Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study

Clinical treatment score post-5 years and survival benefit from extended endocrine therapy for breast cancer patients under and over 50 years of age

BACKGROUND

This study aimed to determine whether clinical treatment score post-5 years (CTS5) could predict the clinical benefits of extended endocrine therapy (ExET) in young and old patients.

METHODS

We reviewed 2495 hormone receptor-positive breast cancer patients treated between 2001 and 2012 who were free from recurrence or death during the 5 years post-surgery in South Korea. The cohort was analyzed separately based on age (≤ 50 years and > 50 years). Multivariable analysis was conducted, and a cutoff of CTS5 < 3.13 was defined as the low group and CTS5 ≥ 3.13 as the intermediate/high (int/high) group.

RESULTS

The median follow-up duration was 115 months. Regardless of young and old age at diagnosis, the low group displayed considerably enhanced disease-free survival. Multivariate analysis revealed that the low group emerged as an independent and favorable prognostic factor for disease-free survival after adjusting for ExET use and prognostic parameters. Patients in the low group demonstrated a trend toward improved overall survival compared to those in the int/high group, reaching marginal statistical significance. ExET use demonstrated a significant correlation with improved disease-free survival, particularly in patients aged ≤ 50 years.

CONCLUSIONS

ExET should be considered in premenopausal and postmenopausal breast cancer patients with high CTS5 levels.

Exploring potential biomarkers and lead molecules in gastric cancer by network biology, drug repurposing and virtual screening strategies

Gastric cancer poses a significant global health challenge, necessitating innovative approaches for biomarker discovery and therapeutic intervention. This study employs a multifaceted strategy integrating network biology, drug repurposing, and virtual screening to elucidate and expand the molecular landscape of gastric cancer. We identified and prioritized key genes implicated in gastric cancer by utilizing data from diverse databases and text-mining techniques. Network analysis underscored intricate gene interactions, emphasizing potential therapeutic targets such as CTNNB1, BCL2, TP53, etc, and highlighted ACTB among the top hub genes crucial in disease progression. Drug repurposing on 626 FDA-approved drugs for digestive system-related cancers revealed Norgestimate and Nimesulide as likely top candidates for gastric cancer, validated by molecular docking and dynamics simulations. Further, combinatorial synthesis of scaffold libraries derived from known chemotypes generated 56,160 virtual compounds, of which 76 new compounds were prioritized based on promising binding affinities and interactions at critical residues. Hotspot residue analysis identified GLU 214 and others as essential for ligand binding stability, enhancing compound efficacy and specificity. These findings support the therapeutic potential of targeting beta-actin protein in gastric cancer treatment, suggesting a future for further experimental validation and clinical translation. In conclusion, this study highlights the potential of repurposable drugs and virtual screening which can be used in combination with existing anti-gastric cancer drugs for gastric cancer therapy, emphasizing the role of computational methodologies in drug discovery.

Unraveling the role of stromal disruption in aggressive breast cancer etiology and outcomes

BACKGROUND

Aggressive (typically high-grade) breast cancers (BCs) remain major contributors to BC-related mortality globally. The tissue changes underpinning their etiology and outcomes, however, remain poorly characterized.

METHODS

Spatially resolved machine-learning algorithms were used to characterize "stromal disruption" as a morphological metric of reduced/altered extracellular matrix and increased immune, inflammatory, and/or wound response-related processes in normal, benign breast disease (BBD), and invasive hematoxylin and eosin (H&E)-stained breast tissues. Associations of stromal disruption with BC etiologic factors were assessed among 4023 healthy breast tissue donors, its impact on BC incidence was assessed among 974 BBD patients in a nested case-control study, while its prognostic associations were assessed in 4 BC patient cohorts (n = 4223).

RESULTS

Epidemiologic risk factors for aggressive BC, including younger age, multiparity, Black race, obesity, and family history, demonstrated strong associations with increasing stromal disruption in H&E sections prior to tumor development. Substantial stromal disruption in BBD H&E was associated with ∼4-fold increased risk of aggressive (high-grade) BC and ∼3 years shorter latency from BBD to BC diagnosis, independently of BBD histology. Across BC cohorts, stromal disruption in H&E was associated with aggressive (mostly high-grade) tumor phenotypes and with markedly poor prognosis among ER-positive patients, irrespective of histology. The immunobiology of stromal disruption reflected heightened innate (CD68+), adaptive (CD3+CD4+, CD3+CD8+), immunoregulatory (CD3+CD4+FOXP3+), immune escape (PD1+PDL1+), endothelial (CD31+), and myofibroblast (α-SMA+) marker expression.

CONCLUSION

Our findings highlight the active stromal role in aggressive BC etiology and outcomes, opening possibilities for readily identifying high-risk women across the BC continuum that may benefit from stroma-centric preventative or therapeutic strategies.

Literature Review of Sex Hormones and Cataract Development, With Modern Implications

Administration of exogenous testosterone and oestrogen has a number of clinical indications, with increasing use as gender-affirming hormone therapy (GAHT) in young individuals. GAHT has been associated with increasing ocular manifestations, but cataracts have not been previously reported. A literature review was conducted to assess for any associations between sex hormone administration and cataracts. Sparse data exist regarding the relationship between androgens and cataract. We also reviewed current knowledge derived from animal studies about oestrogen's effects on the lens, possible biomechanisms and correlations with observational data on cataract incidence with varying estrogen levels. Data surrounding parity, menarche, menopause and hormone replacement therapy in women generally supports a protective role of endogenous and exogenous estrogen on the crystalline lens. Such protection could be suppressed due to long-term GAHT in susceptible individuals, but no relevant studies exist regarding cataract risk in this scenario. Further research via population-based studies would be useful to identify any potential cataractogenic risk factors from GAHT.

The impact of coadministration of venlafaxine, citalopram or gabapentin on the metabolic activation of tamoxifen

PURPOSE

Tamoxifen undergoes metabolic activation by cytochrome P450 (CYP) enzymes to metabolites with more potent anti-estrogenic effects. Numerous studies demonstrate decreased tamoxifen efficacy associated with reduced CYP2D6 activity or lower Z-endoxifen concentrations. Women taking tamoxifen frequently experience vasomotor symptoms (VMS) that may require medical treatment. Many medications used for VMS or depression are CYP substrates that may reduce Z-endoxifen concentrations. While the drug-drug interactions (DDI) from potent CYP2D6 inhibitors (CYPi) on tamoxifen metabolism has been studied, the impact of less potent CYPi including drugs used to treat VMS remains largely unknown.

METHODS

We performed a prospective trial to evaluate the impact of gabapentin or non-potent CYPi (venlafaxine citalopram) on plasma concentrations of tamoxifen and its metabolites (Z-endoxifen, N-desmethyl-tamoxifen (NDMT) and 4-hydroxy-tamoxifen (4HT).

RESULTS

Patients enrolled were intermediate to extensive metabolizers by CYP2D6 genotyping. While tamoxifen and NDMT plasma concentrations were not significantly altered, the percent decrease in plasma Z-endoxifen concentration was statistically significant with the addition of venlafaxine (n = 22) or citalopram (n = 18) (median - 14.7 and - 14.4%, respectively) but not with gabapentin (n = 14) (median - 2.3%). A reduction in Z-endoxifen concentrations below the 5.9 ng/ml threshold associated with tamoxifen efficacy was observed in 12% of patients.

CONCLUSION

The addition of venlafaxine and citalopram but not gabapentin during tamoxifen treatment decreases plasma Z-endoxifen concentrations. SSRIs/SNRIs affecting tamoxifen biotransformation pathways, but with less potent CYPi potential, should be used cautiously in tamoxifen-treated patients and non-CYP inhibiting medications considered when possible.

