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de Oliveira LM, Garcia HO, Curvello KD, Rebelatto TF, Dal Pizzol TDS. Letter to the Editor of Clinical Breast Cancer, on "Time to Update Evidence-Based Guideline Recommendations About Concurrent Tamoxifen and Antidepressant Use? A Systematic Review," Conducted by Michelle Bradbury and Collaborators and Published in Clinical Breast Cancer April Vol 22 no.4 e362-e373, 2022. Clin Breast Cancer 2023; 23:e109-e111. [PMID: 36681576 DOI: 10.1016/j.clbc.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Luciana Mello de Oliveira
- Núcleo de Avaliação de Tecnologias em Saúde do GHC, Gerência de Ensino e Pesquisa, Grupo Hospitalar Conceição (GEP-GHC), Porto Alegre, RS, Brazil.
| | - Helana Ortiz Garcia
- Coordenadoria de Gerência de Laboratórios, Instituto Federal de Educação, Ciência e Tecnologia do Rio Grande do Sul (IFRS), Porto Alegre, RS, Brazil
| | - Karine Duarte Curvello
- Faculdade de Farmácia, Programa de Pós-Graduação em Assistência Farmacêutica (PPASFAR), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Taiane Francielli Rebelatto
- Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia (PPGEPI), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Tatiane da Silva Dal Pizzol
- Faculdade de Farmácia, Programa de Pós-Graduação em Assistência Farmacêutica (PPASFAR), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia (PPGEPI), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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2
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Lyles RH, Zhang Y, Ge L, England C, Ward K, Lash TL, Waller LA. Using Capture-Recapture Methodology to Enhance Precision of Representative Sampling-Based Case Count Estimates. JOURNAL OF SURVEY STATISTICS AND METHODOLOGY 2022; 10:1292-1318. [PMID: 36397765 PMCID: PMC9643167 DOI: 10.1093/jssam/smab052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The application of serial principled sampling designs for diagnostic testing is often viewed as an ideal approach to monitoring prevalence and case counts of infectious or chronic diseases. Considering logistics and the need for timeliness and conservation of resources, surveillance efforts can generally benefit from creative designs and accompanying statistical methods to improve the precision of sampling-based estimates and reduce the size of the necessary sample. One option is to augment the analysis with available data from other surveillance streams that identify cases from the population of interest over the same timeframe, but may do so in a highly nonrepresentative manner. We consider monitoring a closed population (e.g., a long-term care facility, patient registry, or community), and encourage the use of capture-recapture methodology to produce an alternative case total estimate to the one obtained by principled sampling. With care in its implementation, even a relatively small simple or stratified random sample not only provides its own valid estimate, but provides the only fully defensible means of justifying a second estimate based on classical capture-recapture methods. We initially propose weighted averaging of the two estimators to achieve greater precision than can be obtained using either alone, and then show how a novel single capture-recapture estimator provides a unified and preferable alternative. We develop a variant on a Dirichlet-multinomial-based credible interval to accompany our hybrid design-based case count estimates, with a view toward improved coverage properties. Finally, we demonstrate the benefits of the approach through simulations designed to mimic an acute infectious disease daily monitoring program or an annual surveillance program to quantify new cases within a fixed patient registry.
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Affiliation(s)
- Robert H Lyles
- Address correpondence to Robert H. Lyles, Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, 1518 Clifton Rd. N.E., Atlanta, GA 30322, USA; E-mail:
| | - Yuzi Zhang
- Research Assistant Research Assistant with the Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, 1518 Clifton Rd. N.E., Atlanta, GA 30322, USA
| | - Lin Ge
- Research Assistant with the Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, 1518 Clifton Rd. N.E., Atlanta, GA 30322, USA
| | - Cameron England
- Associate Director, Professor with the Department of Epidemiology, The Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - Kevin Ward
- Research Assistant Professor, Professor with the Department of Epidemiology, The Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - Timothy L Lash
- Professor with the Department of Epidemiology, The Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - Lance A Waller
- Professor, Department of Biostatistics and Bioinformatics, The Rollins School of Public Health of Emory University, Atlanta, GA, USA
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3
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Miranda C, Galleguillos M, Torres R, Tardón K, Cáceres DD, Lee K, Redal MA, Varela NM, Quiñones LA. Preliminary Pharmacogenomic-Based Predictive Models of Tamoxifen Response in Hormone-dependent Chilean Breast Cancer Patients. Front Pharmacol 2021; 12:661443. [PMID: 34899282 PMCID: PMC8656167 DOI: 10.3389/fphar.2021.661443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Tamoxifen (TAM), a selective oestrogen receptor modulator, is one of the most used treatments in oestrogen receptor-positive (ER+) early and metastatic breast cancer (BC) patients. The response to TAM has a high degree of inter-individual variability. This is mainly due to genetic variants in CYP2D6 gene, as well as other genes encoding proteins involved in the TAM pharmacokinetic and/or pharmacodynamic. Therefore, prediction of the TAM response using these genetic factors together with other non-genetic variables may be relevant to improve breast cancer treatment. Thus, in this work, we used genetic polymorphisms and clinical variables for TAM response modelling. One hundred sixty-two ER + BC patients with 2 years of TAM treatment were retrospectively recruited, and the genetic polymorphisms CYP2D6*4, CYP3A4*1B (CYP3A4*1.001), CYP3A5*3, UGT2B7*2, UGT2B15*2, SULT1A1*2, and ESRA V364E were analyzed by PCR-RFLP. Concomitantly, the therapeutic response was obtained from clinical records for association with genotypes using univariate and multivariate biostatistical models. Our results show that UGT2B15*1/*2 genotype protects against relapse (OR = 0.09; p = 0.02), CYP3A5*3/*3 genotype avoids endometrial hyperplasia (OR = 0.07; p = 0.01), SULT1A1*1/*2 genotype avoids vaginal bleeding (OR = 0.09; p = 0.03) and ESRA 364E/364E genotype increases the probability of vaginal bleeding (OR = 5.68; p = 0.02). Logistic regression models, including genomic and non-genomic variables, allowed us to obtain preliminary predictive models to explain relapse (p = 0.010), endometrial hyperplasia (p = 0.002) and vaginal bleeding (p = 0.014). Our results suggest that the response to TAM treatment in ER + BC patients might be associated with the presence of the studied genetic variants in UGT2B15, CYP3A5, SULT1A1 and ESRA genes. After clinical validation protocols, these models might be used to help to predict a percentage of BC relapse and adverse reactions, improving the individual response to TAM-based treatment.
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Affiliation(s)
- Carla Miranda
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Macarena Galleguillos
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile
| | | | | | - Dante D Cáceres
- Institute of Population Health, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Kuen Lee
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Faculty of Medicine, University of Chile, Santiago, Chile
| | - María A Redal
- Genetic Division, Department of Medicine, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Nelson M Varela
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Luis A Quiñones
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology (DOBC), Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
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4
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Collin LJ, Maliniak ML, Cronin-Fenton DP, Ahern TP, Christensen KB, Ulrichsen SP, Damkier P, Hamilton-Dutoit S, Yacoub R, Christiansen PM, Sørensen HT, Lash TL. Hypoxia-inducible factor-1α expression and breast cancer recurrence in a Danish population-based case control study. Breast Cancer Res 2021; 23:103. [PMID: 34736510 PMCID: PMC8567651 DOI: 10.1186/s13058-021-01480-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/23/2021] [Indexed: 12/27/2022] Open
Abstract
Background Hypoxia-inducible factor-1α (HIF-1α) is a transcription factor that facilitates the adaptation of cancer cells to hypoxic conditions and may be prognostic of breast cancer recurrence. We evaluated the association of HIF-1α expression with breast cancer recurrence, and its association with timing of breast cancer recurrence. Methods In this population-based case-control study, we included women diagnosed with stage I–III breast cancer between 1985 and 2001, aged 35–69 years, registered in the Danish Breast Cancer Group. We identified 541 cases of breast cancer recurrence among women with estrogen receptor (ER)-positive disease who were treated with tamoxifen for at least 1 year (ER+ TAM+). We also enrolled 300 breast cancer recurrence cases among women with ER-negative disease, not treated with tamoxifen, who survived at least 1 year (ER−/TAM−). Controls were recurrence-free breast cancer patients at the time of case diagnosis, matched to recurrence cases on ER/TAM status, date of surgery, menopausal status, cancer stage, and county of residence. Expression of HIF-1α was measured by immunohistochemistry on tissue microarrays. We fitted logistic regression models to compute odds ratios (ORs) and 95% confidence intervals (CIs) associating HIF-1α expression with recurrence, and with timing of recurrence. Results HIF-1α expression was observed in 23% of cases and 20% of controls in the ER+/TAM+ stratum, and in 47% of cases and 48% of controls in the ER−/TAM− stratum. We observed a near-null association between HIF-1α expression in both ER/TAM groups (ER+/TAM+ OR = 1.21, 95%CI 0.88, 1.67 and ER−/TAM− OR = 0.97, 95%CI 0.68, 1.39). HIF-1α expression was not associated with time to recurrence among women in the ER+/TAM+ stratum, but was associated with early recurrence among women in the ER−/TAM− stratum. Conclusion In this study, HIF-1α expression was not associated with breast cancer recurrence overall but may be associated with early recurrence among women diagnosed with ER− breast cancer. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01480-1.
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Affiliation(s)
- Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA. .,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark. .,Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope Drive, Room 4746, Salt Lake City, UT, 84112, USA.
| | - Maret L Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Thomas P Ahern
- Department of Surgery, The Robert Larner, M.D. College of Medicine, The University of Vermont, Burlington, VT, USA
| | | | - Sinna P Ulrichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Peer M Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark.,The Danish Breast Cancer Group, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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5
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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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6
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Slanař O, Hronová K, Bartošová O, Šíma M. Recent advances in the personalized treatment of estrogen receptor-positive breast cancer with tamoxifen: a focus on pharmacogenomics. Expert Opin Drug Metab Toxicol 2020; 17:307-321. [PMID: 33320718 DOI: 10.1080/17425255.2021.1865310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Tamoxifen is still an important drug in hormone-dependent breast cancer therapy. Personalization of its clinical use beyond hormone receptor positivity could improve the substantial variability of the treatment response.Areas covered: The overview of the current evidence for the treatment personalization using therapeutic drug monitoring, or using genetic biomarkers including CYP2D6 is provided. Although many studies focused on the PK aspects or the impact of CYP2D6 variability the translation into clinical routine is not clearly defined due to the inconsistent clinical outcome data.Expert opinion: We believe that at least the main candidate factors, i.e. CYP2D6 polymorphism, CYP2D6 inhibition, endoxifen serum levels may become important predictors of clinical relevance for tamoxifen treatment personalization in the future. To achieve this aim, however, further research should take into consideration more precise characterization of the disease, epigenetic factors and also utilize an appropriately powered multifactorial approach instead of a single gene evaluating studies.
