Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. Lancet Oncol. 2010;11:1135-1141. [PMID: 21087898 DOI: 10.1016/s1470-2045(10)70257-6]

Fracture risk and assessment in adults with cancer

Individuals with cancer face unique risk factors for osteoporosis and fractures. Clinicians must consider the additive effects of cancer-specific factors, including treatment-induced bone loss, and premorbid fracture risk, utilizing FRAX score and bone mineral densitometry when available. Pharmacologic therapy should be offered as per cancer-specific guidelines, when available, or local general osteoporosis guidelines informed by clinical judgment and patient preferences. Our objective was to review and summarize the epidemiologic burden of osteoporotic fracture risk and fracture risk assessment in adults with cancer, and recommended treatment thresholds for cancer treatment-induced bone loss, with specific focus on breast, prostate, thyroid, gynecological, multiple myeloma, and hematopoietic stem cell transplant. This narrative review was informed by PubMed searches to July 25, 2022, that combined terms for cancer, stem cell transplantation, fracture, bone mineral density (BMD), trabecular bone score, FRAX, Garvan nomogram or fracture risk calculator, QFracture, prediction, and risk factors. The literature informs that cancer can impact bone health in numerous ways, leading to both systemic and localized decreases in BMD. Many cancer treatments can have detrimental effects on bone health. In particular, hormone deprivation therapies for hormone-responsive cancers such as breast cancer and prostate cancer, and hematopoietic stem cell transplant for hematologic malignancies, adversely affect bone turnover, resulting in osteoporosis and fractures. Surgical treatments such as hysterectomy with bilateral salpingo-oophorectomy for gynecological cancers can also lead to deleterious effects on bone health. Radiation therapy is well documented to cause localized bone loss and fractures. Few studies have validated the use of fracture risk prediction tools in the cancer population. Guidelines on cancer-specific treatment thresholds are limited, and major knowledge gaps still exist in fracture risk and fracture risk assessment in patients with cancer. Despite the limitations of current knowledge on fracture risk assessment and treatment thresholds in patients with cancer, clinicians must consider the additive effects of bone damaging factors to which these patients are exposed and their premorbid fracture risk profile. Pharmacologic treatment should be offered as per cancer-specific guidelines when available, or per local general osteoporosis guidelines, in accordance with clinical judgment and patient preferences.

Risk of Cardiovascular Events and Lipid Profile Change in Patients with Breast Cancer Taking Aromatase Inhibitor: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) is one of the most common comorbidities in breast cancer survivors. Recently, the target population and treatment period for aromatase inhibitor (AI) treatment in breast cancer patients has been expanding. However, information on adverse CVD events from the long-term use of AI is still lacking. The aim of this study was to investigate the CVD side effects of AI treatment and to evaluate the changes in lipid profile during AI treatment. A systematic search of PubMed (Medline), EMBASE, and Cochrane Library databases reporting on cardiovascular outcomes or lipid profiles change in adult female breast cancer patients (>19 years old) with AI was performed. The pooled analysis of 25 studies showed that the prevalence rate of any type of cardiovascular disease was 6.08 per 100 persons (95% CI 2.91-10.31). Angina was the most common type of heart-related cardiovascular event accounting for 3.85 per 100 persons, followed by any type of stroke (3.34) and venous thromboembolism (2.95). Ischemic stroke (OR 1.39, 95% CI 1.07-1.81) and myocardial infarction (OR 1.30, 95% CI 0.88-1.93) were more common in AI compared with tamoxifen, whereas the prevalence of venous thromboembolism (OR 0.61, 95% CI 0.37-1) was significantly lower in the AI group. In addition, treatment with AI for 6-12 months showed a decrease in HDL-cholesterol and an increase in LDL-cholesterol and total cholesterol. Various CVDs can occur when using AI, and in particular, the risk of MI and ischemic stroke increases in comparison with the adverse effect of tamoxifen. The occurrence of CVD might be related to the deterioration of the lipid profile after AI treatment. Therefore, a customized individualization strategy considering each patient's CV risk factors is needed during AI treatment.

