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Bahrami N, Jabeen S, Tahiri A, Sauer T, Ødegård HP, Geisler SB, Gravdehaug B, Reitsma LC, Selsås K, Kristensen V, Geisler J. Lack of cross-resistance between non-steroidal and steroidal aromatase inhibitors in breast cancer patients: the potential role of the adipokine leptin. Breast Cancer Res Treat 2021; 190:435-449. [PMID: 34554372 PMCID: PMC8558290 DOI: 10.1007/s10549-021-06399-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/11/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The aromatase inactivator exemestane may cause clinical disease stabilization following progression on non-steroidal aromatase inhibitors like letrozole in patients with metastatic breast cancer, indicating that additional therapeutic effects, not necessarily related to estrogen-suppression, may be involved in this well-known "lack of cross-resistance". METHODS Postmenopausal women with ER positive, HER-2 negative, locally advanced breast cancer were enrolled in the NEOLETEXE-trial and randomized to sequential treatment starting with either letrozole (2.5 mg o.d.) or exemestane (25 mg o.d.) followed by the alternative aromatase inhibitor. Serum levels of 54 cytokines, including 12 adipokines were assessed using Luminex xMAP technology (multiple ELISA). RESULTS Serum levels of leptin were significantly decreased during treatment with exemestane (p < 0.001), regardless whether exemestane was given as first or second neoadjuvant therapy. In contrast, letrozole caused a non-significant increase in serum leptin levels in vivo. CONCLUSIONS Our findings suggest an additional and direct effect of exemestane on CYP-19 (aromatase) synthesis presumably due to effects on the CYP19 promoter use that is not present during therapy with the non-steroidal aromatase inhibitor letrozole. Our findings provide new insights into the influence of clinically important aromatase inhibitors on cytokine levels in vivo that contribute to the understanding of the clinically observed lack of cross-resistance between non-steroidal and steroidal aromatase inhibitors in breast cancer patients. TRIAL REGISTRATION Registered on March 23rd 2015 in the National trial database of Norway (Registration number: REK-SØ-84-2015).
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Affiliation(s)
- Nazli Bahrami
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.,Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Shakila Jabeen
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Andliena Tahiri
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | | | - Berit Gravdehaug
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | | | - Knut Selsås
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Vessela Kristensen
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Bahrami N, Chang G, Kanaya N, Sauer T, Park D, Loeng M, Gravdehaug B, Chen S, Geisler J. Changes in serum estrogenic activity during neoadjuvant therapy with letrozole and exemestane. J Steroid Biochem Mol Biol 2020; 200:105641. [PMID: 32151708 DOI: 10.1016/j.jsbmb.2020.105641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 12/29/2022]
Abstract
The aromatase inhibitors (AIs), letrozole (Femar®/Femara®) and exemestane (Aromasin®), are widely used to treat estrogen receptor (ER) positive breast cancer in postmenopausal patients. In the setting of metastatic breast cancer, these drugs may be used after another causing new responses in selected patients after progressing on the first choice. The precise explanation for this "lack of cross resistance" is still missing. NEOLETEXE is a neoadjuvant, randomized, open-label, cross-over trial. Postmenopausal patients with ER-positive, HER-2 negative, locally advanced breast cancer were enrolled. All patients were randomized to treatment starting with either letrozole or exemestane for at least 2 months followed by another 2 months on the alternative AI. The total estrogenic activities in blood samples were determined using the AroER tri-screen assay developed in the Chen laboratory. Using this highly sensitive assay, estrogenic activity was detected at three time points for all patients. Importantly, a significantly higher total estrogenic activity was found during therapy with exemestane compared to letrozole in 21 out of 26 patients. When letrozole was included in the AroER tri-screen assay, the estrogenic activities in most samples collected during exemestane treatment were further reduced, suggesting that low levels of androgens remained in specimens obtained after exemestane treatment. Our results suggest the AroER tri-screen to be a very sensitive method to estimate the overall estrogen-mediated activity in human samples even during therapy with highly potent aromatase inhibitors. In the present study, serum estrogen activity was significantly higher during exemestane therapy when compared to letrozole therapy.
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Affiliation(s)
- Nazli Bahrami
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway; Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Gregory Chang
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Noriko Kanaya
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Campus AHUS, Norway
| | - Daehoon Park
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Marie Loeng
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
| | - Berit Gravdehaug
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Shiuan Chen
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Campus AHUS, Norway.
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Jakharia-Shah A, Wheatley H, Beesley M. Reminder of an important clinical lesson: breast cancer metastasis to the parotid gland. BMJ Case Rep 2019; 12:e226494. [PMID: 31594782 PMCID: PMC6803134 DOI: 10.1136/bcr-2018-226494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old woman presented to an otolaryngology clinic with an 8-week history of a painless lump over her left parotid gland. Her medical history included an invasive ductal carcinoma (33 mm) and a ductal carcinoma in situ (70 mm) of the right breast, for which she had a mastectomy and various adjuvant therapies. The primary tumour presented 8 years prior to the metachronous metastasis. This patient was a non-smoker and had no significant family history. Post-superficial parotidectomy pathology revealed the parotid gland tumour to be oestrogen receptor-positive and HER2 receptor-positive, thus ruling out the initial differential diagnosis of a pleomorphic adenoma. A consequential total parotidectomy with a posterolateral neck dissection was performed with sparing of the facial nerve. The patient recovered well having only encountered a self-resolving salivary fistula. She portrayed no signs of facial nerve palsy and subsequent imaging scans showed no abnormalities.