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Affiliation(s)
- Ondřej Slanař
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolína Hronová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Olga Bartošová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
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7
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Egeland NG, Jonsdottir K, Lauridsen KL, Skaland I, Hjorth CF, Gudlaugsson EG, Hamilton-Dutoit S, Lash TL, Cronin-Fenton D, Janssen EAM. Digital Image Analysis of Ki-67 Stained Tissue Microarrays and Recurrence in Tamoxifen-Treated Breast Cancer Patients. Clin Epidemiol 2020; 12:771-781. [PMID: 32801916 PMCID: PMC7383278 DOI: 10.2147/clep.s248167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The proliferation marker Ki-67 has been used as a prognostic marker to separate low- and high-risk breast cancer subtypes and guide treatment decisions for adjuvant chemotherapy. The association of Ki-67 with response to tamoxifen therapy is unclear. High-throughput automated scoring of Ki-67 might enable standardization of quantification and definition of clinical cut-off values. We hypothesized that digital image analysis (DIA) of Ki-67 can be used to evaluate proliferation in breast cancer tumors, and that Ki-67 may be associated with tamoxifen resistance in early-stage breast cancer. Patients and Methods Here, we apply DIA technology from Visiopharm using a custom designed algorithm for quantifying the expression of Ki-67, in a case–control study nested in the Danish Breast Cancer Group clinical database, consisting of stages I, II, or III breast cancer patients of 35–69 years of age, diagnosed during 1985–2001, in the Jutland peninsula, Denmark. We assessed DIA-Ki-67 score on tissue microarrays (TMAs) from breast cancer patients in a case–control study including 541 ER-positive and 300 ER-negative recurrent cases and their non-recurrent controls, matched on ER-status, cancer stage, menopausal status, year of diagnosis, and county of residence. We used logistic regression to estimate odds ratios and associated 95% confidence intervals to determine the association of Ki-67 expression with recurrence risk, adjusting for matching factors, chemotherapy, type of surgery, receipt of radiation therapy, age category, and comorbidity. Results Ki-67 was not associated with increased risk of recurrence in tamoxifen-treated patients (ORadj =0.72, 95% CI 0.54, 0.96) or ER-negative patients (ORadj =0.85, 95% CI 0.54, 1.34). Conclusion Our findings suggest that Ki-67 digital image analysis in TMAs is not associated with increased risk of recurrence among tamoxifen-treated ER-positive breast cancer or ER-negative breast cancer patients. Overall, our findings do not support an increased risk of recurrence associated with Ki-67 expression.
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Affiliation(s)
- Nina Gran Egeland
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway.,Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Kristin Jonsdottir
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | | | - Ivar Skaland
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Cathrine F Hjorth
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Emiel A M Janssen
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway.,Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, Stavanger, Norway
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8
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Collin LJ, Ulrichsen SP, Ahern TP, Goodman M, McCullough LE, Waller LA, Bang Christensen K, Damkier P, Hamilton-Dutoit S, Lauridsen KL, Yacoub R, Christiansen PM, Ejlertsen B, Sørensen HT, Cronin-Fenton DP, Lash TL. 17β-Hydroxysteroid dehydrogenase 1:2 and breast cancer recurrence: a Danish population-based study. Acta Oncol 2020; 59:329-333. [PMID: 31671023 DOI: 10.1080/0284186x.2019.1684560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Lindsay J. Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sinna P. Ulrichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas P. Ahern
- Department of Surgery, The Robert Larner, M.D. College of Medicine, The University of Vermont, Burlington, VT, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E. McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Peer M. Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen, Denmark
- Rigshospitalet, Copenhagen, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA, USA
| | | | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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9
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Ahern TP, Collin LJ, Baurley JW, Kjærsgaard A, Nash R, Maliniak ML, Damkier P, Zwick ME, Isett RB, Christiansen PM, Ejlertsen B, Lauridsen KL, Christensen KB, Silliman RA, Sørensen HT, Tramm T, Hamilton-Dutoit S, Lash TL, Cronin-Fenton D. Metabolic Pathway Analysis and Effectiveness of Tamoxifen in Danish Breast Cancer Patients. Cancer Epidemiol Biomarkers Prev 2020; 29:582-590. [PMID: 31932415 PMCID: PMC7060091 DOI: 10.1158/1055-9965.epi-19-0833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/15/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Tamoxifen and its metabolites compete with estrogen to occupy the estrogen receptor. The conventional dose of adjuvant tamoxifen overwhelms estrogen in this competition, reducing breast cancer recurrence risk by nearly half. Phase I metabolism generates active tamoxifen metabolites, and phase II metabolism deactivates them. No earlier pharmacogenetic study has comprehensively evaluated the metabolism and transport pathways, and no earlier study has included a large population of premenopausal women. METHODS We completed a cohort study of 5,959 Danish nonmetastatic premenopausal breast cancer patients, in whom 938 recurrences occurred, and a case-control study of 541 recurrent cases in a cohort of Danish predominantly postmenopausal breast cancer patients, all followed for 10 years. We collected formalin-fixed paraffin-embedded tumor blocks and genotyped 32 variants in 15 genes involved in tamoxifen metabolism or transport. We estimated conventional associations for each variant and used prior information about the tamoxifen metabolic path to evaluate the importance of metabolic and transporter pathways. RESULTS No individual variant was notably associated with risk of recurrence in either study population. Both studies showed weak evidence of the importance of phase I metabolism in the clinical response to adjuvant tamoxifen therapy. CONCLUSIONS Consistent with prior knowledge, our results support the role of phase I metabolic capacity in clinical response to tamoxifen. Nonetheless, no individual variant substantially explained the modest phase I effect on tamoxifen response. IMPACT These results are consistent with guidelines recommending against genotype-guided prescribing of tamoxifen, and for the first time provide evidence supporting these guidelines in premenopausal women.
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Affiliation(s)
- Thomas P Ahern
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, Vermont
| | - Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maret L Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael E Zwick
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - R Benjamin Isett
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - Peer M Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Rebecca A Silliman
- Boston University School of Medicine, Boston University, Boston, Massachusetts
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Winship Cancer Institute, Emory University, Atlanta, Georgia
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10
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Ximenez JPB, de Andrade JM, Marques MP, Coelho EB, Suarez-Kurtz G, Lanchote VL. Hormonal status affects plasma exposure of tamoxifen and its main metabolites in tamoxifen-treated breast cancer patients. BMC Pharmacol Toxicol 2019; 20:81. [PMID: 31852530 PMCID: PMC6921430 DOI: 10.1186/s40360-019-0358-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Tamoxifen is considered a prodrug of its active metabolite endoxifen, which is dependent on the CYP2D6 and CYP3A enzymes. Tamoxifen pharmacokinetic variability influences endoxifen exposure and, consequently, its clinical outcome. This study investigated the impact of hormonal status on the pharmacokinetics of tamoxifen and its metabolites in TAM-treated breast cancer patients. Methods TAM-treated breast cancer patients (n = 40) previously believed to have CYP3A activity within the normal range based on oral midazolam and phenotyped as CYP2D6 normal metabolizers using oral metoprolol were divided into two groups according to premenopausal (n = 20; aged 35–50 years) or postmenopausal (n = 20; aged 60–79 years) status. All patients were treated with 20 mg/day tamoxifen for at least three months. Serial plasma samples were collected within the 24 h dose interval for analysis of unchanged tamoxifen, endoxifen, 4-hydroxytamoxifen and N-desmethyltamoxifen quantified by LC-MS/MS. CYP activities were assessed using midazolam apparent clearance (CYP3A) and the metoprolol/alfa-hydroxymetoprolol plasma metabolic ratio (CYP2D6). CYP3A4, CYP3A5 and CYP2D6 SNPs and copy number variation were investigated using TaqMan assays. Results Postmenopausal status increased steady-state plasma concentrations (Css) of tamoxifen (116.95 vs 201.23 ng/mL), endoxifen (8.01 vs 18.87 ng/mL), N-desmethyltamoxifen (485.16 vs 843.88 ng/mL) and 4-hydroxytamoxifen (2.67 vs 4.11 ng/mL). The final regression models included hormonal status as the only predictor for Css of tamoxifen [β-coef ± SE, p-value (75.03 ± 17.71, p = 0.0001)] and 4-hydroxytamoxifen (1.7822 ± 0.4385, p = 0.0002), while endoxifen Css included hormonal status (8.578 ± 3.402, p = 0.02) and race (11.945 ± 2.836, p = 0.007). For N-desmethyltamoxifen Css, the final model was correlated with hormonal status (286.259 ± 76.766, p = 0.0007) and weight (− 8.585 ± 3.060, p = 0.008). Conclusion The premenopausal status was associated with decreased endoxifen plasma concentrations by 135% compared to postmenopausal status. Thus, the endoxifen plasma concentrations should be monitored mainly in the premenopausal period to maintain plasma levels above the efficacy threshold value. Trial registration RBR-7tqc7k.
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Affiliation(s)
- João Paulo Bianchi Ximenez
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Jurandyr Moreira de Andrade
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Paula Marques
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Eduardo Barbosa Coelho
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Vera Lucia Lanchote
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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11
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Moghbeli M. Genetic and molecular biology of breast cancer among Iranian patients. J Transl Med 2019; 17:218. [PMID: 31286981 PMCID: PMC6615213 DOI: 10.1186/s12967-019-1968-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract Background, Breast cancer (BC) is one of the leading causes of cancer related deaths in Iran. This high ratio of mortality had a rising trend during the recent years which is probably associated with late diagnosis. Main body Therefore it is critical to define a unique panel of genetic markers for the early detection among our population. In present review we summarized all of the reported significant genetic markers among Iranian BC patients for the first time, which are categorized based on their cellular functions. Conclusions This review paves the way of introducing a unique ethnic specific panel of diagnostic markers among Iranian BC patients. Indeed, this review can also clarify the genetic and molecular bases of BC progression among Iranians.
