1
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Buijs SM, Koolen SLW, Mathijssen RHJ, Jager A. Tamoxifen Dose De-Escalation: An Effective Strategy for Reducing Adverse Effects? Drugs 2024; 84:385-401. [PMID: 38480629 PMCID: PMC11101371 DOI: 10.1007/s40265-024-02010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 05/19/2024]
Abstract
Tamoxifen, a cornerstone in the adjuvant treatment of estrogen receptor-positive breast cancer, significantly reduces breast cancer recurrence and breast cancer mortality; however, its standard adjuvant dose of 20 mg daily presents challenges due to a broad spectrum of adverse effects, contributing to high discontinuation rates. Dose reductions of tamoxifen might be an option to reduce treatment-related toxicity, but large randomized controlled trials investigating the tolerability and, more importantly, efficacy of low-dose tamoxifen in the adjuvant setting are lacking. We conducted an extensive literature search to explore evidence on the tolerability and clinical efficacy of reduced doses of tamoxifen. In this review, we discuss two important topics regarding low-dose tamoxifen: (1) the incidence of adverse effects and quality of life among women using low-dose tamoxifen; and (2) the clinical efficacy of low-dose tamoxifen examined in the preventive setting and evaluated through the measurement of several efficacy derivatives. Moreover, practical tools for tamoxifen dose reductions in the adjuvant setting are provided and further research to establish optimal dosing strategies for individual patients are discussed.
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Affiliation(s)
- Sanne M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands.
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
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2
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Sanchez-Spitman AB, Böhringer S, Dezentjé VO, Gelderblom H, Swen JJ, Guchelaar HJ. A Genome-Wide Association Study of Endoxifen Serum Concentrations and Adjuvant Tamoxifen Efficacy in Early-Stage Breast Cancer Patients. Clin Pharmacol Ther 2024. [PMID: 38501904 DOI: 10.1002/cpt.3255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024]
Abstract
Tamoxifen is part of the standard of care of endocrine therapy for adjuvant treatment of breast cancer. However, survival outcomes with tamoxifen are highly variable. The concentration of endoxifen, the 30-100 times more potent metabolite of tamoxifen and bioactivated by the CYP2D6 enzyme, has been described as the most relevant metabolite of tamoxifen metabolism. A genome-wide association study (GWAS) was performed with the objective to identify genetic polymorphisms associated with endoxifen serum concentration levels and clinical outcome in early-stage breast cancer patients receiving tamoxifen. A GWAS was conducted in 608 women of the CYPTAM study (NTR1509/PMID: 30120701). Germline DNA and clinical and survival characteristics were readily available. Genotyping was performed on Infinium Global Screening Array (686,082 markers) and single nucleotide polymorphism (SNP) imputation by using 1000 Genomes. Relapse-free survival during tamoxifen (RFSt) was defined the primary clinical outcome. Endoxifen serum concentration was analyzed as a continuous variable. Several genetic variants reached genome-wide significance (P value: ≤5 × 10-8 ). Endoxifen concentrations analysis identified 430 variants, located in TCF20 and WBP2NL genes (chromosome 22), which are in strong linkage disequilibrium with CYP2D6 variants. In the RFSt analysis, several SNP were identified (LPP gene: rs77693286, HR 18.3, 95% CI: 15.2-21.1; rs6790761, OR 18.2, 95% CI: 15.5-21.1). Endoxifen concentrations have a strong association with the chromosome 22, which contains the CYP2D6 gene.
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Affiliation(s)
| | - Stefan Böhringer
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent Olaf Dezentjé
- Department of Medical Oncology, Antoni van Leeuwenhoek/Dutch Cancer Institute, Amsterdam, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesse Joachim Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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3
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Mc Laughlin AM, Helland T, Klima F, Koolen SLW, van Schaik RHN, Mathijssen RHJ, Neven P, Swen JJ, Guchelaar HJ, Dalenc F, White-Koning M, Michelet R, Mikus G, Schroth W, Mürdter T, Brauch H, Schwab M, Søiland H, Mellgren G, Thomas F, Kloft C, Hertz DL. Nonlinear Mixed-Effects Model of Z-Endoxifen Concentrations in Tamoxifen-Treated Patients from the CEPAM Cohort. Clin Pharmacol Ther 2024. [PMID: 38494911 DOI: 10.1002/cpt.3238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/08/2024] [Indexed: 03/19/2024]
Abstract
Tamoxifen is widely used in patients with hormone receptor-positive breast cancer. The polymorphic enzyme CYP2D6 is primarily responsible for metabolic activation of tamoxifen, resulting in substantial interindividual variability of plasma concentrations of its most important metabolite, Z-endoxifen. The Z-endoxifen concentration thresholds below which tamoxifen treatment is less efficacious have been proposed but not validated, and prospective trials of individualized tamoxifen treatment to achieve Z-endoxifen concentration thresholds are considered infeasible. Therefore, we aim to validate the association between Z-endoxifen concentration and tamoxifen treatment outcomes, and identify a Z-endoxifen concentration threshold of tamoxifen efficacy, using pharmacometric modeling and simulation. As a first step, the CYP2D6 Endoxifen Percentage Activity Model (CEPAM) cohort was created by pooling data from 28 clinical studies (> 7,000 patients) with measured endoxifen plasma concentrations. After cleaning, data from 6,083 patients were used to develop a nonlinear mixed-effect (NLME) model for tamoxifen and Z-endoxifen pharmacokinetics that includes a conversion factor to allow inclusion of studies that measured total endoxifen but not Z-endoxifen. The final parent-metabolite NLME model confirmed the primary role of CYP2D6, and contributions from body weight, CYP2C9 phenotype, and co-medication with CYP2D6 inhibitors, on Z-endoxifen pharmacokinetics. Future work will use the model to simulate Z-endoxifen concentrations in patients receiving single agent tamoxifen treatment within large prospective clinical trials with long-term survival to identify the Z-endoxifen concentration threshold below which tamoxifen is less efficacious. Identification of this concentration threshold would allow personalized tamoxifen treatment to improve outcomes in patients with hormone receptor-positive breast cancer.
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Affiliation(s)
- Anna M Mc Laughlin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Berlin/Potsdam, Germany
| | - Thomas Helland
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fenja Klima
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Berlin/Potsdam, Germany
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patrick Neven
- Department of Gynecological Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, Leuven, Belgium
| | - Jesse J Swen
- Department Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk-Jan Guchelaar
- Department Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Florence Dalenc
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Melanie White-Koning
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Werner Schroth
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
| | - Thomas Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
| | - Hiltrud Brauch
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
- iFIT Cluster of Excellence, University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany
| | - Matthias Schwab
- University Tübingen, Tübingen, Germany
- iFIT Cluster of Excellence, University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany
- Departments of Clinical Pharmacology, and of Biochemistry and Pharmacy, University of Tübingen, Tübingen, Germany
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fabienne Thomas
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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Tremmel R, Hofmann U, Haag M, Schaeffeler E, Schwab M. Circulating Biomarkers Instead of Genotyping to Establish Metabolizer Phenotypes. Annu Rev Pharmacol Toxicol 2024; 64:65-87. [PMID: 37585662 DOI: 10.1146/annurev-pharmtox-032023-121106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Pharmacogenomics (PGx) enables personalized treatment for the prediction of drug response and to avoid adverse drug reactions. Currently, PGx mainly relies on the genetic information of absorption, distribution, metabolism, and excretion (ADME) targets such as drug-metabolizing enzymes or transporters to predict differences in the patient's phenotype. However, there is evidence that the phenotype-genotype concordance is limited. Thus, we discuss different phenotyping strategies using exogenous xenobiotics (e.g., drug cocktails) or endogenous compounds for phenotype prediction. In particular, minimally invasive approaches focusing on liquid biopsies offer great potential to preemptively determine metabolic and transport capacities. Early studies indicate that ADME phenotyping using exosomes released from the liver is reliable. In addition, pharmacometric modeling and artificial intelligence improve phenotype prediction. However, further prospective studies are needed to demonstrate the clinical utility of individualized treatment based on phenotyping strategies, not only relying on genetics. The present review summarizes current knowledge and limitations.
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Affiliation(s)
- Roman Tremmel
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany;
- University of Tuebingen, Tuebingen, Germany
| | - Ute Hofmann
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany;
- University of Tuebingen, Tuebingen, Germany
| | - Mathias Haag
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany;
- University of Tuebingen, Tuebingen, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany;
- University of Tuebingen, Tuebingen, Germany
- Cluster of Excellence iFIT (EXC2180) "Image-Guided and Functionally Instructed Tumor Therapies," University of Tuebingen, Tuebingen, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany;
- University of Tuebingen, Tuebingen, Germany
- Cluster of Excellence iFIT (EXC2180) "Image-Guided and Functionally Instructed Tumor Therapies," University of Tuebingen, Tuebingen, Germany
- Departments of Clinical Pharmacology, and Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center Heidelberg (DKFZ), Partner Site, Tübingen, Germany
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5
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Buijs SM, van Dorst DCH, Kruip MJHA, van den Akker RFP, Cheung KL, Porrazzo R, Oomen-de Hoop E, Jager A, Koolen SLW, Versmissen J, Jan Danser AH, Versteeg HH, Bos MHA, Mathijssen RHJ. The interplay between tamoxifen and endoxifen plasma concentrations and coagulation parameters in patients with primary breast cancer. Biomed Pharmacother 2024; 170:115969. [PMID: 38042112 DOI: 10.1016/j.biopha.2023.115969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Tamoxifen is an effective treatment for primary breast cancer but increases the risk for venous thromboembolism. Tamoxifen decreases anticoagulant proteins, including antithrombin (AT), protein C (PC) and tissue factor (TF) pathway inhibitor, and enhances thrombin generation (TG). However, the relation between plasma concentrations of both tamoxifen and its active metabolite endoxifen and coagulation remains unknown. METHODS Tamoxifen and endoxifen were measured in 141 patients from the prospective open-label intervention TOTAM-study after 3 months (m) and 6 m of tamoxifen treatment. Levels of AT and PC, the procoagulant TF, and TG parameters were determined at both timepoints if samples were available (n = 53-135 per analysis). Levels of coagulation proteins and TG parameters were correlated and compared between: 1) quartiles of tamoxifen and endoxifen levels, and 2) 3 m and 6 m of treatment. RESULTS At 3 m, levels of AT, PC, TF and TG parameters were not associated with tamoxifen nor endoxifen levels. At 6 m, median TF levels were lower in patients in the 3rd (56.6 [33] pg/mL), and 4th (50.1 [19] pg/mL) endoxifen quartiles compared to the 1st (lowest) quartile (76 [69] pg/mL) (P=0.027 and P=0.018, respectively), but no differences in anticoagulant proteins or TG parameters were observed. An increase in circulating TF levels (3 m: 46.0 [15] versus 6 m: 54.4 [39] pg/mL, P < 0.001) and TG parameters was observed at the 6 m treatment timepoint, while AT and PC levels remained stable. CONCLUSIONS Our results indicate that higher tamoxifen and endoxifen levels are not correlated with an increased procoagulant state, suggesting tamoxifen dose escalation does not further promote hypercoagulability.
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Affiliation(s)
- Sanne M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Daan C H van Dorst
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rob F P van den Akker
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Ka L Cheung
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert Porrazzo
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jorie Versmissen
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Henri H Versteeg
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Mettine H A Bos
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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El Desoky ES, Taha AF, Mousa HS, Ibrahim A, Saleh MA, Abdelrady MA, Hareedy MS. Value of therapeutic drug monitoring of endoxifen in Egyptian premenopausal patients with breast cancer given tamoxifen adjuvant therapy: A pilot study. J Oncol Pharm Pract 2023; 29:1673-1686. [PMID: 36567618 DOI: 10.1177/10781552221146531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The complex metabolic profile of tamoxifen anticancer drug and polymorphism in its metabolizing enzymes particularly CYP2D6 contribute to the high-observed inter-individual variability in its main active metabolite endoxifen. Therapeutic drug monitoring of endoxifen may play a key role in optimizing tamoxifen therapy, and control of both adverse effects and cancer recurrence. This pilot study aims to assess the clinical benefits of applying endoxifen measurement during tamoxifen therapy in patients with breast cancer. METHODS Adult premenopausal breast cancer patients ≥ 18 years who received tamoxifen at a fixed dose of 20 mg daily were included. The primary endpoint was to identify the inter-subject variability in serum concentration of the drug and its metabolites especially endoxifen, through fixation of the tamoxifen dose. The secondary endpoint was to check the correlation between endoxifen metabolite concentration and the development of tamoxifen's adverse effects and cancer recurrence. RESULTS Sixty patients were included in the study with a mean age of 38.4 ± 0.6 years (range: 26-50). The mean concentration of tamoxifen and endoxifen was 181 ± 9.6 ng/mL and 31.49 ng/mL, respectively. The inter-individual variability in concentrations for the drug and its active metabolite as estimated by the coefficient of variation percentage was in 41% and 31%, respectively. Cancer recurrence was observed in a group of patients (n = 16) with an average endoxifen level of 24.48 ng/mL. Another group of patients (n = 25) developed different tamoxifen adverse effects including hot flashes, vaginal bleeding, endometrial thickness, and ovarian cysts with the average endoxifen level of 38.61 ng/mL. The rest of the patients (n = 19) who responded smoothly to the drug with no complications had an average endoxifen level of 31.37 ng/mL. Analysis of variance test showed a significant difference in endoxifen levels between the three groups (p = 0.002). CONCLUSION The measurement of the endoxifen active metabolite of tamoxifen in breast cancer patients can help dose optimization in light of the observed wide inter-individual variability in drug fixed-dose related concentration of the metabolite. Monitoring of serum concentration of endoxifen can help to reveal, reduce and control tamoxifen's adverse effects and cancer recurrence.
