, Kanji CR, Stadler N, Stingl J, Stanglmair A, Scholl C, Wekwete W, Masimirembwa C. Population genetic polymorphisms of pharmacogenes in Zimbabwe, a potential guide for the safe and efficacious use of medicines in people of African ancestry. Pharmacogenet Genomics 2022; 32:173-182. [PMID: 35190514 DOI: 10.1097/fpc.0000000000000467] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pharmacogenomics (PGx) is a clinically significant factor in the safe and efficacious use of medicines. While PGx knowledge is abundant for other populations, there are scarce PGx data on African populations and is little knowledge on drug-gene interactions for medicines used to treat diseases common in Africa. The aim of this study was to use a custom-designed open array to genotype clinically actionable variants in a Zimbabwean population. This study also identified some of the commonly used drugs in Zimbabwe and the associated genes involved in their metabolism. METHODS A custom-designed open array that covers 120 genetic variants was used to genotype 522 black Zimbabwean healthy volunteers using TaqMan-based single nucleotide polymorphism genotyping. Data were also accessed from Essential Drugs' List in Zimbabwe (EDLIZ), and the medicines were grouped into the associated biomarker groups based on their metabolism. We also estimated the national drug procurement levels for medicines that could benefit from PGx-guided use based on the data obtained from the national authorities in Zimbabwe. RESULTS The results demonstrate the applicability of an open-array chip in simultaneously determining multiple genetic variants in an individual, thus significantly reducing cost and time to generate PGx data. There were significantly high frequencies of African-specific variants, such as the CYP2D6*17 and *29 variants and the CYP2B6*18 variant. The data obtained showed that the Zimbabwean population exhibits PGx variations in genes important for the safe and efficacious use of drugs approved by the EDLIZ and are procured at significantly large amounts annually. The study has established a cohort of genotyped healthy volunteers that can be accessed and used in the conduct of clinical pharmacogenetic studies for drugs entering a market of people of predominantly African ancestry. CONCLUSION Our study demonstrated the potential benefit of integrating PGx in Zimbabwe for the safe and efficacious use of drugs that are commonly used.
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Affiliation(s)
- Bianza T Mbavha
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Comfort R Kanji
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Nadina Stadler
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - Julia Stingl
- Institute of Clinical Pharmacology, University Hospital RWTH Aachen, Aachen, Germany
| | - Andrea Stanglmair
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - Catharina Scholl
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn
| | - William Wekwete
- Evaluations and Registration Division, Medicines Control Authority of Zimbabwe (MCAZ), Harare, Zimbabwe
| | - Collen Masimirembwa
- Department of Genomic Medicine, African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
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13
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Park YA, Park KH, Yoon HY, Yee J, Gwak HS. Effects of CYP2D6 genotypes on Plasmodium vivax recurrence after primaquine treatment: A meta-analysis. Travel Med Infect Dis 2022; 48:102333. [PMID: 35452835 DOI: 10.1016/j.tmaid.2022.102333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/11/2022] [Accepted: 04/16/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To elucidate the relationship between CYP2D6 polymorphisms and Plasmodium vivax recurrence in patients receiving primaquine-based treatment through systematic review and meta-analysis. METHODS We searched the PubMed, EMBASE, Cochrane Library, and Web of Science databases for eligible studies published up to August of 2021. We included studies investigating the associations between CYP2D6 polymorphisms and P. vivax recurrence. We evaluated the pooled odds ratio (OR) and 95% confidence interval (CI). RESULTS Data from nine studies, including 970 patients, were analyzed. We found that CYP2D6 poor metabolizers (PMs), intermediate metabolizers (IMs), or normal metabolizers slow (NM-Ss) were associated with a 1.8-fold (95% CI, 1.34-2.45; P = 0.0001) higher recurrence of P. vivax than normal metabolizers fast (NM-Fs), extensive metabolizers (EMs), or ultrarapid metabolizer (UMs). Subgroup analysis showed that studies on both Brazilian and Southeast or East Asian individuals had similar results to the main results. Sensitivity analysis by sequentially excluding individual studies also showed robust results (OR range: 1.63-2.01). CONCLUSIONS This meta-analysis confirmed that CYP2D6 PMs, IMs, or NM-Ss increased the risk of P. vivax recurrence compared to NM-Fs, EMs, or UMs. The results of this study could be used to predict P. vivax recurrence and suggest CYP2D6 genotype-based primaquine dosing.