Cancer chemoprevention: signaling pathways and strategic approaches

Although cancer chemopreventive agents have been confirmed to effectively protect high-risk populations from cancer invasion or recurrence, only over ten drugs have been approved by the U.S. Food and Drug Administration. Therefore, screening potent cancer chemopreventive agents is crucial to reduce the constantly increasing incidence and mortality rate of cancer. Considering the lengthy prevention process, an ideal chemopreventive agent should be nontoxic, inexpensive, and oral. Natural compounds have become a natural treasure reservoir for cancer chemoprevention because of their superior ease of availability, cost-effectiveness, and safety. The benefits of natural compounds as chemopreventive agents in cancer prevention have been confirmed in various studies. In light of this, the present review is intended to fully delineate the entire scope of cancer chemoprevention, and primarily focuses on various aspects of cancer chemoprevention based on natural compounds, specifically focusing on the mechanism of action of natural compounds in cancer prevention, and discussing in detail how they exert cancer prevention effects by affecting classical signaling pathways, immune checkpoints, and gut microbiome. We also introduce novel cancer chemoprevention strategies and summarize the role of natural compounds in improving chemotherapy regimens. Furthermore, we describe strategies for discovering anticancer compounds with low abundance and high activity, revealing the broad prospects of natural compounds in drug discovery for cancer chemoprevention. Moreover, we associate cancer chemoprevention with precision medicine, and discuss the challenges encountered in cancer chemoprevention. Finally, we emphasize the transformative potential of natural compounds in advancing the field of cancer chemoprevention and their ability to introduce more effective and less toxic preventive options for oncology.

Spatially Resolved Single-Cell Morphometry of Benign Breast Disease Biopsy Images Uncovers Quantitative Cytomorphometric Features Predictive of Subsequent Invasive Breast Cancer Risk

Currently, benign breast disease (BBD) pathologic classification and invasive breast cancer (BC) risk assessment are based on qualitative epithelial changes, with limited utility for BC risk stratification for women with lower-risk category BBD (ie, nonproliferative disease [NPD] and proliferative disease without atypia [PDWA]). Here, machine learning-based single-cell morphometry was used to characterize quantitative changes in epithelial nuclear morphology that reflect functional/structural decline (ie, increasing nuclear size, assessed as epithelial nuclear area and nuclear perimeter), altered DNA chromatin content (ie, increasing nuclear chromasia), and increased cellular crowding/proliferation (ie, increasing nuclear contour irregularity). Cytomorphologic changes reflecting chronic stromal inflammation were assessed using stromal cellular density. Data and pathology materials were obtained from a case-control study (n = 972) nested within a cohort of 15,395 women diagnosed with BBD at Kaiser Permanente Northwest (1971-2012). Odds ratios (ORs) and 95% confidence intervals (CIs) for associations of cytomorphometric features with risk of subsequent BC were assessed using multivariable logistic regression. More than 55 million epithelial and 37 million stromal cells were profiled across 972 BBD images. Cytomorphometric features were individually predictive of subsequent BC risk, independently of BBD histologic classification. However, cytomorphometric features of epithelial functional/structural decline were statistically significantly predictive of low-grade but not high-grade BC following PDWA (OR for low-grade BC per 1-SD increase in nuclear area and nuclear perimeter, 2.10; 95% CI, 1.26-3.49, and 2.22; 95% CI, 1.30-3.78, respectively), whereas stromal inflammation was predictive of high-grade but not low-grade BC following NPD (OR for high-grade BC per 1-SD increase in stromal cellular density, 1.53; 95% CI, 1.13-2.08). Associations of nuclear chromasia and nuclear contour irregularity with subsequent tumor grade were context specific, with both features predicting low-grade BC risk following PDWA (OR per 1-SD, 1.58; 95% CI, 1.06-2.35, and 2.21; 95% CI, 1.25-3.91, for nuclear chromasia and nuclear contour irregularity, respectively) and high-grade BC following NPD (OR per 1-SD, 1.47; 95% CI, 1.11-1.96, and 1.29; 95% CI, 1.00-1.70, for nuclear chromasia and nuclear contour irregularity, respectively). The results indicate that cytomorphometric features on BBD hematoxylin-eosin-stained images might help to refine BC risk estimation and potentially inform BC risk reduction strategies for BBD patients, particularly those currently designated as low risk.

Low Dose Tamoxifen for Breast Cancer Prevention: A Real-World Experience

PURPOSE

There is limited data on the use of low dose tamoxifen (LDT) for chemoprevention since its introduction in 2019. This study sought to determine the rate of LDT uptake at our institution and describe factors associated with its use.

METHODS

We performed a retrospective chart review of women diagnosed with ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), and/or atypical hyperplasia from 2019 to 2021. Log-binomial models were used to compare the probabilities of receiving standard dose tamoxifen (SDT) relative to LDT by patient and disease characteristics. Since most patients did not experience any AEs, a zero-inflated poison regression model was used to estimate and compare adverse event rates between groups.

RESULTS

Among 477 patients with DCIS, LCIS, and atypical hyperplasia, 27% (N = 129) initiated SDT, 19% (N = 89) LDT, 32% (N = 155) aromatase inhibitor, 2% (N = 9) raloxifene, and 20% (N = 95) declined therapy. LDT was used more frequently than SDT in patients with LCIS or atypical hyperplasia compared to DCIS (31.4% vs 17.4%, P < .0001). There were no significant differences in the frequency of adverse events between patients on SDT and LDT but the incidence rate of AEs in the SDT group was higher (1.9 vs. 1.3 per 1000 days, P = .0186).

CONCLUSION

In our population, 19% of women with DCIS, LCIS, or atypical hyperplasia, initiated chemoprevention with LDT with higher usage in patients with atypical lesions and/or LCIS. Physicians should strongly consider LDT in women with high-risk lesions who are eligible for chemoprevention.

Patients with DCIS Seen at a Specialized High-Risk Breast Clinic Run by Surgical Advanced Practice Providers Have High Rates of Preventive Medication Uptake

BACKGROUND

Preventative medication (PM) uptake is low among patients at an elevated risk of breast cancer, largely due to fears of intolerance. This study aimed to investigate whether a new, surgical advanced practice provider (APP)-run clinic was effectively prescribing PM. We hypothesized equivalent rates of PM uptake compared to consultation with medical oncologists (MD).

PATIENTS AND METHODS

The APP-run clinic and accompanying database were initiated 01/2023, including patients with benign breast complaints and/or an elevated risk of invasive breast cancer. A historic single-institution surgical database and this prospective database were queried for patients with ductal carcinoma in situ between 04/2007-05/2023 and 01/2023-01/2024, respectively. Patients with invasive breast cancer within the prior 5 years were excluded. Chart review abstracted PM type/dose. Chi square analysis compared PM uptake rates and dose.

RESULTS

A total of 523 patients met study criteria; the MD sample and APP sample were relatively well balanced except fewer hormone receptor positive patients in the MD sample (266/309 [86.1%] versus 202/214 [94.4%] APP, p < 0.01). PM uptake was lower in the MD sample (96/309 [31.1%] compared to the APP sample (86/214 [40.2%], p = 0.03). There was significantly more tamoxifen prescribed among the APP sample (58.2% vs. 35.6% among MD, p = 0.02), and low-dose tamoxifen prescribing increased significantly (47.3% vs. 9.8% MD, p < 0.01).

CONCLUSIONS

Our surgical APP-run breast health clinic has demonstrated equivalent PM uptake as compared to patients seen previously by medical oncologists. This model should be considered broadly. Additionally, low-dose tamoxifen has become the prescription of choice; thus, long-term studies of tamoxifen 5 mg are warranted.

Understanding Susceptibility to Breast Cancer: From Risk Factors to Prevention Strategies

Breast cancer is the most common malignancy among women globally, with incidence rates continuing to rise. A comprehensive understanding of its risk factors and the underlying biological mechanisms that drive tumor initiation is essential for developing effective prevention strategies. This review examines key non-modifiable risk factors, such as genetic predisposition, demographic characteristics, family history, mammographic density, and reproductive milestones, as well as modifiable risk factors like exogenous hormone exposure, obesity, diet, and physical inactivity. Importantly, reproductive history plays a dual role, providing long-term protection while temporarily increasing breast cancer risk shortly after pregnancy. Current chemoprevention strategies primarily depend on selective estrogen receptor modulators (SERMs), including tamoxifen and raloxifene, which have demonstrated efficacy in reducing the incidence of estrogen receptor-positive breast cancer but remain underutilized due to adverse effects. Emerging approaches such as aromatase inhibitors, RANKL inhibitors, progesterone antagonists, PI3K inhibitors, and immunoprevention strategies show promise for expanding preventive options. Understanding the interactions between risk factors, hormonal influences, and tumorigenesis is critical for optimizing breast cancer prevention and advancing safer, more targeted chemopreventive interventions.