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Affiliation(s)
| | - Hugh Wheatley
- ENT Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Matthew Beesley
- Pathology Department, Gloucestershire Royal Hospital, Gloucester, UK
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4
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Patient Case Lessons: Endocrine Management of Advanced Breast Cancer. Clin Breast Cancer 2018; 18:192-204. [DOI: 10.1016/j.clbc.2017.05.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 04/07/2017] [Accepted: 05/22/2017] [Indexed: 12/20/2022]
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Zucchini G, Geuna E, Milani A, Aversa C, Martinello R, Montemurro F. Clinical utility of exemestane in the treatment of breast cancer. Int J Womens Health 2015; 7:551-63. [PMID: 26064072 PMCID: PMC4455847 DOI: 10.2147/ijwh.s69475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Breast cancer is the most prevalent cancer in women, causing a significant mortality worldwide. Different endocrine strategies are available for the treatment of hormone-sensitive breast cancer, including antiestrogen tamoxifen and fulvestrant, as well as third-generation aromatase inhibitors (AIs), such as letrozole, anastrozole, and exemestane. In this review, we will focus on exemestane, its clinical use, and its side effects. Exemestane is a steroidal third-generation AI now used in all treatment settings for breast cancer. In the metastatic disease, it has been extensively investigated as the first-, second-, and further-line treatment and it is now registered for the treatment of postmenopausal women with advanced estrogen-receptor-positive breast cancer whose disease has progressed following antiestrogen therapy. A potential lack of cross-resistance with nonsteroidal AIs has been described, giving additional therapeutic opportunities in sequences of endocrine agents. Exemestane is also approved for the adjuvant treatment of postmenopausal early breast cancer, either as upfront monotherapy for 5 years, as a switch following 2–3 years of tamoxifen, or as extended therapy beyond 5 years of adjuvant treatment. New promising data also showed a beneficial effect in young premenopausal early breast cancer patients, when administered together with ovarian suppression. Interesting results have also emerged when exemestane has been investigated as neodjuvant treatment as well as preventive agent in healthy women at high risk for breast cancer. Exemestane is generally well tolerated, with a side effect profile similar to that of other AIs, including menopausal symptoms, arthralgia, and bone loss. In conclusion, exemestane can be considered an effective and well-tolerated endocrine treatment option for all stages of breast cancer.
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Affiliation(s)
- Giorgia Zucchini
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | - Elena Geuna
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | - Andrea Milani
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | | | | | - Filippo Montemurro
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
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6
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Iwase H, Yamamoto Y. Clinical benefit of sequential use of endocrine therapies for metastatic breast cancer. Int J Clin Oncol 2015; 20:253-61. [DOI: 10.1007/s10147-015-0793-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 01/23/2015] [Indexed: 10/24/2022]
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Mori R, Nagao Y. The efficacy of second-line hormone therapy for recurrence during adjuvant hormone therapy for breast cancer. Ther Adv Med Oncol 2014; 6:36-42. [PMID: 24587829 DOI: 10.1177/1758834013517734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The recurrence of breast cancer during adjuvant hormone therapy is often targeted by second-line hormone therapy. However, there has been a lack of prior success with such treatments. We retrospectively investigated the efficacy of subsequent hormone therapy. METHODS Patients who underwent breast cancer surgery between 2006 and 2012 at our institution were investigated. RESULTS A total of 20 patients developed recurrence during adjuvant hormone therapy. There were four patients with luminal A, seven with luminal B and six with luminal HER2 tumors, respectively. Twelve patients received subsequent hormone therapy, and eight patients received chemotherapy. Subsequent hormone therapy produced one partial response (PR), two long stable disease (SD), one SD and five progressive disease (PD). A clinical benefit (CB) was obtained by 33%. Subsequent chemotherapy produced one complete response (CR), two PRs, one long SD and two PD, resulting in a CB in 66%. Among those who received any hormone therapy, the best responses were two PR, three long SD and one SD. A CB was obtained by 38%, while seven patients did not have any CB from hormone therapy. Meanwhile, the best responses to chemotherapy were two CRs, four PRs, three SD and two PD, thus resulting in a CB in 72%. All luminal A cases obtained a long SD or SD with hormone therapy. However, the CB of hormone therapy for non-luminal A cases was only 30%. CONCLUSIONS The efficacy of hormone therapy for recurrence during adjuvant hormone therapy is poor, and when selecting therapy for such patients, the breast cancer subtype should be taken into account.
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Affiliation(s)
- Ryutaro Mori
- Department of Breast Surgery, Gifu Prefectural General Medical Center, 4-6-1, Noishiki, Gifu, Gifu 500-8717, Japan
| | - Yasuko Nagao
- Department of Breast Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
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Shioi Y, Kashiwaba M, Inaba T, Komatsu H, Sugai T, Wakabayashi G. Long-term complete remission of metastatic breast cancer, induced by a steroidal aromatase inhibitor after failure of a non-steroidal aromatase inhibitor. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:85-9. [PMID: 24587856 PMCID: PMC3936946 DOI: 10.12659/ajcr.890023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/08/2013] [Indexed: 11/11/2022]
Abstract
Patient: Female, 56 Final Diagnosis: Breast cancer Symptoms: Solid mass in the right breast Medication: Exemestane Clinical Procedure: — Specialty: Oncology
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Affiliation(s)
- Yoshihiro Shioi
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | | | - Toru Inaba
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | - Hideaki Komatsu
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | - Tamotsu Sugai
- Department of Pathology, Iwate Medical University, Morioka, Japan
| | - Go Wakabayashi
- Department of Surgery, Iwate Medical University, Morioka, Japan
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9
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Van Asten K, Neven P, Lintermans A, Wildiers H, Paridaens R. Aromatase inhibitors in the breast cancer clinic: focus on exemestane. Endocr Relat Cancer 2014; 21:R31-49. [PMID: 24434719 DOI: 10.1530/erc-13-0269] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Breast cancer is the most prevalent type of cancer in women and responsible for significant female cancer-related mortality worldwide. In the Western world, over 80% of breast cancers are hormone-receptor positive for which endocrine therapy is administered. The main anti-estrogen treatments in use consist of selective estrogen-receptor modulators, such as tamoxifen, and third-generation aromatase inhibitors (AIs), such as exemestane, letrozole, and anastrozole. In this review, the focus will lie on exemestane, its clinical use, and its side-effect profile. Exemestane is the only third-generation steroidal AI. Its efficacy as a first-line treatment in metastatic breast cancer has been demonstrated. Therefore, exemestane could be considered a valid first-line therapeutic option, but it also can be used in second-line or further situations. Exemestane is mostly used as part of sequential adjuvant treatment following tamoxifen, but in this setting it is also active in monotherapy. Furthermore, this AI has been studied in the neoadjuvant setting as presurgical treatment, and even as chemoprevention in high-risk healthy postmenopausal women. It may reverse side effects of tamoxifen, such as endometrial changes and thromboembolic disease but may also cause some inconvenient side effects itself. Additionally, there is a lack of total cross-resistance between exemestane and nonsteroidal AIs as far as their anti-tumoral efficacy is concerned; moreover the two classes of AIs display a nontotal overlapping toxicity profile. Taking together, exemestane can be considered as a useful treatment option at all stages of breast cancer.