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Affiliation(s)
- Ehab S El Desoky
- Department of Pharmacology, Faculty of Medicine, Assiut University, Egypt
| | - Amira F Taha
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Assiut University, Egypt
| | - Heba Salah Mousa
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, South Valley University, Qena, Egypt
| | - Abeer Ibrahim
- Department of Medical Oncology and Hematological Malignancy, South Egypt Cancer Institute, Assiut University, Egypt
| | - Medhat A Saleh
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Egypt
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Davezac M, Meneur C, Buscato M, Zahreddine R, Arnal JF, Dalenc F, Lenfant F, Fontaine C. The beneficial effects of tamoxifen on arteries: a key player for cardiovascular health of breast cancer patient. Biochem Pharmacol 2023:115677. [PMID: 37419371 DOI: 10.1016/j.bcp.2023.115677] [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: 04/14/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
Breast cancer is the most common cancer in women. Over the past few decades, advances in cancer detection and treatment have significantly improved survival rate of breast cancer patients. However, due to the cardiovascular toxicity of cancer treatments (chemotherapy, anti-HER2 antibodies and radiotherapy), cardiovascular diseases (CVD) have become an increasingly important cause of long-term morbidity and mortality in breast cancer survivors. Endocrine therapies are prescribed to reduce the risk of recurrence and specific death in estrogen receptor-positive (ER+) early breast cancer patients, but their impact on CVD is a matter of debate. Whereas aromatase inhibitors and luteinizing hormone-releasing hormone (LHRH) analogs inhibit estrogen synthesis, tamoxifen acts as a selective estrogen receptor modulator (SERM), opposing estrogen action in the breast but mimicking their actions in other tissues, including arteries. This review aims to summarize the main clinical and experimental studies reporting the effects of tamoxifen on CVD. In addition, we will discuss how recent findings on the mechanisms of action of these therapies may contribute to a better understanding and anticipation of CVD risk in breast cancer patients.
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Affiliation(s)
- Morgane Davezac
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France
| | - Cecile Meneur
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France; PhysioStim, 10 rue Henri Regnault, 81100, Castres, France
| | - Melissa Buscato
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France
| | - Rana Zahreddine
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France; CREFRE-Anexplo, Service de Microchirurgie Experimentale, UMS006, INSERM, Université de Toulouse, UT3, ENVT, 31062 Toulouse, France
| | - Jean-François Arnal
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France
| | - Florence Dalenc
- Department of Medical Oncology, Claudius Regaud Institute, IUCT-Oncopole, Toulouse, France
| | - Françoise Lenfant
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France
| | - Coralie Fontaine
- I2MC, Institut National de la Santé et de la Recherche Médicale (INSERM) U1297, University of Toulouse 3, Toulouse, France.
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8
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Chiwambutsa SM, Ayeni O, Kapungu N, Kanji C, Thelingwani R, Chen WC, Mokone DH, O’Neil DS, Neugut AI, Jacobson JS, Ruff P, Cubasch H, Joffe M, Masimirembwa C. Effects of Genetic Polymorphisms of Drug Metabolizing Enzymes and co-Medications on Tamoxifen Metabolism in Black South African Women with Breast Cancer. Clin Pharmacol Ther 2023; 114:127-136. [PMID: 37042388 PMCID: PMC11016593 DOI: 10.1002/cpt.2904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/02/2023] [Indexed: 04/13/2023]
Abstract
Clinical outcomes of tamoxifen (TAM) treatment show wide interindividual variability. Comedications and genetic polymorphisms of enzymes involved in TAM metabolism contributes to this variability. Drug-drug and drug-gene interactions have seldom been studied in African Black populations. We evaluated the effects of commonly co-administered medicines on TAM pharmacokinetics in a cohort of 229 South African Black female patients with hormone-receptor positive breast cancer. We also investigated the pharmacokinetic effects of genetic polymorphism in enzymes involved in TAM metabolism, including the variants CYP2D6*17 and *29, which have been mainly reported in people of African descent. TAM and its major metabolites, N-desmethyltamoxifen (NDM), 4-OH-tamoxifen, and endoxifen (ENDO), were quantified in plasma using the liquid chromatography-mass spectrometry. The GenoPharm open array was used to genotype CYP2D6, CYP3A5, CYP3A4, CYP2B6, CYP2C9, and CYP2C19. Results showed that CYP2D6 diplotype and CYP2D6 phenotype significantly affected endoxifen concentration (P < 0.001 and P < 0.001). CYP2D6*17 and CYP2D6*29 significantly reduced the metabolism of NDM to ENDO. Antiretroviral therapy had a significant effect on NDM levels and the TAM/NDM and NDM/ENDO metabolic ratios but did not result in significant effects on ENDO levels. In conclusion, CYP2D6 polymorphisms affected endoxifen concentration and the variants CYP2D6*17 and CYP2D6*29 significantly contributed to low exposure levels of ENDO. This study also suggests a low risk of drug-drug interaction in patients with breast cancer on TAM.
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Affiliation(s)
- Shingirai M. Chiwambutsa
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Human Genetics, National Health Laboratory Service, and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Oluwatosin Ayeni
- Strengthening Oncology Services Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Radiation Oncology, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nyasha Kapungu
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Comfort Kanji
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Roslyn Thelingwani
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Wenlong Carl Chen
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Strengthening Oncology Services Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
| | - Dikeledi H. Mokone
- Department of Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Ga-Rankuwa, South Africa
| | - Daniel S. O’Neil
- Comprehensive Cancer Center and Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Alfred I. Neugut
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Judith S. Jacobson
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Paul Ruff
- Strengthening Oncology Services Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Center, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Oncology, University of the Witwatersrand, Johannesburg, South Africa
| | - Herbert Cubasch
- Strengthening Oncology Services Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Center, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maureen Joffe
- Strengthening Oncology Services Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- South Africa Medical Research Council Common Epithelial Cancers Research Center, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- SAMRC/Wits Developmental Pathways to Health Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Collen Masimirembwa
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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9
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Oceguera-Basurto PE, Figueroa-Ochoa EB, Anguiano-Sevilla LA, Sánchez-Ramírez DR, Quintero-Ramos A, Del Toro-Arreola A, López-Roa RI, Taboada P, Topete A, Daneri-Navarro A. Evaluation of a Polymeric Topical Formulation of Endoxifen in an Estrogen Receptor Positive Breast Cancer Murine Model. Int J Pharm 2023:123175. [PMID: 37369286 DOI: 10.1016/j.ijpharm.2023.123175] [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: 03/14/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
Breast cancer (BC) has surpassed lung cancer as the most diagnosed cancer and, in terms of mortality, is the fifth leading cause with 684,996 new deaths (6.7% of all cancer-related deaths) and the highest mortality amongst all cancers (15.5%) in women. Selective estrogen-receptor modulators (SERMs) have been used for the last thirty years for estrogen receptor-positive (ER+) breast cancer prevention and treatment. Tamoxifen (TAM), the most widely used SERM, is orally administered and its long-term oral administration has been associated to toxicity and adverse side effects. Endoxifen (EDX) is one of the known active metabolites of TAM, with an affinity to ERα 100 times higher than TAM. Furthermore, EDX has shown antiproliferative activity against the ER+ breast cancer cell line MCF-7. Alternative administration routes that avoid the metabolic processing of TAM seem an appealing alternative to its oral administration. With this aim, we have prepared a polymeric gel-like solution of Pluronic® F127 as vehicle for topical administration of EDX. In order to shed light on the potential clinical use of this formulation we have compare it with the standard pharmaceutical form, i.e. orally administered TAM. The biodistribution, antitumor efficacy and toxic effects of topical EDX and oral TAM were evaluated in ER+ tumor xenograft athymic nu/nu mouse models. The results showed a statistically significant antitumor effect and reduced toxicity of topical EDX as compared to oral TAM or empty F127 gel. This novel administration route of SERMs could also have a strong impact in the prevention of BC at early development stages and could help to ameliorate the mortality and morbidity related to this disease.
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Affiliation(s)
- Paola E Oceguera-Basurto
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México
| | - Edgar B Figueroa-Ochoa
- Laboratorio de Proyectos Modulares, Departamento de Química, CUCEI, Universidad de Guadalajara, Blvd. M. García Barragán 1421, Guadalajara, 44430, México
| | - Luis A Anguiano-Sevilla
- Departamento de Farmacobiología, CUCEI, Universidad de Guadalajara, Blvd. M. García Barragán 1421, Guadalajara, 44430, México
| | - Dante R Sánchez-Ramírez
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México; Departamento de Química Aplicada, Universidad Tecnológica de Jalisco, Colonia Luis J. Jiménez 577, Guadalajara, 44979, México
| | - Antonio Quintero-Ramos
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México
| | - Alicia Del Toro-Arreola
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México
| | - Rocío I López-Roa
- Laboratorio de Investigación y Desarrollo Farmacéutico, CUCEI, Universidad de Guadalajara, Blvd. M. García Barragán 1421, Guadalajara, 44430 México
| | - Pablo Taboada
- Grupo de Física de Coloides y Polímeros, Departamento de Física de la Materia Condensada Universidad de Santiago de Compostela, Instituto de Investigación Sanitaria de Santiago de Compostela IDIS e Instituto de Materiales (IMATUS), Santiago de Compostela, 15782, Spain
| | - Antonio Topete
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México.
| | - Adrián Daneri-Navarro
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, Guadalajara, 44340, México.
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10
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Buhrow SA, Koubek EJ, Goetz MP, Ames MM, Reid JM. Development and validation of a liquid chromatography-mass spectrometry assay for quantification of Z- and E- isomers of endoxifen and its metabolites in plasma from women with estrogen receptor positive breast cancer. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1221:123654. [PMID: 37004493 PMCID: PMC10249430 DOI: 10.1016/j.jchromb.2023.123654] [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: 10/31/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
The selective estrogen receptor modifier tamoxifen (TAM) is widely used for the treatment of women with estrogen receptor positive (ER+ ) breast cancer. Endoxifen (ENDX) is a potent, active metabolite of TAM and is important for TAM's clinical activity. While multiple papers have been published regarding TAM metabolism, few studies have examined or quantified the metabolism of ENDX. To quantify ENDX and its metabolites in patient plasma samples, we have developed and validated a rapid, sensitive, and specific liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantitative determination of the E- and Z-isomers of ENDX (0.5-500 ng/ml) and the ENDX metabolites norendoxifen (1-500 and 0.5-500 ng/ml E and Z, respectfully), ENDX catechol (3.075-307.5 and 1.92-192 ng/ml E and Z, respectfully), 4'-hydroxy ENDX (0.33-166.5 and 0.33-333.5 ng/ml E and Z, respectfully), ENDX methoxycatechol (0.3-300 and 0.2-200 ng/ml E and Z, respectfully), and ENDX glucuronide (2-200 and 3-300 ng/ml E and Z, respectfully) in human plasma. Chromatographic separation was accomplished on a HSS T3 precolumn attached to an Poroshell 120 EC-C18 analytical column using 0.1 % formic acid/water and 0.1 % formic acid/methanol as eluents followed by MS/MS detection. The analytical run time was 6.5 min. Standard curves were linear (R2 ≥ 0.98) over the concentration ranges. The intra- and inter-day precision and accuracy, determined at high-, middle-, and low-quality control concentrations for all analytes, were within the acceptable range of 85 % and 115 %. The average percent recoveries were all above 90 %. The method was successfully applied to clinical plasma samples from a Phase I study of daily oral Z-ENDX.
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Affiliation(s)
- Sarah A Buhrow
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Emily J Koubek
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Pharmacology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Matthew M Ames
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Pharmacology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Pharmacology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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11
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Agema BC, Buijs SM, Sassen SDT, Mürdter TE, Schwab M, Koch BCP, Jager A, van Schaik RHN, Mathijssen RHJ, Koolen SLW. Toward model-informed precision dosing for tamoxifen: A population-pharmacokinetic model with a continuous CYP2D6 activity scale. Biomed Pharmacother 2023; 160:114369. [PMID: 36753957 DOI: 10.1016/j.biopha.2023.114369] [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: 01/11/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Tamoxifen is important in the adjuvant treatment of breast cancer. A plasma concentration of the active metabolite endoxifen of > 16 nM is associated with a lower risk of breast cancer-recurrence. Since inter-individual variability is high and > 20 % of patients do not reach endoxifen levels > 16 nM with the standard dose tamoxifen, therapeutic drug monitoring is advised. However, ideally, the correct tamoxifen dose should be known prior to start of therapy. Our aim is to develop a population pharmacokinetic (POP-PK) model incorporating a continuous CYP2D6 activity scale to support model informed precision dosing (MIPD) of tamoxifen to determine the optimal tamoxifen starting dose. METHODS Data from eight different clinical studies were pooled (539 patients, 3661 samples) and used to develop a POP-PK model. In this model, CYP2D6 activity per allele was estimated on a continuous scale. After inclusion of covariates, the model was subsequently validated using an independent external dataset (378 patients). Thereafter, dosing cut-off values for MIPD were determined. RESULTS A joint tamoxifen/endoxifen POP-PK model was developed describing the endoxifen formation rate. Using a continuous CYP2D6 activity scale, variability in predicting endoxifen levels was decreased by 37 % compared to using standard CYP2D6 genotype predicted phenotyping. After external validation and determination of dosing cut-off points, MIPD could reduce the proportion of patients with subtherapeutic endoxifen levels at from 22.1 % toward 4.8 %. CONCLUSION Implementing MIPD from the start of tamoxifen treatment with this POP-PK model can reduce the proportion of patients with subtherapeutic endoxifen levels at steady-state to less than 5 %.