Long-Term Adherence to Adjuvant Endocrine Therapy Following Various Radiotherapy Modalities in Early Stage Hormone Receptor Positive Breast Cancer

INTRODUCTION

We compared the rates of long-term adjuvant endocrine therapy (AET) adherence after various radiation therapy (RT) modalities among patients with early stage breast cancer.

MATERIALS AND METHODS

Medical records from patients with stage 0, I, or IIA (tumors ≤3 cm), hormone receptor (HR) positive breast cancer that received adjuvant radiation therapy (RT) from 2013 to 2015 at a single institution were retrospectively reviewed. All patients received breast conserving surgery (BCS) followed by adjuvant RT via one of the following modalities: whole breast radiotherapy (WBI), partial breast irradiation (PBI) with either external beam radiation therapy (EBRT) or fractionated intracavitary high-dose rate (HDR) brachytherapy, or single fraction HDR-brachytherapy intraoperative-radiation therapy (IORT).

RESULTS

One hundred fourteen patients were reviewed. Thirty patients received WBI, 41 PBI, and 43 IORT with a median follow up of 64.2, 72.0, and 58.6 months, respectively. For the entire cohort, AET adherence was approximately 64% at 2 years and 56% at 5 years. Among patients in the IORT clinical trial, adherence to AET was approximately 51% at 2 years and 40% at 5 years. After controlling for additional factors, DCIS histology (vs invasive disease) and IORT (compared to other radiation modalities) were associated with decreased endocrine therapy adherence (P < 0.05).

CONCLUSION

DCIS histology and receipt of IORT were associated with lower rates of adherence to AET at 5 years. Our findings suggest that examination of the efficacy of RT interventions such as PBI and IORT in patients who do not receive AET is warranted.

Low Rates of Medical Oncology Consultation for Older Women (≥ 70 Years) with Newly Diagnosed, Non-Metastatic Breast Cancer: A Population-Based Study

BACKGROUND

Curative intent cancer treatment needs to be balanced with patient comorbidities and quality of life when treating older women with breast cancer. We examined consultation patterns and association of age at diagnosis with lack of specialist cancer consultations for older women with breast cancer.

METHODS

We conducted a population-based retrospective cohort study of older women (≥ 70 years of age) with incident, non-metastatic breast cancer (2010-2018) by linking administrative databases in Ontario, Canada. The outcomes of interest were lack of specialist cancer consultation (surgeon, medical oncology, or radiation oncology) within 12 months of diagnosis. Association of age with lack of specialist cancer consultation was examined using Poisson regression modeling.

RESULTS

Of 21,849 older women, 2.4% (n = 517) did not have any specialist cancer consultation within 12 months of diagnosis; lack of any specialist cancer consultation increased with age (0.8% for age 70-74 years, 1.3% for age 75-79 years, 2.5% for age 80-84 years, and 7.0% for age ≥ 85 years; p < 0.001). The proportion of patients who did not have consultations with surgeons, medical oncologists, and radiation oncologists was 8.6% (n = 1888), 34.4% (n = 7510), and 24.7% (n = 5404), respectively. Older age group was independently associated with an increased likelihood of lacking any specialist consultation, as well as not receiving surgical and medical oncology consultations.

CONCLUSION

More than one-third of women ≥ 70 years of age with non-metastatic breast cancer did not have a consultation with a medical oncologist, with women aged ≥ 85 years least likely to have a medical oncology consultation.

Adjuvant Systemic Therapy for Postmenopausal, Hormone Receptor-Positive Early Breast Cancer

There is now a deeper understanding of the biology of hormone receptor-positive (HR+) early breast cancer (EBC) that can be used to inform assessment of risk and prognosis, and also guide more effective adjuvant systemic therapies. For postmenopausal HR+ EBC endocrine therapy remains the mainstay of treatment with extended duration up to 10 years for some, the addition of targeted CDK 4/6 inhibitors for those with node-positive high-risk disease, and de-escalation of chemotherapy use for those in whom it is unlikely to be of benefit. As such, systemic adjuvant therapy is now highly tailored and individualized.