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Affiliation(s)
- Meysam Moghbeli
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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12
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Collin LJ, Cronin-Fenton DP, Ahern TP, Christensen KB, Damkier P, Hamilton-Dutoit S, Kjaersgaard A, Lauridsen KL, Yacoub R, Christiansen P, Sørensen HT, Lash TL. Expression of survivin does not appear to influence breast cancer recurrence risk. Acta Oncol 2019; 58:154-161. [PMID: 30351173 DOI: 10.1080/0284186x.2018.1503419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Survivin is an inhibitor of apoptosis, and its expression associates with poor outcomes in multiple cancers. It may be a therapeutic target due to its unique expression in cancer cells. METHODS We estimated the association between nuclear and cytoplasmic survivin expression in primary tumors and breast cancer recurrence. In this case-control study, we included women age 35-69, diagnosed with stage I-III breast cancer between 1985 and 2001, and registered with the Danish Breast Cancer Group. We identified 541 patients with breast cancer recurrence with estrogen receptor-positive disease who were treated with tamoxifen for at least 1 year (ER+/TAM+) and 300 with estrogen receptor-negative carcinomas, not treated with tamoxifen, and who survived at least 1 year (ER-/TAM-). Controls were matched to cases on ER/TAM status, date of surgery, menopausal status, stage and county. Survivin expression was estimated by immunohistochemistry on tissue microarrays. We fit logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) associating nuclear and cytoplasmic survivin expression with recurrence. RESULTS Associations between nuclear and cytoplasmic survivin expression and breast cancer recurrence were near-null in both ER+/TAM + and ER-/TAM - strata. For the cytoplasmic to nuclear ratio (CNR) of survivin expression, we found a null association in the ER+/TAM + group comparing CNR ≥5 with CNR <5, but an association (OR =2.48, 95% CI: 1.15, 5.31) in the ER-/TAM - group. CONCLUSIONS Survivin expression was not associated with breast cancer recurrence in this study. The CNR ratio may warrant further investigation especially among ER - tumors.
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Affiliation(s)
- Lindsay J. Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Thomas P. Ahern
- Department of Surgery, College of Medicine at The University of Vermont, Burlington, VT, USA
| | | | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Anders Kjaersgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Peer Christiansen
- Breast Unit, Aarhus Denmark and on behalf of the Danish Breast Cancer Group, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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13
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Hjorth CF, Nielsen AS, Sørensen HT, Lash TL, Damkier P, Hamilton-Dutoit S, Cronin-Fenton D. Multi-drug resistance protein 2 (MRP2) expression, adjuvant tamoxifen therapy, and risk of breast cancer recurrence: a Danish population-based nested case-control study. Acta Oncol 2019; 58:168-174. [PMID: 30458661 DOI: 10.1080/0284186x.2018.1537508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Adjuvant tamoxifen therapy approximately halves the risk of recurrence in estrogen receptor-positive (ER+) breast cancer patients, but many women respond insufficiently to therapy. Expression of multi-drug resistance protein 2 (MRP2) in breast cancer may potentiate tamoxifen resistance. Thus, we investigated the expression of MRP2 in breast cancer as a predictor of tamoxifen therapy effectiveness. MATERIAL AND METHODS We conducted a case-control study nested in the Danish Breast Cancer Group clinical database. The study included women aged 35-69 years diagnosed with stage l-lll breast cancer during 1985-2001, in Jutland, Denmark. We identified 541 recurrent breast cancers (cases) among women with estrogen receptor positive (ER+) disease treated with tamoxifen for at least 1 year (ER+/TAM+) and 300 cases among women with estrogen receptor-negative (ER-) disease, never treated with tamoxifen (ER-/TAM-). We matched one recurrence-free control to each recurrent case. We retrieved paraffin-embedded primary tumor tissue for all patients, and all available recurrent tumor tissue from pathology archives. MRP2 expression was evaluated using immunohistochemistry. We computed odds ratios (ORs) and 95% confidence intervals (95% CIs) associating MRP2 expression (positive vs. none) with breast cancer recurrence in conditional logistic regression models. We compared MRP2 expression in paired primary- and recurrent tumors. RESULTS MRP2 expression was more prevalent in the ER+/TAM + group, than in the ER-/TAM - group. No predictive utility of MRP2 for breast cancer recurrence was found in the ER+/TAM + group (ORadj = 0.96, 95% CI 0.70, 1.33). Further, no prognostic utility was found in the ER-/TAM - group (ORadj = 0.81, 95% CI 0.53, 1.23). MRP2 expression was not increased in recurrent versus primary tumors. CONCLUSIONS MRP2 expression is neither a predictive marker of tamoxifen effectiveness nor a prognostic marker in breast cancer.
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Affiliation(s)
- Cathrine F. Hjorth
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anja S. Nielsen
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L. Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, and Winship Cancer Institute, Emory University, Atlanta, USA
| | - Per Damkier
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Abstract
Tamoxifen is a prodrug, and most of the therapeutic effect in treating breast cancer stems from its metabolite, endoxifen. Since cytochrome P450 (CYP) 2D6 is the most important enzyme in the production of endoxifen, drugs that inhibit CYP2D6 would be expected to reduce tamoxifen efficacy. In addition to drug–drug interactions (DDI) involving CYP2D6, there is growing evidence that enzyme inducers can substantially alter the disposition of endoxifen, reducing tamoxifen efficacy. Although the clinical evidence on the impact of CYP2D6 inhibitors on tamoxifen efficacy is mixed, there were serious flaws in many of the studies. Thus, there is a reasonable chance that CYP2D6 inhibitors do in fact inhibit tamoxifen efficacy. Tamoxifen has extraordinarily complex pharmacokinetics, with more than a dozen drug-metabolizing enzymes and transporters involved in its disposition. Enzyme inducers may increase the activity of several of these pathways, including phase II enzymes, ABC transporters, and various CYP enzymes other than CYP2D6. Based on current clinical evidence, one could argue that enzyme inducers are potentially more dangerous than CYP2D6 inhibitors in patients taking tamoxifen. Moreover, early evidence suggests that the combination of CYP2D6 inhibitors plus enzyme inducers may produce catastrophic inhibition of tamoxifen efficacy. One could argue that, given the available evidence, an agnostic “wait and see” position on tamoxifen DDI is ethically untenable, and that many women with breast cancer are currently being subjected to an unnecessary risk of cancer recurrence. Specific recommendations to reduce the risk of adverse tamoxifen DDI are offered for consideration.
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Affiliation(s)
- Philip D Hansten
- Professor Emeritus, School of Pharmacy, University of Washington, Seattle, WA, 98195, USA.
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15
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CYP2D6-inhibiting medication use and inherited CYP2D6 variation in relation to adverse breast cancer outcomes after tamoxifen therapy. Cancer Causes Control 2018; 30:103-112. [PMID: 30542984 DOI: 10.1007/s10552-018-1117-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 12/04/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Tamoxifen is widely used to reduce the risk of breast cancer (BC) recurrence and extend disease-free survival among women with estrogen-sensitive breast cancers. Tamoxifen efficacy is thought to be attributable to its active metabolite, which is formed through a reaction catalyzed by the P450 enzyme, CYP2D6. Inhibition of tamoxifen metabolism as a result of germline genetic variation and/or use of CYP2D6-inhibiting medications ("inhibitors") is hypothesized to increase the risk of adverse BC outcomes among women taking tamoxifen. METHODS The present cohort study of 960 women diagnosed with early-stage BC between 1993 and 1999 examined the association between concomitant use of CYP2D6 inhibitors and adjuvant tamoxifen and the risk of adverse BC outcomes (recurrence, second primary BC, BC mortality), both overall and according to CYP2D6 metabolic phenotype. RESULTS Six or more months of CYP2D6 inhibitor use concomitant with tamoxifen was not associated with any appreciable increase in risk of recurrence or second primary BC or BC mortality, and there was no clear evidence of variation by CYP2D6 metabolic phenotype. CONCLUSIONS These results are consistent with the relatively few other large, population-based studies conducted to date that have not observed an increased risk of adverse BC outcomes associated with CYP2D6 inhibition.
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Brooks JD, Comen EA, Reiner AS, Orlow I, Leong SF, Liang X, Mellemkjær L, Knight JA, Lynch CF, John EM, Bernstein L, Woods M, Doody DR, Malone KE, Bernstein JL. CYP2D6 phenotype, tamoxifen, and risk of contralateral breast cancer in the WECARE Study. Breast Cancer Res 2018; 20:149. [PMID: 30526633 PMCID: PMC6288916 DOI: 10.1186/s13058-018-1083-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Tamoxifen treatment greatly reduces a woman's risk of developing a second primary breast cancer. There is, however, substantial variability in treatment response, some of which may be attributed to germline genetic variation. CYP2D6 is a key enzyme in the metabolism of tamoxifen to its active metabolites, and variants in this gene have been associated with reduced tamoxifen metabolism. The impact of variation on risk of contralateral breast cancer (CBC) is unknown. METHODS Germline DNA from 1514 CBC cases and 2203 unilateral breast cancer controls was genotyped for seven single nucleotide polymorphisms, one three-nucleotide insertion-deletion, and a full gene deletion. Each variant has an expected impact on enzyme activity, which in combination allows for the classification of women as extensive, intermediate, and poor metabolizers (EM, IM, and PM respectively). Each woman was assigned one of six possible diplotypes and a corresponding CYP2D6 activity score (AS): EM/EM (AS = 2), EM/IM (AS = 1.5), EM/PM (AS = 1), IM/IM (AS = 0.75), IM/PM (AS = 0.5), and PM/PM (AS = 0). We also collapsed categories of the AS to generate an overall phenotype (EM, AS ≥ 1; IM, AS = 0.5-0.75; PM, AS = 0). Rate ratios (RRs) and 95% confidence intervals (CIs) for the association between tamoxifen treatment and risk of CBC in our study population were estimated using conditional logistic regression, stratified by AS. RESULTS Among women with AS ≥ 1 (i.e., EM), tamoxifen treatment was associated with a 20-55% reduced RR of CBC (AS = 2, RR = - 0.81, 95% CI 0.62-1.06; AS = 1.5, RR = 0.45, 95% CI 0.30-0.68; and AS = 1, RR = 0.55, 95% CI 0.40-0.74). Among women with no EM alleles and at least one PM allele (i.e., IM and PM), tamoxifen did not appear to impact the RR of CBC in this population (AS = 0.5, RR = 1.08, 95% CI 0.59-1.96; and AS = 0, RR = 1.17, 95% CI 0.58-2.35) (p for homogeneity = - 0.02). CONCLUSION This study suggests that the CYP2D6 phenotype may contribute to some of the observed variability in the impact of tamoxifen treatment for a first breast cancer on risk of developing CBC.