Environmental Concentrations of Polystyrene Nanoplastics Induce Low-Dose Tamoxifen Toxicity Through Oxidative Stress in Caenorhabditis elegans

In recent years, significant focus has been placed on the negative impacts of nanoplastics on living organisms. However, nanoplastics at environmental concentrations may interact with drugs, leading to more severe side effects in organisms. This study used Caenorhabditis elegans (C. elegans) to investigate how environmental levels (μg/L) of polystyrene nanoparticles (PS-NPs) influence tamoxifen toxicity and its mechanisms. Combined exposure to tamoxifen and PS-NPs significantly impaired locomotion, pumping, brood size, growth, and induced oxidative stress in both parents and offspring compared to single exposures. DAF-2 mutations conferred resistance, while DAF-16 mutations increased susceptibility. The combined exposure promoted DAF-16::GFP nuclear translocation and decreased SOD-3::GFP and HSP-16.2::GFP fluorescence, indicating toxicity through the DAF-2/DAF-16 IIS pathway. Bacterial metabolism was also linked to the toxic effects, feeding C. elegans metabolically inactivated OP50 significantly reduced the toxicity associated with the combined exposure of PS-NPs and tamoxifen. Additionally, dietary N-acetyl-L-cysteine significantly improved resistance to combined PS-NP and tamoxifen exposure. In summary, this study highlights how long-term exposure to environmental nanoplastic levels can enhance drug side effects, providing new insights into nanoplastics' role in drug interactions.

Temporal Dynamics and Clinical Predictors of Brain Metastasis in Breast Cancer: A Two-Decade Cohort Analysis Toward Tailored CNS Screening

BACKGROUND/OBJECTIVES

Breast cancer is the most common malignancy in women and the second leading cause of cancer-related deaths globally. It is also the second most frequent source of brain metastases (BMs), contributing to 5-20% of cases. Despite this, routine brain imaging for screening is not recommended and is only conducted when clinical symptoms or physical findings suggest metastasis. This study aims to identify clinical predictors associated with overall survival (OS) and the timing of BM development in breast cancer patients.

METHODS

We performed a retrospective review of medical records for 113 patients diagnosed with BMs secondary to breast cancer at our institution between 2000 and 2020. Baseline demographic data and clinical characteristics related to BMs were collected. To identify factors associated with OS and time to BM development after breast cancer diagnosis, we conducted univariate analysis using Kaplan-Meier curves, bivariate analysis with the log-rank test, and multivariate analysis via the Cox Proportional Hazard model.

RESULTS

An early diagnosis of BMs was identified as a significant predictor of prolonged OS (aHR = 0.22; 95% CI: 0.049-0.98, p = 0.05). Post-menopausal status at breast cancer diagnosis (aHR = 1.69; 95% CI: 1.13-2.53, p = 0.01), Asian ethnicity (aHR = 2.30; 95% CI: 1.03-5.16, p = 0.04), and the ER+/HER2+ subtype (aHR = 2.06; 95% CI: 1.14-3.71, p = 0.02) were significantly associated with a shorter time to BM diagnosis. A subgroup analysis of patients with ER+ breast tumors revealed that Hispanic or Arabic ethnicity (aHR = 3.63; 95% CI: 1.34-9.81, p = 0.01) and stage IV diagnosis (aHR = 2.09; 95% CI: 1.16-3.76, p = 0.01) were significantly associated with shorter intervals to BM diagnosis.

CONCLUSIONS

Breast cancer remains a significant global health burden for women, yet clear guidelines for routine BMs screening are still lacking. Early detection of BMs has been shown to notably improve long-term survival outcomes. Additionally, post-menopausal status, Hispanic or Arabic ethnicity, and the HER2+ tumor subtype are associated with shorter time to BM development, highlighting these factors as potential indicators for central nervous system screening.

Computational analysis of the gut microbiota-mediated drug metabolism

The gut microbiota, an extensive ecosystem harboring trillions of bacteria, plays a pivotal role in human health and disease, influencing diverse conditions from obesity to cancer. Among the microbiota's myriad functions, the capacity to metabolize drugs remains relatively unexplored despite its potential implications for drug efficacy and toxicity. Experimental methods are resource-intensive, prompting the need for innovative computational approaches. We present a computational analysis, termed MDM, aimed at predicting gut microbiota-mediated drug metabolism. This computational analysis incorporates data from diverse sources, e.g., UHGG, MagMD, MASI, KEGG, and RetroRules. An existing tool, PROXIMAL2, is used iteratively over all drug candidates from experimental databases queried against biotransformation rules from RetroRules to predict potential drug metabolites along with the enzyme commission number responsible for that biotransformation. These potential metabolites are then categorized into gut MDM metabolites by cross referencing UHGG. The analysis' efficacy is validated by its coverage on each of the experimental databases in the gut microbial context, being able to recall up to 74 % of experimental data and producing a list of potential metabolites, of which an average of about 65 % are relevant to the gut microbial context. Moreover, explorations into ranking metabolites, iterative applications to account for multi-step metabolic pathways, and potential applications in experimental studies showcase its versatility and potential impact beyond raw predictions. Overall, this study presents a promising computational framework for further research and applications gut MDM, drug development and human health.

Computational Analysis of the Gut Microbiota-Mediated Drug Metabolism

The gut microbiota, an extensive ecosystem harboring trillions of bacteria, plays a pivotal role in human health and disease, influencing diverse conditions from obesity to cancer. Among the microbiota's myriad functions, the capacity to metabolize drugs remains relatively unexplored despite its potential implications for drug efficacy and toxicity. Experimental methods are resource-intensive, prompting the need for innovative computational approaches. We present a computational analysis, termed MDM, aimed at predicting gut microbiota-mediated drug metabolism. This computational analysis incorporates data from diverse sources, e.g., UHGG, MagMD, MASI, KEGG, and RetroRules. An existing tool, PROXIMAL2, is used iteratively over all drug candidates from experimental databases queried against biotransformation rules from RetroRules to predict potential drug metabolites along with the enzyme commission number responsible for that biotransformation. These potential metabolites are then categorized into gut MDM metabolites by cross referencing UHGG. The analysis' efficacy is validated by its coverage on each of the experimental databases in the gut microbial context, being able to recall up to 74% of experimental data and producing a list of potential metabolites, of which an average of about 65% are relevant to the gut microbial context. Moreover, explorations into ranking metabolites, iterative applications to account for multi-step metabolic pathways, and potential applications in experimental studies showcase its versatility and potential impact beyond raw predictions. Overall, this study presents a promising computational framework for further research and applications gut MDM, drug development and human health.

Non-invasive Lobular Neoplasia: Review and Updates

Non-invasive lobular neoplasia (LN) encompasses atypical lobular hyperplasia (ALH), classic lobular carcinoma in situ (CLCIS), florid lobular carcinoma in situ (FLCIS), and pleomorphic lobular carcinoma in situ (PLCIS). Lobular neoplasia is a neoplastic epithelial proliferation of the terminal duct lobular unit. A defining feature is discohesion due to the loss of E-cadherin, a protein that facilitates cell-to-cell adhesion. Lobular neoplasia is both a risk factor and a non-obligate precursor of invasive breast carcinoma. Classic LN, characterized by small, non-cohesive monomorphic cells, includes ALH and classic LCIS. While classic LN is usually not seen on imaging and, therefore, is diagnosed incidentally, FLCIS and PLCIS are typically the imaging targets, most often manifesting as calcifications. Unlike classic LN, which is typically hormone receptor-positive and HER2-negative, FLCIS and PLCIS may present with less favorable phenotypes. While ALH and CLCIS diagnosed on concordant core biopsy are generally managed with surveillance with or without chemoprevention, complete surgical excision is recommended for FLCIS and PLCIS due to high upgrade rates to invasive carcinoma. Accurate classification of non-invasive breast neoplastic lesions is essential for guiding treatment. This review provides an overview of the clinical features, pathology, and management of lobular neoplasia, emphasizing the importance of accurate diagnosis and individualized patient care.

