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Garg P, Awasthi S, Horne D, Salgia R, Singhal SS. The innate effects of plant secondary metabolites in preclusion of gynecologic cancers: Inflammatory response and therapeutic action. Biochim Biophys Acta Rev Cancer 2023; 1878:188929. [PMID: 37286146 DOI: 10.1016/j.bbcan.2023.188929] [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: 04/24/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
Gynecologic cancers can make up the bulk of cancers in both humans and animals. The stage of diagnosis and the type of tumor, its origin, and its spread are a few of the factors that influence how effectively a treatment modality works. Currently, radiotherapy, chemotherapy, and surgery are the major treatment options recommended for the eradication of malignancies. The use of several anti-carcinogenic drugs increases the chance of harmful side effects, and patients might not react to the treatments as expected. The significance of the relationship between inflammation and cancer has been underscored by recent research. As a result, it has been shown that a variety of phytochemicals with beneficial bioactive effects on inflammatory pathways have the potential to act as anti-carcinogenic medications for the treatment of gynecologic cancer. The current paper reviews the significance of inflammatory pathways in gynecologic malignancies and discusses the role of plants-derived secondary metabolites that are useful in the treatment of cancer.
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Affiliation(s)
- Pankaj Garg
- Department of Chemistry, GLA University, Mathura, Uttar Pradesh 281406, India
| | - Sanjay Awasthi
- Cayman Health, CTMH Doctors Hospital in Cayman Islands, George Town, Grand Cayman, USA
| | - David Horne
- Departments of Molecular Medicine, Beckman Research Institute of City of Hope, Comprehensive Cancer Center and National Medical Center, Duarte, CA 91010, USA
| | - Ravi Salgia
- Departments of Medical Oncology & Therapeutics Research, Beckman Research Institute of City of Hope, Comprehensive Cancer Center and National Medical Center, Duarte, CA 91010, USA
| | - Sharad S Singhal
- Departments of Medical Oncology & Therapeutics Research, Beckman Research Institute of City of Hope, Comprehensive Cancer Center and National Medical Center, Duarte, CA 91010, USA.
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Graff BT, Palanivel C, Jenkins CB, Baranowska-Kortylewicz J, Yan Y. Benzimidazole carbamate induces cytotoxicity in breast cancer cells via two distinct cell death mechanisms. Cell Death Discov 2023; 9:162. [PMID: 37179350 PMCID: PMC10183037 DOI: 10.1038/s41420-023-01454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Metastatic breast cancer (mBC) is responsible for >90% of breast cancer-related deaths. Microtubule-targeting agents (MTAs) are the front-line treatment for mBC. However, the effectiveness of MTAs is frequently limited by the primary or acquired resistance. Furthermore, recurrent mBC derived from cancer cells that survived MTA treatment are typically more chemoresistant. The overall response rates for the second- and third-line MTAs in mBC patients previously treated with MTAs are 12-35%. Thus, there is an ongoing search for novel MTAs with a distinct mode of action that can circumvent chemoresistance mechanisms. Our results show that methyl N-(6-benzoyl-1H-benzimidazol-2-yl)carbamate (BCar), a microtubule-disrupting anthelmintic that binds to the colchicine binding site separate from the binding sites of clinically used MTAs, has the potential to treat MTA-resistant mBC. We have comprehensively evaluated the cellular effects of BCar in a panel of human breast cancer (BC) cell lines and normal breast cells. BCar effects on the clonogenic survival, cell cycle, apoptosis, autophagy, senescence, and mitotic catastrophe were measured. Approximately 25% of BCs harbor mutant p53. For this reason, the p53 status was included as a variable. The results show that BC cells are >10x more sensitive to BCar than normal mammary epithelial cells (HME). p53-mutant BC cells are significantly more sensitive to BCar treatment than p53 wild-type BC cells. Furthermore, BCar appears to kill BC cells primarily via either p53-dependent apoptosis or p53-independent mitotic catastrophe. When compared to docetaxel and vincristine, two clinical MTAs, BCar is fairly innocuous in HME cells, providing a much wider therapeutic window than docetaxel and vincristine. Together, the results strongly support the notion that BCar-based therapeutics may serve as a new line of MTAs for mBC treatment.
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Affiliation(s)
- Brendan T Graff
- Department of Radiation Oncology, College of Medicine University of Nebraska Medical Center Omaha, Nebraska, USA
| | - Chitra Palanivel
- Department of Radiation Oncology, College of Medicine University of Nebraska Medical Center Omaha, Nebraska, USA
| | - Christopher B Jenkins
- Department of Radiation Oncology, College of Medicine University of Nebraska Medical Center Omaha, Nebraska, USA
| | - Janina Baranowska-Kortylewicz
- Department of Pharmaceutical Sciences, College of Pharmacy University of Nebraska Medical Center Omaha, Nebraska, USA.
| | - Ying Yan
- Department of Radiation Oncology, College of Medicine University of Nebraska Medical Center Omaha, Nebraska, USA.
- Department of Biochemistry and Molecular Biology, College of Medicine University of Nebraska Medical Center Omaha, Nebraska, USA.