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Affiliation(s)
- Bram C Agema
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center; Rotterdam, the Netherlands; Dept. of Clinical Pharmacy, Erasmus University Medical Center; Rotterdam, the Netherlands.
| | - Sanne M Buijs
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center; Rotterdam, the Netherlands
| | - Sebastiaan D T Sassen
- Dept. of Clinical Pharmacy, Erasmus University Medical Center; Rotterdam, the Netherlands; Rotterdam Clinical Pharmacometrics Group; Rotterdam, the Netherlands
| | - Thomas E Mürdter
- Margarete Fischer-Bosch-Institute of Clinical Pharmacology; Stuttgart, Germany; University of Tübingen; Tübingen, Germany
| | - Mathias Schwab
- Margarete Fischer-Bosch-Institute of Clinical Pharmacology; Stuttgart, Germany; Dept. of Clinical Pharmacology, University Hospital Tübingen; Tübingen, Germany; iFIT Cluster of Excellence (EXC2180) "Image Guided and Functionally Instructed Tumor Therapies", University of Tübingen, Tübingen, Germany
| | - Birgit C P Koch
- Dept. of Clinical Pharmacy, Erasmus University Medical Center; Rotterdam, the Netherlands; Rotterdam Clinical Pharmacometrics Group; Rotterdam, the Netherlands
| | - Agnes Jager
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center; Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Dept. of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ron H J Mathijssen
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center; Rotterdam, the Netherlands
| | - Stijn L W Koolen
- Dept. of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center; Rotterdam, the Netherlands; Dept. of Clinical Pharmacy, Erasmus University Medical Center; Rotterdam, the Netherlands
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12
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Khor CC, Winter S, Sutiman N, Mürdter TE, Chen S, Lim JSL, Li Z, Li J, Sim KS, Ganchev B, Eccles D, Eccles B, Tapper W, Zgheib NK, Tfayli A, Ng RCH, Yap YS, Lim E, Wong M, Wong NS, Ang PCS, Dent R, Tremmel R, Klein K, Schaeffeler E, Zhou Y, Lauschke VM, Eichelbaum M, Schwab M, Brauch HB, Chowbay B, Schroth W. Cross-Ancestry Genome-Wide Association Study Defines the Extended CYP2D6 Locus as the Principal Genetic Determinant of Endoxifen Plasma Concentrations. Clin Pharmacol Ther 2023; 113:712-723. [PMID: 36629403 DOI: 10.1002/cpt.2846] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023]
Abstract
The therapeutic efficacy of tamoxifen is predominantly mediated by its active metabolites 4-hydroxy-tamoxifen and endoxifen, whose formation is catalyzed by the polymorphic cytochrome P450 2D6 (CYP2D6). Yet, known CYP2D6 polymorphisms only partially determine metabolite concentrations in vivo. We performed the first cross-ancestry genome-wide association study with well-characterized patients of European, Middle-Eastern, and Asian descent (n = 497) to identify genetic factors impacting active and parent metabolite formation. Genome-wide significant variants were functionally evaluated in an independent liver cohort (n = 149) and in silico. Metabolite prediction models were validated in two independent European breast cancer cohorts (n = 287, n = 189). Within a single 1-megabase (Mb) region of chromosome 22q13 encompassing the CYP2D6 gene, 589 variants were significantly associated with tamoxifen metabolite concentrations, particularly endoxifen and metabolic ratio (MR) endoxifen/N-desmethyltamoxifen (minimal P = 5.4E-35 and 2.5E-65, respectively). Previously suggested other loci were not confirmed. Functional analyses revealed 66% of associated, mostly intergenic variants to be significantly correlated with hepatic CYP2D6 activity or expression (ρ = 0.35 to -0.52), and six hotspot regions in the extended 22q13 locus impacting gene regulatory function. Machine learning models based on hotspot variants (n = 12) plus CYP2D6 activity score (AS) increased the explained variability (~ 9%) compared with AS alone, explaining up to 49% (median R2 ) and 72% of the variability in endoxifen and MR endoxifen/N-desmethyltamoxifen, respectively. Our findings suggest that the extended CYP2D6 locus at 22q13 is the principal genetic determinant of endoxifen plasma concentration. Long-distance haplotypes connecting CYP2D6 with adjacent regulatory sites and nongenetic factors may account for the unexplained portion of variability.
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Affiliation(s)
- Chiea Chuen Khor
- Division of Human Genetics, Genome Institute of Singapore, Singapore, Singapore.,Singapore Eye Research Institute, Singapore, Singapore.,Clinical Pharmacology, SingHealth, Singapore, Singapore
| | - Stefan Winter
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Natalia Sutiman
- Clinical Pharmacology Laboratory, Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore
| | - Thomas E Mürdter
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Sylvia Chen
- Clinical Pharmacology Laboratory, Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore
| | - Joanne Siok Liu Lim
- Clinical Pharmacology Laboratory, Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore
| | - Zheng Li
- Division of Human Genetics, Genome Institute of Singapore, Singapore, Singapore
| | - Jingmei Li
- Division of Human Genetics, Genome Institute of Singapore, Singapore, Singapore
| | - Kar Seng Sim
- Division of Human Genetics, Genome Institute of Singapore, Singapore, Singapore
| | - Boian Ganchev
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Diana Eccles
- Faculty of Medicine, Cancer Sciences Academic Unit and University of Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.,University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | - Bryony Eccles
- Faculty of Medicine, Cancer Sciences Academic Unit and University of Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.,University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | - William Tapper
- Faculty of Medicine, Cancer Sciences Academic Unit and University of Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.,University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | - Nathalie K Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Arafat Tfayli
- Hematology-Oncology Division, Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Yoon Sim Yap
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Elaine Lim
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Mabel Wong
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Nan Soon Wong
- OncoCare Cancer Centre, Mount Elizabeth Novena Medical Centre, Singapore, Singapore
| | - Peter Cher Siang Ang
- OncoCare Cancer Centre, Mount Elizabeth Novena Medical Centre, Singapore, Singapore
| | - Rebecca Dent
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Roman Tremmel
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Kathrin Klein
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Elke Schaeffeler
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany.,Image-Guided and Functionally Instructed Tumor Therapies Cluster of Excellence (iFIT), University of Tübingen, Tübingen, Germany
| | - Yitian Zhou
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - Volker M Lauschke
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Michel Eichelbaum
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,Image-Guided and Functionally Instructed Tumor Therapies Cluster of Excellence (iFIT), University of Tübingen, Tübingen, Germany.,Department of Clinical Pharmacology, University of Tübingen, Tübingen, Germany.,Department of Biochemistry and Pharmacy, University of Tübingen, Tübingen, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center, Partner Site Tübingen, Tübingen, Germany
| | - Hiltrud B Brauch
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany.,Image-Guided and Functionally Instructed Tumor Therapies Cluster of Excellence (iFIT), University of Tübingen, Tübingen, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center, Partner Site Tübingen, Tübingen, Germany
| | - Balram Chowbay
- Clinical Pharmacology, SingHealth, Singapore, Singapore.,Clinical Pharmacology Laboratory, Division of Cellular and Molecular Research, National Cancer Centre, Singapore, Singapore.,Centre for Clinician-Scientist Development, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Werner Schroth
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University Tübingen, Tübingen, Germany
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13
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Borges MADH, Passos FRS, Quintans JDSS, Azeredo FJ. Hecogenin and its derivates: A pharmacology review. Biomed Pharmacother 2023; 159:114251. [PMID: 36641922 DOI: 10.1016/j.biopha.2023.114251] [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: 11/21/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Despite the several uses of drugs from natural compounds in the pharmaceutical industry, new molecules have been discovered and associated with pharmacological activities over the years. Hecogenin, a steroidal saponin, has been the subject of several studies due to reports of pharmacological activities. This study combines the articles published to date that show the pharmacological activity and the mechanism of action of hecogenin, its acetate, and its derivates. This compilation shows that the compounds can act in different pathologies that affect many systems of the human body. They showed pharmacological properties in inflammation, mediating cytokines, cells, and environment. Also, it participated in tumoral processes by pathways like PPGARγ, ERK½, and MMP-2 and showed antimicrobial effects against organisms like Candida and Aedes aegypti's larvae. This review indicates that continuing studies with these molecules are essential once they have the potential to be a future drug.
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Affiliation(s)
| | | | | | - Francine Johansson Azeredo
- Pharmacy Graduate Program, Faculty of Pharmacy, Federal University of Bahia, Salvador, Bahia, Brazil; Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA.
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14
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Buijs SM, Hoop EOD, Braal CL, van Rosmalen MM, Drooger JC, van Rossum-Schornagel QC, Vastbinder MB, Koolen SLW, Jager A, Mathijssen RHJ. The impact of endoxifen-guided tamoxifen dose reductions on endocrine side-effects in patients with primary breast cancer. ESMO Open 2023; 8:100786. [PMID: 36753991 PMCID: PMC10024121 DOI: 10.1016/j.esmoop.2023.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Tamoxifen is important in the adjuvant treatment of hormone-sensitive breast cancer and substantially reduces recurrence; however, almost 50% of patients are non-compliant mainly due to side-effects. The aim of this study was to investigate whether endoxifen-guided tamoxifen dose reduction could lead to fewer side-effects. MATERIALS AND METHODS Effects of tamoxifen dose reduction were investigated in patients with bothersome side-effects and endoxifen levels ≥32 nM and compared to patients with side-effects who remained on tamoxifen 20 mg. Endocrine symptoms and health-related quality of life (HR-QOL) were assessed after 3 months with the Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) questionnaire. RESULTS Tamoxifen dose was reduced in 20 patients, 17 of whom were assessable for side-effect analyses. A clinically relevant improvement of >6 points was observed in endocrine symptoms and HR-QOL in 41% and 65% of the patients, respectively. In total, there was a significant and clinically relevant improvement in endocrine symptoms [5.7, 95% confidence interval (CI) -0.5-11.5] and HR-QOL (8.2, 95% CI 0.9-15.4) after dose reduction. This was not seen in patients whose doses were not reduced (n = 60). In 21% of patients, endoxifen dropped slightly below the 16-nM threshold (12.8, 15.5, 15.8, 15.9 nM). CONCLUSIONS Endoxifen-guided dose reduction of tamoxifen significantly improved tamoxifen-related side-effects and HR-QOL. Nearly 80% of patients remained above the most conservative endoxifen threshold.
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Affiliation(s)
- S M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - C L Braal
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M M van Rosmalen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - J C Drooger
- Department of Medical Oncology, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | | | - M B Vastbinder
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den Ijssel, Rotterdam, The Netherlands
| | - S L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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15
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Koubek EJ, Buhrow SA, Safgren SL, Jia L, Goetz MP, Ames MM, Reid JM. Bioavailability and Pharmacokinetics of Endoxifen in Female Rats and Dogs: Evidence to Support the Use of Endoxifen to Overcome the Limitations of CYP2D6-Mediated Tamoxifen Metabolism. Drug Metab Dispos 2023; 51:183-192. [PMID: 36351835 PMCID: PMC9900863 DOI: 10.1124/dmd.122.000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
Endoxifen (ENDX) is an active metabolite of tamoxifen (TAM), a drug commonly used for the treatment of estrogen receptor-positive breast cancer and metabolized by CYP2D6. Genetic or drug-induced reductions in CYP2D6 activity decrease plasma ENDX concentrations and TAM efficacy. It was proposed that direct oral administration of ENDX would circumvent the issues related to metabolic activation of TAM by CYP2D6 and increase patient response. Here, we characterized the pharmacokinetics and oral bioavailability of ENDX in female rats and dogs. Additionally, ENDX exposure was compared following equivalent doses of ENDX and TAM. ENDX exposure was 100-fold and 10-fold greater in rats and dogs, respectively, with ENDX administration compared with an equivalent dose of TAM. In single-dose administration studies, the terminal elimination half-life and plasma clearance values were 6.3 hours and 2.4 L/h per kg in rats given 2 mg/kg i.v. ENDX and 9.2 hours and 0.4 L/h/kg in dogs given 0.5 mg/kg i.v. ENDX, respectively. Plasma concentrations above 0.1 µM and 1 µM ENDX were achieved with 20-mg/kg and 200-mg/kg doses in rats, and concentrations above 1 µM and 10 µM were achieved with 15-mg/kg and 100-mg/kg doses in dogs. Oral absorption of ENDX was linear in rats and dogs, with bioavailability greater than 67% in rats and greater than 50% in dogs. In repeated-dose administration studies, ENDX peak plasma concentrations reached 9 µM in rats and 20 µM in dogs following four daily doses of 200 mg/kg or 30 mg/kg ENDX, respectively. The results indicate that ENDX has high oral bioavailability, and therapeutic concentrations were maintained after repeated dosing. Oral dosing of ENDX resulted in substantially higher ENDX concentrations than a similar dose of TAM. These data support the ongoing development of ENDX to overcome the limitations associated with CYP2D6-mediated metabolism of TAM in humans. SIGNIFICANCE STATEMENT: This study presents for the first time the pharmacokinetics and bioavailability of endoxifen and three key tamoxifen metabolites following repeated oral dosing in female rats and dogs. This study reports that endoxifen has high oral bioavailability, and therapeutic concentrations were maintained after repeated dosing. On the basis of these data, Z-endoxifen (Z-ENDX) was developed as a drug based upon the hypothesis that oral administration of Z-ENDX would overcome the limitations of CYP2D6 metabolism required for full metabolic activation of tamoxifen.
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Affiliation(s)
- Emily J Koubek
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Sarah A Buhrow
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Stephanie L Safgren
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Lee Jia
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Matthew P Goetz
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Matthew M Ames
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
| | - Joel M Reid
- Departments of Oncology (E.J.K., S.A.B., S.L.S., M.P.G., M.M.A., J.M.R.) and Molecular Pharmacology and Experimental Therapeutics (S.L.S., M.P.G., M.M.A., J.M.R.), Mayo Clinic, Rochester, Minnesota; and National Institutes of Health, Frederick, Maryland (L.J.)
