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Rutherford DV, Medley S, Henderson NC, Gersch CL, Vandenberg TA, Albain KS, Dakhil SR, Tirumali NR, Gralow JR, Hortobagyi GN, Pusztai L, Mehta RS, Hayes DF, Kidwell KM, Henry NL, Barlow WE, Rae JM, Hertz DL. Effects of CYP3A4 and CYP2C9 genotype on systemic anastrozole and fulvestrant concentrations in SWOG S0226. Pharmacogenomics 2023; 24:665-673. [PMID: 37615099 PMCID: PMC10565537 DOI: 10.2217/pgs-2023-0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023] Open
Abstract
Objective & methods: This study tested associations of genotype-predicted activity of CYP3A4, other pharmacogenes, SLC28A7 (rs11648166) and ALPPL2 (rs28845026) with systemic concentrations of the endocrine therapies anastrozole and fulvestrant in SWOG S0226 trial participants. Results: Participants in the anastrozole-only arm with low CYP3A4 activity (i.e. CYP3A4*22 carriers) had higher systemic anastrozole concentrations than patients with high CYP3A4 activity (β-coefficient = 10.03; 95% CI: 1.42, 18.6; p = 0.025). In an exploratory analysis, participants with low CYP2C9 activity had lower anastrozole concentrations and higher fulvestrant concentrations than participants with high CYP2C9 activity. Conclusion: Inherited genetic variation in CYP3A4 and CYP2C9 may affect concentrations of endocrine therapy and may be useful to personalize dosing and improve treatment outcomes.
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Affiliation(s)
- Delaney V Rutherford
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Sarah Medley
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Nicholas C Henderson
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Christina L Gersch
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Ted A Vandenberg
- Western University/Canadian Cancer Trials Group, London, ON, N5X 3K8, Canada
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL 60153, USA
| | | | | | - Julie R Gralow
- American Society of Clinical Oncology, Alexandria, 22314, Virginia
| | | | | | - Rita S Mehta
- University of California Irvine Medical Center, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | | | - James M Rae
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
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Anastrozole plus fulvestrant vs. anastrozole alone for hormone receptor-positive advanced breast cancer: a meta-analysis of randomized controlled trials. Breast Cancer Res Treat 2020; 180:269-278. [PMID: 32008124 DOI: 10.1007/s10549-020-05551-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/27/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND For patients with hormone receptor (HR)-positive advanced breast cancer, whether the combination of anastrozole and fulvestrant is more effective than anastrozole alone is controversial. Our meta-analysis aimed to compare the efficacy and safety of the two therapies. METHODS We retrieved relevant studies in Embase, the Cochrane Library, Ovid MEDLINE, PubMed, ScienceDirect, Web of Science, Scopus, and Google Scholar. The primary outcomes were overall survival (OS) and progression-free survival (PFS). The secondary outcomes were the disease control rate (DCR), the objective response rate (ORR), and adverse events (AEs). RESULTS Five articles based on 4 randomized controlled trials containing 2146 patients were identified in our meta-analysis. The combination group had better efficacy in the endpoints of OS (hazard ratio [HR] 0.86; 95% confidence interval [CI] 0.74-0.99, p = 0.03) and PFS (HR 0.87; 95% CI 0.77-0.97, p = 0.02). Regarding the ORR, DCR, total AEs and grade 3-5 AEs, we found no difference between the two treatments. The combination group showed a clearly higher rate of treatment discontinuations (95% CI 1.05-3.60, p = 0.03) and AEs leading to death (95% CI 1.12-9.11, p = 0.03). The subgroup analysis of AEs showed an increased incidence of extremity or muscle pain, hematologic effects, gastrointestinal disorders, and hot flashes in the combination group. CONCLUSIONS For HR-positive advanced breast cancer patients, the combination of anastrozole and fulvestrant appears to be superior to anastrozole alone in extending PFS and OS, despite relatively serious AEs.
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Li J, Wang Z, Shao Z. Fulvestrant in the treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer: A review. Cancer Med 2019; 8:1943-1957. [PMID: 31004402 PMCID: PMC6536994 DOI: 10.1002/cam4.2095] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/30/2019] [Accepted: 02/26/2019] [Indexed: 12/13/2022] Open
Abstract
Nearly 75% of breast cancers are hormone receptor-positive (HR+) and human epidermal growth factor receptor type 2-negative (HER2-), making endocrine therapy the mainstay of treatment for HR+ and HER2- combination. Although endocrine therapy, such as therapy with fulvestrant, is widely used in the clinic, endocrine resistance (primary or secondary) is inevitable and poses a serious clinical concern. However, the therapeutic landscape of HR+/HER2- breast cancer is rapidly changing and evolving. In recent years, molecular insights into the genome of HR+/HER2- breast cancer have helped to identify promising targets, such as alterations in signaling pathways [phosphatidylinositide 3-kinase (PI3K/AKT/mammalian target of rapamycin (mTOR)], dysregulation of the cell cycle (CDK4/6), and identification of new ESR1 mutations. These insights have led to the development of newer targeted therapies, which aims at significantly improving survival in these patients. This review summarizes the role and rationale of fulvestrant when used as a monotherapy or in combination with targeted therapies in patients with HR+/HER2- advanced breast cancer. We also discuss other novel agents and potential future combination treatment options.