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Niwa T, Tahara T, Chase CE, Fang FG, Nakaoka T, Irie S, Hayashinaka E, Wada Y, Mukai H, Masutomi K, Watanabe Y, Cui Y, Hosoya T. Synthesis of 11C-Radiolabeled Eribulin as a Companion Diagnostics PET Tracer for Brain Glioblastoma. BULLETIN OF THE CHEMICAL SOCIETY OF JAPAN 2023. [DOI: 10.1246/bcsj.20220335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Takashi Niwa
- Laboratory for Chemical Biology, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University (TMDU), 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062, Japan
| | - Tsuyoshi Tahara
- Laboratory for Biofunction Dynamics Imaging, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
- Department of in vivo Imaging, Advanced Research Promoting Center, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Charles E. Chase
- Eisai Inc., 35 Cambridgepark Drive Suite 200, Cambridge, MA 02140, USA
| | - Francis G. Fang
- Eisai Inc., 35 Cambridgepark Drive Suite 200, Cambridge, MA 02140, USA
| | - Takayoshi Nakaoka
- Laboratory for Pathophysiological and Health Science, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Satsuki Irie
- Laboratory for Pathophysiological and Health Science, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Emi Hayashinaka
- Laboratory for Pathophysiological and Health Science, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Yasuhiro Wada
- Laboratory for Pathophysiological and Health Science, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Hidefumi Mukai
- Laboratory for Molecular Delivery and Imaging Technology, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Kenkichi Masutomi
- Division of Cancer Stem Cell, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Yasuyoshi Watanabe
- Laboratory for Pathophysiological and Health Science, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Yilong Cui
- Laboratory for Biofunction Dynamics Imaging, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Takamitsu Hosoya
- Laboratory for Chemical Biology, RIKEN Center for Biosystems Dynamics Research (BDR), 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University (TMDU), 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062, Japan
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Hasler-Strub U, Mueller A, Li Q, Thuerlimann B, Ribi K, Gerber S, von Moos R, Fehr M, Rochlitz C, Zaman K, Aebi S, Hochstrasser A, Gick U, Baertschi D, Greuter S, Schreiber A, Caspar CB, Trojan A, Condorelli R, Ruhstaller T. Eribulin as first-line treatment in older patients with advanced breast cancer: A multicenter phase II trial [SAKK 25/14]. J Geriatr Oncol 2023; 14:101372. [PMID: 36127284 DOI: 10.1016/j.jgo.2022.09.001] [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: 02/02/2022] [Revised: 06/11/2022] [Accepted: 09/02/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Standard-dose eribulin mesylate (1.4 mg/m2 d1 + 8) achieves clinical benefit rates of 26%-52% in patients with metastatic breast cancer (mBC). <10% of patients in the registration trial were ≥ 70 years old; dose reductions were common in these older patients. MATERIALS AND METHODS This single-arm phase II trial explored the efficacy of reduced starting dosing of first-line eribulin at 1 mg/m2 d1 + 8 q3 weeks in patients with mBC aged ≥70 years. The primary endpoint was a disease control rate (DCR) ≥55%. The secondary endpoints were objective response (OR), progression-free survival (PFS), overall survival (OS), and patient-reported neurotoxicity. RESULTS Overall, 77 patients were accrued; their median age was 76 years and Eastern Cooperative Oncology Group performance status was 0-1 in 90%. The DCR was 40% (90% confidence interval [CI]: 31-50); therefore, the primary endpoint was not reached. The overall response rate was 22% (95%CI: 13-33), median PFS 5.4 months (95%CI: 4.5-7.7), and median OS 16.1 months (95%CI: 13.5-26.9). Dose modifications were necessary in 35% of patients. In nine patients, more than fifteen cycles were given; 48 patients (62%) experienced at least one grade 3 toxicity. Median patient-reported neurotoxicity scores remained stable for at least fifteen cycles. The main reason for treatment discontinuation was disease progression (57%). DISCUSSION We report the first prospective data on first-line eribulin in older patients. The reduced starting dose of 1.1 mg/m2 was safe, with prolonged treatment and DC achieved in a considerable proportion of patients (but less than the 55% assumed), without cumulative neurotoxicity. The reduced dose was apparently within the range of the minimal effective dose, as shown by the efficacy lack in patients requiring further dose reductions. Thus, our results do not support the approach of a reduced starting dose for older patients.
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Affiliation(s)
- Ursula Hasler-Strub
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland.
| | - Andreas Mueller
- Breast Center, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Qiyu Li
- SAKK Coordinating Center, Bern, Switzerland
| | - Beat Thuerlimann
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Karin Ribi
- SAKK Coordinating Center, Bern, Switzerland; IBCSG International Breast Cancer Study Group, Bern, Switzerland
| | | | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland
| | - Mathias Fehr
- Department of Gynecology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Christoph Rochlitz
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Khalil Zaman
- Department of Oncology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Stefan Aebi
- Department of Medical Oncology, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Ute Gick
- Onko Netz Thun, Thun, Switzerland
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Optimization of G-CSF dosing schedule in patients treated with eribulin: a modeling approach. Cancer Chemother Pharmacol 2022; 89:197-208. [PMID: 34997290 DOI: 10.1007/s00280-021-04395-y] [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: 09/08/2021] [Accepted: 12/28/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Granulocyte colony-stimulating factors (G-CSF) are commonly given to limit chemotherapy-induced neutropenia, but, in case of weekly chemotherapy such as eribulin, their administration schedules remain empirical. OBJECTIVES This pharmacokinetic/pharmacodynamic (PK/PD) study was conducted to establish the effect of different G-CSF regimens on neutropenia's incidence for patients treated by eribulin, to propose an optimal G-CSF dosing schedule. METHODS A population PK/PD model was developed to describe absolute neutrophil counts' (ANC) time course in 87 cancer patients receiving eribulin. The structural model considered ANC dynamics, neutropenic effect of eribulin and stimulating effect of G-CSF. Final model estimates were used to calculate neutropenia's incidence following different G-CSF dosing schedules for 1000 virtual subjects. RESULTS The final model successfully described most of the ANC time course for all patients. Simulations showed that a single G-CSF administration 48 h after each eribulin injection reduced the risk of severe neutropenia from 29.7 to 5.2%. Five days of G-CSF only after the second eribulin injection or no G-CSF administration induces similar incidence of neutropenia. CONCLUSION Simulations showed a single G-CSF administration 48 h after the end of each eribulin injection seems to be the optimal schedule to reduce eribulin-induced neutropenia. However, the new administration scheme should be tested in real life to evaluate its pertinence. TRIAL REGISTRATION Eudract 2015-001753-32, 2015/01/26.
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Chen PH, Yeh DC, Tung HH, Lin CY. Prognostic and predictive factors of eribulin in patients with heavily pre-treated metastatic breast cancer. Medicine (Baltimore) 2021; 100:e27859. [PMID: 34964753 PMCID: PMC8615315 DOI: 10.1097/md.0000000000027859] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
A predictive marker for efficacy of eribulin administered as different lines of treatment in metastatic breast cancer (MBC) has not been identified. We aimed to determine the predictive factors for efficacy of eribulin administered as different lines of treatment in MBC patients.This restrospective cohort study included 49 heavily pre-treated MBC patients who received either eribulin monotherapy or combination therapy with eribulin and anti-Her2 therapy. Associations between clinical response of eribulin-based treatment, time-to-treatment failure (TTF), and possible predictive markers were investigated.Patients' median age was 55 years; 65% were ER+; 43% were HER2+; and 16% were triple-negative. Median TTF was 5.23 months and longer in non-visceral metastases patients. Eastern Cooperative Oncology Group (ECOG) status was 0-1; eribulin as ≥2nd-line treatment; eribulin combined with dual blockades; lymphocyte-monocyte ratio (LMR) ≥3; and monocyte-lymphocyte ratio (MLR) <0.4. In patients with eribulin as >3rd-line treatment, univariate analysis showed that ECOG status was 0-1, and LMR ≥3 and MLR <0.4 were associated with a low risk of TTF. Multivariate analysis showed that ECOG status 0-1 was an independent protective factor. Leukopenia and neutropenia were the most common manageable adverse events.ECOG status is an independent predictor for TTF, while LMR and MLR may have an interactive effect with other biomarkers (e.g., ECOG status) to predict response in MBC patients receiving eribulin as ≥2nd-line treatment.