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16
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Pharmacokinetics of Tamoxifen and Its Major Metabolites and the Effect of the African Ancestry Specific CYP2D6*17 Variant on the Formation of the Active Metabolite, Endoxifen. J Pers Med 2023; 13:jpm13020272. [PMID: 36836506 PMCID: PMC9961245 DOI: 10.3390/jpm13020272] [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: 12/06/2022] [Revised: 01/13/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Tamoxifen (TAM) is widely used in the treatment of hormone receptor-positive breast cancer. TAM is metabolized into the active secondary metabolite endoxifen (ENDO), primarily by CYP2D6. We aimed to investigate the effects of an African-specific CYP2D6 variant allele, CYP2D6*17, on the pharmacokinetics (PK) of TAM and its active metabolites in 42 healthy black Zimbabweans. Subjects were grouped based on CYP2D6 genotypes as CYP2D6*1/*1 or *1/*2 or *2/*2 (CYP2D6*1 or *2), CYP2D6*1/*17 or 2*/*17, and CYP2D6*17/*17. PK parameters for TAM and three metabolites were determined. The pharmacokinetics of ENDO showed statistically significant differences among the three groups. The mean ENDO AUC0-∞ in CYP2D6*17/*17 subjects was 452.01 (196.94) h·*ng/mL, and the AUC0-∞ in CYP2D6*1/*17 subjects was 889.74 h·ng/mL, which was 5-fold and 2.8-fold lower than in CYP2D6*1 or *2 subjects, respectively. Individuals who were heterozygous or homozygous for CYP2D6*17 alleles showed a 2- and 5-fold decrease in Cmax, respectively, compared to the CYP2D6*1 or *2 genotype. CYP2D6*17 gene carriers have significantly lower ENDO exposure levels than CYP2D6*1 or *2 gene carriers. Pharmacokinetic parameters of TAM and the two primary metabolites, N-desmethyl tamoxifen (NDT) and 4-hydroxy tamoxifen (4OHT), did not show any significant difference in the three genotype groups. The African-specific CYP2D6*17 variant had effects on ENDO exposure levels that could potentially have clinical implications for patients homozygous for this variant.
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17
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Keller DN, Medwid SJ, Ross CD, Wigle TJ, Kim RB. Impact of organic anion transporting polypeptide, P-glycoprotein, and breast cancer resistance protein transporters on observed tamoxifen and endoxifen concentration and adverse effects. Pharmacogenet Genomics 2023; 33:10-18. [PMID: 36373739 DOI: 10.1097/fpc.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Drug transporters are important determinants of drug disposition and response. Tamoxifen is an antiestrogen for breast cancer therapy known for adverse drug reactions (ADRs). In this study, the involvement of OATP transporters in tamoxifen and endoxifen transport was studied in vitro while the impact of single nucleotide variation (SNV) in OATP and efflux transporters P-glycoprotein ( ABCB1 ) and Breast Cancer Resistance Protein ( ABCG2 ) on ADRs during tamoxifen therapy were assessed. METHODS Patients receiving tamoxifen for breast cancer, who were CYP2D6 normal metabolizers were enrolled ( n = 296). Patients completed a survey that captured ADRs and a blood sample was collected. Tamoxifen and endoxifen plasma concentration were measured, while DNA was genotyped for SNVs in ABCB1, ABCG2, SLCO1A2, SLCO1B1 , and SLCO2B1 . HEK293T cells were used to determine the extent of OATP-mediated transport of tamoxifen and endoxifen. RESULTS Common SNVs of ABCB1, ABCG2, SLCO1A2 , and SLCO1B1 were not associated with tamoxifen or endoxifen concentration. However, tamoxifen concentration was significantly higher in carriers of SLCO2B1 c.935G>A (129.8 ng/mL) compared to wildtype (114.9 ng/mL; P = 0.036). Interestingly, subjects who carried SLCO1A2 c.38A>G reported significantly less dizziness ( P = 0.016). In-vitro analysis demonstrated increased cellular accumulation of tamoxifen in cells overexpressing OATP1A2 and 1B1, but endoxifen uptake was not effected in OATP overexpressing cells. CONCLUSIONS We showed that OATP1A2 , a transporter known to be expressed at the blood-brain barrier, is capable of tamoxifen transport. Additionally, OATP1A2 c.38A>G was associated with reduced ADRs. Taken together, our findings suggest genetic variation in OATP transporters may be an important predictor of tamoxifen ADRs.
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Affiliation(s)
| | | | - Cameron D Ross
- Department of Medicine, University of Western Ontario, Canada
| | | | - Richard B Kim
- Department of Medicine, University of Western Ontario, Canada
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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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Factors affecting inter-individual variability in endoxifen concentrations in patients with breast cancer: results from the prospective TOTAM trial. Breast Cancer Res Treat 2022; 195:65-74. [PMID: 35842520 PMCID: PMC9338137 DOI: 10.1007/s10549-022-06643-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/30/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Endoxifen-the principal metabolite of tamoxifen-is subject to a high inter-individual variability in serum concentration. Numerous attempts have been made to explain this, but thus far only with limited success. By applying predictive modeling, we aimed to identify factors that determine the inter-individual variability. Our purpose was to develop a prediction model for endoxifen concentrations, as a strategy to individualize tamoxifen treatment by model-informed dosing in order to prevent subtherapeutic exposure (endoxifen < 16 nmol/L) and thus potential failure of therapy. METHODS Tamoxifen pharmacokinetics with demographic and pharmacogenetic data of 303 participants of the prospective TOTAM study were used. The inter-individual variability in endoxifen was analyzed according to multiple regression techniques in combination with multiple imputations to adjust for missing data and bootstrapping to adjust for the over-optimism of parameter estimates used for internal model validation. RESULTS Key predictors of endoxifen concentration were CYP2D6 genotype, age and weight, explaining altogether an average-based optimism corrected 57% (95% CI 0.49-0.64) of the inter-individual variability. CYP2D6 genotype explained 54% of the variability. The remaining 3% could be explained by age and weight. Predictors of risk for subtherapeutic endoxifen (< 16 nmol/L) were CYP2D6 genotype and age. The model showed an optimism-corrected discrimination of 90% (95% CI 0.86-0.95) and sensitivity and specificity of 66% and 98%, respectively. Consecutively, there is a high probability of misclassifying patients with subtherapeutic endoxifen concentrations based on the prediction rule. CONCLUSION The inter-individual variability of endoxifen concentration could largely be explained by CYP2D6 genotype and for a small proportion by age and weight. The model showed a sensitivity and specificity of 66 and 98%, respectively, indicating a high probability of (misclassification) error for the patients with subtherapeutic endoxifen concentrations (< 16 nmol/L). The remaining unexplained inter-individual variability is still high and therefore model-informed tamoxifen dosing should be accompanied by therapeutic drug monitoring.
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20
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Hyder T, Marti JLG, Nasrazadani A, Brufsky AM. Statins and endocrine resistance in breast cancer. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2022; 4:356-364. [PMID: 35582035 PMCID: PMC9019265 DOI: 10.20517/cdr.2020.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/10/2021] [Accepted: 01/15/2021] [Indexed: 12/21/2022]
Abstract
Most breast cancers are hormone-receptor positive (HR+). However, more women eventually die from HR+ breast cancer than from either HER2+ or triple negative breast cancer. Endocrine therapies continue to be the mainstay of treatment. In 40% of these cases, recurrences in early-stage disease and progression in the metastatic setting are largely a function of the development of endocrine resistance. A multitude of mediators and pathways have been associated with endocrine resistance in breast cancer including the mevalonate pathway, which is integral to cholesterol biosynthesis. The mevalonate pathway and the downstream activation of associated cytoplasmic pathways including PI3K-AKT-mTOR and RAS-MEK-ERK have been known to affect cancer cell proliferation, cell survival, cell invasion, and metastasis. These are important mechanisms leading to the inevitable development of endocrine resistance in HR+ breast cancer. Statins are a class of drugs that inhibits HMG-CoA reductase, an enzyme in the mevalonate pathway that plays a central role in cholesterol production. In vitro and in vitro studies suggest that the role of statins in blocking the mevalonate pathway effectively disrupts downstream pathways involved in estrogen receptor expression and cellular processes such as cell survival, proliferation, stress, cell cycle, inhibition of apoptosis, and autophagy. Overcoming these key mechanisms heralds a role for statins in the prevention of endocrine resistance.
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Affiliation(s)
- Tara Hyder
- University of Pittsburgh Physicians, Pittsburgh, PA 15213, USA
| | - Juan Luis Gomez Marti
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Azadeh Nasrazadani
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA 15213, USA
| | - Adam M Brufsky
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA 15213, USA
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(Z)-Endoxifen and Early Recurrence of Breast Cancer: An Explorative Analysis in a Prospective Brazilian Study. J Pers Med 2022; 12:jpm12040511. [PMID: 35455627 PMCID: PMC9030524 DOI: 10.3390/jpm12040511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/12/2022] [Accepted: 03/19/2022] [Indexed: 02/06/2023] Open
Abstract
Adherence to treatment and use of co-medication, but also molecular factors such as CYP2D6 genotype, affect tamoxifen metabolism, with consequences for early breast cancer prognosis. In a prospective study of 149 tamoxifen-treated early-stage breast cancer patients from Brazil followed up for 5 years, we investigated the association between the active tamoxifen metabolite (Z)-endoxifen at 3 months and event-free survival (EFS) adjusted for clinico-pathological factors. Twenty-five patients (16.8%) had recurred or died at a median follow-up of 52.3 months. When we applied a putative 15 nM threshold used in previous independent studies, (Z)-endoxifen levels below the threshold showed an association with shorter EFS in univariate analysis (p = 0.045) and after adjustment for stage (HR 2.52; 95% CI 1.13–5.65; p = 0.024). However, modeling of plasma concentrations with splines instead of dichotomization did not verify a significant association with EFS (univariate analysis: p = 0.158; adjusted for stage: p = 0.117). Hence, in our small exploratory study, the link between impaired tamoxifen metabolism and early breast cancer recurrence could not be unanimously demonstrated. This inconsistency justifies larger modeling studies backed up by mechanistic pharmacodynamic analyses to shed new light on this suspected association and the stipulation of an appropriate predictive (Z)-endoxifen threshold.
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22
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Pharmacogenetics of Drugs Used in the Treatment of Cancers. Genes (Basel) 2022; 13:genes13020311. [PMID: 35205356 PMCID: PMC8871547 DOI: 10.3390/genes13020311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/01/2023] Open
Abstract
Pharmacogenomics is based on the understanding of the individual differences in drug use, the response to drug therapy (efficacy and toxicity), and the mechanisms underlying variable drug responses. The identification of DNA variants which markedly contribute to inter-individual variations in drug responses would improve the efficacy of treatments and decrease the rate of the adverse side effects of drugs. This review focuses only on the impact of polymorphisms within drug-metabolizing enzymes on drug responses. Anticancer drugs usually have a very narrow therapeutic index; therefore, it is very important to use appropriate doses in order to achieve the maximum benefits without putting the patient at risk of life-threatening toxicities. However, the adjustment of the appropriate dose is not so easy, due to the inheritance of specific polymorphisms in the genes encoding the target proteins and drug-metabolizing enzymes. This review presents just a few examples of such polymorphisms and their impact on the response to therapy.
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Association between genetic polymorphisms in cytochrome P450 enzymes and survivals in women with breast cancer receiving adjuvant endocrine therapy: a systematic review and meta-analysis. Expert Rev Mol Med 2022; 24:e1. [PMID: 34991754 PMCID: PMC9884795 DOI: 10.1017/erm.2021.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tamoxifen is commonly prescribed for preventing recurrence in patients with breast cancer. However, the responses of the patients on tamoxifen treatment are variable. Cytochrome P450 genetic variants have been reported to have a significant impact on the clinical outcomes of tamoxifen treatment but no tangible conclusion can be made up till now. The present review attempts to provide a comprehensive review on the associative relationship between genetic polymorphisms in cytochrome P450 enzymes and survival in breast cancer patients on adjuvant tamoxifen therapy. The literature search was conducted using five databases, resulting in the inclusion of 58 studies in the review. An appraisal of the reporting quality of the included studies was conducted using the assessment tool from the Effective Public Health Practice Project (EPHPP). Meta-analyses were performed on CYP2D6 studies using Review Manager 5.3 software. For other studies, descriptive analyses were performed. The results of meta-analyses demonstrated that shorter overall survival, disease-free survival and relapse-free survival were found in the patients with decreased metabolisers when compared to normal metabolisers. The findings also showed that varying and conflicting results were reported by the included studies. The possible explanations for the variable results are discussed in this review.
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Miranda C, Galleguillos M, Torres R, Tardón K, Cáceres DD, Lee K, Redal MA, Varela NM, Quiñones LA. Preliminary Pharmacogenomic-Based Predictive Models of Tamoxifen Response in Hormone-dependent Chilean Breast Cancer Patients. Front Pharmacol 2021; 12:661443. [PMID: 34899282 PMCID: PMC8656167 DOI: 10.3389/fphar.2021.661443] [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: 01/30/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Tamoxifen (TAM), a selective oestrogen receptor modulator, is one of the most used treatments in oestrogen receptor-positive (ER+) early and metastatic breast cancer (BC) patients. The response to TAM has a high degree of inter-individual variability. This is mainly due to genetic variants in CYP2D6 gene, as well as other genes encoding proteins involved in the TAM pharmacokinetic and/or pharmacodynamic. Therefore, prediction of the TAM response using these genetic factors together with other non-genetic variables may be relevant to improve breast cancer treatment. Thus, in this work, we used genetic polymorphisms and clinical variables for TAM response modelling. One hundred sixty-two ER + BC patients with 2 years of TAM treatment were retrospectively recruited, and the genetic polymorphisms CYP2D6*4, CYP3A4*1B (CYP3A4*1.001), CYP3A5*3, UGT2B7*2, UGT2B15*2, SULT1A1*2, and ESRA V364E were analyzed by PCR-RFLP. Concomitantly, the therapeutic response was obtained from clinical records for association with genotypes using univariate and multivariate biostatistical models. Our results show that UGT2B15*1/*2 genotype protects against relapse (OR = 0.09; p = 0.02), CYP3A5*3/*3 genotype avoids endometrial hyperplasia (OR = 0.07; p = 0.01), SULT1A1*1/*2 genotype avoids vaginal bleeding (OR = 0.09; p = 0.03) and ESRA 364E/364E genotype increases the probability of vaginal bleeding (OR = 5.68; p = 0.02). Logistic regression models, including genomic and non-genomic variables, allowed us to obtain preliminary predictive models to explain relapse (p = 0.010), endometrial hyperplasia (p = 0.002) and vaginal bleeding (p = 0.014). Our results suggest that the response to TAM treatment in ER + BC patients might be associated with the presence of the studied genetic variants in UGT2B15, CYP3A5, SULT1A1 and ESRA genes. After clinical validation protocols, these models might be used to help to predict a percentage of BC relapse and adverse reactions, improving the individual response to TAM-based treatment.
