Randomized trial of 2 versus 5 years of adjuvant tamoxifen for women aged 50 years or older with early breast cancer: Italian Interdisciplinary Group Cancer Evaluation Study of Adjuvant Treatment in Breast Cancer 01

Tamoxifen induced hands deformities

Introduction

Tamoxifen is widely used for the treatment of hormone-responsive breast cancer. In this article, we report a case of a patient who developed hand deformities following long-term administration of tamoxifen.

Case report

A 57-year-old woman, followed for invasive ductal carcinoma of the left breast under tamoxifen for 7 years, presenting joint pain with deformities in her fingers.

Management & outcome

Following the appearance of the adverse effect, tamoxifen was stopped. A series of biologic and radiologic analysis were performed in order to explain the appearance of this event. A substitution treatment was discussed and a rheumatologist's opinion was requested.

Discussion

Tamoxifen appears to be associated with the development of inflammatory osteoarthritis resembling rheumatoid arthritis. Possible mechanisms of such an effect are discussed.

Aromatase inhibitors are associated with a higher fracture risk than tamoxifen: a systematic review and meta-analysis

Background

In this paper, our aim was to systematically evaluate published evidence of bone fracture risk associated with tamoxifen and aromatase inhibitors in women aged 65 and under, and diagnosed with nonmetastatic breast cancer.

Methods

We comprehensively searched MEDLINE, EMBASE and CINAHL databases from January 1997 through May 2015, and reference lists of the selected articles to identify English-language randomized controlled trials and cohort studies of fracture risk. Two independent reviewers screened articles and assessed methodological quality using Risk of Bias assessment for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Fracture risk was estimated as pooled risk ratios using a random-effects model and inverse variance method.

Results

Of 1926 identified articles, 21 independent studies fulfilled our selection criteria. Similar fracture risk was observed in women treated and not treated with tamoxifen [pooled risk ratio (RR) 0.95; 95% confidence interval (CI) 0.84-1.07]. A 35% (95% CI 1.21-1.51) higher fracture risk was observed in the aromatase inhibitor group compared with the tamoxifen group. A 17% (95% CI 1.07-1.28) higher fracture risk was observed in the aromatase inhibitor group than the no aromatase inhibitor group. Compared with the tamoxifen group, aromatase inhibitor-associated fracture risk increased by 33% (pooled RR 1.33; 95% CI 1.21-1.47) during the tamoxifen/aromatase inhibitor treatment period, but did not increase (pooled RR 0.99; 95% CI 0.72-1.37) during the post-tamoxifen/aromatase inhibitor treatment period.

Conclusions

Fracture risk is significantly higher in women treated with aromatase inhibitors, especially during the treatment period. Tamoxifen is not associated with lower fracture risk while tamoxifen could potentially preserve bone mass. Better osteoporosis management programs, especially during the treatment period, are needed for this group of women.

Cardiotoxicity of aromatase inhibitors and tamoxifen in postmenopausal women with breast cancer: a systematic review and meta-analysis of randomized controlled trials

Background

Aromatase inhibitors (AIs) have been associated with cardiovascular disease in adjuvant randomized controlled trials (RCTs) comparing these drugs to tamoxifen. However, it is unclear whether this risk is real or due to cardioprotective effects of tamoxifen. To address this question, we conducted a systematic review and meta-analysis of all RCTs of AIs and tamoxifen in adjuvant and extended adjuvant setting.

Patients and methods

We searched PubMed, Embase (OVID), Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov from inception to June 2016 for all RCTs comparing cardiovascular and cerebrovascular safety of AIs to tamoxifen, AIs to placebo or no-treatment, or tamoxifen to placebo or no-treatment in the adjuvant or extended adjuvant setting. Relative risks (RRs) were pooled using DerSimonian and Laird random-effects models with analyses stratified by RCT design.