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Affiliation(s)
- Yoon-A Park
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, South Korea
| | - Ki Hyun Park
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, South Korea
| | - Ha Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, South Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, South Korea.
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, South Korea.
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Preliminary results using a kit to measure tamoxifen and metabolites concentrations in capillary blood samples from women with breast cancer. Sci Rep 2022; 12:1643. [PMID: 35102224 PMCID: PMC8803831 DOI: 10.1038/s41598-022-05443-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
The aim of the study was to compare 3 blood sampling methods, including capillary blood sampling, for determining Tamoxifen (TAM), Z-endoxifen (END), and 4-hydroxytamoxifen (4HT) concentrations. High performance liquid chromatography-mass spectrometry was used to quantify concentrations of TAM, END, and 4HT in plasma, venous blood, and capillary blood samples of 16 participants on TAM therapy for breast cancer. The rhelise kit was used for capillary sampling. Calibration curves using 13C-labeled analogs of TAM, END, and 4HT as internal standards were used for quantifications. A capillary sampling kit was used successfully for all participants. Mean TAM concentrations did not differ significantly in the 3 types of samples. Mean END and 4HT concentrations did differ significantly between capillary and venous blood samples, possibly related to photodegradation in the internal standards prior to use or degradation products with chromatographic retention times similar to the metabolites. TAM, END, and 4HT concentrations were relatively stable when stored for 14 days at 8 °C and 20 °C. Therapeutic drug monitoring of TAM using an innovative kit and capillary blood sampling is feasible. Preliminary data from this study will aid in developing a multicenter, randomized clinical trial of personalized TAM dose monitoring and adjustments, with the goal of enhancing the quality-of-life and outcomes of patients with breast cancer. Clinical Trial Identification: EudraCT No 2017-000641-44.
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15
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Brandão DC, Lima PMAP, Martins IC, Cordeiro CS, Cordeiro AO, Vecchi L, Guerra JFC, Orsolin PC, Gazolla MC, Costa DS, da Silva Filho AA, Araújo TG. Arrabidaea chica chloroform extract modulates estrogen and androgen receptors on luminal breast cancer cells. BMC Complement Med Ther 2022; 22:18. [PMID: 35057779 PMCID: PMC8773405 DOI: 10.1186/s12906-022-03506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Breast Cancer (BC) is the most common cancer in women worldwide and, although 70% of patients are responsive to selective Estrogen Receptor (ER) modulators such as Tamoxifen (Tam), patients' survival is comprised by resistance to endocrine therapy. Brazilian flora, especially the Amazon biome, is one of the richest global sources of native species with potentially bioactive compounds. Arrabidaea chica is a plant native to the Amazon that has been used in the treatment of different diseases. However, its action on BC remains unclear. METHODS Herein the biological effects of the chloroform extract of A. chica (CEAC) were evaluated on BC cells and in in vivo model. After confirmation of CEAC antioxidant capacity, cells were treated with CEAC and Tam, alone and with CEAC+Tam. The cell viability was evaluated by MTT and hormone receptor transcripts levels were assessed (ESR1, ESR2 and AR). Finally, anticarcinogenicity of CEAC was recorded in Drosophila melanogaster through Epithelial Tumor Test (ETT). RESULTS The study confirmed the antioxidant activity of CEAC. CEAC was selective for MCF-7, downregulating ESR2 and AR transcripts and upregulating ESR2 expression. The modulatory effects of CEAC on ERs did not differ between cells treated with Tam and with CEAC+Tam. Interestingly, previous treatment with CEAC, followed by treatment with Tam promoted a significant decrease in cell viability. The extract also presented anticarcinogenic effect in in vivo assay. CONCLUSION The bioassays on breast tumor cells demonstrated the antiproliferative activity of the extract, which modulated the expression of hormone receptors and sensitized luminal tumor cells to Tam. These results suggest that CEAC could be a complementary treatment for BC.