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Affiliation(s)
- Carla Miranda
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Macarena Galleguillos
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile
| | | | | | - Dante D Cáceres
- Institute of Population Health, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Kuen Lee
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Faculty of Medicine, University of Chile, Santiago, Chile
| | - María A Redal
- Genetic Division, Department of Medicine, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Nelson M Varela
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Luis A Quiñones
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
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Jayaraman S, Reid JM, Hawse JR, Goetz MP. Endoxifen, an Estrogen Receptor Targeted Therapy: From Bench to Bedside. Endocrinology 2021; 162:6364076. [PMID: 34480554 PMCID: PMC8787422 DOI: 10.1210/endocr/bqab191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Indexed: 11/19/2022]
Abstract
The selective estrogen receptor (ER) modulator, tamoxifen, is the only endocrine agent with approvals for both the prevention and treatment of premenopausal and postmenopausal estrogen-receptor positive breast cancer as well as for the treatment of male breast cancer. Endoxifen, a secondary metabolite resulting from CYP2D6-dependent biotransformation of the primary tamoxifen metabolite, N-desmethyltamoxifen (NDT), is a more potent antiestrogen than either NDT or the parent drug, tamoxifen. However, endoxifen's antitumor effects may be related to additional molecular mechanisms of action, apart from its effects on ER. In phase 1/2 clinical studies, the efficacy of Z-endoxifen, the active isomer of endoxifen, was evaluated in patients with endocrine-refractory metastatic breast cancer as well as in patients with gynecologic, desmoid, and hormone-receptor positive solid tumors, and demonstrated substantial oral bioavailability and promising antitumor activity. Apart from its potent anticancer effects, Z-endoxifen appears to result in similar or even greater bone agonistic effects while resulting in little or no endometrial proliferative effects compared with tamoxifen. In this review, we summarize the preclinical and clinical studies evaluating endoxifen in the context of breast and other solid tumors, the potential benefits of endoxifen in bone, as well as its emerging role as an antimanic agent in bipolar disorder. In total, the summarized body of literature provides compelling arguments for the ongoing development of Z-endoxifen as a novel drug for multiple indications.
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Affiliation(s)
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - John R Hawse
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew P Goetz
- Correspondence: Matthew P. Goetz, MD, Department of Medical Oncology and Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Pang H, Zhang G, Yan N, Lang J, Liang Y, Xu X, Cui Y, Wu X, Li X, Shan M, Wang X, Meng X, Liu J, Tian G, Cai L, Yuan D, Wang X. Evaluating the Risk of Breast Cancer Recurrence and Metastasis After Adjuvant Tamoxifen Therapy by Integrating Polymorphisms in Cytochrome P450 Genes and Clinicopathological Characteristics. Front Oncol 2021; 11:738222. [PMID: 34868931 PMCID: PMC8639703 DOI: 10.3389/fonc.2021.738222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Tamoxifen (TAM) is the most commonly used adjuvant endocrine drug for hormone receptor-positive (HR+) breast cancer patients. However, how to accurately evaluate the risk of breast cancer recurrence and metastasis after adjuvant TAM therapy is still a major concern. In recent years, many studies have shown that the clinical outcomes of TAM-treated breast cancer patients are influenced by the activity of some cytochrome P450 (CYP) enzymes that catalyze the formation of active TAM metabolites like endoxifen and 4-hydroxytamoxifen. In this study, we aimed to first develop and validate an algorithm combining polymorphisms in CYP genes and clinicopathological signatures to identify a subpopulation of breast cancer patients who might benefit most from TAM adjuvant therapy and meanwhile evaluate major risk factors related to TAM resistance. Specifically, a total of 256 patients with invasive breast cancer who received adjuvant endocrine therapy were selected. The genotypes at 10 loci from three TAM metabolism-related CYP genes were detected by time-of-flight mass spectrometry and multiplex long PCR. Combining the 10 loci with nine clinicopathological characteristics, we obtained 19 important features whose association with cancer recurrence was assessed by importance score via random forests. After that, a logistic regression model was trained to calculate TAM risk-of-recurrence score (TAM RORs), which is adopted to assess a patient's risk of recurrence after TAM treatment. The sensitivity and specificity of the model in an independent test cohort were 86.67% and 64.56%, respectively. This study showed that breast cancer patients with high TAM RORs were less sensitive to TAM treatment and manifested more invasive characteristics, whereas those with low TAM RORs were highly sensitive to TAM treatment, and their conditions were stable during the follow-up period. There were some risk factors that had a significant effect on the efficacy of TAM. They were tissue classification (tumor Grade < 2 vs. Grade ≥ 2, p = 2.2e-16), the number of lymph node metastases (Node-Negative vs. Node < 4, p = 5.3e-07; Node < 4 vs. Node ≥ 4, p = 0.003; Node-Negative vs. Node ≥ 4, p = 7.2e-15), and the expression levels of estrogen receptor (ER) and progesterone receptor (PR) (ER < 50% vs. ER ≥ 50%, p = 1.3e-12; PR < 50% vs. PR ≥ 50%, p = 2.6e-08). The really remarkable thing is that different genotypes of CYP2D6*10(C188T) show significant differences in prediction function (CYP2D6*10 CC vs. TT, p < 0.019; CYP2D6*10 CT vs. TT, p < 0.037). There are more than 50% Chinese who have CYP2D6*10 mutation. So the genotype of CYP2D6*10(C188T) should be tested before TAM therapy.
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Affiliation(s)
- Hui Pang
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Guoqiang Zhang
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Na Yan
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
- Department of Science, Qingdao Geneis Institute of Big Data Mining and Precision Medicine, Qingdao, China
| | - Jidong Lang
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
- Department of Science, Qingdao Geneis Institute of Big Data Mining and Precision Medicine, Qingdao, China
| | - Yuebin Liang
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
- Department of Science, Qingdao Geneis Institute of Big Data Mining and Precision Medicine, Qingdao, China
| | - Xinyuan Xu
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yaowen Cui
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xueya Wu
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xianjun Li
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Ming Shan
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xiaoqin Wang
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
| | - Xiangzhi Meng
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaxiang Liu
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Geng Tian
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
- Department of Science, Qingdao Geneis Institute of Big Data Mining and Precision Medicine, Qingdao, China
| | - Li Cai
- Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Dawei Yuan
- Department of Science, Geneis (Beijing) Co., Ltd., Beijing, China
| | - Xin Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Braal CL, Jager A, Hoop EOD, Westenberg JD, Lommen KMWT, de Bruijn P, Vastbinder MB, van Rossum-Schornagel QC, Thijs-Visser MF, van Alphen RJ, Struik LEM, Zuetenhorst HJM, Mathijssen RHJ, Koolen SLW. Therapeutic Drug Monitoring of Endoxifen for Tamoxifen Precision Dosing: Feasible in Patients with Hormone-Sensitive Breast Cancer. Clin Pharmacokinet 2021; 61:527-537. [PMID: 34786650 PMCID: PMC8975771 DOI: 10.1007/s40262-021-01077-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 02/08/2023]
Abstract
Background Endoxifen is the most important active metabolite of tamoxifen. Several retrospective studies have suggested a minimal or threshold endoxifen systemic concentration of 14–16 nM is required for a lower recurrence rate. The aim of this study was to investigate the feasibility of reaching a predefined endoxifen level of ≥ 16 nM (5.97 ng/mL) over time using therapeutic drug monitoring (TDM). Methods This prospective open-label intervention study enrolled patients who started treatment with a standard dose of tamoxifen 20 mg once daily for early breast cancer. An outpatient visit was combined with a TDM sample at 3, 4.5, and 6 months after initiation of the tamoxifen treatment. The tamoxifen dose was escalated to a maximum of 40 mg if patients had an endoxifen concentration < 16 nM. The primary endpoint of the study was the percentage of patients with an endoxifen level ≥ 16 nM at 6 months after the start of therapy compared with historical data, in other words, 80% of patients with endoxifen levels ≥ 16 nM with standard therapy. Results In total, 145 patients were included. After 6 months, 89% of the patients had endoxifen levels ≥ 16 nM, compared with a literature-based 80% of patients with endoxifen levels ≥ 16 nM at baseline (95% confidence interval 82–94; P = 0.007). In patients with an affected CYP2D6 allele, it was not always feasible to reach the predefined endoxifen level of ≥ 16 nM. No increase in tamoxifen-related adverse events was reported after dose escalation. Conclusion This study demonstrated that it is feasible to increase the percentage of patients with endoxifen levels ≥ 16 nM using TDM. TDM is a safe strategy that offers the possibility of nearly halving the number of patients with endoxifen levels < 16 nM.
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Affiliation(s)
- C Louwrens Braal
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Justin D Westenberg
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Koen M W T Lommen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mijntje B Vastbinder
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | | | - Martine F Thijs-Visser
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands.,Department of Internal Medicine, Spijkenisse MC, Spijkenisse, The Netherlands
| | - Robbert J van Alphen
- Department of Internal Medicine, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Liesbeth E M Struik
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Rüegg U. Tamoxifen in Duchenne muscular dystrophy - promising first results. Neuromuscul Disord 2021; 31:801-802. [PMID: 34635289 DOI: 10.1016/j.nmd.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Urs Rüegg
- Emeritus Professor of Pharmacology, Pharmaceutical Sciences, University of Geneva, 1211 Geneva 4, Switzerland.
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Kawasaki Y, Sendo T. Three photoinitiators induce breast tumor growth in mouse xenografts with MCF-7 breast cancer cells. Curr Res Toxicol 2021; 2:322-328. [PMID: 34522900 PMCID: PMC8426503 DOI: 10.1016/j.crtox.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/23/2021] [Indexed: 11/19/2022] Open
Abstract
Photoinitiators are utilized in the production of a wide range of commonly used products. However, some photoinitiators exert toxic effects. We previously demonstrated the endocrine-disrupting effects of photoinitiators in vitro. The present study investigated the estrogenic activities of three photoinitiators: 1-hydroxycyclohexyl phenyl ketone (1-HCHPK), methyl 2-benzoylbenzoate (MBB), and 2-methyl-4'-(methylthio)-2-morpholinopropiophenone (MTMP), which were subcutaneously injected into mouse xenografts with MCF-7 breast cancer cells. The results obtained showed that 1-HCHPK, MBB, and MTMP promoted breast tumor growth in these xenografts. A pretreatment with the estrogen receptor antagonist tamoxifen blocked the tumor growth-promoting effects of each photoinitiator. Collectively, the present results suggest that the three photoinitiators exhibit estrogenic agonist activities in vivo. Furthermore, as a factor for breast tumor growth, these photoinitiators potentially have estrogenic properties in vivo.
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Downregulation of RPS14 inhibits the proliferation and metastasis of estrogen receptor-positive breast cancer cells. Anticancer Drugs 2021; 32:1019-1028. [PMID: 34261921 DOI: 10.1097/cad.0000000000001112] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Ribosomal protein S14 (RPS14) is a component of the 40S ribosomal subunit and is considered to be indispensable for ribosomal biogenesis. Previously, we found that RPS14 was significantly downregulated in estrogen receptor-positive (ER+) breast cancer cells following treatment with 4-hydroxytamoxifen (4-OH-TAM). However, its role in breast cancer remains poorly understood. In the present study, we sought to demonstrate, for the first time, that RPS14 is highly expressed in ER+ breast cancer tissues and its downregulation can significantly inhibit the proliferation, cycle, and metastasis of ER+ breast cancer cells, as well as induce cell apoptosis. METHODS Quantitative RT-PCR and western blotting were used to determine the expression of target genes. Herein, lentivirus-mediated small hairpin RNA (shRNA) targeting RPS14 was designed to determine the impact of RPS14 knockdown on ER+ breast cancer cells. Further, bioinformatics analysis was used to reveal the significance of differentially expressed genes in RPS14 knockdown breast cancer cells. RESULTS RPS14 was highly expressed in ER+ breast cancer tissues compared to ER- tissues. The downregulation of RPS14 in two ER+ breast cancer cell lines suppressed cell proliferation, cell cycle and metastasis, and induced apoptosis. Based on bioinformatics analysis, the expression level of several significant genes, such as ASNS, Ret, and S100A4, was altered in breast cancer cells after RPS14 downregulation. Furthermore, the BAG2 and interferon signaling pathways were identified to be significantly activated. CONCLUSIONS The downregulation of RPS14 in ER+ breast cancer cells can inhibit their proliferation and metastasis.
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Wang H, Ma X, Zhang B, Zhang Y, Han N, Wei L, Sun C, Sun S, Zeng X, Guo H, Li Y, Zhang Y, Zhao J, Qin Z, Liu Z, Zhang N. Chinese breast cancer patients with CYP2D6*10 mutant genotypes have a better prognosis with toremifene than with tamoxifen. Asia Pac J Clin Oncol 2021; 18:e148-e153. [PMID: 34196110 PMCID: PMC9290498 DOI: 10.1111/ajco.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Purpose To evaluate the prognosis of estrogen receptor‐positive breast cancer patients with CYP2D6*10 mutant genotypes under tamoxifen or toremifen therapy. Methods Estrogen receptor‐positive breast cancer patients were selected and CYP2D6*10 genotypes (C/C, C/T, and T/T) were determined by Sanger sequencing. Patients were divided into tamoxifen, toremifene, or tamoxifen + toremifene groups according to prior therapy. The correlation between CYP2D6*10 genotype and disease‐free survival was analyzed. Results In total, 293 estrogen receptor‐positive breast cancer patients treated with tamoxifen or toremifene between 2008 and 2017 were studied. Median follow‐up was 39 months (10–141). Of these, 107 (36.52%), 112 (38.23%), and 74 (25.26%) patients had C/C, C/T, and T/T genotypes, respectively. Genotype was significantly associated with disease‐free survival in tamoxifen patients. Patients with C/T and T/T genotypes showed worse disease‐free survival than patients with a C/C genotype. Genotype and disease‐free survival in toremifene and tamoxifen+toremifene patients were not correlated. Of patients with a C/T genotype, toremifene or tamoxifen+toremifene groups showed better disease‐free survival than tamoxifen patients. Although disease‐free survival of patients with a T/T genotype in the three groups was not statistically different, tamoxifen patients showed worse disease‐free survival. There was no correlation between different treatments and disease‐free survival in patients with a C/C genotype. Cox proportional hazard analysis revealed toremifene patients had a better prognosis than tamoxifen patients; toremifene was an independent protective factoremifene for disease‐free survival. Conclusions Tamoxifen was less effective in patients with CYP2D6*10 C/T and T/T genotypes. Estrogen receptor‐positive breast cancer patients with a CYP2D6*10 mutation genotype have a better prognosis with toremifen than tamoxifen.