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Affiliation(s)
- Junjie Li
- Department of Surgery in Breast CancerFudan University Shanghai Cancer CenterShanghaiChina
| | - Zhonghua Wang
- Department of Surgery in Breast CancerFudan University Shanghai Cancer CenterShanghaiChina
| | - Zhimin Shao
- Department of Surgery in Breast CancerFudan University Shanghai Cancer CenterShanghaiChina
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Blackburn SA, Parks RM, Cheung KL. Fulvestrant for the treatment of advanced breast cancer. Expert Rev Anticancer Ther 2018; 18:619-628. [PMID: 29749272 DOI: 10.1080/14737140.2018.1473038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The current issues with endocrine therapy for treatment of advanced breast cancer include balance of efficacy of therapy versus tolerability as well as hormone resistance. The efficacy of fulvestrant, a selective oestrogen receptor degrader (SERD), has been demonstrated in hormone receptor positive patients previously untreated or treated with hormonal therapy. Areas covered: This article discusses the journey of fulvestrant licensing, its efficacy in combination with other endocrine therapies and the future role it may have within breast cancer treatment. Expert commentary: Within phase III trials, fulvestrant has demonstrated equivalent or improved clinical efficacy when compared with established endocrine agents. In the recent decade, fulvestrant has achieved licensing as a second line agent in non-operative advanced breast cancer at initially 250mg, increasing to 500mg. Presently, fulvestrant is licensed globally as first line endocrine management for advanced breast cancer in post-menopausal women. Early combination trials of fulvestrant and cyclin dependent kinase 4/6 inhibitors have demonstrated good clinical efficacy with improved progression free survival when compared to fulvestrant alone.
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Affiliation(s)
| | - Ruth M Parks
- a School of Medicine , University of Nottingham , Nottingham , UK
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Farahi M, Karami B, Jokar A, Eskandari K. An Environmentally Benign Synthesis of Pyrimidine-Fused Coumarin and Triazole Motifs via a Catalytic Domino Reaction. ORG PREP PROCED INT 2017. [DOI: 10.1080/00304948.2017.1380495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Mahnaz Farahi
- Department of Chemistry, Yasouj University, P.O. Box 353, Yasouj, 75918-74831, Iran
| | - Bahador Karami
- Department of Chemistry, Yasouj University, P.O. Box 353, Yasouj, 75918-74831, Iran
| | - Akram Jokar
- Department of Chemistry, Yasouj University, P.O. Box 353, Yasouj, 75918-74831, Iran
| | - Khalil Eskandari
- Young Researchers and Elites Club, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran
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Abstract
Endocrine therapy (ET) of hormone receptor (HR)-positive and human epidermal growth factor receptor 2-(HER2)-negative metastatic breast cancer (MBC) historically focused on estrogen deprivation and antagonism. The identification of several intracellular pathways promoting resistance to antiestrogen therapy led to the introduction of novel endocrine drug combinations that reformed treatment schema and expanded therapeutic options. There is no doubt that efforts to overcome or delay resistance to ET are fruiting, particularly with the introduction of cyclin-dependent kinase 4/6 inhibitors such as palbociclib and ribociclib, and mechanistic target of rapamycin inhibitors such as everolimus. Although still considered incurable by currently available treatment modalities, many patients with MBC nowadays enjoy several years of good quality life coupled with decent tumor control. The diversity of therapies and unusual pattern of side effects can be quite perplexing to the treating physician. The sequence of variable agents and management of side effects, in addition to the timing of initiation of cytotoxic chemotherapy, is among the challenges faced by oncologists. In this review, we shed a spotlight on mechanisms of resistance to ET, and provide a review of landmark studies that have recently reshaped the landscape of treatment options for patients with metastatic HR-positive, HER2-negative MBC. A suggested treatment strategy for newly diagnosed patients is also discussed herein.