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Affiliation(s)
- Pei-Hsin Chen
- Department of Breast Medical Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tanzi Dist., Taichung City, Taiwan
- School of Nursing, National Yang Ming Chiao Tung University, Beitou Dist., Taipei City, Taiwan
| | - Dah-Cherng Yeh
- Department of Breast Medical Center, Cheng Ching Hospital Chung Kang Branch, Xitun Dist., Taichung City, Taiwan
| | - Heng-Hsin Tung
- School of Nursing, National Yang Ming Chiao Tung University, Beitou Dist., Taipei City, Taiwan
| | - Chin-Yao Lin
- Department of Breast Medical Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tanzi Dist., Taichung City, Taiwan
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Tanni KA, Truong CB, Johnson BS, Qian J. Comparative effectiveness and safety of eribulin in advanced or metastatic breast cancer: a systematic review and meta-analysis. Crit Rev Oncol Hematol 2021; 163:103375. [PMID: 34087344 DOI: 10.1016/j.critrevonc.2021.103375] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/08/2021] [Accepted: 05/29/2021] [Indexed: 12/24/2022] Open
Abstract
Eribulin is one of the few recommended chemotherapies for locally advanced breast cancer (LABC) or metastatic breast cancer (MBC). We systematically searched MEDLINE Ovid, Cochrane Library, IPA, CINAHL, Web of Science and ProQuest Dissertations for studies evaluating eribulin versus non-eribulin regimens in LABC/MBC till January 15, 2021. Primary effectiveness and safety outcomes were overall survival (OS) and adverse events (AE), respectively. Hazard ratios (HR) and relative risks (RR) with 95 % confidence intervals (CIs) were calculated using fixed or random-effects meta-analyses. Of 1183 publications identified, 13 studies were included in this review. Eribulin based therapy showed significantly increased OS [HR (95 % CI) = 0.77 (0.67-0.88)] compared to non-eribulin in both main and sensitivity analyses, as well as subgroup analyses according to receptor expression and line of therapy. Incidence of all-grade neutropenia was the only significant AE in eribulin than non-eribulin groups. Eribulin has a manageable toxicity profile and provides significant survival benefit in LABC/MBC patients.
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Affiliation(s)
- Kaniz Afroz Tanni
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL 36849, USA.
| | - Cong Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL 36849, USA.
| | - Brandon S Johnson
- Spencer Cancer Center, East Alabama Medical Center, Opelika, AL 36801, USA.
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL 36849, USA.
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Eribulin Plus Pembrolizumab in Patients with Metastatic Triple-Negative Breast Cancer (ENHANCE 1): A Phase Ib/II Study. Clin Cancer Res 2021; 27:3061-3068. [DOI: 10.1158/1078-0432.ccr-20-4726] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/12/2021] [Accepted: 03/12/2021] [Indexed: 11/16/2022]
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Chemotherapy Options beyond the First Line in HER-Negative Metastatic Breast Cancer. JOURNAL OF ONCOLOGY 2020; 2020:9645294. [PMID: 33312203 PMCID: PMC7719522 DOI: 10.1155/2020/9645294] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/05/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022]
Abstract
Despite the recent advances in the biological understanding of breast cancer (BC), chemotherapy still represents a key component in the armamentarium for this disease. Different agents are available as mono-chemotherapy options in patients with locally advanced or metastatic BC (MBC) who progress after a first- and second-line treatment with anthracyclines and taxanes. However, no clear indication exists on what the best option is in some populations, such as heavily pretreated, elderly patients, triple-negative BC (TNBC), and those who do not respond to the first-line therapy. In this article, we summarize available literature evidence on different chemotherapy agents used beyond the first-line, in locally advanced or MBC patients, including rechallenge with anthracyclines and taxanes, antimetabolite and antimicrotubule agents, such as vinorelbine, capecitabine, eribulin, ixabepilone, and the newest developed agents, such as vinflunine, irinotecan, and etirinotecan.
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Inoue K, Takahashi M, Mukai H, Yamanaka T, Egawa C, Sakata Y, Ikezawa H, Matsuoka T, Tsurutani J. Effectiveness and safety of eribulin in Japanese patients with HER2-negative, advanced breast cancer: a 2-year post-marketing observational study in a real-world setting. Invest New Drugs 2020; 38:1540-1549. [PMID: 31950374 PMCID: PMC7497681 DOI: 10.1007/s10637-019-00890-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/26/2019] [Indexed: 12/31/2022]
Abstract
Background Data on eribulin as the first- or second-line treatment in a clinical setting, especially the overall survival (OS) of patients, are scarce. Therefore, we assessed the effectiveness and safety of eribulin as the first-, second-, and third- or later-line treatments in patients with human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer in Japan. Methods This multicenter, prospective, post-marketing, observational study enrolled patients from September 2014 to February 2016 in Japan and followed them for 2 years. Patients were categorized by eribulin use into the first-, second-, and third- or later-line treatment groups. Results Of 651 registered patients, 637 patients were included in the safety and effectiveness analysis. In all, first-, second-, and third or later-line treatment groups, median OS (95% confidence interval) were 15.6 (13.8-17.6), 22.8 (17.3-31.0), 16.3 (12.4-19.9), and 12.6 (11.2-15.1) months and time to treatment failure (TTF) (95% confidence interval) were 4.2 (3.7-4.4), 5.2 (3.7-5.9), 4.2 (3.7-5.1), and 3.8 (3.5-4.2) months, respectively. Prolonged TTF was associated with complications of diabetes and the development of peripheral neuropathy after eribulin treatment, according to multivariate Cox regression analysis. Grade ≥ 3 adverse drug reactions (ADRs) were reported in 61.7% of the patients. Neutropenia (49.5%) was the most common grade ≥ 3 ADR in all groups. Conclusions The effectiveness and safety results of eribulin as the first- or second-line treatment were favorable. Thus, these suggest eribulin may be a first-line treatment candidate for patients with HER2-negative advanced breast cancer in Japan.
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Affiliation(s)
- Kenichi Inoue
- Division of Breast Oncology, Saitama Cancer Center, Saitama, Japan.