Results

A total of 19 RCTs were included in the meta-analysis (n  =  62 345). In the adjuvant setting, AIs were associated with a 19% (RR: 1.19, 95% confidence interval [CI]: 1.07-1.34) increased risk of cardiovascular events compared with tamoxifen. AIs were not associated with an increased risk compared with placebo in the extended-adjuvant setting (RR: 1.01, 95% CI: 0.85-1.20). In the adjuvant setting, tamoxifen was associated with a 33% (RR: 0.67, 95% CI: 0.45-0.98) decreased risk compared with placebo or no-treatment. The results from extended adjuvant RCTs comparing tamoxifen to placebo were inconclusive but suggestive of a small protective effect (RR: 0.91, 95% CI: 0.77-1.07).

Conclusions

The increased risk of cardiovascular events with AIs relative to tamoxifen is likely the result of cardioprotective effects of the latter. This new evidence should be considered when assessing the benefits and risks of AIs in the treatment of breast cancer.

Nordic Walking as an Exercise Intervention to Reduce Pain in Women With Aromatase Inhibitor-Associated Arthralgia: A Feasibility Study

CONTEXT

Women taking aromatase inhibitors as treatment for breast cancer commonly experience joint pain and stiffness (aromatase inhibitor-associated arthralgia [AIAA]), which can cause problems with adherence. There is evidence that exercise might be helpful, and Nordic walking could reduce joint pain compared to normal walking.

OBJECTIVES

To determine the feasibility of a trial of Nordic walking as an exercise intervention for women with AIAA.

METHODS

A feasibility study was carried out in a sample of women with AIAA using a randomized control design. Women were randomized to exercise (six-week supervised group Nordic walking training once per week with an increasing independent element, followed by six weeks 4 × 30 minutes/week independent Nordic walking); or enhanced usual care. Data were collected on recruitment, retention, exercise adherence, safety, and acceptability. The Brief Pain Inventory, GP Physical Activity Questionnaire, and biopsychosocial measures were completed at baseline, six and 12 weeks.

RESULTS

Forty of 159 eligible women were recruited and attrition was 10%. There was no increased lymphedema and no long-term or serious injury. Adherence was >90% for weekly supervised group Nordic walking, and during independent Nordic walking, >80% women managed one to two Nordic walking sessions per week. From baseline to study end point, overall activity levels increased and pain reduced in both the intervention and control groups.

CONCLUSION

Our findings indicate that women with AIAA are prepared to take up Nordic walking, complete a six-week supervised course and maintain increased activity levels over a 12-week period with no adverse effects.

[Massive pleural effusion after surgery of breast cancer and early discontinuation of tamoxifen: about an observation]

Nous rapportons un cas de pleurésie massive droite probablement métastasique accompagnée d'un lymphœdème du membre supérieur droit ayant fait suite à une mastectomie et curage ganglionnaire indiqués pour un carcinome lobulaire du sein droit, associée à un arrêt précoce de la prise de Tamoxifène, vécu à Lubumbashi.

Breast cancer follow-up strategies in randomized phase III adjuvant clinical trials: a systematic review

The effectiveness of different breast cancer follow-up procedures to decrease breast cancer mortality are still an object of debate, even if intensive follow-up by imaging modalities is not recommended by international guidelines since 1997. We conducted a systematic review of surveillance procedures utilized, in the last ten years, in phase III randomized trials (RCTs) of adjuvant treatments in early stage breast cancer with disease free survival as primary endpoint of the study, in order to verify if a similar variance exists in the scientific world. Follow-up modalities were reported in 66 RCTs, and among them, minimal and intensive approaches were equally represented, each being followed by 33 (50%) trials. The minimal surveillance regimen is preferred by international and North American RCTs (P = 0.001) and by trials involving more than one country (P = 0.004), with no relationship with the number of participating centers (P = 0.173), with pharmaceutical industry sponsorship (P = 0.80) and with trials enrolling > 1000 patients (P = 0.14). At multivariate regression analysis, only geographic location of the trial was predictive for a distinct follow-up methodology (P = 0.008): Western European (P = 0.004) and East Asian studies (P = 0.010) use intensive follow-up procedures with a significantly higher frequency than international RCTs, while no differences have been detected between North American and international RCTs. Stratifying the studies according to the date of beginning of patients enrollment, before or after 1998, in more recent RCTs the minimal approach is more frequently followed by international and North American RCTs (P = 0.01), by trials involving more than one country (P = 0.01) and with more than 50 participating centers (P = 0.02). It would be highly desirable that in the near future breast cancer follow-up procedures will be homogeneous in RCTs and everyday clinical settings.