Challenges to and considerations of designing cancer prevention trials

Prevention trials in oncology are some of the most important cancer clinical trials that can be designed, implemented, analyzed, and interpreted. They are pivotal in the goal of stopping the development of cancer before it starts. Prevention trials are unique in that they not only have some of the same requirements and challenges as treatment trials but also have challenges that may make their design more complex. This paper aims to discuss some types of prevention trials and highlight their most common design challenges, including large sample size requirements, slow accrual rates with long accrual duration, extended follow-up periods with trial adherence issues and missing data, endpoints that require extended follow-up or have a high level of confounding, and problems with optimizing study design. This article provides real study examples and suggestions for designing prevention clinical trials while mitigating the known issues they face.

Comparative efficacy, safety, and tolerability of pharmacotherapies for acute mania in adults: a systematic review and network meta-analysis of randomized controlled trials

The aim of this study was to provide evidence-based recommendations regarding the efficacy, safety, and tolerability of currently used pharmacological treatments for adults with acute bipolar mania. To achieve this, we conducted a systematic review and network meta-analysis (NMA) using R software and related packages. We searched primary clinical databases until February 2023 for reports of randomized controlled trials of drug treatments and adjunctive therapies for adults with acute bipolar mania, with outcomes including efficacy (mean change from baseline to endpoint in mania rating scores), safety (clinically significant adverse events from baseline to end of treatment), and tolerability (the proportion of patients who completed the whole trial to the planned endpoint). A total of 113 studies were included in our analysis, in which 23,491 participants (50.38% males; mean age = 38.6 years; mean study duration = 3.39 weeks; mean manic baseline score = 29.37) were randomly allocated to one of 51 monotherapies, adjunctive treatments, or placebo. Our results showed that tamoxifen (mean difference, -22.31 [-25.97, -18.63], N = 2, n1 = 43, n2 = 39) and tamoxifen+ lithium or valproate (LIT/VAL) (-16.37 [-22.55, -10.25], N = 1, n1 = 20, n2 = 20) had the best and second-best clinical efficacy in adults with acute bipolar mania over the placebo. Furthermore, olanzapine, paliperidone, quetiapine, ziprasidone, risperidone, divalproex, and haloperidol were significantly better tolerated than placebo. Combination therapies of antipsychotics and LIT/VAL appeared to be more effective than their corresponding monotherapies. While pharmacotherapies were associated with specific common adverse events, we found no evidence of increased incidence of headache or depression events compared to the placebo. Overall, our NMAs provided important insights into the effectiveness, safety, and tolerability of pharmacological treatments for acute bipolar mania and can help guide treatment decisions for clinicians.

Current and emerging strategies for the prevention of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths globally, with incident cases expected to rise from 905,700 in 2020 to 1.4 million by 2040. Hepatocellular carcinoma (HCC) accounts for about 80% of all primary liver cancers. Viral hepatitis and chronic excessive alcohol consumption are major risk factors for HCC, but metabolic dysfunction-associated steatotic liver disease is also becoming a dominant cause. The increasing numbers of cases of HCC and changes in risk factors highlight the urgent need for updated and targeted prevention strategies. Preventive interventions encompass strategies to decrease the burden of chronic liver diseases and their progression to HCC. These strategies include nutritional interventions and medications that have shown promise in preclinical models. Although prevailing approaches focus on treating chronic liver disease, leveraging a wider range of interventions represents a promising area to safeguard at-risk populations. In this Review, we explore existing evidence for preventive strategies by highlighting established and potential paths to reducing HCC risk effectively and safely, especially in individuals with chronic liver diseases. We categorize the preventive strategies by the mechanism of action, including anti-inflammatory, antihyperglycaemic, lipid-lowering, nutrition and dietary, antiviral, and antifibrotic pathways. For each category, we discuss the efficacy and safety information derived from mechanistic, translational, observational and clinical trial data, pinpointing knowledge gaps and directions for future research.

Risk-benefits assessment of tamoxifen or raloxifene as chemoprevention for risk reduction of breast cancer among BRCA1 and BRCA2 carriers: a meta-analysis

BACKGROUND

Breast cancer is a major global health burden, with hereditary factors such as BRCA1/2 mutations significantly increasing the lifetime risk. This meta-analysis aimed to evaluate the outcomes of selective estrogen receptor modulators (SERMs), tamoxifen, and raloxifene as chemopreventive agents for breast cancer risk reduction in BRCA1/2 mutation carriers.

METHODS

A meta-analysis was conducted according to the PRISMA guidelines. PubMed, Cochrane Library, and MEDLINE databases were searched for relevant studies published between 2000 and 2024. Case-control studies and observational cohort studies examining the use of tamoxifen/raloxifene in BRCA1/2 carriers were included. Data on the incidence and risk ratios of breast cancer were also extracted. Quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects meta-analysis was performed using Review Manager (version 5.4.0).

RESULTS

Nine studies (13,676 women) were included. Two studies had low risk, and the remaining seven studies had moderate risk, as assessed by the NOS checklist. Pooled analysis showed tamoxifen/raloxifene decreased breast cancer risk compared to controls (RR 0.80, 95% CI 0.72-0.88, p = 0.04). The risk ratio of breast cancer incidence among BRCA1/2 carriers was reduced after tamoxifen use (RR 1.82, 95% CI 1.48-2.23, p < 0.00001). Subgroup analysis revealed reduced breast cancer risk with SERM use in both BRCA1 (RR 1.51, 95% CI 1.48-1.51) and BRCA2 carriers (RR 1.48, 95% CI 1.40-1.58). The heterogeneity ranged from 51 to 85%, representing high significance and variation in true effect sizes underlying the different included studies. Whereas the heterogeneity among subgroups BRCA1 and BRCA2 was 98%, and the difference was 0%, showing no difference in response to SERM for risk reduction of breast cancer.

CONCLUSION

This meta-analysis provides evidence that tamoxifen and raloxifene significantly reduce the breast cancer risk in women with BRCA1/2 mutations. Chemoprevention efficacy was similar for both BRCA1 and BRCA2 carriers. Further research is needed to validate these findings and to optimize their use in high-risk populations.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Bilateral Risk-Reducing Mastectomy: Indications, Outcomes, and Risks

Bilateral risk-reducing mastectomy (BRRM) is the surgical removal of both breasts to reduce the risk of cancer. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, outcomes, and risks of BRRM to update the society's 2017 statement. We held a virtual meeting to outline key topics and conducted a literature search using PubMed to identify relevant articles. After literature review, recommendations were made according to group consensus. Individuals with a high lifetime risk of breast cancer due to pathogenic variants in high penetrance breast cancer-predisposition genes, early chest or breast radiation exposure, or a compelling family history should be counseled on the option of BRRM. However, BRRM is not recommended for most patients with high-risk lesions and may be contraindicated in patients who have other competing cancers and/or a high risk of surgical complications. BRRM effectively reduces the risk of breast cancer development, although the survival benefit is unclear. For patients with low-to-moderate breast cancer risk, alternative management strategies should be encouraged, including lifestyle modifications, high-risk screening, and risk-reducing medications. Discussions of BRRM should cover: (1) breast-cancer risk estimates; (2) the procedure's degree of risk reduction and impact on survival; (3) surgical techniques, potential surgical complications and long-term sequelae; and (4) alternatives to surgery. Surgeons should encourage shared and informed decision making with patients who have an elevated lifetime risk of developing breast cancer.

Pharmacovigilance insights into medication-induced risk of dural arteriovenous fistula

BACKGROUND

Dural arteriovenous fistulas (DAVFs) pose a significant health threat owing to their high misdiagnosis rate. Case reports suggest that DAVFs or related acute events may follow medication use; however, drug-related risk factors remain unclear. In clinical practice, the concomitant use of multiple drugs for therapy is known as "polypharmacy situations," further increasing the risk of drug-induced DAVF. Real-world studies linking medications and DAVF can alert clinicians to their possibilities and contribute to clinical decision-making and patient education.