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Affiliation(s)
- Douglas C. Brandão
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
| | - Paula M. A. P. Lima
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
- Laboratory of Cytogenetic and Mutagenesis, University Center of Patos de Minas, Patos de Minas, MG Brazil
| | - Isabella C. Martins
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
| | - Carina S. Cordeiro
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
| | - Antonielle O. Cordeiro
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
- Laboratory of Nanobiotechnology, Institute of Biotechnology, Federal University of Uberlandia, Uberlandia, MG Brazil
| | - Lara Vecchi
- Laboratory of Nanobiotechnology, Institute of Biotechnology, Federal University of Uberlandia, Uberlandia, MG Brazil
| | - Joyce F. C. Guerra
- Institute of Biotechnology, Federal University of Uberlandia, Patos de Minas, MG Brazil
| | - Priscila C. Orsolin
- Laboratory of Cytogenetic and Mutagenesis, University Center of Patos de Minas, Patos de Minas, MG Brazil
| | - Matheus C. Gazolla
- Faculty of Pharmacy, Department of Pharmaceutical Sciences, Federal University of Juiz de Fora, Juiz de Fora, MG Brazil
| | - Danilo S. Costa
- Faculty of Pharmacy, Department of Pharmaceutical Sciences, Federal University of Juiz de Fora, Juiz de Fora, MG Brazil
| | - Ademar A. da Silva Filho
- Faculty of Pharmacy, Department of Pharmaceutical Sciences, Federal University of Juiz de Fora, Juiz de Fora, MG Brazil
| | - Thaise G. Araújo
- Laboratory of Genetics and Biotechnology, Institute of Biotechnology, Federal University of Uberlandia, Rua Major Jerônimo, 566, Sala 601, Patos de Minas, MG 38700-002 Brazil
- Laboratory of Nanobiotechnology, Institute of Biotechnology, Federal University of Uberlandia, Uberlandia, MG Brazil
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Yeast Double Transporter Gene Deletion Library for Identification of Xenobiotic Carriers in Low or High Throughput. mBio 2021; 12:e0322121. [PMID: 34903049 PMCID: PMC8669479 DOI: 10.1128/mbio.03221-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The routes of uptake and efflux should be considered when developing new drugs so that they can effectively address their intracellular targets. As a general rule, drugs appear to enter cells via protein carriers that normally carry nutrients or metabolites. A previously developed pipeline that searched for drug transporters using Saccharomyces cerevisiae mutants carrying single-gene deletions identified import routes for most compounds tested. However, due to the redundancy of transporter functions, we propose that this methodology can be improved by utilizing double mutant strains in both low- and high-throughput screens. We constructed a library of over 14,000 strains harboring double deletions of genes encoding 122 nonessential plasma membrane transporters and performed low- and high-throughput screens identifying possible drug import routes for 23 compounds. In addition, the high-throughput assay enabled the identification of putative efflux routes for 21 compounds. Focusing on azole antifungals, we were able to identify the involvement of the myo-inositol transporter, Itr1p, in the uptake of these molecules and to confirm the role of Pdr5p in their export.
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Ahern TP, MacLehose RF, Haines L, Cronin-Fenton DP, Damkier P, Collin LJ, Lash TL. Improving the transparency of meta-analyses with interactive web applications. BMJ Evid Based Med 2021; 26:327-332. [PMID: 32220861 PMCID: PMC7530078 DOI: 10.1136/bmjebm-2019-111308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 12/27/2022]
Abstract
Increased transparency in study design and analysis is one proposed solution to the perceived reproducibility crisis facing science. Systematic review and meta-analysis-through which individual studies on a specific association are ascertained, assessed for quality and quantitatively combined-is a critical process for building consensus in medical research. However, the conventional publication model creates static evidence summaries that force the quality assessment criteria and analytical choices of a small number of authors onto all stakeholders, some of whom will have different views on the quality assessment and key features of the analysis. This leads to discordant inferences from meta-analysis results and delayed arrival at consensus. We propose a shift to interactive meta-analysis, through which stakeholders can take control of the evidence synthesis using their own quality criteria and preferred analytic approach-including the option to incorporate prior information on the association in question-to reveal how their summary estimate differs from that reported by the original analysts. We demonstrate this concept using a web-based meta-analysis of the association between genetic variation in a key tamoxifen-metabolising enzyme and breast cancer recurrence in tamoxifen-treated women. We argue that interactive meta-analyses would speed consensus-building to the degree that they reveal invariance of inferences to different study selection and analysis criteria. On the other hand, when inferences are found to differ substantially as a function of these choices, the disparities highlight where future research resources should be invested to resolve lingering sources of disagreement.
