Pituitary Adenomas in Transgender Individuals?

Transgender individuals may receive long-term hormonal treatment as part of their sexual transition; limited literature has suggested that they consequently may be predisposed to development of prolactinomas. We questioned whether we had encountered such cases. Pathology databases were searched for the years 2000-2019 for tissue specimens from transgender individuals; Sixty surgical specimens from 58 individuals and 8 cytology specimens were identified. Two of these 60 were pituitary adenomas, neither of which were lactotroph adenomas (prolactinomas).The first occurred in a 71-year-old transgender male-to-female who had undergone high-dose hormone therapy, followed by orchiectomy 30 years prior. Chronic hypertension, dizziness, and vertigo prompted an endocrine workup which revealed elevated IGF-1 and prolactin; The pituitary mass proved to be a mixed somatotroph/lactotroph adenoma. The second occurred in a 53-year-old transgender male-to-female who was being evaluated by an endocrinologist prior to initiating hormone therapy for transition when a slightly elevated prolactin level was discovered. This pituitary macroadenoma proved to be a gonadotroph adenoma. The most common surgical specimens were 33 bilateral mastectomies, 13 hysterectomies, and 4 orchiectomies, almost all for gender transition purposes rather than medical conditions. Pathologists may wish to be aware of the occurrence of pituitary adenomas in transgender individuals, although the incidence is quite low.

Hormone Therapy Effects on the Uterus

The uterus and especially the endometrium are sensitive targets for steroid sex hormones, capable to modify structure and function with promptitude and versatility in order to secure reproductive functions. Hormone therapy is used to counteract deprivation, abnormal, and deleterious functions of "natural" hormones. It is widely prescribed, being used by millions of women all over the world. It seems that most women would use at least some hormone therapy at some point of their life, as contraceptives, ovarian stimulation, replacement therapy, or hormone antitumoral therapy. The diagnosis of uterine tissue, mostly of the frequently performed endometrial biopsies taken from women undergoing hormone therapy, is often confusing and difficult to interpret due to the complexity of histologic changes. Permanently changing hormonal pharmaceutical products, regimens, dosages, as well as new concepts of therapy are challenges for both users and medical prescribers. This chapter addresses the most commonly issues arising from the gynecological pathology interpretation of hormonal therapy effects on the uterus.

Risk of postmenopausal hormone therapy and patient history factors for the survival rate in women with endometrial carcinoma

PURPOSE

Postmenopausal hormone therapy (HT) is known to affect the development of hormone-dependent endometrial carcinoma (type I EC). Several studies on breast and ovarian carcinoma have shown that HT influences the molecular profile and prognostic behavior of these tumors. This study aimed to investigate the influence of prior HT and other risk factors on the prognosis in a cohort of patients with invasive endometrial carcinoma (EC).

METHODS

Among 525 patients diagnosed with EC between 1987 and 2010, 426 postmenopausal patients were identified. Information regarding HT was available in 287 of these patients, 78 of whom had a history of HT and 209 of whom did not. Both overall survival (OS) and progression-free survival (PFS) were analyzed. In addition to OS and PFS, risk factors such as age at diagnosis, postmenopausal HT, body mass index (BMI), diabetes mellitus, tumor stage, EC type (I or II), and recurrences were analyzed.

RESULTS

Relative to HT alone, women with EC and a history of HT had a longer survival than those with no HT. However, the Cox proportional hazards model showed that it was not HT itself, but rather other characteristics in the HT group that were causally associated with longer survival.

CONCLUSIONS

Age (the older, the worse) and tumor stage (the higher, the worse) were significant influences on overall survival. Patients with HT also had lower BMIs, less diabetes, more type I EC, and fewer recurrences in comparison with the non-HT group. With regard to the PFS, it made no difference whether the patient was receiving HT.

Randomized double-blind placebo-controlled trial of the effect of Morus nigra L. (black mulberry) leaf powder on symptoms and quality of life among climacteric women

OBJECTIVE

To test the efficacy of Morus nigra L. (MN) leaf powder for treating climacteric symptoms by comparison with hormone therapy (HT) and placebo.

METHODS

A randomized controlled trial among 62 climacteric women attending Hospital of the Federal University of Maranhão, Brazil. Women were divided into MN, HT, and placebo groups, and received 250 mg of MN leaf powder, 1 mg of estradiol, or placebo for 60 days. Primary outcomes were the Blatt-Kupperman index (BKI) for climacteric symptoms and SF-36 health questionnaire scores.

RESULTS

Baseline sociodemographic variables, BKI scores, symptoms, and SF-36 domains did not differ among the groups. There was a reduction in mean BKI in the MN (17.5 vs 9.7, P<0.001), HT (15.4 vs 8.6, P=0.001), and placebo (16.1 vs 12.4, P=0.040) groups. Analysis of quality of life (QoL) showed that functional capacity (P=0.006), vitality (P=0.031), mental health (P=0.017), and social aspect (P<0.01) improved after treatment in the MN group. The HT group showed improvement in emotional limitation (P=0.040), and the placebo group showed better functional capacity (P=0.030) after treatment.

CONCLUSIONS

Climacteric symptoms and QoL improved after administration of 250 mg of MN leaf powder for 60 days, similar to the effects of HT. The trial is registered in the Brazilian Registry of Clinical Trials (REBEC) under registration number RBR-9t4xxk.

Should surgical treatment of catamenial pneumothorax include diaphragmatic repair?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether treatment with hormones or pleural symphysis is better than operative procedures such as diaphragmatic repair with mesh to surgically manage recurrent pneumothoraces in patients with catamenial pneumothorax. Diaphragmatic repair with synthetic meshes, hormonal treatment and pleural symphysis are all accepted interventions for the treatment of recurrent catamenial pneumothoraces; however, there is uncertainty over the best combination of treatment. Altogether, 396 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. However, it should be noted that the studies included were small in terms of sample size, and have demonstrated significant bias and surgical heterogeneity. Our literature review found that the recurrence rates of pneumothorax were greatly reduced in the treatment group where surgery and hormone therapy were combined (pooled average recurrence rate of 0%); however, the recurrence rates were significantly higher when these interventions were used alone: hormone therapy alone (58.5%), diaphragmatic repair alone (33.3%) and surgery alone (63.3%). Our results therefore demonstrate that a multimodality approach is required to reduce pneumothorax recurrence rates in patients with catamenial pneumothorax.

Transition memories: experiences of trans adult women with hormone therapy and their beliefs on the usage of hormone blockers to suppress puberty

PURPOSE

In recent years, an increasing number of specialized gender clinics have been prescribing gonadotropin-releasing hormone (GnRH) analogs to adolescents diagnosed with gender dysphoria (GD) to suppress puberty. This paper presents qualitative research on the hormone therapy (HT) experiences of older trans-people and their views on puberty suppression. The main aim of this research was to explore the psychological aspects of hormonal treatments for gender non-conforming adults, including the controversial use of puberty suppression treatments.

METHODS

Using a semi-structured interview format, ten adult trans-women were interviewed (mean age: 37.4) to explore their personal histories regarding GD onset and development, their HT experiences, and their views on the use of GnRH analogs to suppress puberty in trans-children and adolescents.

RESULTS

the interview transcripts were analyzed using the consensual qualitative research method from which several themes emerged: the onset of GD, childhood experiences, experiences with puberty and HT, views on the puberty suspension procedure, and the effects of this suspension on gender identity and sexuality.

CONCLUSIONS

The interviews showed that overall, the participants valued the new treatment protocol due to the opportunity to prevent the severe body dysphoria and social phobia trans-people experience with puberty. It seems that the risk of social isolation and psychological suffering is increased by the general lack of acceptance and stigma toward trans-identities in the Italian society. However, during gender transitions, they highlight the need to focus more on internal and psychological aspects, rather than over-emphasize physical appearance. This study gives a voice to an under-represented group regarding the use of GnRH analogs to suppress puberty in trans-individuals, and collected firsthand insights on this controversial treatment and its recommendations in professional international guidelines.

An integrative DNA methylation model for improved prognostication of postsurgery recurrence and therapy in prostate cancer patients

PURPOSE

Patients with clinically localized, high-risk prostate cancer are often treated with surgery, but exhibit variable prognosis requiring long-term monitoring. An ongoing challenge for such patients is developing optimal strategies and biomarkers capable of differentiating between men at risk of early recurrence (<3 years) that will benefit from adjuvant therapies and men at risk of late recurrence (>5 years) who will benefit from long-term monitoring and/or salvage therapies.