METHOD

This study investigated adverse events spanning a decade from the FAERS database, employing pharmacovigilance analysis to systematically assess the risk of drug-induced DAVF. Furthermore, the clinical characteristics of these drug-related DAVFs, such as demographic information, complications, and outcomes, were characterized.

RESULT

This study generated a broad spectrum of drugs associated with DAVFs. A total of 355 DAVF events, involving 161 drugs across 73 categories, were compiled from millions of records. We identified eight classes of drugs for thorough investigation. Pharmacovigilance analysis revealed that tamoxifen, methylprednisolone, betamethasone, prednisone, rebif, ustekinumab, natalizumab, baclofen, dabigatran etexilate, and bupivacaine have the potential to induce DAVFs. Cerebrovascular thrombotic and embolic events emerge as the most prominent co-adverse events of drug-induced DAVFs. Analyses based on drug-disease targets suggested that the regulation of angiogenesis could be a potential mechanism in tamoxifen-induced DAVFs. Apart from medications with gender-specific prescription patterns, most medications exhibit a high risk of DAVF in adult male cohorts. Five patients with drug-related DAVFs experienced severe (fatal) outcomes, with four reports attributed to tamoxifen.

CONCLUSION

These findings highlight the diverse range of drugs implicated in the occurrence or progression of DAVF. Drugs such as tamoxifen, corticosteroids, multiple sclerosis medications, and oral anticoagulants require particular attention. Future research should focus on elucidating the underlying mechanisms and risk factors, such as thrombosis, contributing to drug-induced DAVF to inform preventive strategies and optimize patient care.

Hereditary Breast Cancer: Comprehensive Risk Assessment and Prevention Strategies

Women carrying pathogenic/likely pathogenic (P/LP) variants in moderate- or high-penetrance genes have an increased risk of developing breast cancer. However, most P/LP variants associated with breast cancer risk show incomplete penetrance. Age, gender, family history, polygenic risk, lifestyle, reproductive, hormonal, and environmental factors can affect the expressivity and penetrance of the disease. However, there are gaps in translating how individual genomic variation affects phenotypic presentation. The expansion of criteria for genetic testing and the increasing utilization of comprehensive genetic panels may enhance the identification of individuals carrying P/LP variants linked to hereditary breast cancer. Individualized risk assessment could facilitate the implementation of personalized risk-reduction strategies for these individuals. Preventive interventions encompass lifestyle modifications, chemoprevention, enhanced surveillance through breast imaging, and risk-reducing surgeries. This review addresses the current literature's inconsistencies and limitations, particularly regarding risk factors and the intensity of preventive strategies for women with P/LP variants in moderate- and high-penetrance genes. In addition, it synthesizes the latest evidence on risk assessment and primary and secondary prevention in women at high risk of breast cancer.

Machine learning Nomogram for Predicting endometrial lesions after tamoxifen therapy in breast Cancer patients

Objective Endometrial lesions are a frequent complication following breast cancer, and current diagnostic tools have limitations. This study aims to develop a machine learning-based nomogram model for predicting the early detection of endometrial lesions in patients. The model is designed to assess risk and facilitate individualized treatment strategies for premenopausal breast cancer patients. Method A retrospective study was conducted on 224 patients who underwent diagnostic curettage post-tamoxifen (TAM) therapy between November 2012 and November 2023. These patients exhibited signs of endometrial abnormalities or symptoms such as colporrhagia. Clinical data were collected and analyzed using R software (version 4.3.2) to identify factors influencing the occurrence of endometrial lesions and evaluate their predictive values. Three machine learning methods were employed to develop a risk prediction model, and their performances were compared. The best-performing model was selected to construct a nomogram of endometrial lesions. Internal validation was conducted using the bootstrap method, and the model's accuracy and fit were assessed using the concordance index (C-index) and calibration curves. Results Independent risk factors for endometrial lesions included ultrasound characteristics, duration of TAM therapy, presence of colporrhagia, and endometrial thickness (P < 0.05). Among the machine learning methods compared, the LASSO regression integrated with a multifactorial logistic regression model demonstrated strong performance, with a concordance index (C-index) of 0.874 and effective calibration (mean absolute error of conformity: 0.014). This model achieved an accuracy of 0.853 and a precision of 0.917, with a training set AUC of 0.874 (95% CI: 0.794-0.831) and a test set AUC of 0.891 (95% CI: 0.777-1.000), closely aligning the predicted risk with the actual observed risk. Conclusion The developed prediction model is effective in evaluating endometrial lesions in premenopausal breast cancer patients. This model offers a theoretical foundation for improving clinical predictions and devising tailored treatment strategies for this patient group.

Targeting Oestrogen Receptor Signalling in Breast Cancer Therapy

There has been over 130 years of research into the treatment of breast cancer using approaches that target oestrogen receptor signalling. Here, we summarise the development of the key pillars of such endocrine therapy, namely, oestrogen deprivation, achieved through ovarian suppression and/or aromatase inhibition, and oestrogen receptor blockade, through selective oestrogen receptor modulators, downregulators and novel compounds entering early phase development. The translation of these compounds from advanced to early breast cancer settings is discussed with a focus on the placebo-controlled breast cancer prevention studies to most accurately describe the side effect profiles of the main approaches.

A roadmap to reduce the incidence and mortality of breast cancer by rethinking our approach to women's health

Despite progress, breast cancer remains the most feared disease among women. In the USA alone, the incidence is now almost 300,000 new cancers per year, a rate that has nearly doubled in the last 30 years. Most women survive, but over 40,000 women a year still die of their disease [99]. It is the most diagnosed cancer among women and the second leading cause of cancer death. Important disparities exist in breast cancer outcomes among African American women, where women die of breast cancer at higher rates, are diagnosed younger, and at a more advanced stage. We are proposing a radical shift in our thinking about breast cancer prevention with an aspiration to dramatically lower breast cancer incidence. Most breast cancers are driven by steroid hormones. Throughout the life course, women are offered an array of hormonal treatments for menstrual cycle control, family planning, in vitro fertilization, postpartum weaning, and menopausal symptom management. There are mixed data on the extent to which each of these may contribute to increased or decreased risk for breast cancer. These endocrine manipulations could represent a great opportunity to potentially reduce breast cancer incidence and improve quality of life for survivors. To date, they have not been designed to explicitly reduce breast cancer risk. A new holistic approach will require scientists, drug developers, breast oncologists, obstetricians, gynecologists, endocrinologists, radiologists, and family medicine/internists to work together toward the common goal of reducing breast cancer risk while addressing other critical issues in women's health.

Nomograph of cancer-specific survival in elderly patients with endometrial cancer based on SEER database

OBJECTIVE

This study aims to identify prognostic factors for elderly patients with endometrial cancer and to develop a nomogram for predicting cancer-specific survival in this population.

METHODS

Clinicopathological data of elderly patients diagnosed with endometrial cancer between 2004 and 2015 were extracted from the SEER database. Patients were randomly assigned to either a training cohort or a validation cohort at a ratio of 7:3. Univariate and multivariable Cox regression analyses were performed to identify independent prognostic factors. A nomogram was then constructed based on these factors, and its predictive accuracy and discriminative ability were assessed using the C-index, receiver operating characteristic (ROC), and calibration curve.

RESULTS

Multivariate analysis identified age, marital status, grade, Federation of International of Gynecology and Obstetrics, surgery, chemotherapy, radiation, and tumor size as independent prognostic factors for elderly patients with endometrial carcinoma. Nomograms derived from these factors demonstrated excellent calibration and discrimination. The C-indexes were 0.83 for the training set and 0.82 for the validation set. The area under the curve (AUC) values for the training set were 0.88, 0.87, and 0.86 at 1, 3, and 5 year respectively. Corresponding AUC values for the validation set were 0.89, 0.86, and 0.86. Calibration curves for both cohorts demonstrated close alignment with the diagonal, indicating robust agreement between nomogram predictions and actual outcomes.