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Affiliation(s)
- Thomas P Ahern
- Departments of Surgery and Biochemistry, The Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Richard F MacLehose
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Laura Haines
- Dana Medical Library, The Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | | | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, University of Southern Denmark, Odense, Denmark
| | - Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Sharma S, George P, Waddell N. Precision diagnostics: Integration of tissue pathology and genomics in cancer. Pathology 2021; 53:809-817. [PMID: 34635323 DOI: 10.1016/j.pathol.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/09/2022]
Abstract
Traditionally, cancer diagnosis and management has been reactionary in that symptoms lead to investigations, then a diagnosis is followed by clinical management. This process is heavily dependent on tissue diagnosis mainly by histopathology and to a lesser extent, cytopathology. However, in recent times there has been a shift towards precision medicine to enable prevention, prediction and personalisation in healthcare. The core of precision medicine is optimising therapeutic benefit for patients, by using genomic and molecular profiling, analogously termed precision pathology. This review explores (1) the evolution of pathology from a para-clinical discipline to a mainstream medical field integral to oncology tumour boards; (2) its critical role in preventative, diagnostic, therapeutic and follow-up cancer care; (3) the future of tissue pathology in the era of precision oncology; and (4) how pathologists may evolve to future-proof their profession.
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Affiliation(s)
- Sowmya Sharma
- Medlab Pathology, Auburn, NSW, Australia; QIMR Berghofer Medical Research Institute, Department of Genetics and Computational Biology, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia.
| | - Peter George
- Medlab Pathology, Auburn, NSW, Australia; genomiQa, Brisbane, Qld, Australia
| | - Nicola Waddell
- QIMR Berghofer Medical Research Institute, Department of Genetics and Computational Biology, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; genomiQa, Brisbane, Qld, Australia
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19
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Chen Y, Marcath LA, Eliassen FM, Lende TH, Soiland H, Mellgren G, Helland T, Hertz DL. Effect of Genetic Variability in 20 Pharmacogenes on Concentrations of Tamoxifen and Its Metabolites. J Pers Med 2021; 11:jpm11060507. [PMID: 34199712 PMCID: PMC8228634 DOI: 10.3390/jpm11060507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Tamoxifen, as a treatment of estrogen receptor positive (ER+) breast cancer, is a weak anti-estrogen that requires metabolic activation to form metabolites with higher anti-estrogenic activity. Endoxifen is the most-studied active tamoxifen metabolite, and endoxifen concentrations are highly associated with CYP2D6 activity. Associations of tamoxifen efficacy with measured or CYP2D6-predicted endoxifen concentrations have been inconclusive. Another active metabolite, 4-OHtam, and other, less active metabolites, Z-4'-endoxifen and Z-4'-OHtam, have also been reported to be associated with tamoxifen efficacy. METHOD Genotype for 20 pharmacogenes was determined by VeriDose® Core Panel and VeriDose®CYP2D6 CNV Panel, followed by translation to metabolic activity phenotype following standard activity scoring. Concentrations of tamoxifen and seven metabolites were measured by UPLC-MS/MS in serum samples collected from patients receiving 20 mg tamoxifen per day. Metabolic activity was tested for association with tamoxifen and its metabolites using linear regression with adjustment for upstream metabolites to identify genes associated with each step in the tamoxifen metabolism pathway. RESULTS A total of 187 patients with genetic and tamoxifen concentration data were included in the analysis. CYP2D6 was the primary gene associated with the tamoxifen metabolism pathway, especially the conversion of tamoxifen to endoxifen. CYP3A4 and CYP2C9 were also responsible for the metabolism of tamoxifen. CYP2C9 especially impacted the hydroxylation to 4-OHtam, and this involved the OATP1B1 (SLCO1B1) transporter. CONCLUSION Multiple genes are involved in tamoxifen metabolism and multi-gene panels could be useful to predict active metabolite concentrations and guide tamoxifen dosing.
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Affiliation(s)
- Yuanhuang Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA; (Y.C.); (T.H.)
| | - Lauren A. Marcath
- Department of Pharmacotherapy, Washington State University College of Pharmacy & Pharmaceutical Sciences, Spokane, WA 99202, USA;
| | - Finn Magnus Eliassen
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway; (F.M.E.); (T.H.L.)
| | - Tone Hoel Lende
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway; (F.M.E.); (T.H.L.)
| | - Havard Soiland
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway; (H.S.); (G.M.)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Gunnar Mellgren
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway; (H.S.); (G.M.)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Thomas Helland
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA; (Y.C.); (T.H.)