| | - Masato Takahashi
- Department of Breast Surgery, National Hospital Organization Hokkaido Cancer Center, Hokkaido, Japan
| | - Hirofumi Mukai
- Division of Breast and Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Yamanaka
- Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, Kanagawa, Japan
| | - Chiyomi Egawa
- Department of Breast Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Yukinori Sakata
- Clinical Planning and Development Department, Eisai Co., Ltd., Tokyo, Japan
| | - Hiroki Ikezawa
- Clinical Planning and Development Department, Eisai Co., Ltd., Tokyo, Japan
| | - Toshiyuki Matsuoka
- Clinical Planning and Development Department, Eisai Co., Ltd., Tokyo, Japan
| | - Junji Tsurutani
- Advanced Cancer Translational Research Institute, Showa University, Tokyo, Japan
- Department of Medical Oncology, Kindai University, Osaka, Japan
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Pizzuti L, Krasniqi E, Barchiesi G, Mazzotta M, Barba M, Amodio A, Massimiani G, Pelle F, Kayal R, Vizza E, Grassadonia A, Tomao S, Venuti A, Gamucci T, Marchetti P, Natoli C, Sanguineti G, Ciliberto G, Vici P. Eribulin in Triple Negative Metastatic Breast Cancer: Critic Interpretation of Current Evidence and Projection for Future Scenarios. J Cancer 2019; 10:5903-5914. [PMID: 31762800 PMCID: PMC6856581 DOI: 10.7150/jca.35109] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
Triple negative breast cancer (TNBC) is characterized by distinctive biological features that confer an aggressive clinical behavior. In TNBC patients, the absence of well-defined driver pathways such as hormonal receptor expression or hyperactivation of the human epidermal growth factor receptor 2 (HER2) significantly reduce the spectrum of therapeutic options, which are currently mainly confined to chemotherapy. Thus far, median overall survival for patients with metastatic TNBC is about 9-12 months with conventional cytotoxic agents. However, the heterogeneity recently revealed at a gene expression level inside the TNBC family may help inform therapeutic decisions concerning the use of chemotherapy and hopefully lead the way to novel targeted options that include immunotherapy. Eribulin, a halichondrin class antineoplastic drug, is currently recommended for treatment of HER2 negative metastatic or recurrent breast cancer (BC) previously exposed to anthracyclines and taxanes, also for patients with a TNBC. It is currently indicated from the second line of treatment. In this review, we aim to analyze a wide range of cumulated evidence on eribulin use in TNBC including preclinical studies, intervention and observational clinical trials. Data from the real-world setting and the emerging evidence increasingly substantiating the rationale for combinations with new generation treatment strategies, e.g., PARP-inhibitors, immune checkpoint inhibitors, will be also discussed.
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Affiliation(s)
- Laura Pizzuti
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Eriseld Krasniqi
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Giacomo Barchiesi
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Marco Mazzotta
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Azienda Ospedaliera Sant'Andrea, 00189 Rome, Italy
| | - Maddalena Barba
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Antonella Amodio
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Gioia Massimiani
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Fabio Pelle
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Ramy Kayal
- Radiology and Diagnostic Imaging Department, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Enrico Vizza
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Antonino Grassadonia
- Department of Medical, Oral & Biotechnological Sciences University G. D'Annunzio, Chieti-Pescara, Italy
| | - Silverio Tomao
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, 'Sapienza' University of Rome, Policlinico Umberto I, I-00161 Rome, Italy
| | - Aldo Venuti
- HPV-Unit-UOSD Tumor Immunology and Immunotherapy, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy
| | | | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Azienda Ospedaliera Sant'Andrea, 00189 Rome, Italy
| | - Clara Natoli
- Department of Medical, Oral & Biotechnological Sciences University G. D'Annunzio, Chieti-Pescara, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Gennaro Ciliberto
- Scientific Direction , IRCCS Regina Elena National Cancer Institute , Via Elio Chianesi 53, 00144, Rome, Italy
| | - Patrizia Vici
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
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12
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Perez-Garcia JM, Cortes J. The safety of eribulin for the treatment of metastatic breast cancer. Expert Opin Drug Saf 2019; 18:347-355. [PMID: 31107111 DOI: 10.1080/14740338.2019.1608946] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Eribulin mesylate is a highly potent anticancer agent approved for use in pretreated metastatic breast cancer (MBC). Clinical trials of eribulin in MBC have demonstrated activity against this tumor type, and a phase 3 study in patients with MBC previously treated with an anthracycline and a taxane showed a significant increase in overall survival (OS) with eribulin versus control regimens. Areas covered: This review presents overviews of the development of eribulin, its pharmacology, and its efficacy in MBC. A detailed review of its safety profile is presented, and the safety of eribulin is compared with other agents commonly used to treat MBC. Expert opinion: As eribulin is the only drug shown to improve OS in patients with pretreated MBC, it is an important treatment option for many patients. Eribulin is currently considered a second-line (Europe) or third-line (United States) therapy, and studies have been examining use in the first-line setting. The use of eribulin in combination with other therapies is beginning to be explored because its manageable safety profile makes it an ideal combination-treatment partner. Emerging eribulin combination-treatment data suggest a manageable toxicity profile, and eribulin is set to be a key drug for the treatment of MBC in the future.
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Affiliation(s)
- Jose Manuel Perez-Garcia
- a Medica Scientia Innovation Research (MedSIR) , Barcelona , Spain.,b IOB Institute of Oncology, Quirónsalud Group , Madrid and Barcelona , Spain
| | - Javier Cortes
- a Medica Scientia Innovation Research (MedSIR) , Barcelona , Spain.,b IOB Institute of Oncology, Quirónsalud Group , Madrid and Barcelona , Spain.,c Vall d'Hebron Institute of Oncology , Barcelona , Spain
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13
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O'Shaughnessy J, Kaklamani V, Kalinsky K. Perspectives on the mechanism of action and clinical application of eribulin for metastatic breast cancer. Future Oncol 2019; 15:1641-1653. [DOI: 10.2217/fon-2018-0936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Eribulin is a novel microtubule inhibitor with mitotic and nonmitotic mechanisms of action. Both pooled and subgroup analyses from large-scale Phase III clinical trials demonstrated that eribulin has substantial activity in patients with pretreated (anthracycline and a taxane) advanced or metastatic breast cancer. We review recent pharmacological and clinical findings pertaining to eribulin use in metastatic breast cancer – particularly highlighting eribulin in difficult-to-treat and aggressive disease, and safety data in specific patient populations. Additionally, recent advancements in our understanding of the mechanism of action of eribulin and potential future directions for its clinical development are discussed. Ongoing studies of eribulin in combination with immunotherapies and established cytotoxic agents may help shape the future landscape of breast cancer treatment.