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Affiliation(s)
- Hongyue Wang
- Department of Science Research and Academic, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Xinchi Ma
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Bin Zhang
- Department of Breast Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Yaotian Zhang
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Ning Han
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Linlin Wei
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Chaonan Sun
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Shichen Sun
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Xue Zeng
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Hong Guo
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Yubing Li
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Yanyu Zhang
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Jiaming Zhao
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Zilan Qin
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Zhuang Liu
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
| | - Na Zhang
- Department of Breast Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, P. R. China
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Maggadani BP, Harmita, Haryono SJ, Rinaldi MR, Harahap Y. Volumetric Absorptive Microsampling as a New Biosampling Tool for Monitoring of Tamoxifen, Endoxifen, 4-OH Tamoxifen and N-Desmethyltamoxifen in Breast Cancer Patients. Drug Des Devel Ther 2021; 15:2417-2430. [PMID: 34113081 PMCID: PMC8187001 DOI: 10.2147/dddt.s286409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/14/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION In this research, we used a volumetric absorptive microsampling (VAMS) technique to collect blood samples from the patients. A rapid and simple sample preparation method and LC-MS.MS assay was then developed and validated for the simultaneous analysis of tamoxifen and its three active metabolites. METHODS VAMS extraction was performed in methanol by sonication-assisted extraction method for 25 min after 2 hof VAMS drying. Separation was carried out using Acquity UPLC BEH C18 column (2.1 x 100 mm; 1.7 µm), with a flow rate of 0.2 mL/min, and the mobile phase gradient of formic acid 0.1% and formic acid 0.1% in acetonitrile for 5 min. The multiple reaction monitoring (MRM) values were set at m/z 358.31>58.27 for N-desmethyltamoxifen, m/z 372.33>72.28 for tamoxifen, m/z 388.22>72.28 for 4-hydroxytamoxifen, m/z 374.25>58.25 for endoxifen, and m/z 260.26>116.12 for propranolol. RESULTS AND DISCUSSION The lower limit of quantification value (LLOQ) was 2.50 ng/mL for tamoxifen, 2.50 ng/mL for endoxifen, 1.50 ng/mL for 4-hydroxitamoxifen, and 2.00 ng/mL for N-desmethyltamoxifen. Accuracy (%bias) and precision (%CV) were within 20% for LLOQ and 15% for other concentrations. There were no interference responses >20% of the LLOQ and 5% of the internal standard. The level of ion suppression in all analytes was less than 7%. The preparation system developed in this study successfully extracted more than 90% of analytes from the matrix with precision below 15%. Carryover was shown to be below 6% in all analytes. Stability of analytes in VAMS was demonstrated for up to 30 days, under room temperature storage in a sealed plastic bag with desiccant. This method was successfully applied to analyze tamoxifen and the metabolites level in 30 ER+ breast cancer patients.
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Affiliation(s)
| | - Harmita
- Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, Indonesia
| | - Samuel J Haryono
- Surgical Oncology Division, MRCCC Siloam Hospital, Jakarta, Indonesia
| | | | - Yahdiana Harahap
- Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, Indonesia
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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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Mueller-Schoell A, Michelet R, Klopp-Schulze L, van Dyk M, Mürdter TE, Schwab M, Joerger M, Huisinga W, Mikus G, Kloft C. Computational Treatment Simulations to Assess the Need for Personalized Tamoxifen Dosing in Breast Cancer Patients of Different Biogeographical Groups. Cancers (Basel) 2021; 13:cancers13102432. [PMID: 34069810 PMCID: PMC8157244 DOI: 10.3390/cancers13102432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Tamoxifen is a drug often used to treat the most common type of breast cancer. Its metabolite endoxifen is formed by the liver enzyme CYP2D6, whose activity is variable and depends on a patient’s genetic profile. The frequency of CYP2D6 variants with different functional enzymatic activity varies largely between populations. To ensure sufficient efficacy of tamoxifen, a certain target concentration of endoxifen is needed, and 20% of White breast cancer patients have been shown not to reach this target concentration. However, little is known about the risk of not attaining the endoxifen target amongst other ethnic populations. This study investigated the risk for suboptimal endoxifen concentration in nine different biogeographical populations based on their distinct CYP2D6 genetic profile. The variability between the populations was high (up to three-fold), and East Asian breast cancer patients were identified as the population with the highest need for personalized tamoxifen dosing. Abstract Tamoxifen is used worldwide to treat estrogen receptor-positive breast cancer. It is extensively metabolized, and minimum steady-state concentrations of its metabolite endoxifen (CSS,min ENDX) >5.97 ng/mL have been associated with favorable outcome. Endoxifen formation is mediated by the enzyme CYP2D6, and impaired CYP2D6 function has been associated with lower CSS,min ENDX. In the Women’s Healthy Eating and Living (WHEL) study proposing the target concentration, 20% of patients showed subtarget CSS,min ENDX at tamoxifen standard dosing. CYP2D6 allele frequencies vary largely between populations, and as 87% of the patients in the WHEL study were White, little is known about the risk for subtarget CSS,min ENDX in other populations. Applying pharmacokinetic simulations, this study investigated the risk for subtarget CSS,min ENDX at tamoxifen standard dosing and the need for dose individualization in nine different biogeographical groups with distinct CYP2D6 allele frequencies. The high variability in CYP2D6 allele frequencies amongst the biogeographical groups resulted in an up to three-fold difference in the percentages of patients with subtarget CSS,min ENDX. Based on their CYP2D6 allele frequencies, East Asian breast cancer patients were identified as the population for which personalized, model-informed precision dosing would be most beneficial (28% of patients with subtarget CSS,min ENDX).
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Lena Klopp-Schulze
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia;
| | - Thomas E. Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, and University Tübingen, 70376 Tübingen, Germany;
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany;
- German Cancer Consortium (DKTK), Partner Site Tübingen, German Cancer Research, 69120 Heidelberg, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University Tübingen, 72076 Tübingen, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St. Gallen, Switzerland;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, 53113 Bonn, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Correspondence:
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Helland T, Alsomairy S, Lin C, Søiland H, Mellgren G, Hertz DL. Generating a Precision Endoxifen Prediction Algorithm to Advance Personalized Tamoxifen Treatment in Patients with Breast Cancer. J Pers Med 2021; 11:jpm11030201. [PMID: 33805613 PMCID: PMC8000933 DOI: 10.3390/jpm11030201] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Tamoxifen is an endocrine treatment for hormone receptor positive breast cancer. The effectiveness of tamoxifen may be compromised in patients with metabolic resistance, who have insufficient metabolic generation of the active metabolites endoxifen and 4-hydroxy-tamoxifen. This has been challenging to validate due to the lack of measured metabolite concentrations in tamoxifen clinical trials. CYP2D6 activity is the primary determinant of endoxifen concentration. Inconclusive results from studies investigating whether CYP2D6 genotype is associated with tamoxifen efficacy may be due to the imprecision in using CYP2D6 genotype as a surrogate of endoxifen concentration without incorporating the influence of other genetic and clinical variables. This review summarizes the evidence that active metabolite concentrations determine tamoxifen efficacy. We then introduce a novel approach to validate this relationship by generating a precision endoxifen prediction algorithm and comprehensively review the factors that must be incorporated into the algorithm, including genetics of CYP2D6 and other pharmacogenes. A precision endoxifen algorithm could be used to validate metabolic resistance in existing tamoxifen clinical trial cohorts and could then be used to select personalized tamoxifen doses to ensure all patients achieve adequate endoxifen concentrations and maximum benefit from tamoxifen treatment.
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Affiliation(s)
- Thomas Helland
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway;
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Correspondence: ; Tel.: +47-92847793
| | - Sarah Alsomairy
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
| | - Chenchia Lin
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway;
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
| | - Daniel Louis Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA; (S.A.); (C.L.); (D.L.H.)
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36
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Jones CJ, Subramaniam M, Emch MJ, Bruinsma ES, Ingle JN, Goetz MP, Hawse JR. Development and Characterization of Novel Endoxifen-Resistant Breast Cancer Cell Lines Highlight Numerous Differences from Tamoxifen-Resistant Models. Mol Cancer Res 2021; 19:1026-1039. [PMID: 33627502 DOI: 10.1158/1541-7786.mcr-20-0872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/25/2021] [Accepted: 02/19/2021] [Indexed: 12/24/2022]
Abstract
Despite the availability of drugs that target ERα-positive breast cancer, resistance commonly occurs, resulting in relapse, metastasis, and death. Tamoxifen remains the most commonly-prescribed endocrine therapy worldwide, and "tamoxifen resistance" has been extensively studied. However, little consideration has been given to the role of endoxifen, the most abundant active tamoxifen metabolite detected in patients, in driving resistance mechanisms. Endoxifen functions differently from the parent drug and other primary metabolites, including 4-hydroxy-tamoxifen (4HT). Many studies have shown that patients who extensively metabolize tamoxifen into endoxifen have superior outcomes relative to patients who do not, supporting a primary role for endoxifen in driving tamoxifen responses. Therefore, "tamoxifen resistance" may be better modeled by "endoxifen resistance" for some patients. Here, we report the development of novel endoxifen-resistant breast cancer cell lines and have extensively compared these models to 4HT and fulvestrant (ICI)-resistant models. Endoxifen-resistant cells were phenotypically and molecularly distinct from 4HT-resistant cells and more closely resembled ICI-resistant cells overall. Specifically, endoxifen resistance was associated with ERα and PR loss, estrogen insensitivity, unique gene signatures, and striking resistance to most FDA-approved second- and third-line therapies. Given these findings, and the importance of endoxifen in the efficacy of tamoxifen therapy, our data indicate that endoxifen-resistant models may be more clinically relevant than existing models and suggest that a better understanding of endoxifen resistance could substantially improve patient care. IMPLICATIONS: Here we report on the development and characterization of the first endoxifen-resistant models and demonstrate that endoxifen resistance may better model tamoxifen resistance in a subset of patients.
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Affiliation(s)
- Calley J Jones
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael J Emch
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth S Bruinsma
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | - James N Ingle
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - John R Hawse
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota.
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Jeiziner C, Stäuble CK, Lampert ML, Hersberger KE, Meyer Zu Schwabedissen HE. Enriching Medication Review with a Pharmacogenetic Profile - A Case of Tamoxifen Adverse Drug Reactions. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:279-286. [PMID: 33642872 PMCID: PMC7903951 DOI: 10.2147/pgpm.s285807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/11/2021] [Indexed: 01/13/2023]
Abstract
Pharmacogenotyping is applied to determine the hereditable component of a patient's susceptibility to experience therapy failure and/or adverse drug reactions (ADRs). We present the case of a female patient diagnosed with breast cancer and treated with tamoxifen as recurrence therapy who experienced various ADRs. Pharmacogenotyping revealed variants in the cytochrome P450 (CYP) enzymes CYP2D6, CYP2C9, and CYP2C19. The observed genotype was associated with a risk for lower tamoxifen efficacy. Aside from the tamoxifen therapy, the comedication was reviewed for the influence of the patient’s pharmacogenetic profile. As a result of this pharmacist-led medication review with pharmacogenetic analyses, concrete genotype-driven recommendations for the treating gynecologist were compiled. This case revealed the added value of a large pharmacogenetic panel and the complexity of integrating a pharmacogenetic profile into a recommendation.
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Affiliation(s)
- Chiara Jeiziner
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Céline K Stäuble
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Markus L Lampert
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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38
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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: 18] [Impact Index Per Article: 6.0] [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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Mueller-Schoell A, Klopp-Schulze L, Michelet R, van Dyk M, Mürdter TE, Schwab M, Joerger M, Huisinga W, Mikus G, Kloft C. Simulation-Based Assessment of the Impact of Non-Adherence on Endoxifen Target Attainment in Different Tamoxifen Dosing Strategies. Pharmaceuticals (Basel) 2021; 14:ph14020115. [PMID: 33546125 PMCID: PMC7913149 DOI: 10.3390/ph14020115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022] Open
Abstract
Tamoxifen is widely used in breast cancer treatment and minimum steady-state concentrations of its active metabolite endoxifen (CSS,min ENDX) above 5.97 ng/mL have been associated with favourable disease outcome. Yet, about 20% of patients do not reach target CSS,min ENDX applying conventional tamoxifen dosing. Moreover, 4-75% of patients are non-adherent, resulting in worse disease outcomes. Assuming complete adherence, we previously showed model-informed precision dosing (MIPD) to be superior to conventional and CYP2D6-guided dosing in minimising the proportion of patients with subtarget CSS,min ENDX. Given the high non-adherence rate in long-term tamoxifen therapy, this study investigated the impact of non-adherence on CSS,min ENDX target attainment in different dosing strategies. We show that MIPD allows to account for the expected level of non-adherence (here: up to 2 missed doses/week): increasing the MIPD target threshold from 5.97 ng/mL to 9 ng/mL (the lowest reported CSS,min ENDX in CYP2D6 normal metabolisers) as a safeguard resulted in the lowest interindividual variability and proportion of patients with subtarget CSS,min ENDX even in non-adherent patients. This is a significant improvement to conventional and CYP2D6-guided dosing. Adding a fixed increment to the originally selected dose is not recommended, since it inflates interindividual variability.