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Affiliation(s)
- Jennifer D. Brooks
- University of Toronto, Dalla Lana School of Public Health Sciences, 155 College St. HSB 676, Toronto, ON M5T 3M7 Canada
| | | | - Anne S. Reiner
- Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Irene Orlow
- Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Siok F. Leong
- Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Xiaolin Liang
- Memorial Sloan Kettering Cancer Center, New York, NY USA
| | | | - Julia A. Knight
- University of Toronto, Dalla Lana School of Public Health Sciences, 155 College St. HSB 676, Toronto, ON M5T 3M7 Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | | | - Esther M. John
- Department of Medicine and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA USA
| | - Leslie Bernstein
- Beckman Research Institute, City of Hope National Medical Centre, Duarte, CA USA
| | - Meghan Woods
- Memorial Sloan Kettering Cancer Center, New York, NY USA
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Collin LJ, Cronin-Fenton DP, Ahern TP, Christiansen PM, Damkier P, Ejlertsen B, Hamilton-Dutoit S, Kjærsgaard A, Silliman RA, Sørensen HT, Lash TL. Cohort Profile: the Predictors of Breast Cancer Recurrence (ProBe CaRE) Premenopausal Breast Cancer Cohort Study in Denmark. BMJ Open 2018; 8:e021805. [PMID: 30068618 PMCID: PMC6074634 DOI: 10.1136/bmjopen-2018-021805] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The Predictors of Breast Cancer Recurrence (ProBe CaRe) study was established to evaluate modification of tamoxifen (TAM) effectiveness in premenopausal women through reduced activity of TAM-metabolising enzymes. It comprehensively evaluates the effects of pharmacogenetic variants, use of concomitant medications and biomarkers involved in oestrogen metabolism on breast cancer recurrence risk. PARTICIPANTS The ProBe CaRe study was established using resources from the Danish Breast Cancer Group (DBCG), including 5959 premenopausal women diagnosed with stage I-III primary breast cancer between 2002 and 2010 in Denmark. Eligible participants were divided into two groups based on oestrogen receptor alpha (ERα) expression and receipt of TAM therapy, 4600 are classified as ERα+/TAM+ and 1359 are classified as ERα-/TAM-. The ProBe CaRe study is a population-based cohort study nested in a nearly complete source population, clinical, tumour and demographic data were abstracted from DBCG registry data. Linkage to Danish registries allows for abstraction of information regarding comorbid conditions, comedication use and mortality. Formalin-fixed paraffin-embedded tissue samples have been prepared for DNA extraction and immunohistochemical assay. FINDINGS TO DATE To mitigate incorrect classification of patients into specific categories, we conducted a validation substudy. We compared data acquired from registry and from medical record review to calculate positive predictive values (PPVs) and negative predictive values. We observed PPVs near 100% for tumour size, lymph node involvement, receptor status, surgery type, receipt of radiotherapy, receipt of chemotherapy and TAM treatment. We found that the PPVs were 96% (95% CI 83% to 100%) for change in endocrine therapy and 61% (95% CI 42% to 77%) for menopausal transition. FUTURE PLANS The ProBeCaRe cohort study is well positioned to comprehensively examine pharmacogenetic variants. We will use a Bayesian pathway analysis to evaluate the complete TAM metabolic path to allow for gene-gene interactions, incorporating information of other important patient characteristics.
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Affiliation(s)
- Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Thomas P Ahern
- Department of Surgery, The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, Vermont, USA
| | - Peer M Christiansen
- Breast Unit, Surgical Department, Randers Regional Hospital, Randers, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Danish Breast Cancer Group, Copenhagen, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen, Denmark
- Rigshospitalet, Copenhagen, Denmark
| | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca A Silliman
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Boston University School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, California, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Cronin-Fenton DP, Damkier P. Tamoxifen and CYP2D6: A Controversy in Pharmacogenetics. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:65-91. [PMID: 29801584 DOI: 10.1016/bs.apha.2018.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tamoxifen reduces the rate of breast cancer recurrence by about one-half. It is converted to more active metabolites by enzymes encoded by polymorphic genes, including cytochrome P450 2D6 (CYP2D6) and transported by ATP-binding cassette transporters. Genetic polymorphisms that confer reduced CYP2D6 activity or concurrent use of CYP2D6-inhibiting drugs may reduce the clinical efficacy of tamoxifen. The issue of the clinical utility of CYP2D6 genotype testing is subject to considerable and ongoing academic and clinical controversy. In this chapter, we outline tamoxifen's clinical pharmacology and give an overview of the research to date on the association between CYP2D6 inhibition and tamoxifen effectiveness. Based on the evidence to date, the impact of drug-induced and/or gene-induced inhibition of CYP2D6 activity is likely to be null or small, or at most moderate in subjects carrying two reduced function alleles. Future research should examine the effect of polymorphisms in genes encoding enzymes in tamoxifen's complete metabolic pathway, should comprehensively evaluate other biomarkers that affect tamoxifen effectiveness, such as the transport enzymes, and focus on subgroups of patients, such as premenopausal breast cancer patients, for whom tamoxifen is the only guideline approved endocrine therapy.
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Affiliation(s)
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Brantley KD, Kjærsgaard A, Cronin-Fenton D, Yacoub R, Nielsen AS, Lauridsen KL, Hamilton-Dutoit S, Lash TL. Stanniocalcin Expression as a Predictor of Late Breast Cancer Recurrence. Cancer Epidemiol Biomarkers Prev 2018; 27:653-659. [PMID: 29593009 DOI: 10.1158/1055-9965.epi-17-0905] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/12/2017] [Accepted: 03/20/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Expression of human paracrine hormones stanniocalcin 1 (STC1) and stanniocalcin 2 (STC2) may potentiate late breast cancer recurrence. We tested the hypothesis that expression of STC1 and STC2 in primary breast tumors is more strongly associated with late versus early recurrences.Methods: A total of 541 estrogen receptor-positive, tamoxifen-treated (ER+/TAM+) and 300 ER-negative, tamoxifen-untreated (ER-/TAM-) breast cancer patients who experienced recurrence within 10 years of primary diagnosis and matched recurrence-free controls were selected from a cohort of 11,251 Danish breast cancer patients diagnosed with stage I, II, or III breast cancer during 1985 to 2001. The association between IHC expression of STC1 and STC2 in primary breast tumor tissue microarrays and breast cancer recurrence was evaluated within median time to recurrence quintiles.Results: The association between STC1 expression, dichotomized as positive or negative, and recurrence was strongly positive for the final time quintile (6-10 years postdiagnosis) in the ER+/TAM+ group [aOR = 2.70; 95% confidence interval (CI): 1.22-5.98]. Regression of the log ORs relating dichotomous STC1 and STC2 expression to recurrence by median time to recurrence (year) resulted in a relatively large positive effect estimate for STC1 (β = 0.16; 95% CI, -0.03-0.36) and a near-null positive effect estimate for STC2 (β = 0.04; 95% CI, -0.14-0.21).Conclusions: Our results suggest a stronger association between primary tumor STC1 expression and late recurrence, as opposed to early recurrence, although no clear trend was apparent.Impact: STC1 expression in the primary tumor may potentiate late recurrences, suggesting dormancy pathways that merit further investigation. Cancer Epidemiol Biomarkers Prev; 27(6); 653-9. ©2018 AACR.
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Affiliation(s)
- Kristen D Brantley
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anja S Nielsen
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Winship Cancer Institute, Atlanta, Georgia
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Cronin-Fenton D, Lash TL, Ahern TP, Damkier P, Christiansen P, Ejlertsen B, Sørensen HT. Concurrent new drug prescriptions and prognosis of early breast cancer: studies using the Danish Breast Cancer Group clinical database. Acta Oncol 2018; 57:120-128. [PMID: 29202630 DOI: 10.1080/0284186x.2017.1407040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Myriad reports suggest that frequently used prescription drugs alter the viability of breast cancer cells in pre-clinical studies. Routine use of these drugs, therefore, may impact breast cancer prognosis, and could have important implications for public health. METHODS The Danish Breast Cancer Group (DBCG) clinical database provides high-quality prospectively collected data on breast cancer diagnosis, treatment, and routine follow-up for breast cancer recurrence. Individual-level linkage of DBCG data to other population-based and medical registries in Denmark, including the Danish National Prescription Registry, has facilitated large population-based pharmacoepidemiology studies. A unique advantage of using DBCG data for such studies is the ability to investigate the association of drugs with breast cancer recurrence rather than breast cancer mortality - which may be misclassified - or all-cause mortality. Here we summarize findings from pharmacoepidemiological studies, based on DBCG data, on the association between routinely used prescription drugs and risk of breast cancer recurrence. RESULTS Our findings suggest that concurrent use of glucocorticoids, ACE inhibitors, aspirin, NSAIDs, selective COX-2 inhibitors, digoxin, and opioids has little impact on breast cancer recurrence. Similarly, patients who use SSRIs concurrently with tamoxifen treatment are not at increased risk of recurrence. In contrast, post-diagnostic use of simvastatin, a lipophilic statin, correlates with a decreased risk of breast cancer recurrence, providing a rationale for a prospective randomized clinical trial investigating simvastatin as an adjuvant therapy for breast cancer. CONCLUSION As a whole, findings of pharmacoepidemiological studies based on DBCG data provide reassurance to physicians and healthcare personnel who provide supportive care during and after cancer (including prescriptions for comedications) and to breast cancer survivors for whom the risk of breast cancer recurrence is a major concern.
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Affiliation(s)
| | - Timothy L. Lash
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas P. Ahern
- Departments of Surgery and Biochemistry, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peer Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
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21
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Thistle JE, Hellberg Y, Mortensen K, Hamilton-Dutoit S, Kjærsgaard A, Cronin-Fenton D, Sørensen HT, Lash TL. The effect of 14-3-3ζ expression on tamoxifen resistance and breast cancer recurrence: a Danish population-based study. Breast Cancer Res Treat 2017. [PMID: 28643021 DOI: 10.1007/s10549-017-4289-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Overexpression of 14-3-3ζ has been linked to breast cancer recurrence in several studies, including studies assessing its effect on tamoxifen resistance. The study was performed to estimate the effect of 14-3-3ζ and differentiate potential prognostic or predictive utility. METHODS A case-control study, nested in a population of 11,251 females residing on the Jutland Peninsula of Denmark, was performed. Participants were aged 35-69, diagnosed with stage I, II, or III breast cancer between 1985 and 2001, and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent breast cancer cases with estrogen receptor-positive disease treated with tamoxifen for at least 1 year (ER+/TAM+) and 300 cases with estrogen receptor-negative disease never treated with tamoxifen (ER-/TAM-). We matched cases to controls on ER/TAM status, date of surgery, menopausal status, stage, and county. 14-3-3ζ expression was assessed using immunohistochemistry on tissue microarrays. We computed the odds ratio (OR) associating 14-3-3ζ expression with breast cancer recurrence adjusting for confounding using logistic regression. A quantitative bias analysis was performed to account for bias due to expression assay methods. RESULTS Associations for cytoplasmic and nuclear 14-3-3ζ staining above the 50th percentile were near null in both ER+/TAM+ and ER-/TAM- patients. When examining combined 14-3-3ζ staining, the association increased in the ER+/TAM+ group (adjusted OR 1.44, 95% confidence interval (CI) 1.05, 1.99). A nearly twofold increase in odds of recurrence was observed in above the 75th percentile staining of combined 14-3-3ζ, both for ER+/TAM+ patients (adjusted OR 1.93, 95% CI 1.15, 3.24) and ER-/TAM- patients (adjusted OR 1.93, 95% CI 1.03, 3.62), indicating potential prognostic utility. CONCLUSION Evidence is lacking to conclude that 14-3-3ζ is a useful marker of tamoxifen resistance; however, 14-3-3ζ expression is a potentially useful prognostic marker of breast cancer recurrence. Independent utility beyond established prognostic markers needs to be determined.