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Affiliation(s)
- Kathleen Van Asten
- KU Leuven, Department of Oncology, Leuven, Belgium University Hospitals Leuven, Department of Gynecology and Obstetrics, Leuven, Belgium University Hospitals Leuven, Department of General Medical Oncology, Leuven, Belgium
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10
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Palmieri C, Patten DK, Januszewski A, Zucchini G, Howell SJ. Breast cancer: current and future endocrine therapies. Mol Cell Endocrinol 2014; 382:695-723. [PMID: 23933149 DOI: 10.1016/j.mce.2013.08.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 12/29/2022]
Abstract
Endocrine therapy forms a central modality in the treatment of estrogen receptor positive breast cancer. The routine use of 5 years of adjuvant tamoxifen has improved survival rates for early breast cancer, and more recently has evolved in the postmenopausal setting to include aromatase inhibitors. The optimal duration of adjuvant endocrine therapy remains an active area of clinical study with recent data supporting 10 years rather than 5 years of adjuvant tamoxifen. However, endocrine therapy is limited by the development of resistance, this can occur by a number of possible mechanisms and numerous studies have been performed which combine endocrine therapy with agents that modulate these mechanisms with the aim of preventing or delaying the emergence of resistance. Recent trial data regarding the combination of the mammalian target of rapamycin (mTOR) inhibitor, everolimus with endocrine therapy have resulted in a redefinition of the clinical treatment pathway in the metastatic setting. This review details the current endocrine therapy utilized in both early and advanced disease, as well as exploring potential new targets which modulate pathways of resistance, as well as agents which aim to modulate adrenal derived steroidogenic hormones.
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Affiliation(s)
- Carlo Palmieri
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool L69 3GA, UK; Liverpool & Merseyside Breast Academic Unit, The Linda McCartney Centre, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; Academic Department of Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wiral CH63 4JY, UK.
| | - Darren K Patten
- Department of Surgery, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Adam Januszewski
- Department of Medical Oncology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Giorgia Zucchini
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Sacha J Howell
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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11
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Yamamoto Y, Ishikawa T, Hozumi Y, Ikeda M, Iwata H, Yamashita H, Toyama T, Chishima T, Saji S, Yamamoto-Ibusuki M, Iwase H. Randomized controlled trial of toremifene 120 mg compared with exemestane 25 mg after prior treatment with a non-steroidal aromatase inhibitor in postmenopausal women with hormone receptor-positive metastatic breast cancer. BMC Cancer 2013; 13:239. [PMID: 23679192 PMCID: PMC3661372 DOI: 10.1186/1471-2407-13-239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 05/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After the failure of a non-steroidal aromatase inhibitor (nsAI) for postmenopausal patients with metastatic breast cancer (mBC), it is unclear which of various kinds of endocrine therapy is the most appropriate. A randomized controlled trial was performed to compare the efficacy and safety of daily toremifene 120 mg (TOR120), a selective estrogen receptor modulator, and exemestane 25 mg (EXE), a steroidal aromatase inhibitor. The primary end point was the clinical benefit rate (CBR). The secondary end points were objective response rate (ORR), progression-free survival (PFS), overall survival (OS) and toxicity. METHODS Initially, a total of 91 women was registered in the study and randomly assigned to either TOR120 (n = 46) or EXE (n = 45) from October 2008 to November 2011. Three of the 46 patients in the TOR120 arm were not received treatment, 2 patients having withdrawn from the trial by their preference and one having been dropped due to administration of another SERM. RESULTS When analyzed after a median observation period of 16.9 months, the intention-to-treat analysis showed that there were no statistical difference between TOR120 (N = 46) and EXE (n = 45) in terms of CBR (41.3% vs. 26.7%; P = 0.14), ORR (10.8% vs. 2.2%; P = 0.083), and OS (Hazard ratio, 0.60; P = 0.22). The PFS of TOR120 was longer than that of EXE, the difference being statistically significant (Hazard ratio, 0.61, P = 0.045). The results in treatment-received cohort (N = 88) were similar to those in ITT cohort. Both treatments were well-tolerated with no severe adverse events, although the treatment of 3 of 43 women administered TOR120 was stopped after a few days because of nausea, general fatigue, hot flush and night sweating. CONCLUSIONS TOR120, as a subsequent endocrine therapy for mBC patients who failed non-steroidal AI treatment, could potentially be more beneficial than EXE. TRIAL REGISTRATION NUMBER UMIN000001841.
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12
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Aromatase inhibitors in the treatment of elderly women with metastatic breast cancer. Breast 2013; 22:142-149. [PMID: 23321585 DOI: 10.1016/j.breast.2012.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 10/26/2012] [Accepted: 12/17/2012] [Indexed: 11/22/2022] Open
Abstract
The proportion of elderly women in the population is rising, and in tandem, the incidence of breast cancer rises with age. Because of health and tolerability concerns, as well as life expectancy, physicians may be reluctant to advise a standard treatment regimen for elderly patients with metastatic breast cancer. To elucidate this issue, we performed a literature review of clinical studies that included women with metastatic breast cancer who were over the age of 65. Our results show that although little clinical evidence exists, what is available suggests that standard treatment is tolerated and beneficial for patients meeting certain criteria. A geriatric assessment may identify specific patient groups (independent, dependent, or frail) and thereby guide treatment. Treatment recommendations for elderly patients with metastatic breast cancer are sparse, although first-line endocrine treatment, usually aromatase inhibitors or tamoxifen, is recommended for hormone-sensitive disease. In general, the evidence from clinical studies suggests that aromatase inhibitors are more effective than either tamoxifen or megestrol acetate as first- or second-line treatment in postmenopausal women with metastatic breast cancer. Ultimately, quality of life, treatment effects, and comorbidities are important aspects in this population and may guide treatment choice. To provide evidence-based treatment guidance, future clinical trials should include more patients over the age of 65 years.
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13
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Miller WR, Larionov AA. Understanding the mechanisms of aromatase inhibitor resistance. Breast Cancer Res 2012; 14:201. [PMID: 22277572 PMCID: PMC3496110 DOI: 10.1186/bcr2931] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aromatase inhibitors (AIs) have a central role in the treatment of breast cancer; however, resistance is a major obstacle to optimal management. Evidence from endocrine, molecular and pathological measurements in clinical material taken before and after therapy with AIs and data from clinical trials in which AIs have been given as treatment either alone or in combination with other targeted agents suggest diverse causes for resistance. These include inherent tumour insensitivity to oestrogen, ineffective inhibition of aromatase, sources of oestrogenic hormones independent of aromatase, activation of signalling by non-endocrine pathways, enhanced cell survival and selection of hormone-insensitive cellular clones during treatment.