Adjuvant endocrine therapy initiation and persistence in a diverse sample of patients with breast cancer

Adjuvant endocrine therapy for breast cancer reduces recurrence and improves survival rates. Many patients never start treatment or discontinue prematurely. A better understanding of factors associated with endocrine therapy initiation and persistence could inform practitioners how to support patients. We analyzed data from a longitudinal study of 2,268 women diagnosed with breast cancer and reported to the Metropolitan Detroit and Los Angeles SEER cancer registries in 2005-2007. Patients were surveyed approximately both 9 months and 4 years after diagnosis. At the 4-year mark, patients were asked if they had initiated endocrine therapy, terminated therapy, or were currently taking therapy (defined as persistence). Multivariable logistic regression models examined factors associated with initiation and persistence. Of the 743 patients eligible for endocrine therapy, 80 (10.8 %) never initiated therapy, 112 (15.1 %) started therapy but discontinued prematurely, and 551 (74.2 %) continued use at the second time point. Compared with whites, Latinas (OR 2.80, 95 % CI 1.08-7.23) and black women (OR 3.63, 95 % CI 1.22-10.78) were more likely to initiate therapy. Other factors associated with initiation included worry about recurrence (OR 3.54, 95 % CI 1.31-9.56) and inadequate information about side effects (OR 0.24, 95 % CI 0.10-0.55). Factors associated with persistence included two or more medications taken weekly (OR 4.19, 95 % CI 2.28-7.68) and increased age (OR 0.98, 95 % CI 0.95-0.99). Enhanced patient education about potential side effects and the effectiveness of adjuvant endocrine therapy in improving outcomes may improve initiation and persistence rates and optimize breast cancer survival.

Adjuvant therapy for postmenopausal women with endocrine-sensitive breast cancer

Approximately 180,000 women are diagnosed with breast cancer in the United States annually. The majority of these women are postmenopausal and have endocrine-sensitive tumors. Over the last four decades, multiple clinical trials have been conducted in efforts to establish and advance adjuvant endocrine therapies. We review the available evidence for adjuvant endocrine therapies and current recommendations for therapy in postmenopausal women. Although we have made substantial progress in the treatment of endocrine-sensitive breast cancer, future study will require incorporation of biological and translational questions with the goal of enhancing treatment benefits and minimizing toxicity.

Impact of the duration of adjuvant hormonal therapy in patients with locally advanced prostate cancer treated with radiotherapy: a secondary analysis of RTOG 85-31

PURPOSE

Radiation Therapy Oncology Group 85-31 was a randomized trial of androgen suppression for life for patients with locally advanced prostate cancer. However, not all patients continued on the protocol-mandated long-term hormonal therapy despite no evidence of recurrence. We correlated duration of adjuvant hormonal therapy and outcomes among patients who prematurely discontinued hormonal therapy.

PATIENTS AND METHODS

The protocol mandated pelvic radiotherapy followed by goserelin given indefinitely or until disease progression. There were 189 analyzable patients. Patients were divided in groups based on the tertile of hormonal therapy duration (HTD) as follows: < or = 1 year, more than 1 year and < or = 5 years, and more than 5 years. Overall survival (OS), disease-free survival (DFS), cause-specific mortality, local failure (LF), and distant metastasis (DM) were studied. Kaplan-Meier estimation and Cox proportional hazards regression model were used for OS and DFS, and Fine and Gray's regression model was used for the other outcomes.