Psychological measures of stress and biomarkers of inflammation, aging, and endothelial dysfunction in breast cancer survivors on aromatase inhibitors

The use of aromatase inhibitors (AIs) is associated with higher rates of cardiovascular events and lower endothelial function in breast cancer survivors. Psychosocial stress is associated with higher levels of inflammatory and aging markers, and lower endothelial function in otherwise healthy subjects. These associations among breast cancer survivors on AIs are not well defined. A cross-sectional study of 30 breast cancer survivors on AIs was performed to assess the associations between self-reported scores of psychosocial measures of depression, anxiety, and stress assessed by validated questionnaires with markers of inflammation (CRP; IL-6; IL-18), aging (p16^INK4a), and endothelial function (ICAM-1, EndoPAT ratio). Significant positive correlations were observed between psychosocial measures and inflammatory markers including CRP, IL-6, and ICAM-1. However, no psychosocial scores were related to endothelial function or gene expression of the aging biomarker p16INK4a. Overall, survivors had endothelial dysfunction with reduced EndoPAT ratios. Psychosocial stress is associated with greater inflammation in breast cancer survivors on AIs, corroborating previous studies in cancer-free populations. The lack of association between psychosocial stress and either endothelial function or aging biomarkers could be due to the already low endothelial function and accelerated aging in our cohort of breast cancer survivors on AIs, though our small sample size limits conclusions. Further work in a larger and more diverse cohort of patients is needed to further understand the relationships among inflammation, aging and endothelial function in breast cancer survivors.

Prevention of aromatase inhibitor-induced bone loss with anti-resorptive therapy in post-menopausal women with early-stage breast cancer

We assessed if antiresorptive treatment can prevent aromatase inhibitor-induced bone loss in patients with early breast cancer. We observed that patients who did not receive antiresorptive treatment had a 20.8-fold increase in risk of bone loss after 24 months of aromatase inhibitors therapy.

PURPOSE

This study aimed to describe changes in femoral and lumbar bone mineral density (BMD) after 24 months of aromatase inhibitors (AIs) and antiresorptive treatment in postmenopausal women with estrogen receptor-positive breast cancer.

METHODS

Prospective, longitudinal study in a real-life setting with a 2-year follow-up. Patients underwent a complete baseline bone assessment including clinical assessment, biological evaluation, BMD measurement, and spine X-ray. Antiresorptive treatment was prescribed to patients with a T-score <  - 2 or a T-score <  - 1.5 SD with additional osteoporosis risk factors. A follow-up bone assessment was carried out after 24 months.

RESULTS

Among 328 patients referred to our center, 168 patients (67.7 ± 10.6 years) were included in our study, and 144 were eligible for antiresorptive treatment. After 24 months, patients receiving antiresorptive treatment experienced a significant increase of + 6.28% in femoral-BMD (F-BMD) and + 7.79% in lumbar-BMD (L-BMD). This increase was not significantly different between osteoporotic and osteopenic patients. Conversely, patients not receiving antiresorptive treatment presented significant F-BMD and L-BMD loss regardless of the baseline BMD. In the multivariate logistic model, the lack of antiresorptive treatment was the only predictive factor for major femoral bone loss with a 20.83 odds ratio (CI95%:4.2-100, p < 0.001).

CONCLUSION

This real-life study confirmed that antiresorptive treatment significantly increases femoral and lumbar BMD regardless of the baseline BMD in postmenopausal patients receiving AIs for early breast cancer. Patients who did not receive antiresorptive treatment had a 20.8-fold increased risk of major bone loss. Nevertheless, the best threshold to adopt for starting antiresorptive agents remains undetermined.