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway; (H.S.); (G.M.)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Daniel Louis Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA; (Y.C.); (T.H.)
- Correspondence: ; Tel.: +1-734-763-0015; Fax: +1-734-763-4480
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Mulder TAM, de With M, del Re M, Danesi R, Mathijssen RHJ, van Schaik RHN. Clinical CYP2D6 Genotyping to Personalize Adjuvant Tamoxifen Treatment in ER-Positive Breast Cancer Patients: Current Status of a Controversy. Cancers (Basel) 2021; 13:cancers13040771. [PMID: 33673305 PMCID: PMC7917604 DOI: 10.3390/cancers13040771] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Tamoxifen is an important adjuvant endocrine therapy in estrogen receptor (ER)-positive breast cancer patients. It is mainly catalyzed by the enzyme CYP2D6 into the most active metabolite endoxifen. Genetic variation in the CYP2D6 gene influences endoxifen formation and thereby potentially therapy outcome. However, the association between CYP2D6 genotype and clinical outcome on tamoxifen is still under debate, as contradictory outcomes have been published. This review describes the latest insights in both CYP2D6 genotype and endoxifen concentrations, as well CYP2D6 genotype and clinical outcome, from 2018 to 2020. Abstract Tamoxifen is a major option for adjuvant endocrine treatment in estrogen receptor (ER) positive breast cancer patients. The conversion of the prodrug tamoxifen into the most active metabolite endoxifen is mainly catalyzed by the enzyme cytochrome P450 2D6 (CYP2D6). Genetic variation in the CYP2D6 gene leads to altered enzyme activity, which influences endoxifen formation and thereby potentially therapy outcome. The association between genetically compromised CYP2D6 activity and low endoxifen plasma concentrations is generally accepted, and it was shown that tamoxifen dose increments in compromised patients resulted in higher endoxifen concentrations. However, the correlation between CYP2D6 genotype and clinical outcome is still under debate. This has led to genotype-based tamoxifen dosing recommendations by the Clinical Pharmacogenetic Implementation Consortium (CPIC) in 2018, whereas in 2019, the European Society of Medical Oncology (ESMO) discouraged the use of CYP2D6 genotyping in clinical practice for tamoxifen therapy. This paper describes the latest developments on CYP2D6 genotyping in relation to endoxifen plasma concentrations and tamoxifen-related clinical outcome. Therefore, we focused on Pharmacogenetic publications from 2018 (CPIC publication) to 2021 in order to shed a light on the current status of this debate.
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Affiliation(s)
- Tessa A. M. Mulder
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
| | - Mirjam de With
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus MC, Wytemaweg 80, 3015CN Rotterdam, The Netherlands;
| | - Marzia del Re
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 55, Via Roma, 56126 Pisa, Italy
| | - Romano Danesi
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 55, Via Roma, 56126 Pisa, Italy
| | - Ron H. J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus MC, Wytemaweg 80, 3015CN Rotterdam, The Netherlands;
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry, Erasmus MC University Hospital, Wytemaweg 80, 3015CN Rotterdam, The Netherlands; (T.A.M.M.); (M.d.W.); (M.d.R.); (R.D.)
- Correspondence: ; Tel.: +31-10-703-3119
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Genetic variation of pharmacogenomic VIP variants in Zhuang nationality of southern China. THE PHARMACOGENOMICS JOURNAL 2020; 21:60-68. [PMID: 32699276 DOI: 10.1038/s41397-020-0177-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/18/2020] [Accepted: 07/09/2020] [Indexed: 11/09/2022]
Abstract
Drug gene polymorphisms are strongly associated with disease. Previous studies have shown that the frequency of drug genes varies in different populations. At present, there are no reports about the polymorphism of the drug genome in the Zhuang population in southern China. This study conducted a pharmacogenomics study on the Zhuang population in southern China. Therefore, we conducted genotyping on 105 Zhuang samples, and compared the genotyping results with those of other 11 ethnic groups after statistical analysis. Our results show that, compared with the 11 populations in the HapMap data set, the differences between the CYP2E1 rs2070676 and CYP2D6 rs1065852 of the Zhuang nationality are the largest. This study fills in the blank of the drug genome information of the Zhuang nationality in southern China. The two sites of Rs2070676 (CYP2E1) and rs1065852 (CYP2D6) provide a reliable basis for the prediction of the efficacy of certain drugs. Its main purpose is to provide theoretical basis for safe drug use in the Zhuang region of southern China.