PATIENTS AND METHODS

DNA methylation changes for 12 genes associated with disease progression were analyzed in 453 prostate tumors. A 4-gene prognostic model (4-G model) for biochemical recurrence (BCR) was derived utilizing LASSO from Cohort 1 (n = 254) and validated in Cohort 2 (n = 199). Subsequently, the 4-G model was evaluated for its association with salvage radiotherapy (RT) and/or hormone therapy, and the additive potential to CAPRA-S to develop an integrative gene model was assessed.

RESULTS

The 4-G model was significantly associated with BCR in both cohorts (chi-squared analysis P≤ 0.004) and specifically, with late recurrence at 5+ years (P < 0.001, Cohort 1; P= 0.028, Cohort 2). Multivariable Cox proportional regression analysis identified the 4-G model as significantly associated with salvage RT or hormone therapy in Cohort 1 (hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.29-2.10, P< 0.001) and further validated in Cohort 2 (HR 1.63, 95% CI 1.18-2.25, P< 0.001). The integrative model outperformed prostate-specific antigen and the 4-G model alone for predicting BCR and was associated with patients who received hormone therapy 3+ years postsurgery.

CONCLUSIONS

We have identified and validated a novel integrative gene model as an independent prognosticator of BCR and demonstrated its association with late BCR. These patients require more long-term postsurgical monitoring and could be spared the comorbidities of adjuvant therapies.

Fatigue, quality of life and metabolic changes in men treated with first-line enzalutamide versus abiraterone plus prednisolone for metastatic castration-resistant prostate cancer (HEAT): a randomised trial protocol

INTRODUCTION

Enzalutamide and abiraterone acetate plus prednisolone (AAP) are used in combination with androgen-deprivation therapy to further suppress the androgen stimulation of metastatic castration-resistant prostate cancer (mCRPC). First-line mCRPC treatment with enzalutamide and AAP yields similar overall survival and radiographic progression-free survival in phase III trials. Thus, treatment selection relies on patient choice, cost and side effects. The aim of this randomised trial is to investigate differences in fatigue, health-related quality of life (HRQoL) and metabolic side effects in men with mCRPC treated with first-line enzalutamide versus AAP.

METHODS AND ANALYSIS

In this ongoing open-label randomised (1:1) clinical trial, enzalutamide is compared with AAP as first-line treatment for men with mCRPC. The primary endpoint is fatigue assessed with the questionnaire Functional Assessment of Chronic Illness Therapy-Fatigue version 4. Secondary endpoints are changes in body composition (ie, fat mass, visceral adipose tissue, subcutaneous adipose tissue and lean body mass assessed with dual energy X-ray absorptiometry), glucose metabolism assessed with a 2-hour oral glucose tolerance test, serum lipids, blood pressure and HRQoL assessed with the questionnaire Functional Assessment of Cancer Therapy-Prostate (FACT-P). All study endpoints are assessed at baseline and 12-week postintervention. Blood and urine samples are collected at baseline and at time of progression on allocated treatment for future investigation of predictive and prognostic biomarkers in prostate cancer treatment. The planned sample size is 170 participants. All participants are recruited from Herlev and Gentofte Hospital, Denmark. Estimated last patient's last visit is February 2020.

ETHICS AND DISSEMINATION

The study received project approval from the National Committee on Health Research Ethics and Danish Data Protection Agency and Danish Medicines Agency (EudraCT no.: 2017-000027-99). The results of the study will be published in peer-reviewed international journals and will be presented at national and international conferences and symposiums.

TRIAL REGISTRATION NUMBER

Clinicaltrialsregister.eu (2017-000099-27).

Oophorectomy as a Hormonal Ablation Therapy in Metastatic and Recurrent Breast Cancer: Current Indications and Results

Breast cancer is the commonest malignancy affecting females. Hormone-positive cancers carry a better prognosis. Many adjuvant and palliative endocrine therapies are in use, including surgical ablation. We retrospectively studied seventy-four patients who did bilateral salpingo-oophorectomy (BSO)/bilateral oophorectomy (BO) for factors affecting survival and prognosis. BSO was superior in overall and progression-free survival. Incidental ovarian metastasis carried a grave prognosis. Surgical hormonal ablation is a viable option with laparoscopic BSO as the approach of choice.

Clinical Characteristics and Outcomes of Single Versus Double Hormone Receptor-Positive Breast Cancer in 2 Large Databases

PURPOSE

To identify biologic and outcome differences between double hormone receptor (HR)-positive (dHR⁺, estrogen receptor (ER)⁺/progesterone receptor [PgR⁺]) and single HR-positive (sHR⁺, either ER⁺/PgR^- or ER^-/PgR⁺) breast cancer; and to explore whether hormone therapy (HT) response in HER2-negative breast cancer correlates with HR status.

PATIENTS AND METHODS

This retrospective study was conducted by using 2 large breast cancer databases: the Surveillance, Epidemiology, and End Results (SEER) database and the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) clinical data set. Cox regression analysis was used to estimate overall survival (OS) and breast cancer-specific survival (BCSS) among sHR⁺ and dHR⁺ patients.

RESULTS

In the SEER database, dHR⁺ patients had significantly longer OS and BCSS than ER⁺/PgR^- patients in short-term follow-up (OS: hazard ratio = 0.620; 95% confidence interval [CI], 0.590, 0.652; P < .001; BCSS: hazard ratio = 0.493; 95% CI, 0.462, 0.526; P < .001). Meanwhile, ER^-/PgR⁺ patients had younger age, larger tumor size, and higher disease grade than dHR⁺ and ER⁺/PgR^- patients. In patients who received HT, dHR⁺ patients had a more favorable OS than ER⁺/PgR^- patients (hazard ratio = 0.789; 95% CI, 0.635, 0.982; P = .034), and ER^-/PgR⁺ patients had a worse OS than ER⁺/PgR^- patients at 10 years' follow-up (hazard ratio = 7.991; 95% CI, 1.053, 60.644; P = .044). However, these groups had similar outcomes over longer periods.

CONCLUSION

In HER2-negative breast cancer, sHR⁺ patients are associated with relatively worse characteristics and worse short-term outcomes than dHR⁺ patients. Additionally, the outcome of patients receiving HT may differ according to the HR status. However, further studies are needed to confirm these conclusions.

Sex Hormones and Cognition: Where Do We Stand?

Hypothalamic-pituitary-gonadal axis regulates the reproductive system. The overall health and wellbeing of a woman is subject to fluctuations in the sex hormones throughout her lifespan. Menopause, either natural or surgically induced, is often associated with cognitive complaints, especially memory disturbances. Sex hormones, besides affecting the reproductive function, affect the central nervous system in many ways. Here, we aim to review the role of sex hormones in cognition and the current evidence on use of or against menopausal hormonal therapy as a cognition enhancer in women with cognitive disturbances, including those with Alzheimer's disease.

A single-blind randomized trial

BACKGROUND

The role of microRNAs (miRs) in hormone therapy (HT) is of keen interest in developing biomarkers and treatments for individuals with breast cancer. Although miRs are often moderate regulators under homeostatic conditions, their function is changed more in response to physical activity.

OBJECTIVE

This single-blind randomized trial aimed to explore the effect of high-intensity interval training (HIIT) on serum levels of miRs in individuals with early-stage breast cancer undergoing HT.

METHODS

Hormone receptor-positive women with breast cancer and healthy women were randomly assigned to a healthy control group (n=15), healthy group with HIIT (n=15), breast cancer group with HT (HT, n=26), and breast cancer group with HT and HIIT (HT+HIIT, n=26). The exercise groups underwent interval uphill walking training on a treadmill 3 times a week for 12weeks. At the end of the study, we analyzed changes in levels of cancer-related miRs (oncomiRs) and tumour suppressor miRs (TSmiRs) in response to the HT and HIIT.

RESULTS

In women with breast cancer versus healthy controls, the expression of some oncomiRs was significantly increased - miR-21 (P<0.001), miR-155 (P=0.001), miR-221 (P=0.008), miR-27a (P<0.001), and miR-10b (P=0.007) - and that of some TSmiRs was significantly decreased - miR-206 (P=0.048), miR-145 (P=0.011), miR-143 (P=0.008), miR-9 (P=0.020), and let-7a (P=0.005). Moreover, HT considerably downregulated oncomiRs and upregulated TSmiRs. HIIT for 12weeks with HT significantly decreased the expression of the oncomiRs and significantly increased that of the TSmiRs as compared with HT alone.