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Coleman RE, Bertelli G, Beaumont T, Kunkler I, Miles D, Simmonds PD, Jones AL, Smith IE. UK guidance document: treatment of metastatic breast cancer. Clin Oncol (R Coll Radiol) 2011; 24:169-76. [PMID: 22075442 DOI: 10.1016/j.clon.2011.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 09/26/2011] [Accepted: 09/27/2011] [Indexed: 12/25/2022]
Abstract
Although there have been major improvements in the management of breast cancer, with a rapidly falling death rate despite an increasing incidence of the disease, metastatic breast cancer remains common and the cause of death in nearly 12 000 women annually in the UK. Numerous treatment options are available that either target the tumour or reduce the complications of the disease. Clinical decision making depends on knowledge of the extent and biology of the disease and available drug options, an understanding of the functional status, and also the wishes and expectations of the individual patient. In addition, the organisation of services and support of the patient are essential components of high-quality care. The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for the treatment of advanced breast cancer, which in some areas have perhaps failed to appreciate the complexity of patient management. This guidance document aims to provide succinct practical advice on the treatment of metastatic breast cancer, highlight some limitations of the NICE guidelines, and provide suggestions for management where available data are limited.
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Affiliation(s)
- R E Coleman
- Academic Unit of Clinical Oncology, Weston Park Hospital, University of Sheffield, Sheffield, UK
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15
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Cruz Jurado J, Richart Aznar P, García Mata J, Fernández Martínez R, Peláez Fernández I, Sampedro Gimeno T, Galve Calvo E, Murillo Jaso L, Polo Marqués E, García Palomo A. Management of patients with metastatic breast cancer. Adv Ther 2011; 28 Suppl 6:50-65. [PMID: 21922395 DOI: 10.1007/s12325-011-0046-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Indexed: 11/29/2022]
Abstract
Hormone treatment is one of the key strategies in the management of metastatic breast cancer. Hormone treatment is one of the key strategies in the management of metastatic breast cancer. Aromatase inhibitors (AI) have been extensively studied in this setting. This section summarizes the key data regarding the use of AI in advanced breast cancer. In postmenopausal women, AI are the first line of treatment for untreated patients, or those who had prior AI treatment and progress after 12 months of adjuvant therapy. A longer disease-free interval and absence of visceral disease is associated with a better response. If tumors recur in less than 12 months, it is recommended that tamoxifen (TAM) or the estrogen-receptor antagonist fulvestrant (FUL) treatment be initiated. In the second-line setting, the best option after progression is the administration of either FUL or TAM. In the third-line setting, reintroduction of AI is considered an acceptable option. In premenopausal women who have not received prior treatment or who have progressed after 12 months following adjuvant treatment, it is recommended to initiate therapy with a combination of TAM and a luteinizing hormone-releasing hormone (LHRH) analog. If there is treatment failure with the use of this combination, megestrol acetate or an LHRH agonist plus an AI may be reasonable alternatives. Intensive research is ongoing to understand the mechanisms of resistance to hormone therapy. In human epidermal growth factor receptor 2 positive-patients, combinations with HER2 antagonists are associated with significant clinical activity.
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Affiliation(s)
- J Cruz Jurado
- Oncology Department, Hospital Universitario Canarias, S/C Tenerife, Islas Canarias, Spain
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Llombart-Cussac A, Ruiz A, Antón A, Barnadas A, Antolín S, Alés-Martínez JE, Alvarez I, Andrés R, García Saenz JA, Lao J, Carrasco E, Cámara C, Casas I, Martín M. Exemestane versus anastrozole as front-line endocrine therapy in postmenopausal patients with hormone receptor-positive, advanced breast cancer: final results from the Spanish Breast Cancer Group 2001-03 phase 2 randomized trial. Cancer 2011; 118:241-7. [PMID: 21717449 DOI: 10.1002/cncr.26299] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/15/2011] [Accepted: 04/25/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Several aromatase inhibitor studies have reported variations in the inhibitory potency of these agents that could lead to differences in clinical outcomes. In the current study, the authors formally evaluated the activity of anastrozole and exemestane in postmenopausal women with hormone-responsive, advanced breast cancer. METHODS Postmenopausal women who had measurable disease according to Response Evaluation Criteria in Solid Tumors and had not received previous endocrine therapy for advanced breast cancer were randomized to receive either oral exemestane 25 mg daily or oral anastrozole 1 mg daily until they had disease progression. The primary endpoint was the objective response rate (ORR), and secondary endpoints included the clinical benefit rate (CBR), time to progression (TTP), overall survival, and safety. Crossover to the other aromatase inhibitor was permitted at the time of disease progression; ORR, CBR, and TTP after second-line treatment also were explored. RESULTS In total, 103 patients were enrolled. The median patient age was 71.6 years, 52.4% of patients had visceral disease, and 75.8% of patients had ≥ 2 disease sites. Half of the patients had received previous tamoxifen, and 60% had received previous chemotherapy. The efficacy observed in the exemestane and anastrozole groups was an ORR of 36.2% and 46%, respectively; a CBR of 59.6% and 68%, respectively, and a TTP of 6.1 months and 12.1 months, respectively. At progression, 28 patients crossed over to the other aromatase inhibitor, including 16 patients who switched to exemestane (CBR, 43.7%; TTP, 4.4 months) and 12 patients who switched to anastrozole (CBR, 8.3%; TTP, 2 months). Both drugs were generally well tolerated, and no study drug-related serious adverse events were reported. CONCLUSIONS In this phase 2 randomized trial, no significant differences in clinical activity were observed in favor of exemestane to justify a superiority phase 3 trial design in the first-line setting.
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Affiliation(s)
- Antonio Llombart-Cussac
- Medical Oncology Service, Biomedical Research Institute, Arnau de Vilanova University Hospital, Lleida, Spain.