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Carr DF, Turner RM, Pirmohamed M. Pharmacogenomics of anticancer drugs: Personalising the choice and dose to manage drug response. Br J Clin Pharmacol 2020; 87:237-255. [PMID: 32501544 DOI: 10.1111/bcp.14407] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/11/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
The field of pharmacogenomics has made great strides in oncology over the last 20 years and indeed a significant number of pre-emptive genetic tests are now routinely undertaken prior to anticancer drug administration. Many of these gene-drug interactions are the fruits of candidate gene and genome-wide association studies, which have largely focused on common genetic variants (allele frequency>1%). Examples where there is clinical utility include genotyping or phenotyping for G6PD to prevent rasburicase-induced RBC haemolysis, and TPMT to prevent thiopurine-induced bone marrow suppression. Other associations such as CYP2D6 status in determining the efficacy of tamoxifen are more controversial because of contradictory evidence from different sources, which has led to variability in the implementation of testing. As genomic technology becomes ever cheaper and more accessible, we must look to the additional data our genome can provide to explain interindividual variability in anticancer drug response. Clearly genes do not act on their own and it is therefore important to investigate genetic factors in conjunction with clinical factors, interacting concomitant drug therapies and other factors such as the microbiome, which can all affect drug disposition. Taking account of all of these factors, in conjunction with the somatic genome, is more likely to provide better predictive accuracy in determining anticancer drug response, both efficacy and safety. This review summarises the existing knowledge related to the pharmacogenomics of anticancer drugs and discusses areas of opportunity for further advances in personalisation of therapy in order to improve both drug safety and efficacy.
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Affiliation(s)
- Daniel F Carr
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Richard M Turner
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Marin JJG, Serrano MA, Monte MJ, Sanchez-Martin A, Temprano AG, Briz O, Romero MR. Role of Genetic Variations in the Hepatic Handling of Drugs. Int J Mol Sci 2020; 21:E2884. [PMID: 32326111 PMCID: PMC7215464 DOI: 10.3390/ijms21082884] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
The liver plays a pivotal role in drug handling due to its contribution to the processes of detoxification (phases 0 to 3). In addition, the liver is also an essential organ for the mechanism of action of many families of drugs, such as cholesterol-lowering, antidiabetic, antiviral, anticoagulant, and anticancer agents. Accordingly, the presence of genetic variants affecting a high number of genes expressed in hepatocytes has a critical clinical impact. The present review is not an exhaustive list but a general overview of the most relevant variants of genes involved in detoxification phases. The available information highlights the importance of defining the genomic profile responsible for the hepatic handling of drugs in many ways, such as (i) impaired uptake, (ii) enhanced export, (iii) altered metabolism due to decreased activation of prodrugs or enhanced inactivation of active compounds, and (iv) altered molecular targets located in the liver due to genetic changes or activation/downregulation of alternative/compensatory pathways. In conclusion, the advance in this field of modern pharmacology, which allows one to predict the outcome of the treatments and to develop more effective and selective agents able to overcome the lack of effect associated with the existence of some genetic variants, is required to step forward toward a more personalized medicine.
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Affiliation(s)
- Jose J. G. Marin
- HEVEFARM Group, Center for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Carlos III National Institute of Health, University of Salamanca, IBSAL, 37007 Salamanca, Spain; (M.A.S.); (M.J.M.); (A.S.-M.); (A.G.T.); (O.B.); (M.R.R.)