CONCLUSIONS

HITT could amplify the decrease and/or increase in expression of miRs associated with HT in women with breast cancer. A prospective trial could determine whether the use of circulating miRs for monitoring treatment can be useful in therapy decisions.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (No.: IRCT201202289171N1).

Encapsulation of Mesenchymal Stem Cells in 3D Ovarian Cell Constructs Promotes Stable and Long-Term Hormone Secretion with Improved Physiological Outcomes in a Syngeneic Rat Model

Loss of ovarian function (e.g., due to menopause) leads to profound physiological effects in women including changes in sexual function and osteoporosis. Hormone therapies are a known solution, but their use has significantly decreased due to concerns over cardiovascular disease and certain cancers. We recently reported a tissue-engineering strategy for cell hormone therapy (cHT) in which granulosa cells and theca cells are encapsulated to mimic native ovarian follicles. cHT improved physiological outcomes and safety compared to pharmacological hormone therapies in a rat ovariectomy model. However, cHT did not achieve estrogen levels as high as ovary-intact animals. In this report, we examined if hormone secretion from cHT constructs is impacted by incorporation of bone marrow-derived mesenchymal stem cells (BMSC) since these cells contain regulatory factors such as aromatase necessary for estrogen production. Incorporation of BMSCs led to enhanced estrogen secretion in vitro. Moreover, cHT constructs with BMSCs achieved estrogen secretion levels significantly greater than constructs without BMSCs in ovariectomized rats from 70 to 90 days after implantation, while also regulating pituitary hormones. cHT constructs with BMSC ameliorated estrogen deficiency-induced uterine atrophy without hyperplasia. The results indicate that inclusion of BMSC in cHT strategies can improve performance.

Transgender bone health

Gonadal sex steroids play a pivotal role in bone health. Medical and surgical therapies for gender dysphoria in both adolescents and adults can lead to skeletal changes. This review evaluates the literature on transgender bone health, and how the data can be translated into clinical practice.

French recommendations on strategies for preventing and treating osteoporosis induced by adjuvant breast cancer therapies

Standard adjuvant therapies for breast cancer such as chemotherapy or aromatase inhibitor and LH-RH agonist hormone therapy are associated with significant survival gains but also induce bone loss by aggravating the estrogen deprivation. The bone loss may be substantial, notably during early treatment, and occurs regardless of the baseline bone mineral density values. The objective of developing these recommendations was to achieve a practical consensus among various scientific societies, based on literature review, about osteoporosis prevention and treatment in these patients. The following scientific societies contributed to the work: Société Française de Rhumatologie (SFR), Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), Groupe Européen d'Etudes des Métastases Osseuses (GEMO), Association Francophone pour les Soins Oncologiques de Support (AFSOS), Société Française de Sénologie et de Pathologie Mammaire (SFSPM), Société Française de Radiothérapie Oncologique (SFRO). Drug prescription and reimbursement modalities in France were taken into account. These recommendations apply to postmenopausal women taking systemic chemotherapy and/or aromatase inhibitor therapy, non-postmenopausal women taking LH-RH agonist therapy, and non-postmenopausal women with persistent amenorrhea 1 year after chemotherapy completion. All women in these three categories should undergo an evaluation of bone health and receive interventions to combat risk factors for bone loss. Patients with a history of severe osteoporotic fracture and/or a T-score value <-2.5 should receive osteoporosis drug therapy. The FRAX® score should be used to guide treatment decisions in patients whose T-score is between -1 and -2.5. General osteoporosis prevention measures should be applied in patients without criteria for osteoporosis drug therapy, who should undergo bone mineral density measurements 18-24 months later if the baseline T-score is<-1 and 3-5 years later if the baseline T-score is>-1. The anti-tumor effect of bisphosphonates and denosumab was not considered when establishing these recommendations.

[Chemotherapy combined with androgen-deprivation therapy in high-volume metastatic hormone sensitive prostate cancer: a short-term efficacy and safety analysis]

Objective: To investigate the short-term efficacy and adverse events of chemotherapy combined with androgen-deprivation therapy in high-volume metastatic hormone sensitive prostate cancer. Methods: From March 2015 to August 2017, 55 patients with high-volume metastatic hormone sensitive prostate cancer were enrolled at Department of Urology, Fudan University Shanghai Cancer Center receiving chemotherapy combined with androgen-deprivation therapy. The age was 65(8) years (M(Q(R))) (range: 46 to 79 years). Patients were enrolled in the study for continuous androgen-deprivation therapy (medical or surgical castration), combined with docetaxel 75 mg/m(2) intravenous injection on the first day, repeated every 21 days (6 cycles). Endpoints included overall survival, progression-free survival of prostate cancer, prostate specific antigen (PSA) response rate, and adverse events. Results: The follow-up time was 21.2(11.7) months. The PSA value before chemotherapy was 144.9(415.3) μg/L. The days in patients undergoing androgen deprivation therapy before chemotherapy was 14(23) days. Four patients (7.3%) presented 0 in Eastern Cooperative Oncology Group scoring system and 51 patients(92.7%) presented 1. Thirty-nine patients (70.9%) completed more than 6 cycles of combined chemotherapy, 17 patients (30.9%) showed PSA<0.2 μg/L at 6 months after treatment, and 14 patients (25.5%) showed PSA<0.2 μg/L at 12 months after treatment. Twenty-eight patients (50.9%) had grade 3 to 4 neutropenia and 1 patient (1.8%) developed infectious neutropenia and died. Nausea and vomit occurred in 16 patients (29.1%). Twelve patients (21.8%) underwent dose adjustment due to adverse events in blood system. Conclusions: The short-term effect was confirmed in high-volume metastatic hormone sensitive prostate cancer using chemotherapy combined androgen-deprivation therapy, and the long-term effect remains to be seen. Myelosuppression during chemotherapy requires close attention, and taking timely examination is recommended.

Symptoms and QOL in breast cancer patients receiving hormone therapy in Japan

BACKGROUND

The aim was to clarify subjective symptoms and quality of life (QOL) in breast cancer patients receiving hormone therapy.

METHODS

After obtaining approval from the research ethics committee, an observational study using a self-administered questionnaire was conducted at outpatient clinical oncology offices in 3 facilities that targeted breast cancer patients under the age of 50 who had been undergoing hormone therapy for less than 1 year. The study examined elements such as the breast cancer patients' basic information, symptoms, pain in daily life, QOL, and depression/anxiety.

RESULTS

There were 214 valid responses. The respondents had an average age of 43.6. Of them, 100% were also treated with Tamoxifen and 30% with LH-RH agonist. There were 75% who were cognizant of side effects. Difficult symptoms that occurred with high frequency were stiff shoulders/back pain, decreased physical strength, hot flashes, and sweating. Over half the respondents were uncertain as to whether the subjective symptoms were side effects. They lost confidence in their physical strength and felt distressed over weight gain. There were 51 with a HADS anxiety score of 8 or higher, and 46 who scored 8 points or higher for depression.

CONCLUSION

Breast cancer patients undergoing hormone therapy experience a variety of pains, and some also have serious psychological symptoms. Reassessing support systems to examine screening and self-care support is an issue going forward.

Menopause: Hormones, Lifestyle, and Optimizing Aging

Although American women spend approximately 30% to 40% of their lives in menopause, a state defined by the cessation of estrogen production by the ovaries, obstetricians and gynecologists in North America receive little formal education about menopausal health. Hormonal therapy has been available for more than 75 years; however, controversies surrounding its use have impacted training of care providers in all specialties. This article offers updates on care for menopausal women, focusing on symptomatology and health issues that arise related to the decline in all reproductive hormones. Lifestyle adaptations and nonmedical approaches, and nonhormonal and hormonal medications are discussed.

The potential markers of endocrine resistance among HR+ /HER2+ breast cancer patients

PURPOSE

Breast cancer with positive hormone receptor (HR) and human epidermal growth factor receptor-2 (HER2) is a special subgroup with different clinical features and survival, especially the endocrine therapy resistance. The main purpose of the study is to find the potential markers to predict the survival and endocrine therapy resistance of patients with HR+ /HER2+ breast cancer.

METHODS

Surveillance, Epidemiology, and End Results (SEER) database was used to collect patients' clinical information and tumor features including age, tumor size, grade, stage and long-term survival; the BioPortal for Cancer Genomics (https://cbioportal.org) was used to download the gene data for specific patient group; cluster analyses of gene expression were conducted through the DAVID Bioinformatics Resources 6.8 software.