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Affiliation(s)
- Mohamad Adham Salkeni
- Department of Medicine, West Virginia University Cancer Institute, Morgantown, WV 26506, USA
| | - Samantha June Hall
- Department of Medicine, West Virginia University Cancer Institute, Morgantown, WV 26506, USA
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TSA-catalyzed regioselective synthesis of medicinally important 4-aryl-substituted dihydropyrimidine derivatives fused to pyrazole and triazole scaffolds via an efficient and green Domino reaction. MONATSHEFTE FUR CHEMIE 2017. [DOI: 10.1007/s00706-017-1932-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hertz DL, Henry NL, Rae JM. Germline genetic predictors of aromatase inhibitor concentrations, estrogen suppression and drug efficacy and toxicity in breast cancer patients. Pharmacogenomics 2017; 18:481-499. [PMID: 28346074 PMCID: PMC6219438 DOI: 10.2217/pgs-2016-0205] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
The third-generation aromatase inhibitors (AIs), anastrozole, letrozole and exemestane, are highly effective for the treatment of estrogen receptor-positive breast cancer in postmenopausal women. AIs inhibit the aromatase (CYP19A1)-mediated production of estrogens. Most patients taking AIs achieve undetectable blood estrogen concentrations resulting in drug efficacy with tolerable side effects. However, some patients have suboptimal outcomes, which may be due, in part, to inherited germline genetic variants. This review summarizes published germline genetic associations with AI treatment outcomes including systemic AI concentrations, estrogenic response to AIs, AI treatment efficacy and AI treatment toxicities. Significant associations are highlighted with commentary about prioritization for future validation to identify pharmacogenetic predictors of AI treatment outcomes that can be used to inform personalized treatment decisions in patients with estrogen receptor-positive breast cancer.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA
| | - N Lynn Henry
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84103, USA
| | - James M Rae
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI 48109-1065, USA
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Pagani O. Endocrine Therapies in the Adjuvant and Advanced Disease Settings. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Gervasini G, Jara C, Olier C, Romero N, Martínez R, Carrillo JA. Polymorphisms in ABCB1 and CYP19A1 genes affect anastrozole plasma concentrations and clinical outcomes in postmenopausal breast cancer patients. Br J Clin Pharmacol 2016; 83:562-571. [PMID: 27747906 DOI: 10.1111/bcp.13130] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/01/2016] [Accepted: 09/11/2016] [Indexed: 01/11/2023] Open
Abstract
AIMS Anastrozole, an aromatase inhibitor widely used in breast cancer, has recently been indicated to be a P-glycoprotein (ABCB1) substrate. We have aimed to determine whether ABCB1 single-nucleotide polymorphisms (SNPs) can affect anastrozole plasma concentrations in these patients. In addition, we assessed the impact of SNPs in CYP19A1 and TCL1A on the development of arthralgia and cancer recurrence in our series. METHODS This study included 110 postmenopausal women with hormone receptor-positive breast cancer. Anastrozole plasma levels were determined by a liquid chromatography-electrospray ionization-quadrupole-time-of-flight mass spectrometry system. Patients were genotyped for SNPs in the ABCB1, TCL1A and CYP19A1 genes to search for associations with pharmacokinetic and pharmacodynamics parameters using logistic regression models. RESULTS Anastrozole concentrations showed an almost nine-fold interindividual variability (mean 26.95 ± 11.91 ng ml-1 ). The ABCB1 2677-TT genotype was associated with higher plasma levels (32.22 ± 12.82 vs. 25.86 ± 11.56 ng ml-1 for GG/GT subjects; 95% confidence interval: -12.3 to -0.40), whilst the 3435-TT genotype showed a protective effect on the risk of arthralgia (odds ratio = 0.32 [0.11-0.89]; P = 0.029). The CYP19A1 rs1008805 GG genotype was strongly and inversely associated with arthralgia (odds ratio = 0.24 [0.09-0.65], P = 0.004); however, SNPs near the TCL1A gene were not linked to this adverse effect. None of the patients who had cancer recurrence harboured the CYP19A1 rs727479 AA genotype, which, in contrast, was present in 38% of patients who did not relapse (P for trend = 0.031). CONCLUSION Our findings indicate that variability in anastrozole plasma levels may be attributable to the status of the ABCB1 gene locus. Furthermore, genetic variants in CYP19A1 were associated with arthralgia and cancer recurrence in our patients.