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Affiliation(s)
- Joyce O'Shaughnessy
- Baylor University Medical Center, Texas Oncology, US Oncology, Dallas, TX, USA
| | - Virginia Kaklamani
- Department of Medicine, Division of Hematology/Oncology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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14
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Manso L, Moreno Antón F, Izarzugaza Perón Y, Delgado Mingorance JI, Borrega García P, Echarri González MJ, Martínez-Jañez N, López-González A, Olier Garate C, Ballesteros García A, Chacón López-Muñíz I, Ciruelos Gil E, García-Sáenz JA, Paz-Ares L. Safety of eribulin as third-line chemotherapy in HER2-negative, advanced breast cancer pre-treated with taxanes and anthracycline: OnSITE study. Breast J 2019; 25:219-225. [PMID: 30734437 DOI: 10.1111/tbj.13199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 12/27/2022]
Abstract
Eribulin is active and safe in heavily pre-treated metastatic breast cancer patients. Few safety data have been published in third line. We aimed to report the specific safety profile on third line beyond taxanes and anthracyclines in advanced breast cancer (ABC). A multicenter phase II, prospective study was conducted in anthracyclines and taxanes pre-treated HER2-negative ABC, programmed to receive eribulin as third-line chemotherapy. Adverse events (AEs) were assessed and classified according to CTCAE. In addition, efficacy, in terms of overall survival (OS) and progression-free survival (PFS), and the dynamics of circulating tumor cells (CTCs) during treatment were assessed. 59 patients fulfilled the criteria. All but one showed AEs with a cumulative number of 598 AEs. The most frequent grade 3/4 drug-related AEs were neutropenia (1.7%), febrile neutropenia (0.5%), leukopenia (0.5%), alopecia (0.5%), asthenia (0.3%), elevated gamma glutamyl transferase levels (0.2%), and respiratory tract infection (0.2%). Median PFS was 4 months (95% CI 3.1-5.9) and median OS was 13.6 months (11.8-not reached). The mean number of CTCs in peripheral blood was significantly reduced from baseline to cycle 2 (16.8 vs 5.4 CTCs; P < 0.001). Median OS was significantly longer in <5 baseline CTC patients compared to ≥5 baseline CTC patients (13.1 months [95% CI: 11.8-not reached] vs 12.5 months [95% CI: 7.6-not reached]; P = 0.045). A significant correlation (P = 0.0129) was observed between CTC levels at cycle 2 and death when CTCs were analyzed using cox regression. Eribulin chemotherapy is effective and safe as third line in advanced HER2-negative breast cancer. CTC levels correlate with overall survival.
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Affiliation(s)
- Luis Manso
- Medical Oncology Department, Hospital 12 De Octubre, Madrid, Spain
| | | | | | | | | | | | | | | | - Clara Olier Garate
- Medical Oncology Department, Hospital Fundación Alcorcón, Alcorcón, Spain
| | | | | | - Eva Ciruelos Gil
- Medical Oncology Department, Hospital 12 De Octubre, Madrid, Spain
| | | | - Luis Paz-Ares
- Medical Oncology Department, Hospital 12 De Octubre, Madrid, Spain
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15
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Guadagni S, Aigner K, Zoras O, Masedu F, Fiorentini G, Ricevuto E, Deraco M, Clementi M. Isolated thoracic perfusion in lung metastases from breast cancer: a retrospective observational study. Updates Surg 2018; 71:165-177. [PMID: 30542956 DOI: 10.1007/s13304-018-00613-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/05/2018] [Indexed: 01/19/2023]
Abstract
The median overall survival of metastatic breast cancer (MBC) patients is still approximately 2 years. This is even lower in triple-negative breast cancer (TNBC) patients with concomitant lung metastases. These patients are often not suitable for surgery and not responsive to systemic chemotherapy. Isolated thoracic perfusion (ITP) followed by chemofiltration has been used for palliation in selected specialised centres. A retrospective observational study evaluating 162 MBC patients who underwent 407 ITP procedures was performed. The primary objective was the evaluation of the feasibility, safety, tolerability and efficacy of ITP in the complete cohort of 162 patients with LM from breast cancer. The secondary objective of the study was the evaluation of responses and median survivals in 43 TNBC patients with LM. In the 162 patients, ITP appeared safe and well tolerated with MST from LM diagnosis to death or last contact of 19.5 months. In the subgroup of patients treated with systemic chemotherapy followed by ITP at progression, the MST from LM diagnosis to death or last contact was 29 months. In the subgroup of TNBC patients treated with systemic chemotherapy followed by ITP at progression, the MST from LM diagnosis to death or last contact was 19 months (ITP overall response rate was 65.52%). ITP followed by chemofiltration could be adopted in the sequential palliation treatments of BC patients with LM in progression after systemic chemotherapy, especially with TNBC. The present data allow interesting considerations about tolerability and responses, but do not allow robust conclusions about survival.
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Affiliation(s)
- Stefano Guadagni
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy.
| | - Karl Aigner
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany
| | - Odisseas Zoras
- Department of Surgical Oncology, University of Crete, Heraklion, Greece
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Giammaria Fiorentini
- Department of Oncology and Hematology, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Enrico Ricevuto
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, via Vetoio, 67100, L'Aquila, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marco Clementi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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16
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Cadoo KA, Kaufman PA, Seidman AD, Chang C, Xing D, Traina TA. Phase 2 Study of Dose-Dense Doxorubicin and Cyclophosphamide Followed by Eribulin Mesylate With or Without Prophylactic Growth Factor for Adjuvant Treatment of Early-Stage Human Epidermal Growth Factor Receptor 2-Negative Breast Cancer. Clin Breast Cancer 2018; 18:433-440.e1. [PMID: 29895438 PMCID: PMC6174098 DOI: 10.1016/j.clbc.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/26/2018] [Accepted: 04/01/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Eribulin has significantly improved overall survival for patients with metastatic breast cancer who received ≥ 2 prior chemotherapy regimens for advanced disease. This trial assessed eribulin as adjuvant therapy for patients with early-stage breast cancer. PATIENTS AND METHODS Patients with human epidermal growth factor receptor 2-negative, stage I to III breast cancer received doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 provided intravenously on day 1 of each 14-day cycle for 4 cycles, with pegfilgrastim on day 2, followed by 4 cycles of eribulin mesylate 1.4 mg/m2 provided intravenously on days 1 and 8 every 21 days. There were 2 cohorts, as follows: cohort 1: no prophylactic growth factor with eribulin (allowed at physician's discretion only); cohort 2: prophylactic filgrastim with eribulin. The primary end point was feasibility, defined as the percentage of patients who completed the eribulin portion of the regimen without a dose omission, delay, or reduction due to an eribulin-related adverse event. Relative dose intensity of eribulin and toxicities are summarized by cohort. Exploratory end points included 3-year disease-free survival and overall survival. RESULTS Eighty-one patients (cohort 1, n = 55; cohort 2, n = 26) entered the treatment phase; 88% completed treatment. Feasibility was 72.9 % (90% confidence interval, 60.4, 83.2) in cohort 1 and 60.0% (90% confidence interval, 41.7, 76.4) in cohort 2. The most frequent eribulin-related adverse events (all grades) were fatigue (75.9%), peripheral neuropathy (54.4%), nausea (39.2%), neutropenia (35.4% [31.5% of patients in cohort 1; 44.0% in cohort 2]), and arthralgia (26.6%). CONCLUSION The primary end point of > 80% feasibility was not met. No unexpected adverse events were observed, and 62% of patients received full dosing with no dose delay or reduction. Further investigation of this regimen with alternative dosing schedules or use of growth factors could be considered.