RESULTS

All of the included patients were diagnosed as HR positive breast cancer, but the PR positive rates were more common in HER2- group and also the ER+ /PR+ disease. Patients in HR+ /HER2+ group were more likely to present as stage III-IV and grade III disease. Among HR+ /HER2+ patients, 68.6% received chemotherapy, while only 28.9% in HR+ /HER2- group received chemotherapy (P < 0.0001). The survival of HR+ /HER2+ group was poorer. From TCGA database, series genes which were differed between HR+ /HER2+ and HR+ /HER2- were screened out that related to ERBB2 closely: IKZF3, LASP1, CDK12, MLLT6, and RARA. The first three candidate genes were associated with patients' survival, especially in patients who received hormone therapies.

CONCLUSION

This study analyzed the clinical characteristics and survival of patients with HR+/HER2+ breast cancer as a special subgroup. ERBB2, IKZF3, LASP1, and CDK12 were the potential markers of the resistance of endocrine therapy, and they will provide new strategies for clinicians.

The effect of testosterone therapy on personality traits of trans men: a controlled prospective study in Germany and Switzerland

Gender dysphoria in transgender men is generally treated with exogenous testosterone administration aiming to suppress secondary female sex characteristics and achieve masculinization. However, the effect of testosterone on the personality of transgender men remains largely unknown. Therefore, we conducted a controlled study with 23 trans men (M = 27.2 years, Range = 18-51 years), recruited from internet-groups, medical and psychiatric services in Switzerland and Germany versus 27 cisgender women matched by age as control group. Data were collected prior to hormone therapy (HT), three and six months after the first treatment. Non-pathological personality traits (Big Five) were measured with the revised NEO-Personality-Inventory (NEO-PI-R). The greatest changes in the Big Five and its subdimensions occurred within the first three months. Interaction effects showed a significant decrease in the dimension Neuroticism (p < 0.01) - with the most relevant decline in its facet Depression - conversely, Extraversion (p < 0.001) increased, in particular, within its facets of Assertiveness (p < 0.01) and Warmth (p < 0.01). Expectedly, personality traits were stable in the control group. An overall decrease in interpersonal stress-related traits and a substantial increase in enhanced social-interaction traits and personal well-being occurred. These results enable medical services to ensure that informed-consent prior to HT is evidence-based with respect to potential changes in personality and may reduce concerns of trans men and their significant others regarding increased aggressiveness.

Osteoporosis and Bone Health in Transgender Persons

This review summarizes current studies, systematic reviews, and clinical practice guidelines regarding the screening, diagnosis, and treatment of osteoporosis in transgender persons. Gender-affirming hormone therapy has been shown to maintain or promote acquisition of bone density as measured by dual-energy x-ray absorptiometry. No differences in fracture rates have been seen in trans women or men in short, prospective trials. Trans children and adolescents on gonadotropin-releasing hormone may be at risk for decreasing bone density while not on sex steroid hormone replacement. Screening for osteoporosis should be based on clinical factors. Treatment for osteoporosis follows the same guidelines as cisgender populations.

Human Immunodeficiency Virus in Transgender Persons

Worldwide, transgender populations are disproportionately affected by human immunodeficiency virus (HIV). Pervasive stigma and discrimination impact social and economic determinants of health, which perpetuate HIV disparities among transgender individuals. This article reviews the prevalence of HIV infection among transgender populations and presents psychosocial, behavioral, and individual level factors that contribute to HIV acquisition. The authors provide practical recommendations regarding a patient-centered approach to HIV/sexually transmitted infection risk assessment. The role of preexposure prophylaxis utilization in preventing the transmission of HIV is discussed as well as the current data on HIV treatment outcomes for transgender people living with HIV.

Estrogen-mediated protection against coronary heart disease: The role of the Notch pathway

Estrogen regulates a plethora of biological processes, under physiological and pathological conditions, by affecting key pathways involved in the regulation of cell proliferation, fate, survival and metabolism. The Notch receptors are mediators of communication between adjacent cells and are key determinants of cell fate during development and in postnatal life. Crosstalk between estrogen and the Notch pathway intervenes in many processes underlying the development and maintenance of the cardiovascular system. The identification of molecular mechanisms underlying the interaction between these types of endocrine and juxtacrine signaling are leading to a deeper understanding of physiological conditions regulated by these steroid hormones and, potentially, to novel therapeutic approaches to prevent pathologies linked to reduced levels of estrogen, such as coronary heart disease, and cardiotoxicity caused by hormone therapy for estrogen-receptor-positive breast cancer.

Oncological control in high-risk prostate cancer after radical prostatectomy and salvage radiotherapy compared to radiotherapy plus primary hormone therapy

INTRODUCTION

In patients with high-risk localized prostate cancer (HRPCa), multimodal treatment plays a fundamental role.

OBJECTIVE

To compare relapse-free survival (RFS) in patients with HRPCa, treated primarily with radiotherapy (RT)+hormone therapy (HT) versus radical prostatectomy (RP) and salvage RT (sRT)±HT when biochemical recurrence (BCR) appears.

MATERIAL AND METHODS

Retrospective analysis of 226 patients with HRPCa (1996-2008), treated primarily with RT+HT (n=137) or RP (n=89). The Kaplan-Meier method has been used to evaluate survival and the log-rank test has been used to evaluate the contrast between the different categories of the variables. Multivariate analysis has been performed using Cox regression to determine variables with an impact on RFS with statistical significance (P<0.05).

RESULTS

The median follow-up of the series was 111 (IQR 85-137.5) months. After RT+HT, 32 (23.4%) patients relapsed, and after RP (P=0.0001), 41 (46.1%) cases. When comparing the primary treatments, the RFS at 5 and 10 years was higher after RT+HT versus RP in monotherapy (P=0.001). The primary treatment with RT+HT reduced the risk of BCR when compared to the RP (HR=0.41, P=0.002). The estimation of the RFS at 5 and 10 years after RP+sRT±HT was 89.7 and 87.1%, while after primary RT+HT was 91.6 and 71.1%, respectively (P=0.01). The only factor that behaved as an independent predictor of RFS was the multimodal treatment with RP+sRT±HT when BCR showed up (HR=2.39, P=0.01).

CONCLUSION

In HRPCa, multimodal treatment with RP+sRT±HT if BCR, significantly improves RFS with respect to treatment with RT+HT.

Use of hormone therapy (HT) among Swedish women with contraindications - A pharmacoepidemiological cohort study

OBJECTIVES

To assess how women in Sweden with breast cancer (BC), endometrial cancer (EC), and/or pulmonary embolism (PE) were dispensed menopausal hormone therapy (HT).

STUDY DESIGN

A retrospective study of Swedish women aged 40 years or more on 31 December 2005 (n = 2,863,643), followed through to December 2011. The study analysed three mandatory national healthcare registries: the Swedish Prescribed Drug Register, the National Inpatient Register and the Cancer Register. New users were defined as having a first dispensation after at least a 9-month break, and thus were possible to identify from April 2006. New users with at least one of the diagnoses BC, EC or PE before the first dispensation were classified as having a relative or absolute contraindication for HT.

MAIN OUTCOME MEASURES

The relative risks of having HT dispensed after being diagnosed with BC, EC and/or PE.

RESULTS

In total, 171,714 women had at least one of the diagnoses BC, EC or PE. The relative risk of having hormone therapy dispensed (current and new users) after being diagnosed with any of the diagnoses was significantly lower (PE, IRR 0.11, 95% CI 0.10-0.12;/ BC, IRR 0.12, 95% CI 0.11-0.13; EC, IRR 0.43, CI 0.40-0.46) than for women without these diagnoses.

CONCLUSIONS

One in about 250 women started treatment with HT after being diagnosed with BC, PE or EC. Swedish prescribers seem to be well aware of the recommendations for HT use in women with contraindications. A few women, however, are prescribed HT despite having BC, EC or PE, possibly after careful evaluation of the risks and benefits and giving informed consent. Women with a history of PE were prescribed transdermal HT to a larger extent than women in general, in line with results from observational studies.