De Novo Design of Imidazopyridine-Tethered Pyrazolines That Target Phosphorylation of STAT3 in Human Breast Cancer Cells

In breast cancer (BC), STAT3 is hyperactivated. This study explored the design of imidazopyridine-tethered pyrazolines as a de novo drug strategy for inhibiting STAT3 phosphorylation in human BC cells. This involved the synthesis and characterization of two series of compounds namely, 1-(3-(2,6-dimethylimidazo [1,2-a]pyridin-3-yl)-5-(3-nitrophenyl)-4,5-dihydro-1H-pyrazol-1-yl)-2-(4-(substituted)piperazin-1-yl)ethanone and N-substituted-3-(2,6-dimethylimidazo[1,2-a]pyridin-3-yl)-5-(3-nitrophenyl)-4,5-dihydro-1H-pyrazoline-1-carbothioamides. Compound 3f with 2,3-dichlorophenyl substitution was recognized among the tested series as a lead structure that inhibited the viability of MCF-7 cells with an IC₅₀ value of 9.2 μM. A dose- and time-dependent inhibition of STAT3 phosphorylation at Tyr705 and Ser727 was observed in MCF-7 and T47D cells when compound 3f was added in vitro. Calculations using density functional theory showed that the title compounds HOMOs and LUMOs are situated on imidazopyridine-pyrazoline and nitrophenyl rings, respectively. Hence, compound 3f effectively inhibited STAT3 phosphorylation in MCF-7 and T47D cells, indicating that these structures may be an alternative synthon to target STAT3 signaling in BC.

Review of bone health in women with estrogen receptor-positive breast cancer receiving endocrine therapy

In estrogen-receptor-positive tumors, adjuvant endocrine therapy has been shown to be highly beneficial for both overall and disease-free survival. Estradiol is key in regulating bone and mineral physiology, and several studies found a strong correlation between these therapies and the risk of fractures. Since these therapies are often given for 5 through 10 years, the timing for bisphosphonates or denosumab initiation seems essential to managing bone metabolism. However, gray zones and discrepancies between guidelines remain as to the best threshold when to start antiresorptive treatment, or whether antiresorptive treatment should be administered to every woman undergoing adjuvant endocrine therapy, independent of their risk factors for fractures. Treatment options and strategies should be discussed at the start of hormone adjuvant therapy to come to a shared decision with the patient, with the final aim of reducing the risk of future fractures as much as possible. This review will cover present guidelines and literature on antiresorptive treatment in this setting, to provide clinicians with useful clues for managing these patients.

Impact of clinicopathological factors on extended endocrine therapy decision making in estrogen receptor-positive breast cancer

Purpose

In our study, we aim to analyze the impact of clinicopathological factors on the recommendation of extended endocrine therapy (EET) in patients with ER+ breast cancer and to retrospectively validate the value of CTS5 in EET decision making.

Patients and methods

The retrospective analysis was performed in patients with ER+ breast cancer who have finished 4.5-5 years of adjuvant endocrine therapy and undergone MDT discussion from October 2017 to November 2019. Multivariate logistic regression was used to identify the independent factors for treatment recommendation. CTS5 was calculated for retrospective validation of the EET decision making.

Results

Two hundred thirty-five patients were received; 4.5-5 years of adjuvant endocrine therapy were included in the study. Multivariate analysis suggested that age (OR 0.460, 95% CI 0.219-0.965, p = 0.04), pN (OR 39.350, 95% CI 9.831-157.341, P < 0.001), and receipt of chemotherapy (OR 3.478, 95% CI 1.336-9.055, p = 0.011) were independent predictors for the recommendation of EET. In the previously selective estrogen receptor modulator (SERM)-treated subgroup, pN and receipt of chemotherapy were independent predictors for the recommendation of EET. In the previously AI-treated subgroup, age, pN, and receipt of chemotherapy were independent predictors. Adverse events did not affect the recommendation in patients previously treated with adjuvant endocrine treatment nor in the previously SERM or AI-treated subgroups. CTS5 (OR 21.887, 95% CI 2.846-168.309, p = 0.003) remained an independent predictor for the recommendation of EET.