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14163 Berlin, Germany; (A.M.-S.); (L.K.-S.); (R.M.); (G.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Lena Klopp-Schulze
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14163 Berlin, Germany; (A.M.-S.); (L.K.-S.); (R.M.); (G.M.)
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14163 Berlin, Germany; (A.M.-S.); (L.K.-S.); (R.M.); (G.M.)
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia;
| | - Thomas E. Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, and University Tübingen, 70376 Tübingen, Germany;
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany;
- German Cancer Consortium (DKTK), Partner Site Tübingen, German Cancer Research, 69120 Heidelberg, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University Tübingen, 72076 Tübingen, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St. Gallen, Switzerland;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14163 Berlin, Germany; (A.M.-S.); (L.K.-S.); (R.M.); (G.M.)
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14163 Berlin, Germany; (A.M.-S.); (L.K.-S.); (R.M.); (G.M.)
- Correspondence:
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40
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Wang T, Zhou Y, Cao G. Pharmacogenetics of tamoxifen therapy in Asian populations: from genetic polymorphism to clinical outcomes. Eur J Clin Pharmacol 2021; 77:1095-1111. [PMID: 33515076 DOI: 10.1007/s00228-021-03088-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Compared with western countries, Asian breast cancer patients have unique pathological and biological characteristics. Most of them are premenopausal women with HR positive. Tamoxifen as the first-line drug for premenopausal women with HR+ is involved in multiple enzymes and transporters during metabolizing and transporting process. Variants that cause decreased or inactive gene products leading to abnormal responses in tamoxifen therapy have well been studied in western countries, whereas such information is much less reported in Asian populations. OBJECTIVE In order to elucidate the relationship between genetic variants and tamoxifen-induced individual drug reactions in different Asian populations and further identify genotypes/phenotypes with potential therapeutic significance. METHODS We reviewed the frequencies of genetic variants in major enzymes and transporter genes involved in the metabolism and transport of tamoxifen across Asian populations as well as significant correlations between genotypes/metabolic phenotypes and metabolites concentrations or BC clinical outcomes. RESULTS Significant inter-ethnic differences in allele frequencies was found among Asian populations, such as CYP2D6*4, *10, *41, CYP2C9*2, ABCB1 C3435T and SLCO1B1*5, and CYP2D6*10/*10 is the most common genotype correlated with adverse clinical outcomes. Moreover, we summarized the barriers and controversies of implementing pharmacogenetics in tamoxifen therapy and concluded that more population-specific pharmacogenetic studies are needed in the future. CONCLUSION This review revealed more systematic pharmacogenomics of genes involved in the metabolism and transport besides CYP2D6, are required to optimize the genotyping strategies and guide the personalized tamoxifen therapy in Asian populations.
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Affiliation(s)
- Tingyu Wang
- College of Pharmacy, Hubei University of Chinese Medicine, Wuhan, 430065, China
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Guosheng Cao
- College of Pharmacy, Hubei University of Chinese Medicine, Wuhan, 430065, China.
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41
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Sula A, Hollingworth D, Ng LCT, Larmore M, DeCaen PG, Wallace BA. A tamoxifen receptor within a voltage-gated sodium channel. Mol Cell 2021; 81:1160-1169.e5. [PMID: 33503406 PMCID: PMC7980221 DOI: 10.1016/j.molcel.2020.12.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 08/24/2020] [Accepted: 12/14/2020] [Indexed: 12/22/2022]
Abstract
Voltage-gated sodium channels are targets for many analgesic and antiepileptic drugs whose therapeutic mechanisms and binding sites have been well characterized. We describe the identification of a previously unidentified receptor site within the NavMs voltage-gated sodium channel. Tamoxifen, an estrogen receptor modulator, and its primary and secondary metabolic products bind at the intracellular exit of the channel, which is a site that is distinct from other previously characterized sodium channel drug sites. These compounds inhibit NavMs and human sodium channels with similar potencies and prevent sodium conductance by delaying channel recovery from the inactivated state. This study therefore not only describes the structure and pharmacology of a site that could be leveraged for the development of new drugs for the treatment of sodium channelopathies but may also have important implications for off-target health effects of this widely used therapeutic drug.
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Affiliation(s)
- Altin Sula
- Institute of Structural and Molecular Biology, Birkbeck College, University of London, London WC1E 7HX, UK
| | - David Hollingworth
- Institute of Structural and Molecular Biology, Birkbeck College, University of London, London WC1E 7HX, UK
| | - Leo C T Ng
- Department of Pharmacology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Megan Larmore
- Department of Pharmacology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Paul G DeCaen
- Department of Pharmacology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - B A Wallace
- Institute of Structural and Molecular Biology, Birkbeck College, University of London, London WC1E 7HX, UK.
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42
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Sanchez-Spitman AB, Swen JJ, Dezentjé VO, Moes DJAR, Gelderblom H, Guchelaar HJ. Effect of CYP2C19 genotypes on tamoxifen metabolism and early-breast cancer relapse. Sci Rep 2021; 11:415. [PMID: 33432065 PMCID: PMC7801676 DOI: 10.1038/s41598-020-79972-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
CYP2C19*2 and CYP2C19*17 might influence tamoxifen metabolism and clinical outcome. Our aim was to investigate the effect of CYP2C19 genotypes on tamoxifen concentrations and metabolic ratios (MRs) and breast cancer recurrence in a large cohort of Caucasian women. Genetic variants (CYP2D6 and CYP2C19 genotypes), tamoxifen and metabolites concentrations, baseline characteristics, and breast cancer recurrence from the CYPTAM study (NTR1509) were used. CYP2C19*2 and CYP2C19*17 genotypes were evaluated as alleles and as groups based on CYP2D6 genotypes (high, intermediate and low activity). Log-rank test and Kaplan–Meier analysis were used to evaluate differences in recurrence defined as relapse-free survival (RFS). Classification tree analyses (CTAs) were conducted to assess the levels of interactions per polymorphism (CYP2D6 and CYP2C19 genotypes) on endoxifen concentrations. No differences in mean concentrations and MRs were observed when comparing CYP2C19 genotypes (CYP2C19*1/*1; CYP2C19*1/*2; CYP2C19*2/*2; CYP2C19*1/*17; CYP2C19*17/*17; CYP2C19*2/*17). Only significant differences (p value < 0.05) in mean concentrations and MRs were observed when comparing tamoxifen activity groups (high, intermediate and low activity). A log-rank test did not find an association across CYP2C19 genotypes (p value 0.898). CTAs showed a significant relationship between CYP2D6 and endoxifen (p value < 0.0001), but no association with CYP2C19 genotypes was found. CYP2C19 polymorphisms do not have a significant impact on tamoxifen metabolism or breast cancer relapse.
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Affiliation(s)
- A B Sanchez-Spitman
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden University Medical Center, Leiden, The Netherlands
| | - J J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden University Medical Center, Leiden, The Netherlands
| | - V O Dezentjé
- Department of Medical Oncology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden University Medical Center, Leiden, The Netherlands
| | - H Gelderblom
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - H J Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Leiden Network for Personalised Therapeutics, Leiden University Medical Center, Leiden, The Netherlands.
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43
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Slanař O, Hronová K, Bartošová O, Šíma M. Recent advances in the personalized treatment of estrogen receptor-positive breast cancer with tamoxifen: a focus on pharmacogenomics. Expert Opin Drug Metab Toxicol 2020; 17:307-321. [PMID: 33320718 DOI: 10.1080/17425255.2021.1865310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Tamoxifen is still an important drug in hormone-dependent breast cancer therapy. Personalization of its clinical use beyond hormone receptor positivity could improve the substantial variability of the treatment response.Areas covered: The overview of the current evidence for the treatment personalization using therapeutic drug monitoring, or using genetic biomarkers including CYP2D6 is provided. Although many studies focused on the PK aspects or the impact of CYP2D6 variability the translation into clinical routine is not clearly defined due to the inconsistent clinical outcome data.Expert opinion: We believe that at least the main candidate factors, i.e. CYP2D6 polymorphism, CYP2D6 inhibition, endoxifen serum levels may become important predictors of clinical relevance for tamoxifen treatment personalization in the future. To achieve this aim, however, further research should take into consideration more precise characterization of the disease, epigenetic factors and also utilize an appropriately powered multifactorial approach instead of a single gene evaluating studies.
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Affiliation(s)
- Ondřej Slanař
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolína Hronová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Olga Bartošová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
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44
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Helland T, Naume B, Hustad S, Bifulco E, Kvaløy JT, Saetersdal AB, Synnestvedt M, Lende TH, Gilje B, Mjaaland I, Weyde K, Blix ES, Wiedswang G, Borgen E, Hertz DL, Janssen EAM, Mellgren G, Søiland H. Low Z-4OHtam concentrations are associated with adverse clinical outcome among early stage premenopausal breast cancer patients treated with adjuvant tamoxifen. Mol Oncol 2020; 15:957-967. [PMID: 33252186 PMCID: PMC8024735 DOI: 10.1002/1878-0261.12865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/01/2020] [Accepted: 11/27/2020] [Indexed: 11/06/2022] Open
Abstract
Low steady-state levels of active tamoxifen metabolites have been associated with inferior treatment outcomes. In this retrospective analysis of 406 estrogen receptor-positive breast cancer (BC) patients receiving adjuvant tamoxifen as initial treatment, we have associated our previously reported thresholds for the two active metabolites, Z-endoxifen and Z-4-hydroxy-tamoxifen (Z-4OHtam), with treatment outcomes in an independent cohort of BC patients. Among all patients, metabolite levels did not affect survival. However, in the premenopausal subgroup receiving tamoxifen alone (n = 191) we confirmed an inferior BC -specific survival in patients with the previously described serum concentration threshold of Z-4OHtam ≤ 3.26 nm (HR = 2.37, 95% CI = 1.02-5.48, P = 0.039). The 'dose-response' survival trend in patients categorized to ordinal concentration cut-points of Z-4OHtamoxifen (≤ 3.26, 3.27-8.13, > 8.13 nm) was also replicated (P-trend log-rank = 0.048). Z-endoxifen was not associated with outcome. This is the first study to confirm the association between a published active tamoxifen metabolite threshold and BC outcome in an independent patient cohort. Premenopausal patients receiving 5-year of tamoxifen alone may benefit from therapeutic drug monitoring to ensure tamoxifen effectiveness.
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Affiliation(s)
- Thomas Helland
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
| | - Bjørn Naume
- Department of Oncology, Division of Cancer Medicine, Oslo University Hospital, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Steinar Hustad
- Core Facility for Metabolomics, Department of Clinical Science, University of Bergen, Norway
| | - Ersilia Bifulco
- Core Facility for Metabolomics, Department of Clinical Science, University of Bergen, Norway
| | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, Norway.,Department of Research, Stavanger University Hospital, Norway
| | | | - Marit Synnestvedt
- Department of Oncology, Division of Cancer Medicine, Oslo University Hospital, Norway
| | - Tone Hoel Lende
- Department of Surgery, Section for Breast and Endocrine Surgery, Stavanger University Hospital, Norway
| | - Bjørnar Gilje
- Department of Oncology and Radiotherapy, Stavanger University Hospital, Norway
| | - Ingvil Mjaaland
- Department of Oncology and Radiotherapy, Stavanger University Hospital, Norway
| | - Kjetil Weyde
- Department of Oncology, Sykehuset Innlandet, Gjøvik, Norway
| | - Egil Støre Blix
- Immunology Research Group, Institute of Medical Biology, University of Tromsø, Norway.,Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - Gro Wiedswang
- Department of GI-Surgery, Oslo University Hospital, Norway
| | - Elin Borgen
- Department of Pathology, Oslo University Hospital, Norway
| | - Daniel Louis Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Emiel Adrianus Maria Janssen
- Department of Pathology, Stavanger University Hospital, Norway.,Department of Bioscience and Environmental Engineering, University of Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Norway.,Department of Oncology and Radiotherapy, Stavanger University Hospital, Norway
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Puszkiel A, Arellano C, Vachoux C, Evrard A, Le Morvan V, Boyer JC, Robert J, Delmas C, Dalenc F, Debled M, Venat-Bouvet L, Jacot W, Dohollou N, Bernard-Marty C, Laharie-Mineur H, Filleron T, Roché H, Chatelut E, Thomas F, White-Koning M. Model-Based Quantification of Impact of Genetic Polymorphisms and Co-Medications on Pharmacokinetics of Tamoxifen and Six Metabolites in Breast Cancer. Clin Pharmacol Ther 2020; 109:1244-1255. [PMID: 33047329 DOI: 10.1002/cpt.2077] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/04/2020] [Indexed: 12/21/2022]
Abstract
Variations in clinical response to tamoxifen (TAM) may be related to polymorphic cytochromes P450 (CYPs) involved in forming its active metabolite endoxifen (ENDO). We developed a population pharmacokinetic (PopPK) model for tamoxifen and six metabolites to determine clinically relevant factors of ENDO exposure. Concentration-time data for TAM and 6 metabolites come from a prospective, multicenter, 3-year follow-up study of adjuvant TAM (20 mg/day) in patients with breast cancer, with plasma samples drawn every 6 months, and genotypes for 63 genetic polymorphisms (PHACS study, NCT01127295). Concentration data for TAM and 6 metabolites from 928 patients (n = 27,433 concentrations) were analyzed simultaneously with a 7-compartment PopPK model. CYP2D6 phenotype (poor metabolizer (PM), intermediate metabolizer (IM), normal metabolizer (NM), and ultra-rapid metabolizer (UM)), CYP3A4*22, CYP2C19*2, and CYP2B6*6 genotypes, concomitant CYP2D6 inhibitors, age, and body weight had a significant impact on TAM metabolism. Formation of ENDO from N-desmethyltamoxifen was decreased by 84% (relative standard error (RSE) = 14%) in PM patients and by 47% (RSE = 9%) in IM patients and increased in UM patients by 27% (RSE = 12%) compared with NM patients. Dose-adjustment simulations support an increase from 20 mg/day to 40 and 80 mg/day in IM patients and PM patients, respectively, to reach ENDO levels similar to those in NM patients. However, when considering Antiestrogenic Activity Score (AAS), a dose increase to 60 mg/day in PM patients seems sufficient. This PopPK model can be used as a tool to predict ENDO levels or AAS according to the patient's CYP2D6 phenotype for TAM dose adaptation.