Durable clinical benefit of letrozole in leptomeningeal metastasis of breast cancer

A case of a woman in her 60s with breast cancer, whose leptomeningeal metastasis (LM) of breast cancer improved remarkably with letrozole monotherapy, is reported. The patient complained of numbness of her left hand and hoarseness, followed by progressive asymmetric extremity weakness and a bladder and rectal disturbance. The patient had undergone surgery for left breast cancer 18 years earlier and was concerned about recurrence of breast cancer, but there were no typical findings with some imaging modalities. The third lumbar puncture showed the malignant cytology of breast cancer, and the patient was diagnosed with recurrent breast cancer. Her performance status was very poor, and it was difficult to administer systemic chemotherapy. Letrozole was started because immunohistochemistry was positive for estrogen and progesterone receptors. After 4 months of letrozole therapy, the symptoms improved gradually. LM has a poor prognosis, and there is little evidence on which to base treatment, but hormone therapy may be an option for LM when the tumor is hormone receptor-positive, slow growing, and has a small volume.

Macroscopic locoregional relapse from prostate cancer: which role for salvage radiotherapy?

INTRODUCTION

Salvage radiotherapy (SRT) after radical prostatectomy for prostate cancer (PCa) is recommended as soon as PSA rises above 0.20 ng/ml, but many patients (pts) still experience local macroscopic relapse. The aim of this multicentric retrospective analysis was to evaluate the role of SRT in pts with macroscopic relapse.

MATERIALS AND METHODS

From 2001 to 2016, 105 consecutive pts with macroscopic PCa relapse underwent SRT ± androgen deprivation therapy (ADT). Mean age was 72 years. At time of relapse, 29 pts had a PSA value < 1.0 ng/mL, 50 from 1.1 to 5, and 25 pts > 5. Before SRT, 23 pts had undergone 18F-choline PET and 15 pts pelvic MRI. Ninety-four pts had prostatic bed relapse only, and four nodal involvement. Fifty-one pts were previously submitted to first-line ADT, while 6 pts received ≥ 2 lines.

RESULTS

At a median follow-up of 52 months, 89 pts were alive, while 16 were dead. Total RT dose to macroscopic lesions was > 70 Gy in 58 pts, 66-70 Gy in 43, and < 66 Gy in 4 pts. In 72 pts, target volume encompassed only the prostatic bed with sequential boost to macroscopic site; 33 pts received prophylactic pelvic RT. Ten-year overall survival was 76.1%, while distant metastasis-free survival was 73.3%. No grade 4-5 toxicities were found.

CONCLUSIONS

SRT ± ADT for macroscopic relapse showed a favorable oncological outcome supporting its important role in this scenario. Data from this series suggest that SRT may either postpone ADT or improve results over ADT alone in appropriately selected pts.

[LHRH analogs in adjuvant endocrine therapy for pre-menopausal localized breast cancers: Ending the controversy for novel guidelines?]

Endocrine treatment represents the cornerstone of endocrine-sensitive pre-menopausal early breast cancer. The estrogen blockade plays a leading role in the therapeutic management with surgery, radiotherapy and selective antiestrogen treatment. For several years, selective estrogen receptor modulators, such as tamoxifen, have revolutionized medical care of hormone receptors-positive breast cancer and have conquered the therapeutic arsenal while becoming the gold standard of treatment. Other combinations associating the ovarian function suppression using LHRH agonists with tamoxifen or aromatase inhibitors have been recently investigated, leading to mitigated opinions regarding the clinical benefit of these associations. We propose here a comprehensive overview on existing data and their actualization concerning LHRH analogues, whilst emphasizing benefit-risk balance for this targeted population.

Combined hormonal influence of cyproterone acetate and nomegestrol acetate on meningioma: a case report

Cyproterone acetate (CPA) is an antiandrogenic drug which has recently been recognized to promote the occurrence and growth of intracranial meningiomas. Nomegestrol acetate (NOMAC) is a widely used progestin-like drug that could be suggested as an alternative for patients taking CPA. We report a case of CPA-related meningioma for which relay from CPA to NOMAC led to further tumor growth and cessation of NOMAC-induced tumor shrinkage. We suggest NOMAC can have a similar effect than CPA on meningiomas. The use of NOMAC as replacement for CPA in the presence of a meningioma should be discouraged until further evidence becomes available on the role of NOMAC in such instances.

Hormone therapy use and breast tissue DNA methylation: analysis of epigenome wide data from the normal breast study

Hormone therapy (HT) is associated with increased risk of breast cancer, strongly dependent on type, duration, and recency of use. HT use could affect cancer risk by changing breast tissue transcriptional programs. We hypothesize that these changes are preceded by changes in DNA methylation. To explore this hypothesis we used histologically normal-appearing breast tissue from the Normal Breast Study (NBS). DNA methylation β-values were obtained using the Illumina HumanMethylation 450 BeadChips for 90 samples including all NBS-participants who used HT within 5 y before surgery. Data were analyzed using the reference-free cell mixture method. Cancer Genome Atlas (TCGA) mRNA-Seq data were used to assess correlation between DNA methylation and gene expression. We identified 527 CpG sites in 403 genes that were associated with ever using HT at genome wide significance (FDR q < 0.05), of these, 68 sites were also significantly associated with duration of use or recency of use. Twelve sites reached significance in all analyses one of which was cg01382688 in ARHGEF4 (p < 1.2x10⁻⁷). Mutations in ARHGEF4 have been reported in breast tumors, but this is the first report of possible breast cancer-related DNA methylation changes. In addition, 22 genes included more than one significant CpG site and a majority of these sites were significantly correlated with gene expression. Although based on small numbers, these findings support the hypothesis that HT is associated with epigenetic alterations in breast tissue, and identifies genes with altered DNA methylation states which could be linked to breast cancer development.

Catamenial Pneumothorax, a Commonly Misdiagnosed Thoracic Condition: Multicentre Experience and Audit of a Small Case Series With Review of the Literature

BACKGROUND

Catamenial pneumothorax (CP) is an unusual condition affecting premenopausal women and commonly misdiagnosed as simple pneumothorax. It is characterised by its recurrence between the day before and within 72 hours after the onset of menstruation. It has been associated with thoracic endometriosis but the aetiology is not well understood and there is no unified agreement for its optimal management. The aim of this study is to determine the incidence of CP in surgical patients and the results of their treatment.

METHODS

Females between the ages of 30 to 50 years with a diagnosis of pneumothorax, admitted for surgery over a 10-year period in four different hospitals were retrospectively reviewed for evidence of CP. An audit of surgical and medical management of the patients with CP and their short to midterm outcomes was performed in addition to a systemic review of the literature on CP.

RESULT

A total of 120 premenopausal female patients with a diagnosis of pneumothorax were admitted for Video Assisted Thoracoscopic (VAT) surgery and five women (4.1%) with a mean age of 42.6 years were diagnosed to have CP through surgical and histological findings. The first case was diagnosed 5 years ago and the last three within recent 12 months after the changes in surgical practices of inspecting diaphragmatic surface in suspected cases of CP. Four patients underwent diaphragmatic plication and one patient had a pleural biopsy. All patients underwent talc pleurodesis and hormone therapy in the postoperative period. Short to midterm (mean follow-up period of 25.2 months) results of the patients with CP were encouraging.

CONCLUSIONS

It is possible that many of the cohort of premenopausal female patients presenting with recurrent pneumothorax are misdiagnosed as spontaneous pneumothorax (SP) because routine inspection of the diaphragmatic surface is not often performed. A thorough menstrual history and its temporal relation to pneumothorax onset should be assessed on every woman presenting with recurrent pneumothorax and intraoperative exploration of diaphragmatic surface should be performed in the patients with high suspicion of CP as the patients diagnosed with CP have a good outcome with surgery and hormone therapy.

Hematology reference intervals for transgender adults on stable hormone therapy

BACKGROUND

The complete blood count (CBC) is a cornerstone of patient care. Several of the normal values for the components of the CBC differ by sex and, therefore, male-specific and female-specific reference intervals are required to interpret these laboratory results. Transgender individuals are often prescribed hormone therapy to affirm their gender, with resulting serum hormone concentrations similar to those of cisgender individuals. Gender-specific reference intervals for transgender men and women have not been established for any laboratory measurements, including hematology. We established clinically relevant hematological reference intervals for transgender individuals receiving stable hormone therapy.

METHODS

Healthy transgender individuals prescribed testosterone (n = 79) or estrogen (n = 93) for ≥12 months were recruited from internal medicine and primary care clinics that specialize in transgender medical care. Concentrations for hemoglobin, hematocrit, MCV, MCHC, and RDWCV, as well as counts for red cells, white cells, and platelets, were evaluated. Results were interpreted in reference to the overall distribution of values and relative to serum estradiol and total testosterone concentrations. Calculated reference intervals were compared to established cisgender reference intervals.