Conclusions

Our study indicated that age, lymph nodal status, and receipt of chemotherapy were independent predictors for the recommendation of EET. The application of the CTS5 on EET decision making might be valuable among ER+ breast cancer patients.

Research Status of Systemic Adjuvant Therapy for Early Breast Cancer

Breast cancer has surpassed lung cancer as the most common cause of cancer deaths, worldwide. Early breast cancers are treatment sensitive and patients under standardized treatment have prolonged. Breast cancer treatment has significantly evolved from the conventional surgical approach and radiotherapy to local and systemic adjuvant therapies. Though localized breast cancers are clinically manageable, distant recurrence is a cause of morbid concern. Adjuvant systemic therapy is effective in both distant and local recurrences and hence gained significant attention. Early breast cancer prognosis has greatly improved in the past 3 decades with reduced mortality rates due to the widespread use of adjuvant therapy. It can markedly increase the cure rate of breast cancers, and postoperative adjuvant therapy became a part of comprehensive breast cancer treatment. Further research to understand the early breast cancer characteristics could expand the treatment modalities that can improve the outcomes and survival benefits of breast cancer patients.

Measurable Serum Estradiol and Estrone in Women 36-56 Years During Adjuvant Treatment With Aromatase Inhibitors for a Hormone Receptor-Positive Breast Cancer. Case Studies and Cross-sectional Study Using an Ultra-sensitive LC-MS/MS-Method

BACKGROUND AND PURPOSE

Ovarian function recovery (OFR) during adjuvant use of an aromatase inhibitor (AI) negatively impacts breast cancer outcome. We measured serum FSH and estrogen levels in consecutive AI-users with an uncertain menopausal status during follow-up and report associated risk factors of OFR METHODS: A retrospective cross sectional observational monocentric study including breast cancer patients in follow-up using an adjuvant AI, age 36 to 56 years, with at least one serum estradiol (E2) and estrone (E1) measurement between 2013 and 2020. Estrogens were quantified using a sensitive liquid chromatography-tandem mass spectrometry method (LC-MS/MS). Women on LHRH agonist were included while those with a bilateral oophorectomy or ovarian irradiation were not. We aimed to identify risk factors of OFR considering age, body mass index (BMI), previous chemotherapy and duration of AI use. Univariable analysis was used to evaluate risk factors of OFR.

RESULTS

E2/E1 levels were assessed in 207 patients with a median age of 50 years (range 36-56). 17 of 159 on AI (10.7%) and 3 of 48 on AI + LHRH (6.3%) had OFR. Seven out of 17 patients (41,2%) with OFR in the AI only group and 2 out of 3 patients (66,7%) in the AI+LHRH agonist group were in amenorrhea. Age <50 y and adjuvant chemotherapy were statistically significantly different between the OFR group and the group with postmenopausal estrogen levels.

CONCLUSION

Breast cancer patients aged 36 to56 years need to be monitored closely during adjuvant treatment with aromatase inhibitors: to confirm menopausal status, to evaluate compliance and to ensure ovarian activity remains adequately suppressed. Estrone might be a better marker then estradiol to detect ovarian reactivation.

New Concepts in Cardio-Oncology

Cancer and cardiovascular disease are the two major causes of morbidity and mortality in worldwide. Discovering new therapeutic agents for the management of breast cancer (BC) has increased the numbers of cancer survivors but with the risk of cardiovascular adverse events (CV-AEs). All drugs can potentially damage the cardiovascular system, with different types of clinical manifestations from ischemic myocardial disease to vasculitis, thrombosis or pericarditis. An early detection of CV-AEs guarantees an earlier treatment, which is associated with better outcomes. Cardio-oncology field enlarged its studies to improve prevention, monitoring and treatment of all cardiotoxic manifestations related to old or modern oncological agents. A multidisciplinary approach with a close partnership between oncologists and cardiologists is essential for an optimal management and therapeutic decision-making. The aim of this chapter is to review all types of cardiotoxic manifestations related to novel and old agents approved for treatment of BC patients including chemotherapy, anti-HER2 agents, cyclin-dependent kinase 4/6 inhibitors, PolyADP-ribose polymerase (PARP) inhibitors, antiangiogenic drugs and immunotherapy. We also focused our discussion on prevention, monitoring, treatment, and management of CV-AEs.