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Affiliation(s)
- Jake E Thistle
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ylva Hellberg
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
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Klebaner D, Hamilton-Dutoit S, Ahern T, Crawford A, Jakobsen T, Cronin-Fenton DP, Damkier P, Janssen E, Kjaersgaard A, Ording AG, Søiland H, Sørensen HT, Lash TL, Hellberg Y. Apolipoprotein D expression does not predict breast cancer recurrence among tamoxifen-treated patients. PLoS One 2017; 12:e0171453. [PMID: 28301514 PMCID: PMC5354364 DOI: 10.1371/journal.pone.0171453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/20/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Apolipoprotein D (ApoD) has been proposed as a predictor of breast cancer recurrence among estrogen receptor-positive (ER+), tamoxifen-treated patients. METHODS We conducted a population-based case-control study nested in a population of 11,251 women aged 35-69 years at diagnosis with Stage I-III breast cancer between 1985 and 2001 on Denmark's Jutland Peninsula and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent or contralateral breast cancers cases among women with ER+ disease treated with tamoxifen for at least 1 year and 300 cases in women with ER- disease never treated with tamoxifen. We matched one control subject per case and assessed ApoD expression in the tumor cell nucleus and cytoplasm using tissue microarray immunohistochemistry. We computed the odds ratio (OR) associating ApoD expression with recurrence and adjusted for potential confounding using logistic regression. RESULTS Cytoplasmic ApoD expression was seen in 68% of ER+ tumors, in 66% of ER- tumors, and in 66% of controls across both groups. In women with ER+ tumors, the associations of cytoplasmic ApoD expression with recurrence (OR = 1.0; 95% CI = 0.7 to 1.4) and increasing cytoplasmic expression with recurrence (OR = 1.0; 95% CI = 0.996 to 1.003) were null, as were those for women with ER- tumors. Associations for nuclear ApoD expression and combined nuclear and cytoplasmic expression were similarly near-null. CONCLUSION ApoD expression is likely not a predictor of recurrence in tamoxifen-treated patients. IMPACT This study eliminates the previously suggested marker ApoD as a predictor of recurrence among tamoxifen-treated women.
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Affiliation(s)
- Daniella Klebaner
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | | | - Thomas Ahern
- Departments of Surgery and Biochemistry, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Anatasha Crawford
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Thomas Jakobsen
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Per Damkier
- Department of Clinical Chemistry & Pharmacology, Odense University Hospital, Odense, Denmark
| | - Emiel Janssen
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Håvard Søiland
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Ylva Hellberg
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
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Gao J, Tian X, Zhou J, Cui MZ, Zhang HF, Gao N, Wen Q, Qiao HL. From Genotype to Phenotype: Cytochrome P450 2D6-Mediated Drug Clearance in Humans. Mol Pharm 2017; 14:649-657. [DOI: 10.1021/acs.molpharmaceut.6b00920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jie Gao
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Xin Tian
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Jun Zhou
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Ming-Zhu Cui
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Hai-Feng Zhang
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Na Gao
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Qiang Wen
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Hai-Ling Qiao
- Institute
of Clinical Pharmacology, Zhengzhou University, Zhengzhou, Henan 450052, China
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Ahern TP, Hertz DL, Damkier P, Ejlertsen B, Hamilton-Dutoit SJ, Rae JM, Regan MM, Thompson AM, Lash TL, Cronin-Fenton DP. Cytochrome P-450 2D6 (CYP2D6) Genotype and Breast Cancer Recurrence in Tamoxifen-Treated Patients: Evaluating the Importance of Loss of Heterozygosity. Am J Epidemiol 2017; 185:75-85. [PMID: 27988492 DOI: 10.1093/aje/kww178] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 10/25/2016] [Indexed: 12/11/2022] Open
Abstract
Tamoxifen therapy for estrogen receptor-positive breast cancer reduces the risk of recurrence by approximately one-half. Cytochrome P-450 2D6, encoded by the polymorphic cytochrome P-450 2D6 gene (CYP2D6), oxidizes tamoxifen to its most active metabolites. Steady-state concentrations of endoxifen (4-hydroxy-N-desmethyltamoxifen), the most potent antiestrogenic metabolite, are reduced in women whose CYP2D6 genotypes confer poor enzyme function. Thirty-one studies of the association of CYP2D6 genotype with breast cancer survival have yielded heterogeneous results. Some influential studies genotyped DNA from tumor-infiltrated tissues, and their results may have been susceptible to germline genotype misclassification from loss of heterozygosity at the CYP2D6 locus. We systematically reviewed 6 studies of concordance between genotypes obtained from paired nonneoplastic and breast tumor-infiltrated tissues, all of which showed excellent CYP2D6 genotype agreement. We applied these concordance data to a quantitative bias analysis of the subset of the 31 studies that were based on genotypes from tumor-infiltrated tissue to examine whether genotyping errors substantially biased estimates of association. The bias analysis showed negligible bias by discordant genotypes. Summary estimates of association, with or without bias adjustment, indicated no clinically important association between CYP2D6 genotype and breast cancer survival in tamoxifen-treated women.
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25
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Harris LN, Ismaila N, McShane LM, Andre F. Reply to D.C. Sgroi et al, T. Sanft et al, M.S. Copur et al, and M.P. Goetz et al. J Clin Oncol 2016; 34:3946-3948. [DOI: 10.1200/jco.2016.68.7020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lyndsay N. Harris
- Lyndsay N. Harris, National Cancer Institute, Bethesda, MD; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; National Cancer Institute, Bethesda, MD; and Fabrice Andre, Institute Gustave Roussy, Paris, France
| | - Nofisat Ismaila
- Lyndsay N. Harris, National Cancer Institute, Bethesda, MD; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; National Cancer Institute, Bethesda, MD; and Fabrice Andre, Institute Gustave Roussy, Paris, France
| | - Lisa M. McShane
- Lyndsay N. Harris, National Cancer Institute, Bethesda, MD; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; National Cancer Institute, Bethesda, MD; and Fabrice Andre, Institute Gustave Roussy, Paris, France
| | - Fabrice Andre
- Lyndsay N. Harris, National Cancer Institute, Bethesda, MD; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; National Cancer Institute, Bethesda, MD; and Fabrice Andre, Institute Gustave Roussy, Paris, France
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26
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Ahern TP, Cronin-Fenton DP, Lash TL, Sørensen HT, Ording AG, Hamilton-Dutoit SJ, Hellberg Y. Pak1, adjuvant tamoxifen therapy, and breast cancer recurrence risk in a Danish population-based study. Acta Oncol 2016; 55:734-41. [PMID: 27056567 DOI: 10.3109/0284186x.2016.1150606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Adjuvant tamoxifen therapy approximately halves the risk of estrogen receptor-positive (ER+) breast cancer recurrence, but many women do not respond to therapy. Observational studies nested in clinical trial populations suggest that overexpression or nuclear localization of p21-activated kinase 1 (Pak1) in primary tumors predicts tamoxifen failure. Material and methods We measured the association between Pak1 expression and breast cancer recurrence in a Danish population-based case-control study. Pak1 cytoplasmic expression level and nuclear positivity were determined by immunohistochemical staining of primary breast tumors from recurrence cases and matched controls from two breast cancer populations; women diagnosed with ER-positive tumors who received at least one year of tamoxifen therapy (ER+/TAM+), and women diagnosed with ER-negative tumors who survived for at least one year (ER-/TAM-). Pak1 staining was assessed by a single, blinded pathologist, and associations were estimated with conditional logistic regression models. Results We included 541 recurrence cases and 1:1 matched controls from the ER+/TAM + group and 300 recurrence cases and 1:1 matched controls from the ER-/TAM - group. Pak1 cytoplasmic intensity was not associated with breast cancer recurrence in either group (ER+/TAM + ORadj for strong vs. no cytoplasmic staining = 0.91, 95% CI 0.57, 1.5; ER-/TAM - ORadj for strong vs. no cytoplasmic staining = 0.74, 95% CI 0.39, 1.4). Associations between Pak1 nuclear positivity and breast cancer recurrence were similarly near null in both groups. Conclusion Pak1 positivity in primary breast tumors was neither predictive nor prognostic in this prospective, population-based study.
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Affiliation(s)
- Thomas P. Ahern
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
| | | | - Timothy L. Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Gulbech Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ylva Hellberg
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
- Department of Pathology, Hvidovre Hospital, Hvidovre Municipality, Denmark
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27
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de Vries Schultink AHM, Zwart W, Linn SC, Beijnen JH, Huitema ADR. Effects of Pharmacogenetics on the Pharmacokinetics and Pharmacodynamics of Tamoxifen. Clin Pharmacokinet 2016; 54:797-810. [PMID: 25940823 PMCID: PMC4513218 DOI: 10.1007/s40262-015-0273-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The antiestrogenic drug tamoxifen is widely used in the treatment of estrogen receptor-α-positive breast cancer and substantially decreases recurrence and mortality rates. However, high interindividual variability in response is observed, calling for a personalized approach to tamoxifen treatment. Tamoxifen is bioactivated by cytochrome P450 (CYP) enzymes such as CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4/5, resulting in the formation of active metabolites, including 4-hydroxy-tamoxifen and endoxifen. Therefore, polymorphisms in the genes encoding these enzymes are proposed to influence tamoxifen and active tamoxifen metabolites in the serum and consequently affect patient response rates. To tailor tamoxifen treatment, multiple studies have been performed to clarify the influence of polymorphisms on its pharmacokinetics and pharmacodynamics. Nevertheless, personalized treatment of tamoxifen based on genotyping has not yet met consensus. This article critically reviews the published data on the effect of various genetic polymorphisms on the pharmacokinetics and pharmacodynamics of tamoxifen, and reviews the clinical implications of its findings. For each CYP enzyme, the influence of polymorphisms on pharmacokinetic and pharmacodynamic outcome measures is described throughout this review. No clear effects on pharmacokinetics and pharmacodynamics were seen for various polymorphisms in the CYP encoding genes CYP2B6, CYP2C9, CYP2C19 and CYP3A4/5. For CYP2D6, there was a clear gene-exposure effect that was able to partially explain the interindividual variability in plasma concentrations of the pharmacologically most active metabolite endoxifen; however, a clear exposure-response effect remained controversial. These controversial findings and the partial contribution of genotype in explaining interindividual variability in plasma concentrations of, in particular, endoxifen, imply that tailored tamoxifen treatment may not be fully realized through pharmacogenetics of metabolizing enzymes alone.