CONCLUSION

A novel nomogram has been developed for personalized prognosis assessment in elderly patients with endometrial carcinoma, aiming to enhance tailored treatment strategies and clinical management.

Long term follow-up of women treated for screen detected atypical ductal hyperplasia or lobular neoplasia in a large UK screening centre

BACKGROUND

Atypical ductal hyperplasia (ADH) and lobular neoplasia (LN) increase subsequent breast cancer (BC) risk. However, optimal surveillance and risk reduction regimes remain uncertain. We report management and outcomes of women with ADH and LN to provide data on potential screening/prevention strategies.

METHODS

Women diagnosed with screen detected ADH and/or LN between 2010-2018 at our institution were identified and demographic data, MDT decisions and BC diagnoses extracted from electronic patient records in 2019 and 2023.

RESULTS

Of 107 women, 74 were discharged to the NHS Breast Screening Programme and 33 were offered enhanced screening (ES). The proportion offered ES increased significantly over time (p = 0.037). 15/105 (14.3%) developed BC (median follow-up 117 months), 9 screen-detected and 6 symptomatic, with 3 interval cancers diagnosed 12-25 months following their last screen. 3/15 were lymph node positive and 13/14 invasive cancers were estrogen receptor (ER) positive. BC incidence rate was 1499.6/100,000 women/year (SIR = 4.7), lower in the first 5 years of follow-up compared with post 5 years.

CONCLUSIONS

In women with ADH/LN most BCs occur beyond 5 years. ES regimens should therefore extend to at least 10 years and be at least biennial. Preventative therapy should be considered given the high BC SIR and ER positivity of subsequent tumours.

Access to and Utilization of Endocrine Therapy Among Breast Cancer Survivors in Botswana

PURPOSE

Breast cancer (BC) is the most common female cancer worldwide, and the burden is increasing across sub-Saharan Africa. For women with hormone receptor-positive (HR+) cancers, endocrine therapy (ET) taken for 5-10 years can reduce the risk of recurrence by half. We explored experiences with ET and barriers to utilization among survivors in Botswana.

METHODS

We recruited women with nonmetastatic disease from a survivorship cohort who had undergone mastectomy within 1-5 years for semi-structured interviews to explore experiences with treatment. This thematic content analysis focused on ET, so the sample included women with HR+ cancer who should have received ET and HR- women who reported taking ET.

RESULTS

We analyzed interviews with 19 women (mean age 54 years, 42% stage I/II, 58% stage III). Three key themes were identified: (1) limited provider counseling, (2) challenges refilling prescriptions at public pharmacies, and (3) high medication and transportation costs associated with private pharmacies. Subthemes included immunohistochemistry result communication, lack of knowledge, frequent public pharmacy stockouts, inconvenient prescription refill policies, and medication switching and discontinuation, especially among participants with low socioeconomic positions (SEPs). Women's persistence, SEP, and financial support facilitated refills. Although some experienced side effects, they were not a common reason for discontinuation.

CONCLUSION

BC survivors in Botswana face multilevel barriers to accessing and adhering to ET. Provider and health system improvements are needed to effectively communicate ET importance and increase access to consistently available and affordable medication.

Endometrial cancer in the elderly: Characteristics, prognostic and risk factors, and treatment options

Endometrial cancer incidence and related mortality are on the rise due to aging demographics. This population often presents with unfavorable features, such as myometrial invasion, non-endometrioid histology, high-grade tumors, worse prognosis, etc. The role of age as an independent prognostic factor is still debated, and screening tools addressing frailty emerge as pivotal in guiding treatment decisions; however, they are still underutilized. Treatment disparities are evident in the case of older patients with endometrial cancer, who frequently receive suboptimal care, hindering their survival. Radiotherapy and minimally invasive surgical approaches could be performed in older patients. Data on chemotherapy and immunotherapy are scarce, but their potential remains promising and data are being gathered by recent trials, contingent on optimal patient selection through geriatric assessments. Overall, we recommend personalized, screening tool-guided approaches, adherence to guideline-recommended treatments, and inclusion of older people in clinical trials to help identify the best course of treatment.

Chemoprevention strategies in hereditary breast and ovarian cancer syndromes

Hereditary breast and/or ovarian cancer syndromes are inherited disorders in which there is an increased risk of developing breast and/or ovarian cancer in the lifetime, usually at a younger age compared to the general population. Cancer prevention in these syndromes includes prophylactic surgeries, personalized surveillance programs and chemopreventive strategies. Chemoprevention exploits the use of certain drugs or other substances to help lower the risk of developing cancer. In this context, tamoxifen was the first agent considered for breast cancer prevention, followed by raloxifene and the third-generation aromatase inhibitors. On the other hand, the first and most widespread type of chemoprevention for ovarian cancer was combined hormonal contraceptive use. Although several strategies have been studied and showed promising results, only a few of these are currently applied in daily clinical practice. Side effects along with several psychological variables such as cancer perceived risk, worries and related distress, strongly influence women's decision on chemoprevention. The present review explores and summarizes the available evidence on breast and ovarian cancer chemoprevention approaches.

Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction

INTRODUCTION

Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction.

METHODS

A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests.

RESULTS

34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035).

CONCLUSION

In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.

Treating endometrial hyperplasia (EH) post-tamoxifen treatment in breast cancer survivors: what are our options?

Tamoxifen is known to raise the risk of endometrial hyperplasia and cancer. There is virtually limited literature on how to handle Tamoxifen-induced endometrial hyperplasia (EH) in a breast cancer survivor. Levonorgestrel-releasing intrauterine system (LNG-IUS) has been explored as preventive strategies, but its impact on breast cancer recurrence especially in Progesterone receptor (PR)-positive patient is not clear. Aromatase Inhibitors (AIs) have shown beneficial results in EH after tamoxifen and their role should be explored in further trials.

Caffeine mitigates tamoxifen-induced fatty liver in Wistar rats

PURPOSE

Tamoxifen, a widely used drug for breast cancer treatment, is associated with adverse effects on the liver, including the development of fatty liver. This study aimed to investigate the potential protective effect of caffeine against tamoxifen-induced fatty liver in Wistar rats.

METHODS

Rats were divided into normal control, tamoxifen + saline, and tamoxifen + caffeine. Plasma samples were assessed for biochemical markers related to oxidative stress, inflammation, liver function, and cell damage. Additionally, liver histopathology was examined to quantify the extent of fatty infiltration.

RESULTS

In the tamoxifen + saline group, elevated levels of plasma malondialdehyde (MDA), tumor necrosis factor-alpha (TNF-α), alanine aminotransferase (ALT), cytokeratin 18, and soluble ST2 were observed compared to the normal control group, indicating increased oxidative stress, inflammation, and liver injury (p < 0.01). Moreover, histopathological examination revealed a significant increase in fatty infiltration (p < 0.001). However, in the tamoxifen + caffeine group, these markers were markedly reduced (p < 0.05, p < 0.01), and fatty infiltration was significantly mitigated (p < 0.001).

CONCLUSIONS

The findings suggest that caffeine administration attenuates tamoxifen-induced fatty liver in rats by ameliorating oxidative stress, inflammation, liver injury, and cell damage. Histopathological evidence further supports the protective role of caffeine. This study highlights the potential of caffeine as a therapeutic intervention to counter tamoxifen-induced hepatic complications, contributing to the optimization of breast cancer treatment strategies.

Discovery of therapeutic targets in cancer using chromatin accessibility and transcriptomic data

Most cancer types lack targeted therapeutic options, and when first-line targeted therapies are available, treatment resistance is a huge challenge. Recent technological advances enable the use of assay for transposase-accessible chromatin with sequencing (ATAC-seq) and RNA sequencing (RNA-seq) on patient tissue in a high-throughput manner. Here, we present a computational approach that leverages these datasets to identify drug targets based on tumor lineage. We constructed gene regulatory networks for 371 patients of 22 cancer types using machine learning approaches trained with three-dimensional genomic data for enhancer-to-promoter contacts. Next, we identified the key transcription factors (TFs) in these networks, which are used to find therapeutic vulnerabilities, by direct targeting of either TFs or the proteins that they interact with. We validated four candidates identified for neuroendocrine, liver, and renal cancers, which have a dismal prognosis with current therapeutic options.