RESULTS

Regardless of serum hormone concentration, individuals prescribed testosterone or estrogen had hematology parameters that were not clinically different from cisgender males and females, respectively.

CONCLUSION

The hematology parameters for transgender men and women receiving stable hormone therapy should be evaluated against the cisgender male and cisgender female reference ranges, respectively and does not require concurrent sex hormone analysis. Care providers can utilize this observation to aid in interpretation of hematology laboratory values for transgender people.

The impact of an exercise program on quality of life in older breast cancer survivors undergoing aromatase inhibitor therapy: a randomized controlled trial

BACKGROUND

This study evaluated the impact of an exercise program on quality of life in older breast cancer survivors undergoing aromatase inhibitor therapy.

METHODS

Older breast cancer survivors were randomized into two groups: combined training: resistance + aerobic exercise program for nine months (n = 18) or control group (n = 18). Quality of life was assessed by the questionnaires SF36, EORTC QLQ-C30, and EORTC QLQ-BR23 at baseline, and at three, six, and nine months. The exercise group performed 40 min of resistance exercises on machines followed by 30 min of aerobic training on a treadmill 3x/wk. Repeated measures ANOVA was used to compare the groups over time.

RESULTS

Significant time x group interactions and moderate to high effect sizes were found for physical functioning, physical health, bodily pain, general health perception, vitality, social functioning, fatigue, sleep disturbance, body image, and upset by hair loss, favoring the exercise group.

CONCLUSION

This study demonstrated the potential benefits and high clinical relevance of exercise programs to improve quality of life in older breast cancer survivors undergoing aromatase inhibitor therapy.

How Are Patients With Prostate Cancer Managing Androgen Deprivation Therapy Side Effects?

BACKGROUND

Androgen deprivation therapy (ADT) for prostate cancer has numerous side effects. Clinical guidelines for side effect management exist; however, these are not always integrated into routine practice. What remains undocumented and therefore the objective of this study, is to describe patients' willingness to employ established strategies.

PATIENTS AND METHODS

Study participants were 91 men who had attended an educational program (ie, attend a class plus read a book), designed to prepare patients for managing ADT side effects. Three months later, patients completed the ADT Management Strategies Inventory, to determine use of strategies. Descriptive analyses were conducted.

RESULTS

At the time of class attendance, the average ADT duration was 133 days. Patient preferences for a variety of strategies for each side effect are presented. Highlights include: a high degree (> 65%) of patients using or willing to use exercise to manage medical risks and physical side effects. Forty percent of patients continued to engage in non-penetrative sexual activities, despite reduced sexual desire and erectile dysfunction.

CONCLUSIONS

When educated about options, patients are willing to use a wide array of ADT management strategies. Consequently, health care providers should ensure that patients know about side effects and how to manage them. Exercise appears to be the single best strategy to encourage, because it is helpful in managing many side effects (eg, weight gain, muscle weakening, fatigue) and reducing medical risks of ADT (eg, cardiovascular disease, type II diabetes, and osteoporosis). A general trend was patient's preference for behavioral and lifestyle strategies over pharmacologic interventions.

Toward More Targeted and Cost-Effective Gonadotropin-Releasing Hormone Analog Treatment in Girls with Central Precocious Puberty

The use of gonadotropin-releasing hormone analogs (GnRHa) for the treatment of central precocious puberty (CPP), especially in girls, has increased rapidly in recent years. In the context of a secular trend towards earlier puberty onset, many girls now treated for CPP are healthy children experiencing puberty onset within the early end of the normal range. Justifications for GnRHa treatment include the preservation of adult height (AH) potential and the alleviation of presumed distress of early maturation and menarche. With a case of a family requesting treatment for an 8-year-old girl in early puberty as a background, studies of the effect of untreated CPP and of GnRHa treatment of CPP on AH are reviewed. In addition, the limited evidence relating CPP to significant psychological distress - in part due to early menses, and for the amelioration of such distress by GnRHa treatment - is discussed. Taken together, current information suggests that for girls with mildly early onset of puberty (ages 7-9 years), an informed assent discussion with the family should include the consideration of reassurance and observation for many girls who might otherwise receive 2-4 years of GnRHa treatment for a poorly defined benefit and at a cost of at least $20-30,000 per year.

Postmenopausal health interventions: Time to move on from the Women's Health Initiative?

Menopause is a critical period during which, without timely interventions, increased risks of cardiovascular and metabolic diseases, osteoporosis, sexual dysfunction and premature cognitive decline will contribute to diminished quality-of-life in women. Hormone therapy (HT) used to be the standard of care for managing vasomotor symptoms and prevention of chronic diseases until publication of the Women's Health Initiative (WHI) in 2002. Concerned about risks highlighted in WHI publications, many symptomatic women promptly ceased HT which resulted in increased vasomotor symptoms, osteoporosis-related-fractures and insomnia. Data from post-hoc WHI analyses and newer clinical trials consistently show reductions in coronary heart disease and mortality when estrogen therapy is initiated soon after menopause, whereas administration in later years and/or in combination with progesterone carries increased risks. However, no validated primary preventive strategies are available for younger postmenopausal women (<60 years), highlighting the need to re-evaluate the use of estrogen alone for which the risk-benefit balance appears positive. In contrast, in older women (>60 years), risks associated with oral HT exceed benefits; however transdermal estrogen may offer a safer alternative and should be further evaluated. Alternative therapies such as phytoestrogens and non-hormonal prescriptions may be beneficial for older women or those who are unsuitable for HT. Long-term head-to-head comparisons of HT with alternative interventions are warranted to confirm their efficacy for chronic disease prevention.

Evolving concepts in prostatic neuroendocrine manifestations: from focal divergent differentiation to amphicrine carcinoma

Prostatic neuroendocrine manifestations encompass a heterogeneous spectrum of morphologic entities. In the era of evidence-based and precision-led treatment, distinction of biologically relevant clinical manifestations expanded the evolving clinical role of pathologists. Recent observations on the occurrence of hormone therapy-induced aggressive prostatic cancers with neuroendocrine features have triggered the need to refine the spectrum and nomenclature of prostatic neuroendocrine manifestations. Although the morphologic assessment still remains the basis of the diagnostic workup of prostatic neoplasms, the application of ancillary biomarkers is crucial in the accurate classification of such presentations. This review provides a diagnostic roadmap for the practicing pathologist by reviewing the characteristic morphologic, immunohistochemical, and molecular correlates of various faces of prostatic neuroendocrine manifestations.

Determinants of hormone therapy uptake and decision-making after bilateral oophorectomy (BO): A narrative review

Objective Early surgical menopause (≤45 years) can have significant short- and long-term health consequences. Hormone therapy (HT) is recommended for women with no contraindications. However, HT is greatly underutilized among these women due to their fear of the associated risks. The objective of this study is to identify and describe determinants of HT uptake and decision-making in women after surgical menopause. Methods We searched Medline, EMBASE, and CINAHL, from inception to April 2018, to identify relevant literature. Inclusion criteria included studies that assessed factors affecting the uptake of HT and decision-making about HT after surgical menopause. Studies including both women with natural and surgical menopause were included. Search terms were derived from 3 main concepts: surgical menopause, hormone therapy, and decision-making. Papers included in the review had to be in the English language and to report human studies. Results Of the 1952 articles identified, 23 were eligible for inclusion. Studies were mostly published before the WHI (61%) and had a quantitative cross-sectional study design. Only 22% focused on surgical menopause per se. The mean age at time of surgical menopause was 43.6 years (range 29-68). HT uptake was associated with younger age, higher level of education, higher income and adopting positive lifestyle behaviors. Factors affecting decision-making were mostly perceptions, beliefs, and values women associate with HT, as well as knowledge of and experiences with HT and surgical menopause. External factors related to physicians' recommendations and information sources also influenced HT decision-making. Conclusion Our review highlights the complex nature of decision-making about HT after surgical menopause and the numerous factors involved. Women tend to rely on subjective perceptions and inferences from information sources, which may hamper the ability to make informed treatment decisions. There is a need for tailored decision-aid interventions to help support women and guide informed treatment decisions.