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Takashima S, Kiyoto S, Takahashi M, Hara F, Takabatake D, Aogi K, Ohsumi S. Examination of the use of Exemestane in patients with metastatic breast cancer. Breast Cancer 2011; 18:189-94. [PMID: 21437667 DOI: 10.1007/s12282-011-0258-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Endocrine therapy is the preferred systemic treatment for metastatic breast cancer to prolong disease control. Aromatase inhibitors (AIs) are becoming the first choice for postmenopausal patients with metastatic breast cancer. AIs are divided into non-steroidal and steroidal agents. METHODS We retrospectively analyzed 81 patients with metastatic breast cancer who were administered Exemestane (EXE). The response rate (RR) and clinical benefit rate (CBR) were evaluated. RESULTS No significant differences were observed between the first-line treatment group and the second- and third-line treatment groups with respect to the CBR. With respect to the CBR, patients with metastases only of the bone and soft tissue had superior results than those with visceral metastasis. There were no significant differences in the RR and CBR of EXE because of differences in prior treatments. On the other hand, no clinical response was achieved in any patients for whom Anastrozole (ANA) was used following EXE. With regard to the switch from EXE to tamoxifen and to medroxyprogesterone acetate, a CB response was not achieved in those receiving EXE, but it was achieved in the others. EXE following ANA had moderate efficacy, with a CBR of 39%. Moreover, a clinical response was achieved in 3 out of 10 patients in whom no response had been achieved with ANA. CONCLUSION EXE seems to be a useful alternative treatment when the first-line treatment has not been effective. If the use of both agents, ANA and EXE, is planned, it might be desirable to initiate treatment with ANA and then switch to EXE.
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Affiliation(s)
- Seiki Takashima
- Department of Breast Oncology, National Hospital Organization Shikoku Cancer Center, 160 Ko, Minamiumemoto-cho, Matsuyama, Ehime, 791-0280, Japan.
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Beresford M, Tumur I, Chakrabarti J, Barden J, Rao N, Makris A. A qualitative systematic review of the evidence base for non-cross-resistance between steroidal and non-steroidal aromatase inhibitors in metastatic breast cancer. Clin Oncol (R Coll Radiol) 2010; 23:209-15. [PMID: 21134732 DOI: 10.1016/j.clon.2010.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 10/21/2010] [Accepted: 10/25/2010] [Indexed: 11/16/2022]
Abstract
AIMS The most effective sequence of tamoxifen and both steroidal (SAIs) and non-steroidal aromatase inhibitors (NSAIs) has been extensively studied in the adjuvant setting. However, treatments for women who have failed initial aromatase inhibitor therapy in the metastatic setting have received relatively little attention. A systematic review was undertaken to assess the use of SAIs and NSAIs in metastatic breast cancer. MATERIALS AND METHODS Medline, Embase and the Cochrane library were searched using free text and MeSH terms. Studies assessing the cross-resistance, efficacy and safety of SAIs and NSAIs for postmenopausal women with advanced metastatic breast cancer confirmed by histology/cytology were included. Patients had progressed/relapsed from previous adjuvant, first- or second-line aromatase inhibitor treatment and had undergone treatment with at least two regimens consisting of aminoglutethimide, anastrozole, letrozole and/or exemestane. RESULTS Nine studies reported results for patients treated with an SAI after treatment failure with an NSAI. For SAI after NSAI, clinical benefit was the most frequently reported outcome. The clinical benefit for exemestane (SAI) after any NSAI failure or before treatment ranged from 12% (complete response not recorded, partial response 2%, stable disease 10%) to 55% (complete response 6%, partial response 13%, stable disease 35%) Survival outcomes were infrequently reported; four studies reported disease progression. The time to progression ranged from 3.7 to 5.2 months. Only one study reported a median overall survival with exemestane at 15.2 months. Only one study reported information for an NSAI after SAI and an NSAI followed by another NSAI. DISCUSSION This review suggests that switching from an NSAI to an SAI is a reasonable option. This would be particularly important for patients who would probably respond to further endocrine manoeuvres; strongly oestrogen receptor-positive disease, non-visceral disease, a good prior response or a long duration of response. Further research to optimise the sequence of endocrine therapies in metastatic breast cancer is needed.
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Affiliation(s)
- M Beresford
- Bristol Oncology and Haematology Centre, Horfield Road, Bristol, UK.
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Exemestane as first-line therapy in postmenopausal women with recurrent or metastatic breast cancer. Am J Clin Oncol 2010; 33:314-9. [PMID: 19730353 DOI: 10.1097/coc.0b013e31819fdf9b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antiestrogen therapies generally offer significant disease control to hormone receptor-positive recurrent or metastatic breast cancer patients and are substantially better tolerated than standard chemotherapy regimens, thus representing an attractive first treatment option. The steroidal aromatase inhibitor (AI) exemestane exhibits antitumor effects by lowering full-body estrogen production in postmenopausal women and is an established treatment option for metastatic breast cancer. We review data from 2 recent phase III clinical trials that have confirmed exemestane activity in the first-line metastatic breast cancer setting, with moderate improvements in median progression-free survival (10-12 months) and objective response rates (37%-46%) compared with tamoxifen. The activity of first-line exemestane is comparable with other antiestrogen therapies, including fulvestrant and the nonsteroidal AIs letrozole and anastrozole. Additional findings demonstrating the clinical benefits of exemestane in women who previously progressed on nonsteroidal AIs highlight a partial lack of cross-resistance between these therapies and reinforce the opportunity to use multiple antiestrogen treatments sequentially. Future therapeutic developments in hormone receptor-positive metastatic breast cancer could include combinations with other targeted compounds plus AIs or other antiestrogen-based combinations and the identification of new strategies to evaluate differences among antiestrogen therapies to help optimize the treatment sequence and potential combinations.
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Gerber B, Freund M, Reimer T. Recurrent breast cancer: treatment strategies for maintaining and prolonging good quality of life. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:85-91. [PMID: 20204119 PMCID: PMC2832109 DOI: 10.3238/arztebl.2010.0085] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 06/17/2009] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recurrent breast cancer remains a challenge for interdisciplinary treatment even though new therapeutic options are available. METHODS The PubMed database was selectively searched for articles that appeared from 1999 to 2009 and contained the key words "breast cancer," "recurrence," "metastatic," "advanced," and "treatment". Further sources consulted for this review included the German S3 guideline, the treatment recommendations of the German AGO-Mamma group, the NCCN guidelines, and the Cochrane database. RESULTS Locoregional recurrences are treated with curative intent. Metastatic breast cancer must be treated on an individualized basis: The treatment should be continued as long as its benefits for the individual patient outweigh its adverse side effects. Endocrine treatment is indicated for all patients whose tumors are hormone-receptor positive or of unknown receptor status and who have enough time for a response to be seen. Chemotherapy should be given if the tumor is hormone-receptor negative, if a rapid response is urgently needed, or if endocrine treatment has failed to produce a response. Combination chemotherapy improves response rates and prolongs progression-free survival, yet it does not prolong overall survival in comparison to monochemotherapy. In HER2-positive patients, first-line treatment with trastuzumab and monochemotherapy prolongs overall survival. Other treatment options include angiogenesis inhibitors, various tyrosine kinases inhibitors, radiotherapy, bisphosphonates, surgical or other ablative treatment of metastases, or a combination of these approaches, applied either simultaneously or consecutively. CONCLUSIONS While locoregional recurrences of breast cancer should be treated with curative intent, breast cancer with distant metastases is currently not curable. It is treated with the intention of restoring and maintaining good quality of life and relieving symptoms due to the metastases, rather than prolonging survival.