Breast cancer incidence and mortality by metabolic syndrome and obesity: The Women's Health Initiative

BACKGROUND

In the Women's Health Initiative (WHI) randomized trial, dietary intervention significantly reduced breast cancer mortality, especially in women with more metabolic syndrome (MetS) components. Therefore, this study investigated the associations of MetS and obesity with postmenopausal breast cancer after long-term follow-up in the WHI clinical trials.

METHODS

A total of 68,132 postmenopausal women, without prior breast cancer and with normal mammogram, were entered into WHI randomized clinical trials; 63,330 women with an entry MetS score comprised the study population. At entry, body mass index (BMI) was determined; MetS score (0, 1-2, and 3-4) included the following: (1) high waist circumference (≥88 cm), (2) high blood pressure (systolic ≥130 mm Hg and/or diastolic ≥85 mm Hg, or hypertension history), (3) high-cholesterol history, and (4) diabetes history. Study outcomes included breast cancer incidence, breast cancer mortality, deaths after breast cancer, and results by hormone receptor status.

RESULTS

After a >20-year mortality follow-up, a higher MetS score (3-4), adjusted for BMI, was significantly associated with more poor prognosis, estrogen receptor (ER)-positive, progesterone receptor (PR)-negative cancers (p = .03), 53% more deaths after breast cancer (p < .001), and 44% higher breast cancer mortality (p = .03). Obesity status, adjusted for MetS score, was significantly associated with more good prognosis, ER-positive, PR-positive cancers (p < .001), more total breast cancers (p < .001), and more deaths after breast cancer (p < .001), with higher breast cancer mortality only in women with severe obesity (BMI, ≥35 kg/m2; p < .001).

CONCLUSIONS

MetS and obesity status have independent, but differential, adverse associations with breast cancer receptor subtypes and breast cancer mortality risk. Both represent separate targets for breast cancer prediction and prevention strategies.

Therapeutic Opportunities for Biomarkers in Metastatic Spine Tumors

For many spine surgeons, patients with metastatic cancer are often present in an emergent situation with rapidly progressive neurological dysfunction. Since the Patchell trial, scoring systems such as NOMS and SINS have emerged to guide the extent of surgical excision and fusion in the context of chemotherapy and radiation therapy. Yet, while multidisciplinary decision-making is the gold standard of cancer care, in the middle of the night, when a patient needs spinal surgery, the wealth of chemotherapy data, clinical trials, and other medical advances can feel overwhelming. The goal of this review is to provide an overview of the relevant molecular biomarkers and therapies driving patient survival in lung, breast, prostate, and renal cell cancer. We highlight the molecular differences between primary tumors (i.e., the patient's original lung cancer) and the subsequent spinal metastasis. This distinction is crucial, as there are limited data investigating how metastases respond to their primary tumor's targeted molecular therapies. Integrating information from primary and metastatic markers allows for a more comprehensive and personalized approach to cancer treatment.

Low ozone concentrations do not exert cytoprotective effects on tamoxifen-treated breast cancer cells in vitro

Medical treatment with low ozone concentrations proved to exert therapeutic effects in various diseases by inducing a cytoprotective antioxidant response through the nuclear factor erythroid derived-like 2 (Nrf2) transcription factor pathway. Low ozone doses are increasingly administered to oncological patients as a complementary treatment to mitigate some adverse side-effects of antitumor treatments. However, a widespread concern exists about the possibility that the cytoprotective effect of Nrf2 activation may confer drug resistance to cancer cells or at least reduce the efficacy of antitumor agents. In this study, the effect of low ozone concentrations on tamoxifen-treated MCF7 human breast cancer cells has been investigated in vitro by histochemical and molecular techniques. Results demonstrated that cell viability, proliferation and migration were generally similar in tamoxifen-treated cells as in cells concomitantly treated with tamoxifen and ozone. Notably, low ozone concentrations were unable to overstimulate the antioxidant response through the Nfr2 pathway, thus excluding a possible ozone-driven cytoprotective effect that would lead to increased tumor cell survival during the antineoplastic treatment. These findings, though obtained in an in vitro model, support the hypothesis that low ozone concentrations do not interfere with the tamoxifen-induced effects on breast cancer cells.

Evaluation of an Italian Population-Based Programme for Risk Assessment and Genetic Counselling and Testing for BRCA1/2-Related Hereditary Breast and Ovarian Cancer after 10 Years of Operation: An Observational Study Protocol

Hereditary breast/ovarian cancer (HBOC) syndrome is caused by the inheritance of monoallelic germline BRCA1/2 gene mutations. If BRCA1/2 mutation carriers are identified before the disease develops, effective actions against HBOC can be taken, including intensive screening, risk-reducing mastectomy and salpingo-oophorectomy, and risk-reducing medications. The Italian National Prevention Plan mandates the creation of regional BRCA genetic testing programmes. So far, however, only informal data have been reported on their implementation. We have designed a study aimed at evaluating the results of a population-based programme for risk assessment and genetic counselling and testing for BRCA1/2-related HBOC that is underway in the Emilia-Romagna region (northern Italy). The programme-which is entirely free-includes basic screening with an estimate of the likelihood of carrying a BRCA1/2 mutation using a familial risk assessment tool, a closer examination of women with suspected risk increase, an assessment of the need for further genetic counselling and, if needed, genetic testing and risk-reducing interventions. In this paper, the design of the programme and the protocol of the study are presented. The study has an observational, historical cohort design. Eligible are the women found to be at an increased risk of HBOC (profile 3 women). The main objectives are (i) to determine the precision of the programme in measuring the level of risk of HBOC for profile 3 women; (ii) to determine the characteristics of profile 3 women and their association with the risk management strategy chosen; (iii) to compare the age at onset, histologic type, tumour stage, molecular subtype, and prognosis of breast/ovarian cancers observed in the cohort of profile 3 women with the features of sporadic cancers observed in the general female population; (iv) to determine the level and the determinants of adherence to recommendations; and (v) to determine the appropriateness and timing of risk-reducing surgery and medications. Investigating the quality and results of the programme is necessary because the best practices in risk assessment and genetic counselling and testing for BRCA1/2-related cancer and the challenges they encounter should be identified and shared. The study has the potential to provide sound empirical evidence for the factors affecting the effectiveness of this type of service.

Patterns and Frequency of Pathogenic Germline Mutations among Patients with Newly-Diagnosed Endometrial Cancer: The Jordanian Exploratory Cancer Genetics (Jo-ECAG) Endometrial Study

Most of endometrial cancers are sporadic, with 5% or less being attributed to inherited pathogenic germline mutations and mostly related to the Lynch syndrome. To our knowledge, this is the first study to investigate patterns and frequencies of germline mutations in patients with endometrial cancer in an Arab region. Consecutive patients with endometrial cancer (n = 130), regardless of their age and family history, were enrolled. Germline genetic testing, using an 84-gene panel, was performed on all. Almost half of the patient population (n = 64, 49.2%) was tested based on international guidelines, while the remaining patients (n = 66, 50.8%) were tested as part of an ongoing universal germline genetic testing program. Among the whole group, 18 (13.8%) patients had positive pathogenic or likely pathogenic (P/LP) germline variants. The most common variants encountered were in MLH1 (n = 4, 22.2%), PMS2 (n = 3, 16.7%), ATM, MSH2, MUTYH, and BRCA2 (n = 2, 11.1% each). In addition, three (2.3%) patients were found to have an increased risk allele of the APC gene. P/LP variants were more common among patients with carcinosarcoma and clear cell carcinoma, younger patients (age ≤ 50 years), and in patients with a non-metastatic disease. We conclude that germline genetic variants, mostly in genes related to the Lynch syndrome, are relatively common among Arab patients with endometrial cancer.