RESULTS

The median follow-up for surviving patients is 9.6 years. The median duration of adjuvant hormonal therapy was 2.2 years. The HTD more than 5 years group is significantly associated with an improved survival and DFS and fewer DMs than other HTD groups. After adjustment for age, radical prostatectomy, nodal status, Gleason score, and stage variables, the HTD more than 5 years group remains significantly associated with better OS and DFS than other HTD groups.

CONCLUSION

In this hypothesis-generating analysis, prolonged HTD of more than 5 years seems significantly associated with improvements in most outcomes. Given these data, decreasing HTD to < or = 5 years may have a detrimental effect on patients with locally advanced prostate cancer. Only a randomized trial will conclusively clarify this issue.

Cardiovascular reserve and risk profile of postmenopausal women after chemoendocrine therapy for hormone receptor--positive operable breast cancer

Purpose. To examine cardiovascular function and risk profile of postmenopausal women treated with chemoendocrine therapy (CET) for hormone receptor-positive operable breast cancer. Methods. Forty-seven breast cancer patients and 11 age-matched healthy controls were studied. Participants performed a cardiopulmonary exercise test with expired gas analysis and impedance cardiography to assess peak aerobic power (VO(2peak)) and cardiovascular function (stroke volume, cardiac output, cardiac power output, and cardiac reserve). Traditional (i.e., body mass index, lipid profile, and fasting insulin and glucose) and novel (i.e., C-reactive protein, brain natriuretic peptide) cardiovascular risk biochemical factors were also assessed. Results. Breast cancer patients had significantly lower peak exercise stroke volume (68 +/- 9 versus 76 +/- 11 ml/beat), cardiac output (10.4 +/- 1.5 versus 11.7 +/- 2.4 l/minute), cardiac power output (3.0 +/- 0.5 versus 3.5 +/- 0.9 Watts), cardiac power output reserve (1.7 +/- 0.6 versus 2.4 +/- 0.8 Watts), and VO(2peak) (1.3 +/- 0.3 versus 1.6 +/- 0.2 l x min(-1)) than control subjects (p-values < .05). Patients with the greatest impairment in VO(2peak) had the worse cardiovascular risk profile. Exploratory analyses revealed several differences in study outcomes between the 26 patients receiving hormonal therapy with tamoxifen (TAM) and the 21 patients receiving aromatase inhibitor (AI) therapy. Conclusion. Breast cancer patients treated with adjuvant CET have a significantly and markedly lower cardiorespiratory fitness and cardiac functional reserve compared with age- and sex-matched controls. AI therapy may be associated with a more unfavorable cardiovascular risk profile than TAM. Prospective studies are required to further investigate the clinical value of these findings.

Patient centered experiences in breast cancer: predicting long-term adherence to tamoxifen use

BACKGROUND

Among breast cancer patients, tamoxifen use is associated with reduced risk of disease relapse and death, but it is often difficult for women to sustain therapy during the 5 years required to obtain maximum benefit.

OBJECTIVES

We sought to examine the influence of patient-centered care activities on ongoing tamoxifen use 4 years after initiation, we examined key components of patient-centered care and rates of ongoing tamoxifen.

METHODS

Using a prospective cohort study that included observational data from the National Initiative for Cancer Care Quality (NICCQ), we studied 881 patients with stage I-III breast cancer who were registered with an initial diagnosis in 1998 by an American College of Surgeons-approved hospital cancer registry in 1 of 5 metropolitan areas, who initiated tamoxifen treatment. A patient survey and medical record abstraction were used as measurements.