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Affiliation(s)
- Aurelia H M de Vries Schultink
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek-The Netherlands Cancer Institute, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
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28
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Reich M, Kotecki N. Interactions médicamenteuses entre les psychotropes et les thérapies pharmacologiques en oncologie : quelles modalités de prescription ? PSYCHO-ONCOLOGIE 2016. [DOI: 10.1007/s11839-015-0540-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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29
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Yazdi MF, Rafieian S, Gholi-Nataj M, Sheikhha MH, Nazari T, Neamatzadeh H. CYP2D6 Genotype and Risk of Recurrence in Tamoxifen Treated Breast Cancer Patients. Asian Pac J Cancer Prev 2015; 16:6783-7. [DOI: 10.7314/apjcp.2015.16.15.6783] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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30
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Abreu M, Gomes M, Menezes F, Afonso N, Abreu P, Medeiros R, Pereira D, Lopes C. CYP2D6*4 polymorphism: A new marker of response to hormonotherapy in male breast cancer? Breast 2015; 24:481-6. [DOI: 10.1016/j.breast.2015.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 04/13/2015] [Accepted: 04/19/2015] [Indexed: 12/01/2022] Open
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Binkhorst L, Kloth JSL, de Wit AS, de Bruijn P, Lam MH, Chaves I, Burger H, van Alphen RJ, Hamberg P, van Schaik RHN, Jager A, Koch BCP, Wiemer EAC, van Gelder T, van der Horst GTJ, Mathijssen RHJ. Circadian variation in tamoxifen pharmacokinetics in mice and breast cancer patients. Breast Cancer Res Treat 2015; 152:119-128. [PMID: 26050156 PMCID: PMC4469299 DOI: 10.1007/s10549-015-3452-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/25/2015] [Indexed: 11/29/2022]
Abstract
The anti-estrogen tamoxifen is characterized by a large variability in response, partly due to pharmacokinetic differences. We examined circadian variation in tamoxifen pharmacokinetics in mice and breast cancer patients. Pharmacokinetic analysis was performed in mice, dosed at six different times (24-h period). Tissue samples were used for mRNA expression analysis of drug-metabolizing enzymes. In patients, a cross-over study was performed. During three 24-h periods, after tamoxifen dosing at 8 a.m., 1 p.m., and 8 p.m., for at least 4 weeks, blood samples were collected for pharmacokinetic measurements. Differences in tamoxifen pharmacokinetics between administration times were assessed. The mRNA expression of drug-metabolizing enzymes showed circadian variation in mouse tissues. Tamoxifen exposure seemed to be highest after administration at midnight. In humans, marginal differences were observed in pharmacokinetic parameters between morning and evening administration. Tamoxifen C(max )and area under the curve (AUC)0-8 h were 20 % higher (P < 0.001), and tamoxifen t(max) was shorter (2.1 vs. 8.1 h; P = 0.001), indicating variation in absorption. Systemic exposure (AUC0-24 h) to endoxifen was 15 % higher (P < 0.001) following morning administration. The results suggest that dosing time is of marginal influence on tamoxifen pharmacokinetics. Our study was not designed to detect potential changes in clinical outcome or toxicity, based on a difference in the time of administration. Circadian rhythm may be one of the many determinants of the interpatient and intrapatient pharmacokinetic variability of tamoxifen.
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Affiliation(s)
- Lisette Binkhorst
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
| | - Jacqueline S L Kloth
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Annelieke S de Wit
- Department of Genetics, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Mei H Lam
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Ines Chaves
- Department of Genetics, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Herman Burger
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robbert J van Alphen
- Department of Internal Medicine, TweeSteden Ziekenhuis, P.O. Box 90107, 5000 LA, Tilburg, Netherlands
| | - Paul Hamberg
- Department of Internal Medicine, Sint Franciscus Gasthuis, P.O. Box 10900, 3004 BA, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Erik A C Wiemer
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
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Damkier P. CYP2D6 genotyping and tamoxifen in the treatment of post-menopausal breast cancer. Br J Clin Pharmacol 2015; 78:431-2. [PMID: 24446761 DOI: 10.1111/bcp.12329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/31/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
- Per Damkier
- Clinical Pharmacology, Department of Clinical Chemistry and Pharmacology, Odense University Hospital, Denmark
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Binkhorst L, Mathijssen RH, Jager A, van Gelder T. Individualization of tamoxifen therapy: Much more than just CYP2D6 genotyping. Cancer Treat Rev 2015; 41:289-99. [DOI: 10.1016/j.ctrv.2015.01.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 12/30/2014] [Accepted: 01/07/2015] [Indexed: 12/12/2022]
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Zembutsu H. Pharmacogenomics toward personalized tamoxifen therapy for breast cancer. Pharmacogenomics 2015; 16:287-96. [DOI: 10.2217/pgs.14.171] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Tamoxifen has been used not only for the treatment or prevention of recurrence in patients with estrogen receptor positive breast cancers but also for recurrent breast cancer. Because CYP2D6 is known to be an important enzyme responsible for the generation of the potent tamoxifen metabolite, ‘endoxifen’, lots of studies reported that genetic variation which reduced its enzyme activity were associated with poor clinical outcome of breast cancer patients treated with tamoxifen. However, there are some discrepant reports questioning the association between CYP2D6 genotype and clinical outcome after tamoxifen therapy. Dose-adjustment study of tamoxifen based on CYP2D6 genotypes provides the evidence that dose adjustment is useful for the patients carrying reduced or null allele of CYP2D6 to maintain the effective endoxifen level. This review describes critical issues in pharmacogenomic studies as well as summarizes the results of the association of CYP2D6 genotype with tamoxifen efficacy.
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Drewe J, Bucher KA, Zahner C. A systematic review of non-hormonal treatments of vasomotor symptoms in climacteric and cancer patients. SPRINGERPLUS 2015; 4:65. [PMID: 25713759 PMCID: PMC4331402 DOI: 10.1186/s40064-015-0808-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/09/2015] [Indexed: 12/03/2022]
Abstract
The cardinal climacteric symptoms of hot flushes and night sweats affect 24-93% of all women during the physiological transition from reproductive to post-reproductive life. Though efficacious, hormonal therapy and partial oestrogenic compounds are linked to a significant increase in breast cancer. Non-hormonal treatments are thus greatly appreciated. This systematic review of published hormonal and non-hormonal treatments for climacteric, and breast and prostate cancer-associated hot flushes, examines clinical efficacy and therapy-related cancer risk modulation. A PubMed search included literature up to June 19, 2014 without limits for initial dates or language, with the search terms, (hot flush* OR hot flash*) AND (clinical trial* OR clinical stud*) AND (randomi* OR observational) NOT review). Retrieved references identified further papers. The focus was on hot flushes; other symptoms (night sweats, irritability, etc.) were not specifically screened. Included were some 610 clinical studies where a measured effect of the intervention, intensity and severity were documented, and where patients received treatment of pharmaceutical quality. Only 147 of these references described studies with alternative non-hormonal treatments in post-menopausal women and in breast and prostate cancer survivors; these results are presented in Additional file 1. The most effective hot flush treatment is oestrogenic hormones, or a combination of oestrogen and progestins, though benefits are partially outweighed by a significantly increased risk for breast cancer development. This review illustrates that certain non-hormonal treatments, including selective serotonin reuptake inhibitors, gabapentin/pregabalin, and Cimicifuga racemosa extracts, show a positive risk-benefit ratio. Key pointsSeveral non-hormonal alternatives to hormonal therapy have been established and registered for the treatment of vasomotor climacteric symptoms in peri- and post-menopausal women. There are indications that non-hormonal treatments are useful alternatives in patients with a history of breast and prostate cancer. However, confirmation by larger clinical trials is required.
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Affiliation(s)
- Juergen Drewe
- Max Zeller AG, Seeblickstr. 4, 8590 Romanshorn, Switzerland
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Maximov PY, McDaniel RE, Fernandes DJ, Bhatta P, Korostyshevskiy VR, Curpan RF, Jordan VC. Pharmacological relevance of endoxifen in a laboratory simulation of breast cancer in postmenopausal patients. J Natl Cancer Inst 2014; 106:dju283. [PMID: 25258390 DOI: 10.1093/jnci/dju283] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Tamoxifen is metabolically activated via a CYP2D6 enzyme system to the more potent hydroxylated derivatives 4-hydroxytamoxifen and endoxifen. This study addresses the pharmacological importance of endoxifen by simulating clinical scenarios in vitro. METHODS Clinical levels of tamoxifen metabolites in postmenopausal breast cancer patients previously genotyped for CYP2D6 were used in vitro along with clinical estrogen levels (estrone and estradiol) in postmenopausal patients determined in previous studies. The biological effects on cell growth were evaluated in a panel of estrogen receptor-positive breast cancer cell lines via cell proliferation assays and real-time polymerase chain reaction (PCR). Data were analyzed with one- and two-way analysis of variance and Student's t test. All statistical tests were two-sided. RESULTS Postmenopausal levels of estrogen-induced proliferation of all test breast cancer cell lines (mean fold induction ± SD vs vehicle control: MCF-7 = 11 ± 1.74, P < .001; T47D = 7.52 ± 0.72, P < .001; BT474 = 1.75 ± 0.23, P < .001; ZR-75-1 = 5.5 ± 1.95, P = .001. Tamoxifen and primary metabolites completely inhibited cell growth regardless of the CYP2D6 genotype in all cell lines (mean fold induction ± SD vs vehicle control: MCF-7 = 1.57 ± 0.38, P = .54; T47D = 1.17 ± 0.23, P = .79; BT474 = 0.96 ± 0.2, P = .98; ZR-75-1 = 0.86 ± 0.67, P = .99). Interestingly, tamoxifen and its primary metabolites were not able to fully inhibit the estrogen-stimulated expression of estrogen-responsive genes in MCF-7 cells (P < .05 for all genes), but the addition of endoxifen was able to produce additional antiestrogenic effect on these genes. CONCLUSIONS The results indicate that tamoxifen and other metabolites, excluding endoxifen, completely inhibit estrogen-stimulated growth in all cell lines, but additional antiestrogenic action from endoxifen is necessary for complete blockade of estrogen-stimulated genes. Endoxifen is of supportive importance for the therapeutic effect of tamoxifen in a postmenopausal setting.
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Affiliation(s)
- Philipp Y Maximov
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - Russell E McDaniel
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - Daphne J Fernandes
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - Puspanjali Bhatta
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - Valeriy R Korostyshevskiy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - Ramona F Curpan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC)
| | - V Craig Jordan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC (PYM, REM, DJF, PB, VRK, CJ); Institute of Chemistry, Romanian Academy, Timisoara, Romania (RFC).