Equol: a metabolite of gut microbiota with potential antitumor effects

An increasing number of studies have shown that the consumption of soybeans and soybeans products is beneficial to human health, and the biological activity of soy products may be attributed to the presence of Soy Isoflavones (SI) in soybeans. In the intestinal tracts of humans and animals, certain specific bacteria can metabolize soy isoflavones into equol. Equol has a similar chemical structure to endogenous estradiol in the human body, which can bind with estrogen receptors and exert weak estrogen effects. Therefore, equol plays an important role in the occurrence and development of a variety of hormone-dependent malignancies such as breast cancer and prostate cancer. Despite the numerous health benefits of equol for humans, only 30-50% of the population can metabolize soy isoflavones into equol, with individual variation in gut microbiota being the main reason. This article provides an overview of the relevant gut microbiota involved in the synthesis of equol and its anti-tumor effects in various types of cancer. It also summarizes the molecular mechanisms underlying its anti-tumor properties, aiming to provide a more reliable theoretical basis for the rational utilization of equol in the field of cancer treatment.

Breast Articles From 2023: Informing Practice Across the Continuum of Care

With new investigations and clinical trials in breast oncology reported every year, it is critical that surgeons be aware of advances and insights into the evolving care paradigms and treatments available to their patients. This article highlights five publications found to be particularly impactful this past year. These articles report on efforts to select the minimal effective dose of tamoxifen for prevention, to challenge the existing age-based screening guidelines as they relate to race and ethnicity, to refine axillary management treatment standards, to optimize systemic therapy in multidisciplinary care settings, and to reduce the burden of breast cancer-related lymphedema after treatment. Taken together, these efforts have an impact on all facets of the continuum of care from prevention and screening through treatment and survivorship.

Nonsurgical Management of High-Risk Lesions

This article highlights the recent publications and changing trends in practice regarding management of high-risk lesions of the breast. Traditional management has always been a surgical operation but this is recognized as overtreatment. It is recognized that overdiagnosis is inevitable but what we can control is overtreatment. Vacuum-assisted excision is now established as an alternative technique to surgery for further sampling of these high-risk lesions in the United Kingdom. Guidelines from the United Kingdom and Europe now recognize this alternative pathway, and data are available showing that vacuum-assisted excision is a safe alternative to surgery.

ESR1 and p53 interactome alteration defines mechanisms of tamoxifen response in luminal breast cancer

The canonical mechanism behind tamoxifen's therapeutic effect on estrogen receptor α/ESR1+ breast cancers is inhibition of ESR1-dependent estrogen signaling. Although ESR1+ tumors expressing wild-type p53 were reported to be more responsive to tamoxifen (Tam) therapy, p53 has not been factored into choice of this therapy and the mechanism underlying the role of p53 in Tam response remains unclear. In a window-of-opportunity trial on patients with newly diagnosed stage I-III ESR1+/HER2/wild-type p53 breast cancer who were randomized to arms with or without Tam prior to surgery, we reveal that the ESR1-p53 interaction in tumors was inhibited by Tam. This resulted in functional reactivation of p53 leading to transcriptional reprogramming that favors tumor-suppressive signaling, as well as downregulation of oncogenic pathways. These findings illustrating the convergence of ESR1 and p53 signaling during Tam therapy enrich mechanistic understanding of the impact of p53 on the response to Tam therapy.

Nature's weapons: Bioactive compounds as anti-cancer agents

Cancer represents a major global health burden, prompting continuous research for effective therapeutic strategies. Natural compounds derived from plants have emerged as potential strategies for preventing cancer and treatment because of their inherent pharmacological properties. This comprehensive review aimed to evaluate the therapeutic potential of five key natural compounds: apigenin, quercetin, piperine, curcumin, and resveratrol in cancer prevention and therapy. By examining their molecular mechanisms and preclinical evidence, this review seeks to elucidate their role as potential adjuvants or stand-alone therapies in cancer management. The exploration of natural compounds as cancer therapeutics offers several advantages, including low toxicity, wide availability, and compatibility with conventional chemotherapeutic agents. We highlighted the current understanding of their anticancer mechanisms and clinical applications for advancing personalized cancer care to improve patient outcomes. We discussed the empirical findings from in vitro, in vivo, and clinical studies reporting biological activity and therapeutic efficacy in antioxidant, immunomodulatory, anti-carcinogenic, and chemo-sensitizing modes. Innovative delivery systems and personalized treatment approaches may further enhance their bioavailability and therapeutic utility in a synergistic approach with chemo- and radiotherapeutic disease management. This review underscores the importance of natural compounds in cancer prevention and treatment, promoting a multidisciplinary approach to the development of innovative therapeutic strategies.

Update on Management of Ductal Carcinoma in Situ

Ductal carcinoma in situ (DCIS) represents 18% to 25% of all diagnosed breast cancers, and is a noninvasive, nonobligate precursor lesion to invasive cancer. The diagnosis of DCIS represents a wide range of disease, including lesions with both low and high risk of progression to invasive cancer and recurrence. Over the past decade, research on the topic of DCIS has focused on the possibility of tailoring treatment for patients according to their risk for progression and recurrence, which is based on clinicopathologic, biomolecular and genetic factors. These efforts are ongoing, with recently completed and continuing clinical trials spanning the continuum of cancer care. We conducted a review to identify recent advances on the topic of diagnosis, risk stratification and management of DCIS. While novel imaging techniques have increased the rate of DCIS diagnosis, questions persist regarding the optimal management of lesions that would not be identified with conventional methods. Additionally, among trials investigating the potential for omission of surgery and use of active surveillance, 2 trials have completed accrual and 2 clinical trials are continuing to enroll patients. Identification of novel genetic patterns is expanding our potential for risk stratification and aiding our ability to de-escalate radiation and systemic therapies for DCIS. These advances provide hope for tailoring of DCIS treatment in the near future.

Updates in the Surgical Management of Benign and High-Risk Breast Lesions

Benign breast disease (BBD) is a heterogenous group of lesions often classified as nonproliferative or proliferative, with the latter group further categorized based on the presence of atypia. Although nonproliferative lesions are more common, the risk of breast cancer is elevated in women with proliferative lesions. Historically, the majority of proliferative lesions were excised due to concern for future and/or concomitant breast cancer at the site of the index lesion. However, contemporary data suggest that the risk of cancer associated with various proliferative lesions may be lower than previously thought, and management of BBD has become more nuanced. In this review, we will focus on recent updates in the management of a select group of benign and high-risk lesions.

Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative

BACKGROUND

Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk.

PATIENTS AND METHODS

This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion.

RESULTS

Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI 3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate.

CONCLUSIONS

The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10 mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.

Tamoxifen protects photoreceptors in the sodium iodate model

Because the selective estrogen receptor modulator tamoxifen was shown to be retina-protective in the light damage and rd10 models of retinal degeneration, the purpose of this study was to test whether tamoxifen is retina-protective in a model where retinal pigment epithelium (RPE) toxicity appears to be the primary insult: the sodium iodate (NaIO3) model. C57Bl/6J mice were given oral tamoxifen (in the diet) or the same diet lacking tamoxifen, then given an intraperitoneal injection of NaIO3 at 25 mg/kg. The mice were imaged a week later using optical coherence tomography (OCT). ImageJ with a custom macro was utilized to measure retinal thicknesses in OCT images. Electroretinography (ERG) was used to measure retinal function one week post-injection. After euthanasia, quantitative real-time PCR (qRT-PCR) was performed. Tamoxifen administration partially protected photoreceptors. There was less photoreceptor layer thinning in OCT images of tamoxifen-treated mice. qRT-PCR revealed, in the tamoxifen-treated group, less upregulation of antioxidant and complement factor 3 mRNAs, and less reduction in the rhodopsin and short-wave cone opsin mRNAs. Furthermore, ERG results demonstrated preservation of photoreceptor function for the tamoxifen-treated group. Cone function was better protected than rods. These results indicate that tamoxifen provided structural and functional protection to photoreceptors against NaIO3. RPE cells were not protected. These neuroprotective effects suggest that estrogen-receptor modulation may be retina-protective. The fact that cones are particularly protected is intriguing given their importance for human visual function and their survival until the late stages of retinitis pigmentosa. Further investigation of this protective pathway could lead to new photoreceptor-protective therapeutics.