RESULTS

Among women who initiated tamoxifen, 79% were still taking it 4 years later. Other than older age and the severity of side effects, other demographic, clinical and cancer characteristics, and treatments did not predict ongoing tamoxifen use. In contrast, after adjusting for these factors, the proportion of patients with ongoing tamoxifen use was lower for patients reporting less support than needed (82% vs. 69%, P = 0.0051), less than wanted role in decision-making (80% vs. 70%, P = 0.0486), decision-making about tamoxifen without doctor input (79% vs. 64%, P = 0.0182), and for patients who weren't told about side effects in advance (82% vs. 72%, P = 0.0016).

CONCLUSIONS

Although age and the severity of side-effects remain important, patient-centered care was a primary mediator of patient adherence to ongoing cancer treatment with tamoxifen.

Twelve-year mortality results of a randomized trial of 2 versus 5 years of adjuvant tamoxifen for postmenopausal early-stage breast carcinoma patients (SITAM 01)

BACKGROUND

This study evaluated the impact on overall survival (OS) of 2 versus 5 years adjuvant tamoxifen in early breast carcinoma patients after 12 years of follow-up.

METHODS

Women with breast carcinoma T1-3, N0-3, M0, aged 50-70 years, were eligible for this multicenter randomized Phase III trial. Patients event-free after 2 years of tamoxifen therapy (TAM) were randomly assigned to stop or continue TAM (20 mg/day) for an additional 3 years. The primary endpoint was disease-free survival. Secondary endpoints included OS and toxicity.

RESULTS

From 1989 through 1996, 1901 patients were randomly assigned either to stop treatment (n = 958) or to continue TAM (n = 943). Overall, 98% of patients alive at the previous report (n = 1611) had updated information about OS, of whom 549 had died. The median duration of postrandomization follow-up was 115 months (interquartile range, 86-137). No statistically significant differences between the two arms were detected in the whole population (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.86-1.22) and in estrogen receptor (ER)-positive patients (HR, 0.90; 95% CI, 0.72-1.13). In the latter group, survival curves started to diverge after 90 months, showing a trend in favor of the 5-year arm. In younger (age < or =55 yrs) ER-positive patients longer TAM was associated with a 44% decrease in the risk of death (HR, 0.56; 95% CI, 0.31-1.00), while no clear benefit was documented in women older than 55 years of age (HR, 0.98; 95% CI, 0.77-1.25).

CONCLUSIONS

The benefits of longer TAM on OS start to emerge only after 9 years from diagnosis and seem to be more relevant in younger ER-positive women.

Are Oral Bisphosphonates Effective in Improving Lumbar Bone Mineral Density in Breast Cancer Survivors With Osteopenia or Osteoporosis?

OBJECTIVE

Breast cancer survivors with osteoporosis or osteopenia are commonly encountered in primary care and gynaecology practices. Our objective was to determine whether treatment with oral bisphosphonates (alendronate or cyclic etidronate) was more effective than calcium with vitamin D in improving lumbar spine bone mineral density (BMD) within one year in breast cancer survivors.

METHODS

Breast cancer survivors with at least one year of clinical follow-up were identified from the prospective observational Canadian Database of Osteoporosis and Osteopenia (CANDOO). Analysis of covariance was used to examine the effects of bisphosphonate therapy on change in lumbar spine BMD at one year compared with the effects of calcium with vitamin D (analysis adjusted for baseline L2-L4 BMD, current tamoxifen use, number of prevalent vertebral fractures [VFs], and time since diagnosis of breast cancer, and age).

RESULTS

Eighteen patients took calcium and vitamin D, 25 took cyclic etidronate, and 27 took oral alendronate. Adjusted one-year BMD increases for alendronate and cyclic etidronate compared to calcium and vitamin D were as follows: alendronate 4.53% (95% confidence interval [CI] 1.26%, 7.81%, P = 0.008), and cyclic etidronate 1.85% (-1.55%, 5.25%, P = 0.280). BMD increases were significantly greater in patients with prevalent VF compared to those without VF (P = 0.025). In contrast, time since diagnosis of breast cancer was significantly associated with a decrease in BMD (P = 0.002). We were unable to detect any effect of current tamoxifen use, baseline lumbar spine BMD, or age on changes in BMD at one year.