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Adjusting the dose of tamoxifen in patients with early breast cancer and CYP2D6 poor metabolizer phenotype. Breast 2014; 23:400-6. [DOI: 10.1016/j.breast.2014.02.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 02/12/2014] [Accepted: 02/22/2014] [Indexed: 11/22/2022] Open
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Markkula A, Hjertberg M, Rose C, Ingvar C, Jernström H. No association found between CYP2D6 genotype and early breast cancer events in tamoxifen-treated patients. Acta Oncol 2014; 53:195-200. [PMID: 24125101 DOI: 10.3109/0284186x.2013.840739] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND CYP2D6 is considered the key enzyme in tamoxifen metabolism. Several studies have investigated the relationship between the CYP2D6 genotype and tamoxifen treatment outcome, with discrepant results. CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy may account for some of the discrepancies. We examined the association between CYP2D6 genotype and early breast cancer events in tamoxifen-treated breast cancer patients, in relation to CYP2D6 inhibitor use, aromatase inhibitor use, and chemotherapy. MATERIAL AND METHODS Pre- and postoperative questionnaires on lifestyle and concomitant medications were completed by 634 primary breast cancer patients between 2002 and 2008, among whom 333 patients had ER-positive tumors and received tamoxifen. CYP2D6*3, *4, *6, *10 and *41 were genotyped. Information on clinical data, breast cancer events, and tumor characteristics was obtained from patients' charts, population registries, the Regional Tumor Registry, and pathology reports. RESULTS Median follow-up was 4.9 years. Neither poor metabolizers (adjusted HR 0.50; 95% CI 0.07-3.82) nor intermediate metabolizers (adjusted HR 1.00; 95% CI 0.47-2.11) had an increased risk of early breast cancer events when compared with extensive metabolizers. CYP2D6 activity score (taking into account genotype and CYP2D6 inhibitor use) was not associated with early breast cancer events (LogRank, Ptrend = 0.44). CONCLUSIONS CYP2D6 genotype was not associated with tamoxifen treatment outcome, even when CYP2D6 inhibitor use, aromatase inhibitor use, or chemotherapy was taken into account. CYP2D6 genotype may be of minor importance for tamoxifen-treated patients in Scandinavia.
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Affiliation(s)
- Andrea Markkula
- Division of Oncology, Department of Clinical Sciences, Lund University , Lund , Sweden
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Grassi L, Caruso R, Hammelef K, Nanni MG, Riba M. Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: a review. Int Rev Psychiatry 2014; 26:44-62. [PMID: 24716500 DOI: 10.3109/09540261.2013.842542] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
At least 25-30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.
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Affiliation(s)
- Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara , Ferrara , Italy
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Dieudonné AS, De Nys K, Casteels M, Wildiers H, Neven P. How often did Belgian physicians co-prescribe tamoxifen with strong CYP2D6 inhibitors over the last 6 years? Acta Clin Belg 2014; 69:47-52. [PMID: 24635399 DOI: 10.1179/0001551213z.00000000017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
AIMS Tamoxifen is widely used in the treatment of breast cancer. It is a pro-drug metabolized to the more active endoxifen through CYP2D6. Concomitant intake of CYP2D6 inhibitors results in lower endoxifen levels and could influence efficacy. The objective of this study was to evaluate the evolution of co-prescription of tamoxifen and CYP2D6 inhibitors in Belgium. METHODS Data were retrieved from the Pharmanet database of the National Institute for Health and Disability Insurance for the period January 2006-December 2009. For the analysis of the evolution of the co-prescription, the period was divided in subperiods of 2 months. The category tamoxifen+CYP2D6 inhibitor was defined as women who were delivered tamoxifen and a CYP2D6 inhibitor in that subperiod. The results were validated on the period December 2011-May 2012. RESULTS The percentage of co-prescription decreased over time for the strong CYP2D6 inhibitors and increased for the weak CYP2D6 inhibitor, with these trends persisting in 2012. Tamoxifen and CYP2D6 inhibitors were mostly prescribed by general practitioners and gynaecologists and by general practitioners and psychiatrists, respectively. DISCUSSION This study shows that a proportion of women taking tamoxifen in Belgium are prescribed a strong CYP2D6 inhibitor, which could affect tamoxifen efficacy. Over time, the concomitant intake decreased. Paroxetine was the most prescribed strong CYP2D6 inhibitor. Venlafaxine, a weak CYP2D6 inhibitor, was prescribed more often. This study also shows that tamoxifen and the CYP2D6 inhibitors are not only prescribed by physicians specialized in breast cancer; therefore, all physicians should be aware of this interaction.
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Cronin-Fenton DP, Damkier P, Lash TL. Metabolism and transport of tamoxifen in relation to its effectiveness: new perspectives on an ongoing controversy. Future Oncol 2014; 10:107-22. [PMID: 24328412 PMCID: PMC4319217 DOI: 10.2217/fon.13.168] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Tamoxifen reduces the rate of breast cancer recurrence by approximately a half. Tamoxifen is metabolized to more active metabolites by enzymes encoded by polymorphic genes, including cytochrome P450 2D6 (CYP2D6). Tamoxifen is a substrate for ATP-binding cassette transporter proteins. We review tamoxifen's clinical pharmacology and use meta-analyses to evaluate the clinical epidemiology studies conducted to date on the association between CYP2D6 inhibition and tamoxifen effectiveness. Our findings indicate that the effect of both drug-induced and/or gene-induced inhibition of CYP2D6 activity is likely to be null or small, or at most moderate in subjects carrying two reduced function alleles. Future research should examine the effect of polymorphisms in genes encoding enzymes in tamoxifen's complete metabolic pathway, should comprehensively evaluate other biomarkers that affect tamoxifen effectiveness, such as the transport enzymes, and focus on subgroups of patients, such as premenopausal breast cancer patients, for whom tamoxifen is the only guideline endocrine therapy.
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Affiliation(s)
| | - Per Damkier
- Department of Clinical Chemistry & Pharmacology, Odense University Hospital, Denmark
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Jung JA, Lim HS. Association between CYP2D6 genotypes and the clinical outcomes of adjuvant tamoxifen for breast cancer: a meta-analysis. Pharmacogenomics 2014; 15:49-60. [DOI: 10.2217/pgs.13.221] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: Tamoxifen is one of the most commonly used endocrine therapeutic agents for breast cancer. Although many studies have examined whether the treatment outcomes of tamoxifen for breast cancer differ according to CYP2D6 genotype, the study results have been inconsistent, and the role of CYP2D6 in the prediction of patient outcomes from tamoxifen therapy remains controversial. This study evaluated the association between CYP2D6 genotypes and postoperative tamoxifen treatment outcome in patients with breast cancer, using the available previous study results. Materials & methods: We performed a meta-analysis of ten previous clinical reports (n = 5183) to evaluate the association between CYP2D6 genotype and hazard ratios for the recurrence risk of breast cancer after postoperative tamoxifen treatment. Pooled estimates of hazard ratios were computed using R and NONMEM® software. Results: A significantly increased risk of breast cancer recurrence in patients carrying variant CYP2D6 genotypes was found in this investigation. The mean hazard ratios and 95% CI were 1.60 (1.04–2.47) in the random effect model implemented in R and 1.63 (1.01–2.62) in the random effect model in NONMEM. The bootstrap result (2000 replicates) of NONMEM was 1.64 (1.07–2.79). Conclusion: Our present findings suggest that genetic polymorphisms of CYP2D6 may be important predictors of the clinical outcomes of adjuvant tamoxifen treatment for the patients with breast cancer. A large-scale, prospective, randomized, well-controlled trial is warranted to confirm our findings. Original submitted 23 July 2013; Revision submitted 30 September 2013
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Affiliation(s)
- Jin-A Jung
- Department of Clinical Pharmacology & Therapeutics, Ulsan University College of Medicine, Asan Medical Center, Pungnap-2-dong, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 138–736, Republic of Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology & Therapeutics, Ulsan University College of Medicine, Asan Medical Center, Pungnap-2-dong, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 138–736, Republic of Korea
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Lum DWK, Perel P, Hingorani AD, Holmes MV. CYP2D6 genotype and tamoxifen response for breast cancer: a systematic review and meta-analysis. PLoS One 2013; 8:e76648. [PMID: 24098545 PMCID: PMC3788742 DOI: 10.1371/journal.pone.0076648] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 08/27/2013] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To evaluate evidence on the association between CYP2D6 genotype and tamoxifen response through. DESIGN Systematic review and meta-analysis of prospective, cross-sectional and case-control studies published to 2012. For each study, relative risks and 95% confidence intervals were extracted and pooled with a fixed and random effects model. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed. DATA SOURCES PubMed (inception-2012) and EMBASE (inception-2012). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Criteria for inclusion were studies reporting breast cancer outcomes in patients treated with tamoxifen and genotyped for polymorphisms in the CYP2D6 gene. RESULTS Twenty-five studies of 13,629 individuals were identified, of which 22 investigated the association of CYP2D6 genotype with outcomes in breast cancer women all receiving tamoxifen treatment ("treatment-only" design). Three randomized trials evaluated the effect of CYP2D6 genotype on tamoxifen response ("effect modification" design). In analysis of treatment-only studies, the relative risk (RR) of all-cause mortality (>307 events in 4,936 patients) for carriers of a CYP2D6 reduced function allele was 1.11 (95% confidence interval (CI): 0.94 to 1.31) compared to individuals with normal/increased function CYP2D6 alleles. When we investigated a composite outcome including all-cause mortality and surrogate endpoints for overall survival (>307 events in 6,721 patients), carriers of a CYP2D6 reduced function allele had a RR of 1.27 (95% CI: 1.11 to 1.45). From two randomized trials that permitted effect-modification analysis, one had only 154 patients and showed evidence of effect modification of tamoxifen by CYP2D6 genotype for distant recurrence but was directionally opposite to that predicted, whereas a larger trial of 2,537 patients failed to show evidence of effect modification for breast cancer-free interval (P values for interaction 0.02 and 0.44, respectively). CONCLUSIONS Based on these findings, there is insufficient evidence to recommend CYP2D6 genotyping to guide tamoxifen treatment.
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Affiliation(s)
- Danny W. K. Lum
- Centre for Cardiovascular Genetics, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Pablo Perel
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aroon D. Hingorani
- Centre for Clinical Pharmacology, Division of Medicine, University College London, London, United Kingdom
- Genetic Epidemiology Group, Faculty of Population Health Sciences, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Michael V. Holmes
- Genetic Epidemiology Group, Faculty of Population Health Sciences, Institute of Cardiovascular Science, University College London, London, United Kingdom
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Rae JM, Regan MM, Thibert JN, Gersch C, Thomas D, Leyland-Jones B, Viale G, Pusztai L, Hayes DF, Skaar T, Van Poznak C. Concordance between CYP2D6 genotypes obtained from tumor-derived and germline DNA. J Natl Cancer Inst 2013; 105:1332-4. [PMID: 23958736 DOI: 10.1093/jnci/djt204] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Formalin-fixed, paraffin-embedded tumors (FFPETs) are a valuable source of DNA for genotype association studies and are often the only germline DNA resource from cancer clinical trials. The anti-estrogen tamoxifen is metabolized into endoxifen by CYP2D6, leading to the hypothesis that patients with certain CYP2D6 genotypes may not receive benefit because of their inability to activate the drug. Studies testing this hypothesis using FFPETs have provided conflicting results. It has been postulated that CYP2D6 genotype determined using FFPET may not be accurate because of somatic tumor alterations. In this study, we determined the concordance between CYP2D6 genotypes generated using 3 tissue sources (FFPETs; formalin-fixed, paraffin-embedded unaffected lymph nodes [FFPELNs]; and whole blood cells [WBCs]) from 122 breast cancer patients. Compared with WBCs, FFPET and FFPELN genotypes were highly concordant (>94%), as were the predicted CYP2D6 metabolic phenotypes (>97%). We conclude that CYP2D6 genotypes obtained from FFPETs accurately represent the patient's CYP2D6 metabolic phenotype.