FDXR drives primary and endocrine-resistant tumor cell growth in ER+ breast cancer via CPT1A-mediated fatty acid oxidation

Background

The majority of breast cancers (BCs) expressing estrogen receptor (ER) have shown endocrine resistance. Our previous study demonstrated that ferredoxin reductase (FDXR) promoted mitochondrial function and ER+ breast tumorigenesis. But the underlying mechanism is not clear.

Methods

Liquid chromatography (LC) tandem mass spectrometry (MS/MS)-based metabolite profiling was utilized to reveal the metabolites regulated by FDXR. RNA microarray was utilized to determine the potential downstream targets of FDXR. Seahorse XF24 analyzer was performed to analyze the FAO-mediated oxygen consumption rate (OCR). Q-PCR and western blotting assays were used to measure expression levels of FDXR and CPT1A. MTS, 2D colony formation and anchorage-independent growth assays were used to evaluate the effects of FDXR or drug treatments on tumor cell growth of primary or endocrine-resistant breast cancer cells.

Results

We found that depletion of FDXR inhibited fatty acid oxidation (FAO) by suppressing CPT1A expression. Endocrine treatment increased the expression levels of both FDXR and CPT1A. Further, we showed that depletion of FDXR or FAO inhibitor etomoxir treatment reduced primary and endocrine-resistant breast cancer cell growth. Therapeutically, combining endocrine therapy with FAO inhibitor etomoxir synergistically inhibits primary and endocrine-resistant breast cancer cell growth.

Discussion

We reveal that the FDXR-CPT1A-FAO signaling axis is essential for primary and endocrine-resistant breast cancer cell growth, thus providing a potential combinatory therapy against endocrine resistance in ER+ breast cancer.

Optimizing Adjuvant Treatment Recommendations for Older Women with Biologically Favorable Breast Cancer: Short-Course Radiation or Long-Course Endocrine Therapy?

Omission of radiotherapy among older women taking 5 years of adjuvant endocrine therapy following breast conserving surgery for early-stage, hormone sensitive breast cancers is well-studied. However, endocrine therapy toxicities are significant, and many women have difficulty tolerating endocrine therapy, particularly elderly patients with comorbidities. Omission of endocrine therapy among women receiving adjuvant radiation is less well-studied, but available randomized and non-randomized data suggest that this approach may confer equivalent local control and survival for select patients. Herein we review available randomized and non-randomized outcome data for women treated with radiation monotherapy and emphasize the need for future prospective, randomized studies of endocrine therapy omission.

Managing Bone Health in Breast Cancer

OBJECTIVE

Osteoporosis is a common condition that can be caused or exacerbated by estrogen deficiency.

METHODS

This narrative review will discuss optimizing bone health in the setting of adjuvant endocrine treatments for hormone receptor-positive breast cancer and the current use of antiresorptive agents as adjuvant therapy and as bone modifying agents.

RESULTS

Adjuvant endocrine treatments for hormone receptor-positive breast cancer (tamoxifen and aromatase inhibitors) affect bone health. The exact effect depends on the agent used and the menopausal state of the woman. Antiresorptive medications for osteoporosis, bisphosphonates and denosumab, lower the risk of bone loss from aromatase inhibitors. Use of bisphosphonates as adjuvant treatment in breast cancer, regardless of hormone receptor status, is increasing because of benefits seen to cancer relapse and survival.

CONCLUSION

Optimizing bone health in women with breast cancer during and after cancer treatment is informed by an understanding of breast cancer treatment and its skeletal effect.

Targeting the mTOR Pathway for the Prevention of ER-Negative Breast Cancer

PREVENTION RELEVANCE

Our results show that everolimus delays mammary tumor formation in multiple mouse models, suggesting that mTOR inhibitors will be useful for the prevention of ER-negative and triple-negative breast cancer in humans. See related Spotlight, p. 787.