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Affiliation(s)
- Alicja Puszkiel
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Cécile Arellano
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Christelle Vachoux
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Alexandre Evrard
- Laboratoire de Biochimie et Biologie Moléculaire, Centre Hospitalier Universitaire Nîmes-Carémeau, Nîmes, France.,IRCM, Inserm, Université de Montpellier, ICM, Montpellier, France
| | - Valérie Le Morvan
- Inserm U1218, Université de Bordeaux, Bordeaux, France.,Institut Bergonié, Bordeaux, France
| | - Jean-Christophe Boyer
- Laboratoire de Biochimie et Biologie Moléculaire, Centre Hospitalier Universitaire Nîmes-Carémeau, Nîmes, France
| | - Jacques Robert
- Inserm U1218, Université de Bordeaux, Bordeaux, France.,Institut Bergonié, Bordeaux, France
| | - Caroline Delmas
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France.,Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Florence Dalenc
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France.,Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | | | | | - William Jacot
- Institut du Cancer de Montpellier, Montpellier, France
| | | | | | | | - Thomas Filleron
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Henri Roché
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Etienne Chatelut
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France.,Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Fabienne Thomas
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France.,Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Melanie White-Koning
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
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46
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Lee CI, Low SK, Maldonado R, Fox P, Balakrishnar B, Coulter S, de Bruijn P, Koolen SLW, Gao B, Lynch J, Zdenkowski N, Hui R, Liddle C, Mathijssen RHJ, Wilcken N, Wong M, Gurney H. Simplified phenotyping of CYP2D6 for tamoxifen treatment using the N-desmethyl-tamoxifen/ endoxifen ratio. Breast 2020; 54:229-234. [PMID: 33161337 PMCID: PMC7653100 DOI: 10.1016/j.breast.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction CYP2D6 protein activity can be inferred from the ratio of N-desmethyl-tamoxifen (NDMT) to endoxifen (E). CYP2D6 polymorphisms are common and can affect CYP2D6 protein activity and E level. Some retrospective studies indicate that E < 16 nM may relate to worse outcome. Materials and methods A target NDMT/E ratio was defined as associated with an E level of 15 nM in the 161 patient Test cohort of tamoxifen-treated patients, dichotomizing them into ‘Normal’ (NM) and ‘Slow’ (SM) CYP2D6 metabolizer groups. This ratio was then tested on a validation cohort of 52 patients. Patients were phenotyped based on the standard method (ultrarapid/extensive, intermediate or poor metabolizers; UM/EM, IM, PM) or a simplified system based on whether any variant allele (V) vs wildtype (wt) was present (wt/wt, wt/V, V/V). Comprehensive CYP2D6 genotyping was undertaken on germline DNA. Results A target NDMT/E ratio of 35 correlated with the 15 nM E level, dichotomizing patients into NM (<35; N = 117) and SM (>35; N = 44) groups. The ratio was independently validated by a validation cohort. The simplified system was better in predicting patients without slow metabolism, with specificity and sensitivity of 96% and 44% respectively, compared with the standard method - sensitivity 81% and specificity 83%. Conclusions The simplified classification system based on whether any variant was present better identified patients who were truly not CYP2D6 slow metabolizers more accurately than the current system. However, as CYP2D6 genotype is not the only determinant of endoxifen level, we recommend that direct measurement of endoxifen should also be considered. We used a ratio of two tamoxifen metabolites to categorize CYP2D6 metabolizer groups. We developed a simplified system to identify slow metabolizers based on genotype. The simplified system was more accurate than the standard complex system.
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Affiliation(s)
- Clara Inkyung Lee
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Bankstown, Australia; Faculty of Medicine, University of New South Wales, Australia.
| | - Siew Kee Low
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | | | - Peter Fox
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia
| | | | - Sally Coulter
- Westmead Institute for Medical Research, Westmead, Australia
| | - Peter de Bruijn
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Bo Gao
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia
| | - Jodi Lynch
- St George Hospital, Kogarah, Australia; Sutherland Hospital, Caringbah, Australia
| | | | - Rina Hui
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Christopher Liddle
- Sydney Medical School, University of Sydney, Camperdown, Australia; Westmead Institute for Medical Research, Westmead, Australia
| | | | - Nicholas Wilcken
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Mark Wong
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Howard Gurney
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Sydney Medical School, University of Sydney, Camperdown, Australia; Macquarie University, Australia
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47
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El Daibani AA, Alherz FA, Abunnaja MS, Bairam AF, Rasool MI, Kurogi K, Liu MC. Impact of Human SULT1E1 Polymorphisms on the Sulfation of 17β-Estradiol, 4-Hydroxytamoxifen, and Diethylstilbestrol by SULT1E1 Allozymes. Eur J Drug Metab Pharmacokinet 2020; 46:105-118. [PMID: 33064293 DOI: 10.1007/s13318-020-00653-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Previous studies have revealed that sulfation, as mediated by the estrogen-sulfating cytosolic sulfotransferase (SULT) SULT1E1, is involved in the metabolism of 17β-estradiol (E2), 4-hydroxytamoxifen (4OH-tamoxifen), and diethylstilbestrol in humans. It is an interesting question whether the genetic polymorphisms of SULT1E1, the gene that encodes the SULT1E1 enzyme, may impact on the metabolism of E2 and these two drug compounds through sulfation. METHODS In this study, five missense coding single nucleotide polymorphisms of the SULT1E1 gene were selected to investigate the sulfating activity of the coded SULT1E1 allozymes toward E2, 4OH-tamoxifen, and diethylstilbestrol. Corresponding cDNAs were generated by site-directed mutagenesis, and recombinant SULT1E1 allozymes were bacterially expressed, affinity-purified, and characterized using enzymatic assays. RESULTS Purified SULT1E1 allozymes were shown to display differential sulfating activities toward E2, 4OH-tamoxifen, and diethylstilbestrol. Kinetic analysis revealed further distinct Km (reflecting substrate affinity) and Vmax (reflecting catalytic activity) values of the five SULT1E1 allozymes with E2, 4OH-tamoxifen, and diethylstilbestrol as substrates. CONCLUSIONS Taken together, these findings highlighted the significant differences in E2-, as well as the drug-sulfating activities of SULT1E1 allozymes, which may have implications in the differential metabolism of E2, 4OH-tamoxifen, and diethylstilbestrol in individuals with different SULT1E1 genotypes.
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Affiliation(s)
- Amal A El Daibani
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA
| | - Fatemah A Alherz
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA
| | - Maryam S Abunnaja
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA
| | - Ahsan F Bairam
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA.,Department of Pharmacology, College of Pharmacy, University of Kufa, Najaf, Iraq
| | - Mohammed I Rasool
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA.,Department of Pharmacology, College of Pharmacy, University of Karbala, Karbala, Iraq
| | - Katsuhisa Kurogi
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA.,Biochemistry and Applied Biosciences, University of Miyazaki, Miyazaki, 889-2192, Japan
| | - Ming-Cheh Liu
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH, 43614, USA.
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48
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Mueller-Schoell A, Klopp-Schulze L, Schroth W, Mürdter T, Michelet R, Brauch H, Huisinga W, Joerger M, Neven P, Koolen SLW, Mathijssen RHJ, Copson E, Eccles D, Chen S, Chowbay B, Tfayli A, Zgheib NK, Schwab M, Kloft C. Obesity Alters Endoxifen Plasma Levels in Young Breast Cancer Patients: A Pharmacometric Simulation Approach. Clin Pharmacol Ther 2020; 108:661-670. [PMID: 32578187 DOI: 10.1002/cpt.1960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/29/2020] [Indexed: 01/03/2023]
Abstract
Endoxifen is one of the most important metabolites of the prodrug tamoxifen. High interindividual variability in endoxifen steady-state concentrations (CSS,min ENDX ) is observed under tamoxifen standard dosing and patients with breast cancer who do not reach endoxifen concentrations above a proposed therapeutic threshold of 5.97 ng/mL may be at a 26% higher recurrence risk compared with patients with endoxifen concentrations exceeding this value. In this investigation, 10 clinical tamoxifen studies were pooled (1,388 patients) to investigate influential factors on CSS,min ENDX using nonlinear mixed-effects modeling. Age and body weight were found to significantly impact CSS,min ENDX in addition to CYP2D6 phenotype. Compared with postmenopausal patients, premenopausal patients had a 30% higher risk for subtarget CSS,min ENDX at tamoxifen 20 mg per day. In treatment simulations for distinct patient subpopulations, young overweight patients had a 3.1-13.8-fold higher risk for subtarget CSS,min ENDX compared with elderly low-weight patients. Considering ever-rising obesity rates and the clinical importance of tamoxifen for premenopausal patients, this subpopulation may benefit most from individualized tamoxifen dosing.
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Lena Klopp-Schulze
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Werner Schroth
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
| | - Thomas Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Hiltrud Brauch
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK) and of German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Markus Joerger
- Department of Medical Oncology and Haematology, Cantonal Hospital, St. Gallen, Switzerland
| | - Patrick Neven
- Vesalius Research Center - VIB, University Hospitals Leuven, KU Leuven-University of Leuven, Leuven, Belgium
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ellen Copson
- Cancer Sciences Academic Unit and University of Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Diana Eccles
- Cancer Sciences Academic Unit and University of Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sylvia Chen
- Clinical Pharmacology Laboratory, Division of Cellular & Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore
| | - Balram Chowbay
- Clinical Pharmacology Laboratory, Division of Cellular & Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore
- Center for Clinician-Scientist Development, Duke-NUS Medical School, Singapore
- SingHealth Clinical Pharmacology, SingHealth, Singapore
| | - Arafat Tfayli
- Hematology-Oncology Division, Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie K Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- German Cancer Consortium (DKTK) and of German Cancer Research Center (DKFZ), Heidelberg, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University Tübingen, Tübingen, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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49
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Thorén L, Lindh JD, Ackehed G, Kringen MK, Hall P, Bergh J, Molden E, Margolin S, Eliasson E. Impairment of endoxifen formation in tamoxifen-treated premenopausal breast cancer patients carrying reduced-function CYP2D6 alleles. Br J Clin Pharmacol 2020; 87:1243-1252. [PMID: 32713032 PMCID: PMC9328423 DOI: 10.1111/bcp.14500] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 12/18/2022] Open
Abstract
Aims Tamoxifen is bioactivated to endoxifen by polymorphic CYP2D6‐dependent metabolism. Here, endoxifen levels were compared to CYP2D6 diplotypes, tentative target concentrations and side effects. Methods In total, 118 Swedish premenopausal breast cancer patients diagnosed 2006–2014, with on‐going postoperative tamoxifen treatment January 2017, were included. Biobanked DNA from peripheral blood was used for CYP2D6 genotyping by TaqMan real‐time polymerase chain reaction (CYP2D6*1, *3, *4, *5, *6, *9, *10, *41, *1xN). Plasma levels of tamoxifen and 3 major metabolites were quantified by liquid chromatography–tandem mass spectrometry. Clinical information on treatment and side effects was retrospectively obtained from medical records. Results In the final analysis of 114 patients, a clear relationship between CYP2D6 genotype and plasma endoxifen levels was evident. Low endoxifen (1.6–5.2 ng/mL), i.e. below the suggested threshold for clinical efficacy, was found in all patients with 2 reduced‐function alleles, 2 null‐alleles, or a null/reduced‐function combination. CYP2D6*41 was the most common reduced‐function allele (82%) and 17 of 21 CYP2D6*41‐carriers exhibited a lower CYP2D6 activity than predicted from published guidelines. No difference in endoxifen levels was observed between carriers of 2 null‐alleles vs patients homozygous for CYP2D6*41 or the corresponding heterozygous combination (P = .338). In patients with endoxifen levels <5.9 ng/mL (36/114), side effects were either mild or absent. At higher endoxifen levels moderate‐to‐severe side effects were reported in a concentration‐dependent manner. Conclusion Significantly reduced endoxifen levels were observed not only in all homozygous carriers of CYP2D6 null‐alleles, but also in carriers of 2 reduced‐function alleles. This finding may be highly relevant for future, genotype‐based dose considerations.
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Affiliation(s)
- Linda Thorén
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, South General Hospital, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Gerd Ackehed
- Department of Laboratory Medicine, Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Kristiansen Kringen
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institutet and Breast Cancer Center, Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Sara Margolin
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, South General Hospital, Stockholm, Sweden
| | - Erik Eliasson
- Department of Laboratory Medicine, Clinical Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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50
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Hartkopf AD, Grischke EM, Brucker SY. Endocrine-Resistant Breast Cancer: Mechanisms and Treatment. Breast Care (Basel) 2020; 15:347-354. [PMID: 32982644 PMCID: PMC7490658 DOI: 10.1159/000508675] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Endocrine treatment is one of the most effective therapies for estrogen receptor-positive breast cancer. However, most tumors will develop resistance to endocrine therapy as the cancer progresses. This review focuses on the mechanisms and markers of endocrine-resistant breast cancer. In addition, current and future strategies to overcome endocrine resistance are discussed. SUMMARY Several molecular mechanisms of endocrine resistance have been identified, including alterations in the ESR1 gene or in the PIK3CA/mTOR pathway. Meanwhile, CDK4/6, mTOR, and PI3K inhibition have shown to improve the efficacy of endocrine treatment and new promising approaches are being developed. KEY MESSAGE Overcoming primary or acquired resistance to endocrine treatment remains a major challenge. Since the molecular mechanisms of endocrine resistance are manifold, optimal combination and sequencing strategies will have to be developed in the future.
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