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Affiliation(s)
- Karen A Cadoo
- Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medicine, New York, NY.
| | - Peter A Kaufman
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew D Seidman
- Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medicine, New York, NY
| | | | | | - Tiffany A Traina
- Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medicine, New York, NY
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17
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Kawamura T, Kasai H, Fermanelli V, Takahashi T, Sakata Y, Matsuoka T, Ishii M, Tanigawara Y. Pharmacodynamic analysis of eribulin safety in breast cancer patients using real-world postmarketing surveillance data. Cancer Sci 2018; 109:2822-2829. [PMID: 29933506 PMCID: PMC6125471 DOI: 10.1111/cas.13708] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/13/2018] [Accepted: 06/20/2018] [Indexed: 01/26/2023] Open
Abstract
Postmarketing surveillance is useful to collect safety data in real-world clinical settings. In this study, we applied postmarketing real-world data on a mechanistic model analysis for neutropenic profiles of eribulin in patients with recurrent or metastatic breast cancer. Demographic and safety data were collected using an active surveillance method from eribulin-treated recurrent or metastatic breast cancer patients. Changes in neutrophil counts over time were analyzed using a mechanistic pharmacodynamic model. Pathophysiological factors that might affect the severity of neutropenia were investigated, and neutropenic patterns were simulated for different treatment schedules. Clinical and laboratory data were collected from 401 patients (5199 neutrophil count measurements) who had not received granulocyte colony-stimulating factor and were eligible for pharmacodynamic analysis. The estimated mean parameters were as follows: mean transit time = 104.5 h, neutrophil proliferation rate constant = 0.0377 h-1 , neutrophil elimination rate constant = 0.0295 h-1 , and linear coefficient of drug effect = 0.0413 mL/ng. Low serum albumin levels and low baseline neutrophil counts were associated with severe neutropenia. The probability of grade ≥3 neutropenia was predicted to be 69%, 27%, and 27% for patients on standard, biweekly, and triweekly treatment scenarios, respectively, based on virtual simulations using the developed pharmacodynamic model. In conclusion, this is the first application of postmarketing surveillance data to a model-based safety analysis. This analysis of safety data reflecting authentic clinical settings will provide useful information on the safe use and potential risk factors of eribulin.
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Affiliation(s)
- Takahisa Kawamura
- Department of Clinical Pharmacokinetics and PharmacodynamicsKeio University School of MedicineTokyoJapan
- Division of Thoracic OncologyShizuoka Cancer CenterShizuokaJapan
| | | | - Valentina Fermanelli
- Department of Clinical Pharmacokinetics and PharmacodynamicsKeio University School of MedicineTokyoJapan
- Mathematical SciencesChalmers University of TechnologyGöteborgSweden
- University of GothenburgGöteborgSweden
| | | | | | | | | | - Yusuke Tanigawara
- Department of Clinical Pharmacokinetics and PharmacodynamicsKeio University School of MedicineTokyoJapan
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18
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Basho RK, Yam C, Gilcrease M, Murthy RK, Helgason T, Karp DD, Meric-Bernstam F, Hess KR, Valero V, Albarracin C, Litton JK, Chavez-MacGregor M, Hong D, Kurzrock R, Hortobagyi GN, Janku F, Moulder SL. Comparative Effectiveness of an mTOR-Based Systemic Therapy Regimen in Advanced, Metaplastic and Nonmetaplastic Triple-Negative Breast Cancer. Oncologist 2018; 23:1300-1309. [PMID: 30139837 DOI: 10.1634/theoncologist.2017-0498] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 06/25/2018] [Accepted: 07/10/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) is a heterogeneous disease with subtypes having different "targetable" molecular aberrations. Metaplastic breast cancers (MpBCs) are typically TNBCs and commonly have alterations in the PI3K/Akt/mTOR pathway. We previously reported efficacy for an mTOR-based chemotherapy regimen in MpBC. To determine if tumor subtype influences prognosis, we compared treatment outcomes of patients with MpBC with those of patients with nonmetaplastic TNBC receiving an mTOR-based systemic therapy regimen. PATIENTS AND METHODS Patients with advanced MpBC and nonmetaplastic TNBC were treated at our institution from April 16, 2009, through November 4, 2014, using mTOR inhibition (temsirolimus or everolimus) with liposomal doxorubicin and bevacizumab (DAT/DAE). Median progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Cox regression analyses were used to evaluate associations between tumor histology and outcomes. Multivariable models were adjusted for all covariates. RESULTS Fourteen patients with nonmetaplastic TNBC and 59 patients with advanced MpBC were treated with DAT/DAE. MpBC patients were older (p = .002) and less likely to have a history of bevacizumab use (p = .023). Median PFS for the nonmetaplastic TNBC and MpBC patients was 2.5 months and 4.8 months, respectively. This difference in PFS was statistically significant on univariable (p = .006) but not multivariable analysis (p = .087). Median OS for the nonmetaplastic TNBC and MpBC patients was 3.7 months and 10.0 months, respectively (p = .0003). MpBC remained significantly associated with improved OS on multivariable analysis (p < .0001). CONCLUSION In our study, DAT/DAE appeared to be more effective in MpBC compared with nonmetaplastic TNBC. These data support patient selection for targeted therapy in TNBC. IMPLICATIONS FOR PRACTICE Metaplastic breast cancers (MpBCs) represent <1% of all breast cancers, demonstrate mesenchymal differentiation, and are typically resistant to chemotherapy. Patients with advanced MpBC treated with an mTOR-based systemic therapy regimen had better long-term outcomes compared with patients with nonmetaplastic triple-negative breast cancer treated with the same regimen, suggesting that metaplastic histology may predict benefit from agents targeting the PI3K/Akt/mTOR pathway.
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Affiliation(s)
- Reva K Basho
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clinton Yam
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Gilcrease
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rashmi K Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Thorunn Helgason
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Constance Albarracin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hong
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Razelle Kurzrock
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Division of Hematology and Oncology, The University of California San Diego Moores Cancer Center, San Diego, California, USA
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Filip Janku
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stacy L Moulder
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Investigational Cancer Therapeutics (Phase I Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Zhao B, Zhao H, Zhao J. Incidence and clinical parameters associated with eribulin mesylate-induced peripheral neuropathy. Crit Rev Oncol Hematol 2018; 128:110-117. [PMID: 29958626 DOI: 10.1016/j.critrevonc.2018.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/07/2018] [Accepted: 06/06/2018] [Indexed: 11/18/2022] Open
Abstract
Eribulin mesylate is a microtubule-targeting agent that has been approved for the treatment of breast cancer and liposarcoma. Due to its novel mechanism of action, eribulin therapy induces a distinct profile of adverse events, including peripheral neuropathy. However, the incidence and risk of eribulin-related neurotoxicities are unclear. Here, we conducted a systematic search of PubMed and Embase from their inception to October 2017. Eligible studies included trials in which eribulin was intravenously administered at a standard dose of 1.4 mg/m2 over 2-5 minutes on days 1 and 8 on a 21-day cycle. The events of all-grade and high-grade peripheral neuropathy were collected to calculate the overall incidence and relative risk (RR). A total of thirty-two studies containing 6129 subjects were included in this analysis. The incidences of all-grade and high-grade eribulin monotherapy-related peripheral neuropathy were 28% (95% confidence interval [CI], 24%-32%) and 4% (95% CI, 3%-5%), respectively. Subgroup analysis further revealed that a higher incidence of neurotoxicities was observed in patients with breast cancer and those with longer treatment duration. Moreover, eribulin-treated subjects had a significantly increased risk of all-grade (RR, 2.00; 95% CI, 1.70-2.35; p = 0.008) and high-grade (RR, 3.68; 95% CI, 2.30-5.89; p<0.001) neurotoxicities. Our results suggested that patients treated with eribulin had an increased risk of developing peripheral neuropathy.