Growth factor genes and change in mammographic density after stopping combined hormone therapy in the California Teachers Study

Background

The contribution of genetic polymorphisms to the large inter-individual variation in mammographic density (MD) changes following starting and stopping use of estrogen and progestin combined therapy (EPT) has not been well-studied. Previous studies have shown that circulating levels of insulin-like growth factors are associated with MD and cross-talk between estrogen signaling and growth factors is necessary for cell proliferation in the breast. We evaluated single nucleotide polymorphisms (SNPs) in growth factor genes in association with MD changes after women stop EPT use.

Methods

We genotyped 191 SNPs in 13 growth factor pathway genes in 284 non-Hispanic white California Teachers Study participants who previously used EPT and collected their mammograms before and after quitting EPT. Percent MD was assessed using a computer-assisted method. Change in percent MD was calculated by subtracting percent MD of an ‘off-EPT’ mammogram from percent MD of an ‘on-EPT’ (i.e. baseline) mammogram. We used multivariable linear regression analysis to investigate the association between SNPs and change in percent MD. We calculated P-values corrected for multiple testing within a gene (P_adj).

Results

Rs1983210 in INHA and rs35539615 in IGFBP1/3 showed the strongest associations. Per minor allele of rs1983210, the absolute change in percent MD after stopping EPT use decreased by 1.80% (a difference in absolute change in percent MD) (P_adj= 0.021). For rs35539615, change in percent MD increased by 1.79% per minor allele (P_adj= 0.042). However, after applying a Bonferroni correction for the number of genes tested, these associations were no longer statistically significant.

Conclusions

Genetic variation in growth factor pathway genes INHA and IGFBP1/3 may predict longitudinal MD change after women quit EPT. The observed differences in EPT-associated changes in percent MD in association with these genetic polymorphisms are modest but may be clinically significant considering that the magnitude of absolute increase in percent MD reported from large clinical trials of EPT ranged from 3% to 7%.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4981-6) contains supplementary material, which is available to authorized users.

Cognitive Changes with Reproductive Aging, Perimenopause, and Menopause

This article reviews the role of endogenous estrogen in neural and cognitive processing, followed by an examination of longitudinal cognitive data captured in various stages of the menopausal transition. The remaining text reviews the contradictory results from major hormone therapy trials to date, evidence for the "timing hypothesis," and closes with recommendations for future research and for practicing clinicians.

Compensatory role of insulin-like growth factor 1 receptor in estrogen receptor signaling pathway and possible therapeutic target for hormone therapy-resistant breast cancer

BACKGROUND

Hormone therapy targeting the estrogen receptor (ER) pathway is the most common treatment used for ER-positive breast cancer. However, some patients experience de novo or acquired resistance, which becomes a critical problem. Activation of the insulin-like growth factor (IGF) pathway allows breast cancer cells to proliferate and is associated with the ER pathway. Little is known about the role of the IGF pathway in hormone therapy and resistance; therefore, we investigated whether the inhibition of this pathway may represent a novel therapeutic target for overcoming hormone therapy resistance in ER-positive breast cancers.

METHODS

Crosstalk between the ER and IGF pathways was analyzed in breast cancer cell lines by inhibiting or stimulating either one or both pathways. We studied the effect of insulin-like growth factor one receptor (IGF1R) inhibition in aromatase inhibitor-resistant breast cancer cell lines and fulvestrant-resistant cell lines which were uniquely established in our laboratory.

RESULTS

Under normal conditions, IGF signaling is controlled by ER signaling to promote cell growth. Temporary disruption of the estrogen supply results in attenuated ER signaling, and IGF-1 dramatically increased relative growth compared with normal conditions. In addition, IGF1R inhibitor strongly suppressd cell growth in hormone-resistant breast cancer cells where ER remains than cells where ER decreased or was almost lost.

CONCLUSIONS

Our study suggests that inhibition of the IGF pathway may be an effective strategy for ER-positive breast cancer therapy, even in hormone therapy-resistant cases.

Menopausal hormone therapy and breast cancer: what is the evidence from randomized trials?

The relationship between menopausal hormone therapy (HT) and breast cancer is complex and further complicated by misinformation, perception, and overgeneralization of data. These issues are addressed in this mini-review through the lens of the Women's Health Initiative (WHI) that has colored the view of HT and breast cancer. In the WHI, unopposed conjugated equine estrogen (CEE) reduced breast cancer risk and mortality. In the WHI CEE plus continuously combined medroxyprogesterone acetate (MPA) trial, although the hazard ratio (HR) was elevated it was statistically non-significant for an association between CEE + MPA and breast cancer. In fact, the increased HR was not due to an increased breast cancer incidence rate in women randomized to CEE + MPA therapy but rather due to a decreased and unexpectedly low breast cancer rate in the subgroup of women with prior HT use randomized to placebo. For women who were HT naïve when randomized to the WHI, the breast cancer incidence rate was not affected by CEE + MPA therapy relative to placebo for up to 11 years of follow-up. The current state of science indicates that HT may or may not cause breast cancer but the totality of data neither establish nor refute this possibility. Further, any association that may exist between HT and breast cancer appears to be rare and no greater than other medications commonly used in clinical medicine.

Breast cancer survival predicted by TP53 mutation status differs markedly depending on treatment

Background

Previous studies on the role of TP53 mutation in breast cancer treatment response and survival are contradictory and inconclusive, limited by the use of different endpoints to determine clinical significance and by small sample sizes that prohibit stratification by treatment.

Methods

We utilized large datasets to examine overall survival according to TP53 mutation status in patients across multiple clinical features and treatments.

Results

Confirming other studies, we found that in all patients and in hormone therapy-treated patients, TP53 wild-type status conferred superior 5-year overall survival, but survival curves crossed at 10 or more years. In contrast, further stratification within the large dataset revealed that in patients receiving chemotherapy and no hormone therapy, wild-type TP53 status conferred remarkably poor overall survival. This previously unrecognized inferior survival is consistent with p53 inducing arrest/senescence instead of apoptosis. Addition of hormone therapy to chemotherapy improved survival notably in patients with TP53 wild-type tumors, but not mutant, suggesting hormone therapy could eradicate arrested/senescent cells. Testing this, we found that estrogen receptor-positive, TP53 wild-type breast cancer cells that were made senescent by doxorubicin treatment were sensitive to tamoxifen.

Conclusions

The poor survival of chemotherapy-treated patients with TP53 wild-type tumors may be improved by strategies to eliminate senescent cells, including the addition of hormone therapy when appropriate.

Electronic supplementary material

The online version of this article (10.1186/s13058-018-1044-5) contains supplementary material, which is available to authorized users.

New study suggests patients with advanced prostate cancer on androgen deprivation therapy need more dialogue with health care provider, especially around cardiovascular risk

PURPOSE

To study the current level of patients' awareness, and patient-health care provider (HCP) dialogue with respect to treatment-related risks, especially cardiovascular risk (CVR) associated with advanced prostate cancer (PCa) treatment.

METHODS

This 10-min online survey summarised data by treatment, region, and CVR (high or low).

RESULTS

Of the 411 patients, 83% were at high CVR while only 8% patients were aware of CVR associated with PCa treatment, majority of which (80%) were informed about this risk by HCPs. No significant difference in treatment approach was reported, regardless of patient's CVR status. Compared to other potential risks, patients were more likely to initiate discussion about heart problems with HCPs (38% patients). When prompted, 26% patients rated heart problems as the most concerning risk factor, and this concern was twice in patients with high CVR (28%) versus low CVR (14%). Lifestyle modifications were made by 64% patients, of which 45% patients reported an improvement in overall well-being. Improved diet was the most adopted lifestyle modification.

CONCLUSION

There is a need to enhance a constant patient-HCP dialogue, and both groups need to make a conscious effort in that direction. This would help in increasing patients' awareness of risks, having better treatment choice and acceptance, and reducing side-effects.

Examining the Relationship Between Neurosteroids, Cognition, and Menopause With Neuroimaging Methods

PURPOSE OF REVIEW

Previous literature has shown inconsistent findings regarding the effects of neurosteroids on the brain in postmenopausal women. The goal of this paper is to examine how and whether advances in neuroimaging have helped elucidate the relationship between the withdrawal of and/or treatment with neurosteroids and cognition at menopause.