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Affiliation(s)
- Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt der Hansestadt Rostock, Germany.
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22
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Abstract
Exemestane (Aromasin) is an orally active steroidal irreversible inactivator of the aromatase enzyme indicated as an adjuvant treatment in postmenopausal women with estrogen receptor-positive early-stage breast cancer following 2-3 years of adjuvant treatment with tamoxifen, and for the treatment of advanced breast cancer in postmenopausal women whose disease has progressed following tamoxifen or other antiestrogen therapy. Exemestane is effective for the treatment of postmenopausal women with early-stage or advanced breast cancer. In early-stage disease, switching to exemestane for 2-3 years after 2-3 years of adjuvant tamoxifen treatment was more effective in prolonging disease-free survival than continuing tamoxifen therapy, although it was not associated with an overall survival benefit, except in those with estrogen receptor-positive or unknown receptor status disease when nodal status, hormone replacement therapy (HRT) and chemotherapy use were adjusted for. Moreover, preliminary data suggest that the efficacy of exemestane is generally no different to that of tamoxifen in the primary adjuvant treatment of early-stage breast cancer, although exemestane may be better in prolonging the time to distant recurrence. In advanced disease, exemestane showed equivalent efficacy to megestrol in patients with disease refractory to tamoxifen and an efficacy not significantly different from that of fulvestrant in those refractory to a nonsteroidal aromatase inhibitor. Available data, some of which are limited, suggest exemestane is also effective in the first-line hormonal treatment of advanced breast cancer in postmenopausal women. Exemestane is generally well tolerated, although the potential bone fracture risk of the drug requires further investigation. Results from directly comparative trials indicating the efficacy, tolerability and bone fracture risk of exemestane relative to third-generation aromatase inhibitors and other agents in both early-stage and advanced disease, as well as the optimal sequence of endocrine therapies, are awaited with interest. In the meantime, switching to exemestane should be considered in postmenopausal women who have received 2-3 years of adjuvant tamoxifen treatment for early-stage breast cancer, and is an emerging treatment option for postmenopausal women with advanced breast cancer refractory to one or more antiestrogen therapies.
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Affiliation(s)
- Emma D Deeks
- Wolters Kluwer Health, Adis, Auckland, New Zealand.
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Harichand-Herdt S, Zelnak A, O'Regan R. Endocrine therapy for the treatment of postmenopausal women with breast cancer. Expert Rev Anticancer Ther 2009; 9:187-98. [PMID: 19192957 DOI: 10.1586/14737140.9.2.187] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The treatment of women with estrogen receptor-positive breast cancer has advanced significantly in the past decade. Tamoxifen was the gold standard hormonal therapy for breast cancer until the introduction of aromatase inhibitors and fulvestrant. Many of these new treatments are useful only for patients who are postmenopausal. There are data to support the use of these new agents both in the metastatic and adjuvant settings. Here, we briefly review the recent clinical trials supporting the use of these agents in both the adjuvant and metastatic settings. We will discuss possible mechanisms of resistance to endocrine agents that could be exploited therapeutically to improve the outcome for patients with hormone receptor-positive breast cancers.
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Affiliation(s)
- Seema Harichand-Herdt
- Department of Hematology and Medical Oncology and the Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Milani M, Jha G, Potter DA. Anastrozole Use in Early Stage Breast Cancer of Post-Menopausal Women. ACTA ACUST UNITED AC 2009; 1:141-156. [PMID: 19794821 DOI: 10.4137/cmt.s9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The majority of breast cancers express the estrogen receptor and depend on estradiol (E2) for their growth. Hormonal therapy aims at depriving estrogen signaling either by using selective estrogen receptor modulators (SERM)-that interfere with the binding of E2 to its receptor (ER)-or aromatase inhibitors (AI)-that block the aromatase-dependent synthesis of E2. While SERMs are recommended for both pre- and post-menopausal patients, AIs are indicated only for post-menopausal patients. For the past 20 years, the SERM tamoxifen has been considered the "gold standard" for the treatment of hormone receptor positive breast cancers. However, tamoxifen's role is now challenged by third generation AIs, such as anastrozole, which exhibit greater efficacy in the adjuvant setting in several recently reported trials. This review will focus on anastrozole's mechanism of action, dosing, pharmacology, pharmacokinetics, and clinical applications. It will briefly discuss the clinical trials that determined anastrozole's efficacy in the treatment of advanced breast cancer (ABC) and in the neoadjuvant setting. Finally, it will present the clinical trials that established anastrozole as a frontline agent in the treatment of post-menopausal women with hormone receptor positive early breast cancer.
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Affiliation(s)
- Monica Milani
- Department of Medicine, Division of Hematology Oncology and Transplantation, University of Minnesota, Minneapolis, MN, U.S.A
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Cameron DA, Camidge DR, Oyee J, Hirsch M. Economic evaluation of fulvestrant as an extra step in the treatment sequence for ER-positive advanced breast cancer. Br J Cancer 2008; 99:1984-90. [PMID: 19018261 PMCID: PMC2607221 DOI: 10.1038/sj.bjc.6604790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/20/2008] [Accepted: 10/24/2008] [Indexed: 12/03/2022] Open
Abstract
Drug therapies for advanced breast cancer in hormone-receptor-positive disease include both hormonal and chemotherapies. Current UK practice is to minimise toxicity by using sequential hormonal agents for as long as clinically appropriate. A Markov model was developed to investigate the cost effectiveness of different sequences of therapies, particularly exploring the effects of adding an additional hormonal agent, fulvestrant, to the treatment pathway. A systematic review was undertaken and a panel of seven UK oncologists validated assumptions used for treatment efficacy, treatment pathways and resources used. Fulvestrant was found to be a cost-effective treatment option when added to the treatment sequence as a second- or third-line hormonal therapy for advanced disease. For a cohort of 1000 patients, fulvestrant as a second-line hormone therapy provided an additional 47 life years and 41 quality-adjusted life years (QALYs), at an additional cost of pound 301 359. This equated to pound 6500 per life years gained and pound 7500 per QALY. When used as a third-line option, the fulvestrant arm was dominant providing an increase in health benefit of 27 QALYs for the whole cohort, at a mean overall cost reduction of pound 430 per patient. Sensitivity analyses showed these results to be robust, demonstrating that fulvestrant is an economically viable additional endocrine option in the United Kingdom for the treatment of hormone responsive advanced breast cancer.