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Affiliation(s)
- Bin Zhao
- The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325027, China.
| | - Hong Zhao
- The Third Affiliated Hospital of Harbin Medical University, Harbin, 150081, China.
| | - Jiaxin Zhao
- The Fourth Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
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20
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Effect of eribulin on patients with metastatic breast cancer: multicenter retrospective observational study in Taiwan. Breast Cancer Res Treat 2018; 170:583-591. [PMID: 29623575 PMCID: PMC6022524 DOI: 10.1007/s10549-018-4778-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 01/13/2023]
Abstract
Purpose The aim of this study was to confirm the therapeutic role of eribulin on Taiwanese women with metastatic breast cancer. Methods This retrospective study examined 449 females who received eribulin between March 2014 and June 2017 at 14 hospitals in Taiwan for treatment of locally advanced or metastatic breast cancer. Results The survival rate at 24 months was 57.2% (95% CI 51.0–62.9%) and the median time to treatment failure (TTF) was 3.91 months (95% CI 3.45–3.94). A total of 175 patients (40.1%) received eribulin for fewer than 90 days and the others received it for 90 days or more. Eight patients (1.83%) had complete remission, 82 (18.8%) had partial remission, 202 (46.3%) had stable disease, and 144 (33.0%) had progressive disease (PD). Patients’ tumors with the luminal A subtype had a significantly better objective response rate. Kaplan–Meier analysis indicated that hormone receptor positivity, luminal A subtype, receipt of eribulin as the 1st to 3rd line therapy, and metastasis to fewer than 4 organs were significantly associated with longer TTF. Stepwise multivariate analysis showed that only receipt of eribulin as the 1st to 3rd line therapy was significantly associated with TTF (HR 1.49, p < 0.001). All toxicities were manageable and only 18 patients (4.1%) discontinued treatment due to adverse events. Conclusions Eribulin appears to have better efficacy and cause fewer adverse events, especially neutropenia, in Taiwanese women than Western women.
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21
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Abotaleb M, Kubatka P, Caprnda M, Varghese E, Zolakova B, Zubor P, Opatrilova R, Kruzliak P, Stefanicka P, Büsselberg D. Chemotherapeutic agents for the treatment of metastatic breast cancer: An update. Biomed Pharmacother 2018; 101:458-477. [PMID: 29501768 DOI: 10.1016/j.biopha.2018.02.108] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 12/17/2022] Open
Abstract
Breast cancer is the second greatest cause of death among women worldwide; it comprises a group of heterogeneous diseases that evolves due to uncontrolled cellular growth and differentiation and the loss of normal programmed cell death. There are different molecular sub-types of breast cancer; therefore, various options are selected for treatment of different forms of metastatic breast cancer. However, the use of chemotherapeutic drugs is usually accompanied by deleterious side effects and the development of drug resistance when applied for a longer period. This review offers a classification of these chemotherapeutic agents according to their modes of action and therefore improves the understanding of molecular targets that are affected during treatment. Overall, it will allow the clinician to identify more specific targets to increase the effectiveness of a drug and to reduce general toxicity, resistance and other side effects.
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Affiliation(s)
- Mariam Abotaleb
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia; Department of Experimental Carcinogenesis, Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Martin Caprnda
- 1st Department of Internal Medicine, Medical Faculty, Comenius University in Bratislava, Bratislava, Slovakia
| | - Elizabeth Varghese
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Barbora Zolakova
- Department of Experimental Carcinogenesis, Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Pavol Zubor
- Clinic of Gynecology and Obsterics, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Radka Opatrilova
- Department of Chemical Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | - Peter Kruzliak
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic; 2nd Department of Surgery, Faculty of Medicine, Masaryk University and St. Anne´s University Hospital, Brno, Czech Republic.
| | - Patrik Stefanicka
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Comenius University and University Hospital, Antolska 11, 851 07, Bratislava, Slovakia.
| | - Dietrich Büsselberg
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar.
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Kikuchi Y, Uchida Y, Shirakawa K, Kanauchi H, Niwa T, Nishioka K, Tada K, Hashimoto M, Yasuda H, Sugiura R, Kawabata H, Seto Y, Ogawa T. A multicenter, observational study of metastatic breast cancer patients who were treated with eribulin mesylate or taxane-based regimens. Asia Pac J Clin Oncol 2018; 14:e231-e237. [DOI: 10.1111/ajco.12863] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/24/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Yasuko Kikuchi
- Department of Breast and Endocrine Surgery; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Yoshihiro Uchida
- International University of Health and Welfare Mita Hospital Breast Center; Tokyo Japan
| | | | - Hajime Kanauchi
- Breast and Endocrine Surgery Department; Showa General Hospital; Tokyo Japan
| | - Takayoshi Niwa
- Department of Breast and Endocrine Surgery; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Kotoe Nishioka
- Department of Breast and Endocrine Surgery; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Keiichirou Tada
- Department of Breast and Endocrine Surgery; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | | | | | - Ryoko Sugiura
- National Center for Global Health and Medicine; Tokyo Japan
| | | | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Toshihisa Ogawa
- Breast Center; Dokkyo Medical University Koshigaya Hospital; Saitama Japan
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Demirel MA, Süntar İ. The Role of Secondary Metabolites on Gynecologic Cancer Therapy: Some Pathways and Mechanisms. Turk J Pharm Sci 2017; 14:324-334. [PMID: 32454632 DOI: 10.4274/tjps.49368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/19/2017] [Indexed: 12/27/2022]
Abstract
Gynecologic cancers are among the most common cancers in humans and animals. Treatment success depends on several factors including stage at diagnosis, tumor type, origin and metastasis. Currently, surgery, chemotherapy, and radiotherapy are preferred in the treatment of these cancers. However, many anticarcinogenic drugs can cause severe adverse effects and also the expected response to treatment may not be obtained. In recent studies, the importance of the relationship between cancer and inflammation has been emphasized. Therefore, several phytochemicals that exhibit beneficial bioactive effects towards inflammatory pathways were proven to have anticarcinogenic potential for gynecologic cancer therapy. This review summarizes the role of inflammatory pathways in gynecologic cancers and effective secondary metabolites for cancer therapy.