RECENT FINDINGS

Neuroimaging techniques such as structural and functional MRI have been used in recent studies to examine the relationship between neurosteroids and brain structure and functioning. However, the recent literature shows that different formulations of postmenopausal hormones given at different times, through different routes of administration, and in different combinations with progestins result in a variety of relationships with the brain outcomes. We suggest that still further research is needed to understand how the structural changes resulting from estrogen withdrawal or therapy at menopause can influence cognitive functioning. However, imaging studies are time-, resource-, and expertise-intensive. We believe that this information will help uncover the mechanisms and relationships that can aid in the explanation of the individual differences in the effects of menopause on the brain as well as how this menopause-related hormone change influences risk for pathological aging.

The antagonist properties of Bazedoxifene after acute treatment are shifted to stimulatory action after chronic exposure in the liver but not in the uterus

A promising alternative to conventional hormone therapy for postmenopausal symptoms is treatment combining Bazedoxifene (BZA), a third-generation selective estrogen receptor modulator (SERM), and conjugated equine estrogen (CE). This combination is also known as a tissue-selective estrogen complex (TSEC). Understanding the tissue-specific actions of SERMs and the TSEC remains a major challenge to try to predict their clinical effects. The aim of this study was to compare acute versus chronic treatment with BZA, CE or CE + BZA in two major targets of estrogens, the uterus and the liver. In these two tissues, acute treatment with CE, but not with BZA, induced similar gene expression change than the most important endogenous estrogen, 17-β estradiol (E2). Acute induction of gene expression by E2 or by CE was antagonized by the addition of BZA. Concomitantly, BZA alone or in combination with E2 or CE induced a partial degradation of ERα protein after acute exposure. In uterus, chronic treatment of BZA alone had no impact on tissue weight gain or on epithelial cell proliferation, and also antagonized CE-effect in uterus, thereby mimicking the acute effect. By contrast, in the liver, chronic BZA and CE + BZA elicited agonistic transcriptional effects similar to those of CE alone. In addition, at variance to BZA acute effect, no change in ERα protein abundance was observed after chronic treatment in this tissue. These experimental in vivo data highlight a new aspect of the time-dependent tissue-specific action of BZA or TSEC, i.e. they can act acutely as antagonists but become agonists after chronic treatment. This shift was observed in liver tissue, but not in proliferative sex target such as the uterus.

Quality of life of men and women with gender identity disorder

Background

The aim of this study was to evaluate the self-reported perceived quality of life (QoL) in female to male (FTM) and male to female (MTF) transgenders and compare it with a general population sample, and to find possible determinants that likely contribute to their QoL.

Methods

Participants were 71 trandgenders participating in the communities of Isfahan and Fars provinces, Iran, including 30 MTF and 41 FTM, and 142 gender- and age-matched controls. Persian version of the Short Form 36-Item Questionnaire was used to evaluate self-reported QoL, which measures QoL across eight domains.

Results

Compared to control group, the QoL of transgenders in the most dimensions of the SF-36 questionnaire was lower. MTF had a lower QoL than FTM for the subscale physical functioning (p = 0.044). There was a significant relationship between education and subscales of emotional well-being (p = 0.048) and social function (p = 0.008); economic status and physical function subscale (p = 0.003); employment status and physical function (p = 0.012) and social function subscales (p = 0.003). Compared to male controls, MTF transgenders had lower physical functioning (P < 0.001), role limitation due to physical health (P = 0.015), vitality (P = 0.023), social functioning (P < 0.001) and pain score (P = 0.044) and no significant differences between female controls and FTM transgenders were seen.

Conclusion

Transgenders have lower physical and mental QoL, FTM transgender has better QoL than MTF transgender. Employment, education, province of residence and economic status as well as therapeutic intervention is associated with transgender’s QoL.

Increased risk for stress urinary incontinence in women with postmenopausal hormone therapy

INTRODUCTION AND HYPOTHESIS

The impact of estradiol-based hormone therapy (HT) on the incidence of stress urinary incontinence (SUI) is unknown. Therefore, we compared the use of such HT regimens and tibolone in women with and without SUI.

METHODS

The women with a history of SUI operation (N = 15,002) were identified from the Finnish National Hospital Discharge Register, and the control women without such an operation (N = 44,389) from the Finnish Central Population Register. The use of HT was traced from the National Drug Reimbursement Register, and the odd ratios (ORs) with 95% confidence intervals (95% CIs) for SUI were calculated by using the conditional logistic regression analysis.

RESULTS

The cases had used any HT more often than the controls. The use of systemic estradiol-only or estradiol-progestin therapy was accompanied by an increased SUI risk (OR 3.8, 95% CI: 3.6-4.0 and OR 2.7, 95% CI: 2.6-2.9 respectively). The use of estradiol with noretisterone acetate showed a higher risk of increase than that with medroxyprogesterone acetate. Age over 55 years at the initiation of systemic HT was accompanied by a higher SUI risk increase than that under 55 years of age. The use of tibolone, an estradiol + levonorgestrel-releasing intrauterine device, or vaginal estradiol also increased the risk.

CONCLUSIONS

The use of HT regimens may predispose to the de novo development or worsening of pre-existing SUI. Thus, caution is needed when these regimens are prescribed to women with mild stress-related urine leakage or with established SUI risk factors.

Interactions of alcohol and postmenopausal hormone use in regards to mammographic breast density

PURPOSE

We investigated the association of alcohol intake with mammographic breast density in postmenopausal women by their hormone therapy (HT) status.

METHODS

This study included 2,100 cancer-free postmenopausal women within the Nurses' Health Study and Nurses' Health Study II cohorts. Percent breast density (PD), absolute dense (DA), and non-dense areas (NDA) were measured from digitized film mammograms using a computer-assisted thresholding technique; all measures were square root transformed. Alcohol consumption was assessed with a food frequency questionnaire (0, < 5, and ≥ 5 g/day). Information regarding breast cancer risk factors was obtained from baseline or biennial questionnaires closest to the mammogram date. We used generalized linear regression to examine associations between alcohol and breast density measures in women with no HT history, current, and past HT users.

RESULTS

In multivariable analyses, we found no associations of alcohol consumption with PD (p trend = 0.32) and DA (p trend = 0.53) and an inverse association with NDA (β = - 0.41, 95% CI - 0.73, - 0.09 for ≥ 5 g/day, p trend < 0.01). In the stratified analysis by HT status, alcohol was not associated with PD in any of the strata. We found a significant inverse association of alcohol with NDA among past HT users (β = - 0.79, 95% CI - 1.51, - 0.07 for ≥ 5 g/day, p trend = 0.02). There were no significant interactions between alcohol and HT in relation to PD, DA, and NDA (p interaction = 0.19, 0.42, and 0.43, respectively).

CONCLUSIONS

Our findings suggest that associations of alcohol with breast density do not vary by HT status.

Evaluating the prevalence and predictive factors of vasomotor and psychological symptoms in prostate cancer patients receiving hormonal therapy: Results from a single institution experience

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We assessed vasomotor symptoms in patients on hormone therapy (ADT) for prostate cancer.

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The commonest symptoms were hot flushes & sweats followed by fatigue & sleep disturbances.

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The short term side-effect profile of ADT for prostate cancer was favourable.

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Younger age and higher BMI predicted for severe toxicity.

Background & purpose

The impact of vasomotor symptoms (VMS) occurring in prostate cancer (PC) patients whilst on androgen deprivation therapy (ADT) has not been extensively researched. This longitudinal study sought to assess the VMS and identify any predictive factors.

Material & methods

Data from 250 PC patients on ADT were prospectively evaluated between January 10 and August 13 using a physician-directed questionnaire, to assess the impact of VMS. Parameters including height, weight, body surface area (BSA), body mass index (BMI), duration/type of ADT, co-morbidities and ethnicity were recorded.

Results

Fifty (20%) men reported no toxicity, whilst 171 (68.4%), and 29 (11.6%) reported mild to moderate and severe symptoms, respectively. Drenching sweats and hot flashes were common, and coexisted with sleep disturbances and fatigue. Patients with severe toxicity were younger (73 vs. 77 yrs; p = 0.04), had higher BMI (28 vs. 26; p = 0.02), and higher BSA (1.99 vs. 1.90; p = 0.04), when compared with those experiencing no toxicity. On multivariate analysis, younger age was predictive of sweats and hot flushes, whilst Afro-Caribbean men were twice as likely to experience sweats (OR 2.03, p = 0.05).

Conclusions

The short-term side-effect profile of ADT for prostate cancer was favourable, though debilitating VMS can occur in a significant minority of cases. Younger age and higher BMI predicted for severe toxicity but not the duration of ADT.