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Affiliation(s)
- D A Cameron
- Department of Oncology, Western General Hospital, Edinburgh, UK
| | - D R Camidge
- Department of Developmental Therapeutics and Thoracic Malignancies Programs, University of Colorado Cancer Center, Aurora, CO, USA
| | - J Oyee
- Department of Market Access, Mapi Values, Bollington, UK
| | - M Hirsch
- Department of Global Health Economics and Outcomes Research, AstraZeneca Pharmaceutical Ltd, Macclesfield, Cheshire, UK
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Lack of complete cross-resistance between different aromatase inhibitors; a real finding in search for an explanation? Eur J Cancer 2008; 45:527-35. [PMID: 19062270 DOI: 10.1016/j.ejca.2008.10.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 09/23/2008] [Accepted: 10/16/2008] [Indexed: 11/21/2022]
Abstract
While third-generation aromatase inhibitors (anastrozole, letrozole and exemestane) are successfully implemented as adjuvant and first-line therapy for hormone-sensitive breast cancer in postmenopausal women, important questions remain to be addressed. An issue of particular interest is the question about lack of complete cross-resistance between steroidal and non-steroidal compounds. Although the studies reporting this phenomenon in general contain a small number of patients, the findings across the different reports seem consistent. While several potential mechanisms have been suggested, so far we lack scientific proof what mechanisms may be responsible for this finding. Finally, we do not know whether lack of cross-resistance actually signals an improved efficacy for certain compounds or may be due to alternative mechanisms of action. Neither do we know whether some tumours are more sensitive to particular drugs. This paper summarizes clinical findings up to now with respect to lack of cross-resistance and discuss potential mechanisms involved.
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Miller WR, Bartlett J, Brodie AMH, Brueggemeier RW, di Salle E, Lønning PE, Llombart A, Maass N, Maudelonde T, Sasano H, Goss PE. Aromatase inhibitors: are there differences between steroidal and nonsteroidal aromatase inhibitors and do they matter? Oncologist 2008; 13:829-37. [PMID: 18695261 DOI: 10.1634/theoncologist.2008-0055] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aromatase inhibitors (AIs) are approved for use in both early- and advanced-stage breast cancer in postmenopausal women. Although the currently approved "third-generation" AIs all powerfully inhibit estrogen synthesis, they may be subdivided into steroidal and nonsteroidal inhibitors, which interact with the aromatase enzyme differently. Nonsteroidal AIs bind noncovalently and reversibly to the aromatase protein, whereas steroidal AIs may bind covalently and irreversibly to the aromatase enzyme. The steroidal AI exemestane may exert androgenic effects, but the clinical relevance of this has yet to be determined. Switching between steroidal and nonsteroidal AIs produces modest additional clinical benefits, suggesting partial noncrossresistance between the classes of inhibitor. In these circumstances, the response rates to the second AI have generally been low; additional research is needed regarding the optimal sequence of AIs. To date, clinical studies suggest that combining an estrogen-receptor blocker with a nonsteroidal AI does not improve efficacy, while combination with a steroidal AI has not been evaluated. Results from head-to-head trials comparing steroidal and nonsteroidal AIs will determine whether meaningful clinical differences in efficacy or adverse events exist between the classes of AI. This review summarizes the available evidence regarding known differences and evaluates their potential clinical impact.
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Lønning PE, Geisler J. Experience with Exemestane in the Treatment of Early and Advanced Breast Cancer. Expert Opin Drug Metab Toxicol 2008; 4:987-97. [DOI: 10.1517/17425255.4.7.987] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lønning PE, Geisler J. Indications and limitations of third-generation aromatase inhibitors. Expert Opin Investig Drugs 2008; 17:723-39. [DOI: 10.1517/13543784.17.5.723] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW Several active, well tolerated hormonal agents have become available in recent years for the treatment of patients with advanced, hormone receptor-positive breast cancer. When used in an appropriate sequential strategy, hormonal therapies offer the opportunity of prolonging disease control and maintaining quality of life. The widening use of aromatase inhibitors in the adjuvant setting, however, means that traditional sequential cascades must be revised. The review describes the most relevant evidence that can contribute to the optimal positioning of each agent in the sequence. RECENT FINDINGS Most recent phase II and III trials of hormonal therapy in advanced breast cancer have examined the role of exemestane, letrozole, anastrozole, and fulvestrant in postmenopausal women. SUMMARY Partial non-cross resistance between nonsteroidal (letrozole and anastrozole) and steroidal (exemestane) aromatase inhibitors may allow treatment with exemestane after a nonsteroidal aromatase inhibitor and vice versa. The estrogen receptor downregulator fulvestrant is also an option after treatment with aromatase inhibitors. The role of the progestin megestrol acetate and, paradoxically, of tamoxifen in the sequential strategy for advanced breast cancer is less well studied.
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Carlini P, Bria E, Giannarelli D, Felici A, Papaldo P, Fabi A, Ruggeri EM, Milella M, Nuzzo C, Cecere FL, Gelibter A, Pino MS, Nisticò C, Cuppone F, Metro G, Terzoli E, Cognetti F, Ferretti G. Aromatase inhibitors in post-menopausal metastatic breast carcinoma. Expert Opin Investig Drugs 2007; 16:1023-36. [PMID: 17594187 DOI: 10.1517/13543784.16.7.1023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
To summarise the advances in the hormonal treatment of post-menopausal metastatic breast cancer, this paper reviews the published literature regarding the randomised trials comparing aromatase inhibitors (AIs) versus tamoxifen as a first-line therapeutic choice, or AIs versus megestrole acetate (MEG) as a second-line option. The pooled analysis of these authors on AI versus MEG as a second-line option for post-menopausal metastatic breast cancer suggested that AIs do not add any significant benefit over MEG in terms of overall response rate (ORR) and time to progression. According to the Cochrane Database, use of an AI as a second-line therapy versus any other endocrine therapy (mostly MEG) has shown a significant benefit in terms of overall survival, but not for progression-free survival, clinical benefit (CB) or ORR. Concerning the authors' comparisons between AIs versus tamoxifen as a first-line endocrine option in post-menopausal women with metastatic breast carcinoma, AIs seem to be superior to tamoxifen, with a significant benefit in terms of ORR, CB and time to progression being observed in favour of AIs over tamoxifen with fixed effects estimates. According to the Cochrane Database, there was an advantage to the use of AIs over tamoxifen in terms of progression-free survival and CB, but not for overall survival or ORR. With regards to toxicity, AIs show similar levels of hot flushes and arthralgia, increased risks of nausea, diarrhoea and vomiting, but a decreased risk of vaginal bleeding and thromboembolic events compared with other endocrine therapies. Weight gain, dyspnoea and peripheral oedema seem to be more frequent with MEG. At present, there is no proved overall survival difference in patients who are treated first with an AI and then with tamoxifen compared with the opposite sequence. In the metastatic setting, results are limited and are based on retrospective analyses.