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Affiliation(s)
- James M Rae
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI 48109-5942, USA.
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Binkhorst L, Mathijssen RHJ, van Herk-Sukel MPP, Bannink M, Jager A, Wiemer EAC, van Gelder T. Unjustified prescribing of CYP2D6 inhibiting SSRIs in women treated with tamoxifen. Breast Cancer Res Treat 2013; 139:923-9. [DOI: 10.1007/s10549-013-2585-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/29/2013] [Indexed: 01/01/2023]
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Zeng Z, Liu Y, Liu Z, You J, Chen Z, Wang J, Peng Q, Xie L, Li R, Li S, Qin X. CYP2D6 polymorphisms influence tamoxifen treatment outcomes in breast cancer patients: a meta-analysis. Cancer Chemother Pharmacol 2013; 72:287-303. [PMID: 23712329 DOI: 10.1007/s00280-013-2195-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/11/2013] [Indexed: 02/08/2023]
Abstract
PURPOSE To evaluate whether breast cancer (BC) patients with CYP2D6 gene variation have different clinical tamoxifen (TAM) treatment outcomes to those with normal function of CYP2D6. METHODS Systematic searches of the PubMed up to February 21, 2013, were retrieved. The study end points were disease-free survival (DFS) and overall survival (OS). Fixed or random-effects meta-analytical models were used to calculate summary hazard ratio (HR) and corresponding 95 % confidence intervals (CIs). Meta-regression, Galbraith plots, subgroup analysis, and sensitivity analysis were also performed. RESULTS A total of 11,701 BC patients from 20 trials were included. Compared with reduced CYP2D6 function, normal function was associated with a trend toward improved DFS (HR = 1.37, 95 % CI 1.12-1.69, P = 0.002) and OS (HR = 1.25, 95 % CI 1.03-1.50, P = 0.021). We found significant heterogeneity between studies. When the analysis was stratified into subgroups, significantly worse DFS was found in the groups of intermediate metabolizer versus extensive metabolizer (HR = 1.65, 95 % CI 1.04-2.64, P = 0.035), Asian population (HR = 3.29, 95 % CI 1.64-6.63, P = 0.001), 5 years TAM treatment duration (HR = 1.59; 95 % CI 1.14-2.22, P = 0.006), concomitant chemotherapy (HR = 1.35, 95 % CI 1.04-1.76, P = 0.025), and TAM alone (HR = 1.44, 95 % CI 1.44-2.06, P = 0.045). With respect to OS, no significant association was demonstrated in stratified analyses. CONCLUSIONS We concluded that CYP2D6 polymorphisms may influence tamoxifen treatment outcomes of DFS in BC patients.
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Affiliation(s)
- Zhiyu Zeng
- Department of Geriatrics, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Karle J, Bolbrinker J, Vogl S, Kreutz R, Denkert C, Eucker J, Wischnewsky M, Possinger K, Regierer AC. Influence of CYP2D6-genotype on tamoxifen efficacy in advanced breast cancer. Breast Cancer Res Treat 2013; 139:553-60. [PMID: 23686417 DOI: 10.1007/s10549-013-2565-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 01/17/2023]
Abstract
The influence of CYP2D6 genotype on the efficacy of tamoxifen (Tam) has been extensively analyzed in early breast cancer with conflicting results. However, there is only scarce data regarding this potential influence in advanced breast cancer (ABC). We hypothesize that Tam is more effective in patients with a functional CYP2D6 allele than in patients with impaired CYP2D6 activity. ABC patients with prior or ongoing palliative Tam treatment (20 mg/d) were eligible. Genomic DNA was extracted from blood (n = 51) and formalin-fixed, paraffin-embedded tissue (n = 43). CYP2D6*2, *3, *4, *5, *6, *10, *17, *29, *41, CYP2D6 duplication and multiplication were determined in blood and CYP2D6*4 in tissue samples. Primary endpoint was progression free survival (PFS); secondary endpoints included clinical benefit (CB), and overall survival (OS). The clinical charts were retrospectively analyzed regarding survival and treatment effects. Genotyping was performed blinded and clinical data were analyzed separately. 94 patients were identified with a median age of 59 years (29-90 years). In 6 patients genotyping did not show conclusive results, therefore these patients were excluded from further analysis. Genotyping results were as follows: 1.1 % ultrarapid, 84.1 % extensive, 3.4 % intermediate, and 11.4 % poor metabolizers. Patients without any fully functional allele (IM/IM, IM/PM, PM/PM) had a significant shorter PFS and OS compared to patients with at least one functional allele (EM/EM, EM/IM, EM/PM) (PFS: p = 0.017; HR = 2.19; 95 % CI 1.15-4.18; OS: p = 0.028; HR = 2.79; 95 % CI 1.12-6.99). The CB rate was 73 % for EM-group and 38.5 % for IM + PM-group (p = 0.019). Our results show a significant influence of the CYP2D6 genotype on the efficacy of Tam in the treatment of ABC. In contrast to the adjuvant setting, the evidence in the palliative setting is congruent. CYP2D6 testing in ABC should be considered.
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Affiliation(s)
- Jennifer Karle
- Department of Oncology and Hematology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Nagalla S, Chou JW, Willingham MC, Ruiz J, Vaughn JP, Dubey P, Lash TL, Hamilton-Dutoit SJ, Bergh J, Sotiriou C, Black MA, Miller LD. Interactions between immunity, proliferation and molecular subtype in breast cancer prognosis. Genome Biol 2013; 14:R34. [PMID: 23618380 PMCID: PMC3798758 DOI: 10.1186/gb-2013-14-4-r34] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 04/29/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Gene expression signatures indicative of tumor proliferative capacity and tumor-immune cell interactions have emerged as principal biology-driven predictors of breast cancer outcomes. How these signatures relate to one another in biological and prognostic contexts remains to be clarified. RESULTS To investigate the relationship between proliferation and immune gene signatures, we analyzed an integrated dataset of 1,954 clinically annotated breast tumor expression profiles randomized into training and test sets to allow two-way discovery and validation of gene-survival associations. Hierarchical clustering revealed a large cluster of distant metastasis-free survival-associated genes with known immunological functions that further partitioned into three distinct immune metagenes likely reflecting B cells and/or plasma cells; T cells and natural killer cells; and monocytes and/or dendritic cells. A proliferation metagene allowed stratification of cases into proliferation tertiles. The prognostic strength of these metagenes was largely restricted to tumors within the highest proliferation tertile, though intrinsic subtype-specific differences were observed in the intermediate and low proliferation tertiles. In highly proliferative tumors, high tertile immune metagene expression equated with markedly reduced risk of metastasis whereas tumors with low tertile expression of any one of the three immune metagenes were associated with poor outcome despite higher expression of the other two metagenes. CONCLUSIONS These findings suggest that a productive interplay among multiple immune cell types at the tumor site promotes long-term anti-metastatic immunity in a proliferation-dependent manner. The emergence of a subset of effective immune responders among highly proliferative tumors has novel prognostic ramifications.
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Brooks JD, Teraoka SN, Malone KE, Haile RW, Bernstein L, Lynch CF, Mellemkjær L, Duggan DJ, Reiner AS, Concannon P, Schiermeyer K, Lewinger JP, Bernstein JL, Figueiredo JC. Variants in tamoxifen metabolizing genes: a case-control study of contralateral breast cancer risk in the WECARE study. INTERNATIONAL JOURNAL OF MOLECULAR EPIDEMIOLOGY AND GENETICS 2013; 4:35-48. [PMID: 23565321 PMCID: PMC3612453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/11/2013] [Indexed: 06/02/2023]
Abstract
Tamoxifen has been shown to greatly reduce risk of recurrence and contralateral breast cancer (CBC). Still, second primary contralateral breast cancer is the most common malignancy to follow a first primary breast cancer. Genetic variants in CYP2D6 and other drug-metabolizing enzymes that alter the metabolism of tamoxifen may be associated with CBC risk in women who receive the drug. This is the first study to investigate the impact of this variation on risk of CBC in women who receive tamoxifen. From the population-based Women's Environment Cancer and Radiation Epidemiology (WECARE) Study, we included 624 Caucasian women with CBC (cases) and 1,199 women with unilateral breast cancer (controls) with complete information on tumor characteristics and treatment. Conditional logistic regression was used to assess the risk of CBC associated with 112 single nucleotide polymorphisms (SNPs) in 8 genes involved in the metabolism of tamoxifen among tamoxifen users and non-users. After adjustment for multiple testing, no significant association was observed between any of the genotyped variants and CBC risk in either tamoxifen users or non-users. These results suggest that when using a tagSNP approach, common variants in selected genes involved in the metabolism of tamoxifen are not associated with risk of CBC among women treated with the drug.
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Affiliation(s)
- Jennifer D Brooks
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterUSA
| | - Sharon N Teraoka
- University of Florida Genetics Institute and Department of Pathology, Immunology and Laboratory Medicine, University of FloridaUSA
| | - Kathleen E Malone
- Program in Epidemiology, Division of Public Health Science, Fred Hutchinson Cancer Research CenterUSA
| | - Robert W Haile
- Stanford School of Medicine, Department of Medicine, Division of OncologyUSA
| | - Leslie Bernstein
- Department of Population Sciences, Beckman Research Institute of the City of HopeUSA
| | - Charles F Lynch
- Department of Epidemiology, The University of Iowa College of Public HealthUSA
| | - Lene Mellemkjær
- Research Department II, Institute of Cancer Epidemiology, Danish Cancer SocietyUSA
| | - David J Duggan
- Genetic Basis of Human Disease Division, Translational Genomic Research InstituteUSA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterUSA
| | - Patrick Concannon
- University of Florida Genetics Institute and Department of Pathology, Immunology and Laboratory Medicine, University of FloridaUSA
| | | | - Juan Pablo Lewinger
- Department of Preventive Medicine, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern CaliforniaUSA
| | | | - Jonine L Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterUSA
| | - Jane C Figueiredo
- Department of Preventive Medicine, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern CaliforniaUSA
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