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Affiliation(s)
- Mürşide Ayşe Demirel
- Gazi University, Faculty of Pharmacy, Laboratory Animals Breeding and Experimental Research Center, Ankara, Turkey
| | - İpek Süntar
- Gazi University, Faculty of Pharmacy, Department of Pharmacognosy, Ankara, Turkey
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24
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Zhou H, Wang H, Yu G, Wang Z, Zheng X, Duan H, Sun J. Synergistic inhibitory effects of an engineered antibody-like molecule ATF-Fc and trastuzumab on tumor growth and invasion in a human breast cancer xenograft mouse model. Oncol Lett 2017; 14:5189-5196. [PMID: 29113154 PMCID: PMC5656026 DOI: 10.3892/ol.2017.6896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/11/2017] [Indexed: 01/28/2023] Open
Abstract
The overexpression of the oncogene human epidermal growth factor receptor 2 (HER-2) has been associated with decreased disease-free survival and is a marker of poor prognosis of invasive breast cancer. Although the high efficacy of trastuzumab, a drug that targets the HER-2 oncogene, has been widely recognized, the efficiency of the treatment remains at ~30%. Therefore, novel effective treatments are required for patients with recurrent metastatic breast cancer. The present study aimed to investigate the effects of an engineered antibody-like molecule administered alone or in combination with trastuzumab on the tumor growth and metastasis of HER-2-positive breast cancer. Another aim was to investigate novel cancer therapies for HER-2-positive breast cancer. The engineered antibody-like molecule consists of the amino-terminal fragment (ATF) of human urokinase-type plasminogen (uPA) and is conjugated with the Fc fragment of human immunoglobulin G1 (ATF-Fc). The anti-cancer effect of ATF-Fc (alone and in combination with trastuzumab) on tumor cells and in a nude mouse tumor model was evaluated by detecting the expression of uPA, urokinase plasminogen activator receptor (uPAR) and HER-2. In vitro experiments demonstrated that specifically blocking the uPA-uPAR and HER-2 signaling pathways may effectively promote the apoptosis of breast cancer cells. Additionally, ATF-Fc-induced cell death in HER-2-positive breast cancer cells was observed in vivo. When ATF-Fc was administered in combination with trastuzumab, cell death was increased and breast cancer metastasis was reduced. The novel engineered antibody-like molecule ATF-Fc was able to inhibit HER-2-positive breast cancer cell growth and metastasis by interfering with uPA and its receptor (uPA-uPAR) system. Additionally, the antibody-like molecule exhibits a synergistic inhibitory effect when administered in combination with trastuzumab.
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Affiliation(s)
- Hongwei Zhou
- Department of Geriatric Oncology, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
| | - Hongwei Wang
- Department of Pathology, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
| | - Guangyuan Yu
- Department of Medicine, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
| | - Zhihong Wang
- Department of Geriatric Oncology, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
| | - Xi Zheng
- Department of Geriatric Oncology, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
| | - Haifeng Duan
- Beijing Institute of Radiation Medicine, Beijing 100039, P.R. China
| | - Junzhong Sun
- Department of Geriatric Oncology, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, P.R. China
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25
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Tanaka T, Ueno M, Nakashima Y, Chinen S, Sato E, Masaki M, Mogi A, Sasaki H, Tamura K, Takamatsu Y. Retrospective analysis of the efficacy and safety of eribulin therapy for metastatic breast cancer in daily practice. Thorac Cancer 2017; 8:523-529. [PMID: 28741868 PMCID: PMC5588851 DOI: 10.1111/1759-7714.12482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 11/28/2022] Open
Abstract
Background Evidence of eribulin therapy for metastatic breast cancer (MBC) in clinical practice is not well documented. Methods We retrospectively analyzed the safety and efficacy of eribulin in 29 MBC patients from 2011 to 2016 at Fukuoka University Hospital. Results The median patient age, number of courses, total dose, and relative dose intensity were as follows: 65 years, five courses, 8.6 mg/m2, and 75%, respectively. One patient achieved a complete response, (CR) six a partial response (PR), eight stable disease (SD) and 14 patients exhibited progressive disease. The objective response rate (ORR: CR + PR) was 24.1%, and the clinical benefit rate (CBR: CR + PR + SD) was 51.7%. The median progression‐free survival was 90 days (95% confidence interval [CI] 67–126) and median overall survival was 264 days (95% CI 198–357). In patients who previously received 2–4 regimens, the ORR was 28.5% and the CBR was 57.1%. In patients who received 5–12 regimens, the ORR was 20% and the CBR was 45%. Chemotherapy was administered to 20 patients (69%) after eribulin administration, and the median overall survival rate of cases that achieved greater than a PR was 1088 days. The most frequent treatment‐related grade 3/4 adverse events were neutropenia (55.2%), and febrile neutropenia (20.1%). Grade 3 peripheral neuropathy occurred in 13.8% of patients, but was not exacerbated even if present before treatment. Conclusion Eribulin is effective for MBC patients who have received multiple chemotherapies. Neutropenia and febrile neutropenia may develop after heavy prior therapy.
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Affiliation(s)
- Toshihiro Tanaka
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Miho Ueno
- Department of Pharmacy, Fukuoka University Hospital, Fukuoka, Japan
| | - Yuta Nakashima
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Shotaro Chinen
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Eiichi Sato
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Michio Masaki
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Ai Mogi
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Hidenori Sasaki
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Kazuo Tamura
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Yasushi Takamatsu
- Division of Oncology, Hematology, and Infectious Diseases, Department of Internal Medicine, Fukuoka University Hospital, Fukuoka, Japan
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26
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Shahbazi S, Heidari M, Ghafourifard M. Comparison of Direct and Indirect Methods of Teaching Breast Self-Examination – Influence on Knowledge and Attitudes of Iranian Nursing and Midwifery Personnel. Asian Pac J Cancer Prev 2017; 18:1157-1162. [PMID: 28548468 PMCID: PMC5494231 DOI: 10.22034/apjcp.2017.18.4.1157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Breast cancer is the most common cancer in women. Monthly breast self-examination (BSE) has been presented as one of the best screening methods available. The aim of this study was to compare effects of both direct and indirect methods of teaching of BSE on knowledge and attitudes of nursing and midwifery personnel. Materials and Methods: The present study was performed on 89 nursing and midwifery personnel in Valiasr hospital of Borujen city. Participants were randomly divided into a direct and an indirect training group. Researcher-designed BSE knowledge and attitude and demographic information questionnaires were used for data collection. Results: Before the education intervention, the mean levels of knowledge and attitude were 9.82±2.79 and 56.5±6.21 in the direct training group and 9.59±2.71 and 54.5±4.51 in the indirect training group; after the intervention, they reached 19.2±0.96 and 62.9±4.21, and 11.0±2.58 and 59.0±3.44, respectively. The difference in the mean levels of knowledge and attitude were significantly higher in the direct training group post intervention (P<0.05). Conclusion: It appears that educational planners and hospital personnel education officials should seek to teach aspects of crucial health behavior to female personnel using cooperative and direct training methods.
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Affiliation(s)
- Sara Shahbazi
- Department of Nursing, Borujen Nursing School, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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