CONCLUSION

Treatment with alendronate was associated with significantly greater improvements in lumbar spine BMD within one year in breast cancer survivors when compared with treatment with cyclic etidronate or calcium and vitamin D.

Hormonal therapy for primary breast cancer: scientific rationale and status of clinical research

Endocrine therapies have played an important role in the management of breast cancer for many years. Tamoxifen had been the unchallenged standard in the adjuvant setting until recently. Data from recent clinical trials have emphasized the emerging roles of aromatase inhibitors and ovarian ablation in patients with early breast cancer. This review highlights previous data that led to the recognition of tamoxifen as the gold standard hormonal therapy in the adjuvant treatment of early breast cancer. We then discuss clinical trials demonstrating the impact of aromatase inhibitors as an alternative to tamoxifen or as a component of sequential treatment with tamoxifen in postmenopausal women with early breast cancer. Finally, we review data related to the incorporation of ovarian ablation into the treatment of early breast cancer in premenopausal women.

Switching trial of adjuvant tamoxifen with an aromatase inhibitor in postmenopausal patients with breast cancer

Tamoxifen is currently a standard of care for postmenopausal patients with breast cancer with hormone receptor-positive tumors who are candidates for adjuvant endocrine therapy. This treatment is highly effective and relatively safe. However, a significant proportion of women are constitutively resistant or become resistant to tamoxifen, despite having hormone receptor-positive tumors. Moreover, the prolonged exposure to tamoxifen can produce severe and life-threatening side effects like endometrial carcinoma or thromboembolic disease. Aromatase inhibitors (AI) have been shown to be quite effective in advanced disease, and also have promising efficacy in early-stage breast cancer as alternatives to tamoxifen. This article reviews the results achieved by AI following 2-3 years or 5 years of tamoxifen. At least 3 trials indicate that switching to an AI following 2-3 years of tamoxifen can produce a substantial benefit. A fourth trial indicates that additional benefit can be achieved by a few years of treatment with an AI after 5 years of tamoxifen. The updated results of previous trials and ongoing trials will soon establish criteria for selecting patients who might be better candidates for sequencing, and to fine tune strategies that are more appropriate.

Implications of first-line adjuvant treatment with aromatase inhibitors in recurrent metastatic breast cancer

The role of adjuvant tamoxifen therapy has gone unchallenged until recently. With the introduction of the selective aromatase inhibitors (AIs), the paradigm for treatment of hormone receptor-positive breast cancer in postmenopausal women is changing. New data from randomized clinical trials have shown the impact of the use of an AI compared with tamoxifen or in sequence with tamoxifen. This review will emphasize some of the highlights from these data sets and the limitations of our current knowledge. Finally, we will discuss the implications of the use of nonselective AIs in the adjuvant setting for the patient who develops recurrent metastatic disease.

Current limits of knowledge in adjuvant and neoadjuvant endocrine therapy of breast cancer: the need for more clinical research

Adjuvant endocrine therapy following surgical resection of early, endocrine sensitive breast cancer has proven benefits in reducing risk of recurrence and death, as demonstrated in many mature well controlled clinical trials. The introduction of new endocrine therapies as potential alternatives to tamoxifen or ovarian ablation and the incorporation of neoadjuvant endocrine therapy into the overall management strategy continue to provide exciting challenges for clinical research. In this article the focus is on as yet unanswered questions pertinent to adjuvant or neoadjuvant endocrine therapy for breast cancer. In the process, we broadly outline the current limits of knowledge as we understand it. Many relevant and current clinical trials are ongoing and a list of these with contact details or references are provided. Definitive data is urgently needed in many areas and, when available, will provide important evidence on which the management of breast cancer patients in future can be based. Participation in relevant clinical trials is vital for future progress.