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Chan CWH, Law BMH, So WKW, Chow KM, Waye MMY. Pharmacogenomics of breast cancer: highlighting CYP2D6 and tamoxifen. J Cancer Res Clin Oncol 2020; 146:1395-1404. [PMID: 32270286 DOI: 10.1007/s00432-020-03206-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To review recent pharmacogenomics studies on breast cancer patients undergoing tamoxifen therapy, highlighting how our knowledge on cytochrome P450 2D6 (CYP2D6) can help to guide the development of adjuvant therapies for these patients. METHODS A comprehensive literature search was conducted. Articles reporting findings pertaining to the effect of CYP2D6 on the therapeutic efficacy of tamoxifen, those reporting how targeting CYP2D6 could inform tamoxifen-based therapy development, and those on the tamoxifen effects on cell lines and animal models were included in the review. RESULTS With CYP2D6 being the primary enzyme for tamoxifen metabolism, single-nucleotide polymorphisms (SNPs) in this gene were one of the determinants in the rate of tamoxifen metabolism, thereby potentially having an effect on the efficacy of tamoxifen-based therapies. Our review indicates the potential effectiveness of targeting these SNPs, including those for the CYP2D6*10 allele (c. 100C > T), in modifying the level of tamoxifen metabolism. These findings suggest the importance of pharmacogenomics research in our understanding of the efficacy of adjuvant therapies. However, the involvement of multiple enzymes in tamoxifen metabolism, dietary factors, ethnic differences in gene frequencies, and patients' compliance to tamoxifen therapies in studies do present challenges in pharmacogenomics research. CONCLUSIONS Pharmacogenomics could play important roles in mediating the advancement of tamoxifen-based adjuvant therapies. Research efforts should be directed towards the exploration of further SNPs of CYP2D6 that affect tamoxifen metabolism, as well as epigenetic changes in CYP2D6, enabling the design of precision medicine and confirming clinical validity in the use of pharmacogenomics for tamoxifen.
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Affiliation(s)
- Carmen W H Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F Esther Lee Building, Hong Kong, China
| | - Bernard M H Law
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F Esther Lee Building, Hong Kong, China
| | - Winnie K W So
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F Esther Lee Building, Hong Kong, China
| | - Ka Ming Chow
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F Esther Lee Building, Hong Kong, China
| | - Mary M Y Waye
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F Esther Lee Building, Hong Kong, China. .,The Croucher Laboratory for Human Genomics, The Chinese University of Hong Kong, Hong Kong, China.
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Ahern TP, Collin LJ, Baurley JW, Kjærsgaard A, Nash R, Maliniak ML, Damkier P, Zwick ME, Isett RB, Christiansen PM, Ejlertsen B, Lauridsen KL, Christensen KB, Silliman RA, Sørensen HT, Tramm T, Hamilton-Dutoit S, Lash TL, Cronin-Fenton D. Metabolic Pathway Analysis and Effectiveness of Tamoxifen in Danish Breast Cancer Patients. Cancer Epidemiol Biomarkers Prev 2020; 29:582-590. [PMID: 31932415 PMCID: PMC7060091 DOI: 10.1158/1055-9965.epi-19-0833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/15/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Tamoxifen and its metabolites compete with estrogen to occupy the estrogen receptor. The conventional dose of adjuvant tamoxifen overwhelms estrogen in this competition, reducing breast cancer recurrence risk by nearly half. Phase I metabolism generates active tamoxifen metabolites, and phase II metabolism deactivates them. No earlier pharmacogenetic study has comprehensively evaluated the metabolism and transport pathways, and no earlier study has included a large population of premenopausal women. METHODS We completed a cohort study of 5,959 Danish nonmetastatic premenopausal breast cancer patients, in whom 938 recurrences occurred, and a case-control study of 541 recurrent cases in a cohort of Danish predominantly postmenopausal breast cancer patients, all followed for 10 years. We collected formalin-fixed paraffin-embedded tumor blocks and genotyped 32 variants in 15 genes involved in tamoxifen metabolism or transport. We estimated conventional associations for each variant and used prior information about the tamoxifen metabolic path to evaluate the importance of metabolic and transporter pathways. RESULTS No individual variant was notably associated with risk of recurrence in either study population. Both studies showed weak evidence of the importance of phase I metabolism in the clinical response to adjuvant tamoxifen therapy. CONCLUSIONS Consistent with prior knowledge, our results support the role of phase I metabolic capacity in clinical response to tamoxifen. Nonetheless, no individual variant substantially explained the modest phase I effect on tamoxifen response. IMPACT These results are consistent with guidelines recommending against genotype-guided prescribing of tamoxifen, and for the first time provide evidence supporting these guidelines in premenopausal women.
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Affiliation(s)
- Thomas P Ahern
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, Vermont
| | - Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maret L Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael E Zwick
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - R Benjamin Isett
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - Peer M Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Rebecca A Silliman
- Boston University School of Medicine, Boston University, Boston, Massachusetts
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Winship Cancer Institute, Emory University, Atlanta, Georgia
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