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Affiliation(s)
- Guillermo Gervasini
- Department of Medical and Surgical Therapeutics, Division of Clinical Pharmacology, Medical School, University of Extremadura, Alcorcón, Madrid, Spain
| | - Carlos Jara
- Medical Oncology Department, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Clara Olier
- Medical Oncology Department, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Nuria Romero
- Medical Oncology Department, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Ruth Martínez
- Medical Oncology Department, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Juan Antonio Carrillo
- Department of Medical and Surgical Therapeutics, Division of Clinical Pharmacology, Medical School, University of Extremadura, Alcorcón, Madrid, Spain
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Mancuso MR, Massarweh SA. Endocrine therapy and strategies to overcome therapeutic resistance in breast cancer. Curr Probl Cancer 2016; 40:95-105. [PMID: 27839747 DOI: 10.1016/j.currproblcancer.2016.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 01/04/2023]
Abstract
Despite the remarkable success of endocrine therapy in the treatment of patients with estrogen receptor (ER)- positive breast cancer, not all patients derive benefit from such therapy, or may benefit only temporarily before disease progression or relapse occurs. The value of endocrine therapy, which blocks ER signaling by a variety of strategies, lies in its simplicity, lower toxicity, and better alignment with preserved quality of life, particularly when compared to chemotherapy, which is more toxic and has only modest benefits for many patients with ER-positive breast cancer. It is therefore critical that we discover ways to extend endocrine therapy benefit in patients and prevent therapeutic resistance whenever possible. The tremendous evolution in our understanding of endocrine resistance mechanisms, coupled with the increasing availability of novel agents that target resistance pathways, has led to enhanced treatment approaches for patients with ER-positive breast cancer, primarily through combinations of endocrine agents with a variety of pathway inhibitors. Despite these treatment advances and our changing view of ER-positive breast cancer, there is much work that needs to be done. It remains a problem that we cannot reliably predict which subsets of patients will experience disease relapse or progression on endocrine therapy, and as such, combination strategies with targeted agents have largely been used in unselected patients with ER-positive breast cancer, including those who continue to have endocrine-sensitive disease. Patient selection is a significant issue since most of the targeted therapeutics that we use with endocrine therapy are expensive and can be toxic, and we may be inadvertently overtreating patients whose disease can still be controlled with endocrine therapy alone. In this article, we will review current and future strategies in the treatment of ER-positive breast cancer, as well as the evolving role of targeted therapy in the management of endocrine-resistance.
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Affiliation(s)
| | - Suleiman Alfred Massarweh
- Division of Oncology, Stanford University School of Medicine; Stanford Cancer Institute, Stanford, CA, 94305.
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Hertz DL, Barlow WE, Kidwell KM, Albain KS, Vandenberg TA, Dakhil SR, Tirumali NR, Livingston RB, Gralow J, Hayes DF, Hortobagyi GN, Mehta RS, Rae JM. Fulvestrant decreases anastrozole drug concentrations when taken concurrently by patients with metastatic breast cancer treated on SWOG study S0226. Br J Clin Pharmacol 2016; 81:1134-41. [PMID: 26859101 PMCID: PMC4876171 DOI: 10.1111/bcp.12904] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/25/2016] [Accepted: 02/03/2016] [Indexed: 11/29/2022] Open
Abstract
AIMS In the SWOG S0226 trial the combination of anastrozole plus fulvestrant (n = 349) was superior to anastrozole alone (n = 345) in hormone receptor (HR)-positive metastatic breast cancer. Here we report a pharmacokinetic subset analysis investigating a possible drug interaction between anastrozole and fulvestrant. METHODS Post-menopausal patients with HR-positive metastatic breast cancer were randomized to anastrozole with or without concurrent fulvestrant. Blood samples were collected at 2, 4, 6 and 8 months, just prior to receiving the next dose of anastrozole and fulvestrant. Drug concentrations were measured via LC/MS-MS. Anastrozole concentration was compared in patients on anastrozole alone vs. patients on concomitant fulvestrant. Comparisons were made at each time point using parametric tests and over time using a linear mixed effects model. RESULTS A total of 483 anastrozole concentration measurements were included, 224 samples from 64 patients on the anastrozole alone arm and 259 from 73 patients on the combination arm. The mean anastrozole concentration in the combination arm was significantly lower than that in the anastrozole alone arm at each sample collection time (all P < 0.01) and in the mixed effects model (an estimated difference of 9.85 ng ml(-1) (95% CI 5.69, 14.00 ng ml(-1) ), P < 0.001). CONCLUSION A significant pharmacokinetic drug interaction was detected, in which the addition of fulvestrant to anastrozole treatment decreased the trough anastrozole concentration. Further research is needed to verify whether this interaction affects treatment efficacy and to determine the pharmacological mechanism by which this interaction occurs.
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Affiliation(s)
- Daniel L Hertz
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Kelley M Kidwell
- University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Ted A Vandenberg
- London Health Sciences Center/National Cancer Institute of Canada Clinical, Trials Group, London, ON, Canada
| | | | | | | | - Julie Gralow
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Daniel F Hayes
- Division of Hematology/Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | | | - Rita S Mehta
- University of California Irvine Medical Center, Chao Family Comprehensive, Cancer Center, Orange, CA, USA
| | - James M Rae
- Division of Hematology/Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
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