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Affiliation(s)
- Paolo Carlini
- Regina Elena Cancer Institute, Division of Medical Oncology A, Rome, Italy.
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Perey L, Paridaens R, Hawle H, Zaman K, Nolé F, Wildiers H, Fiche M, Dietrich D, Clément P, Köberle D, Goldhirsch A, Thürlimann B. Clinical benefit of fulvestrant in postmenopausal women with advanced breast cancer and primary or acquired resistance to aromatase inhibitors: final results of phase II Swiss Group for Clinical Cancer Research Trial (SAKK 21/00). Ann Oncol 2006; 18:64-69. [PMID: 17030543 DOI: 10.1093/annonc/mdl341] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy and tolerability of fulvestrant, an estrogen receptor antagonist, in postmenopausal women with hormone-responsive tumors progressing after aromatase inhibitor (AI) treatment. PATIENTS AND METHODS This is a phase II, open, multicenter, noncomparative study. Two patient groups were prospectively considered: group A (n=70) with AI-responsive disease and group B (n=20) with AI-resistant disease. Fulvestrant 250 mg was administered as intramuscular injection every 28 (+/-3) days. RESULTS All patients were pretreated with AI and 84% also with tamoxifen or toremifene; 67% had bone metastases and 45% liver metastases. Fulvestrant administration was well tolerated and yielded a clinical benefit (CB; defined as objective response or stable disease [SD] for >or=24 weeks) in 28% (90% confidence interval [CI] 19% to 39%) of patients in group A and 37% (90% CI 19% to 58%) of patients in group B. Median time to progression (TTP) was 3.6 (95% CI 3.0 to 4.8) months in group A and 3.4 (95% CI 2.5 to 6.7) months in group B. CONCLUSIONS Overall, 30% of patients who had progressed following prior AI treatment gained CB with fulvestrant, thereby delaying indication to start chemotherapy. Prior response to an AI did not appear to be predictive for benefit with fulvestrant.
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Affiliation(s)
- L Perey
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - R Paridaens
- Department of General Medical Oncology, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium
| | - H Hawle
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - K Zaman
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland.
| | - F Nolé
- Unit for Medical Care, Department of Medicine, European Institute of Oncology, Milan, Italy
| | - H Wildiers
- Department of General Medical Oncology, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium
| | - M Fiche
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - D Dietrich
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - P Clément
- Department of General Medical Oncology, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium
| | - D Köberle
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - A Goldhirsch
- Unit for Medical Care, Department of Medicine, European Institute of Oncology, Milan, Italy
| | - B Thürlimann
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
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Board RE, Dean EJ, Mitchell C, Wardley AM. Second-line treatment of postmenopausal women with advanced breast carcinoma. Expert Rev Anticancer Ther 2006; 6:613-24. [PMID: 16613548 DOI: 10.1586/14737140.6.4.613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Breast cancer is the most prevalent cancer in women and, currently, there is no standard of care for the treatment of metastatic disease. Treatment options are based on a number of tumor- and patient-related factors. This review explores some of these options, including the use of hormonal manipulation in the treatment of hormone-positive disease, current chemotherapy options and the use of targeted therapies, such as trastuzumab.
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Affiliation(s)
- Ruth E Board
- Cancer Research UK Department of Medical Oncology, Christie Hospital, Wilmslow Road, Manchester, M20 4BX, UK.
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Bertelli G, Garrone O, Merlano M, Occelli M, Bertolotti L, Castiglione F, Pepi F, Fusco O, Del Mastro L, Leonard RCF. Sequential Treatment with Exemestane and Non-Steroidal Aromatase Inhibitors in Advanced Breast Cancer. Oncology 2006; 69:471-7. [PMID: 16410685 DOI: 10.1159/000090985] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 10/01/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The steroidal aromatase inactivator exemestane has demonstrated activity after prior failure of non-steroidal aromatase inhibitors (including third-generation inhibitors letrozole and anastrozole) in postmenopausal women with advanced breast cancer. If exemestane is used as first anti-aromatase agent, however, it is unclear whether patients can still benefit from letrozole or anastrozole after progression. PATIENTS AND METHODS Postmenopausal patients with advanced, hormone receptor-positive or -unknown breast cancer were eligible for this study. Patients with no prior exposure to anti-aromatase drugs received exemestane, 25 mg daily, as first anti-aromatase agent. At the time of progression, patients were crossed-over to anastrozole or letrozole if further endocrine therapy was considered appropriate. Patients with prior exposure to anti-aromatase agents were also included in the study, and were given anastrozole or letrozole if they had previously received exemestane, or exemestane if they had previously received anastrozole or letrozole. The primary endpoint of the study was the clinical benefit rate (complete response + partial response + stabilization of disease for >or=24 weeks). RESULTS Forty patients received exemestane 25 mg daily as first anti-aromatase agent, with a CB rate of 67.5% (95% CI 52.9-82.0%) and a median time to progression (TTP) of 9.6 months. In 18 patients, letrozole (n = 17) or anastrozole (n = 1) were used after failure of exemestane: the CB rate was 55.6% (95% CI 32.6-78.5%) with a median TTP of 9.3 months. In 23 patients, exemestane was used after failure of letrozole or anastrozole: the CB rate was 43.5% (95% CI 23.2-63.7%) with a median TTP of 5.1 months. CONCLUSIONS Our study confirms that exemestane is active after prior failure of letrozole or anastrozole. We have also shown that patients can receive exemestane as their first anti-aromatase agent and still benefit from letrozole or anastrozole after progression. This suggests that the partial non-cross resistance between steroidal and non-steroidal anti-aromatase agents is independent of the sequence employed.
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