Interpreting the results of noninferiority trials-a review

Noninferiority trials are becoming increasing common, but are often poorly reported and misunderstood. A better understanding of the new components of a noninferiority trial and their interpretation is needed. Noninferiority trials are an extension of conventional superiority trials, which provide a basis for determining if a new treatment, which may have advantages other than efficacy, has sufficient efficacy to be useful in certain situations. A key feature is the need to specify a clinical noninferiority margin above which the lower boundary of the confidence interval for the difference between the new treatment and the conventional treatment must lie. In most cases a nontreated control arm is not included, and when the efficacy of the new treatment is less than that of the standard treatment, determining its efficacy versus no treatment can be a major challenge. Treatments meeting a clinical noninferiority requirement can be statistically significantly superior to standard treatment, of similar efficacy (i.e., no significant difference), or even significantly inferior in a conventional analysis. Noninferiority comparisons are an important addition to the reporting of clinical trials, but require prior consideration of several factors that conventional superiority analyses do not address.

Utility of a Clinically Guided Data-Driven Approach for Predicting Breast Cancer Complications: An Application Using a Population-Based Claims Data Set

PURPOSE

With earlier detection and an increasing number of breast cancer (BCa) survivors, more women are living with side effects of BCa treatment. A predictive approach to studying treatment-related adverse events (AEs) may generate proactive strategies; however, many studies are descriptive in nature. Focusing on short-term AEs, we determine the performance of prediction models of disease- or treatment-related AEs among women diagnosed with BCa.

METHODS

We used administrative claims data from the Blue Health Intelligence National Data Repository. The study sample included female individuals age 18 years and older who were diagnosed with BCa and received cancer-directed treatment between January 1, 2014, and August 1, 2019. Using the information available in the claims data, we constructed longitudinal patient histories and identified disease- and treatment-related AEs occurring within 6 months of treatment. The following prediction models were developed: logistic regression, Lasso regression, gradient boosted tree (GBT), and random forest (RF). We compared models using the area under the receiver operating characteristic curve and its CI, among other metrics.

RESULTS

Data were extracted for 267,473 members meeting study inclusion criteria. The area under the curve for the logistic regression model was 0.82 (0.82-0.86), compared with 0.89 (0.87-0.90) for the Lasso, 0.91 (0.89-0.93) for the GBT, and 0.90 (0.93-0.89) for the RF models. The sensitivity was 0.96 for the GBT, Lasso, and RF models, whereas the specificity was 0.42, 0.44, and 0.39 for the GBT, Lasso, and RF models, respectively. Positive predictive values were 0.96 across all three models.

CONCLUSION

Prediction models developed using big data methods and grounded in a clinically guided framework have the potential to reliably predict short-term treatment-related AEs among women diagnosed with BCa.

Molecular Mechanisms of Anti-Estrogen Therapy Resistance and Novel Targeted Therapies

Breast cancer (BC) is the most commonly diagnosed cancer in women, constituting one-third of all cancers in women, and it is the second leading cause of cancer-related deaths in the United States. Anti-estrogen therapies, such as selective estrogen receptor modulators, significantly improve survival in estrogen receptor-positive (ER+) BC patients, which represents about 70% of cases. However, about 60% of patients inevitably experience intrinsic or acquired resistance to anti-estrogen therapies, representing a major clinical problem that leads to relapse, metastasis, and patient deaths. The resistance mechanisms involve mutations of the direct targets of anti-estrogen therapies, compensatory survival pathways, as well as alterations in the expression of non-coding RNAs (e.g., microRNA) that regulate the activity of survival and signaling pathways. Although cyclin-dependent kinase 4/6 and phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) inhibitors have significantly improved survival, the efficacy of these therapies alone and in combination with anti-estrogen therapy for advanced ER+ BC, are not curative in advanced and metastatic disease. Therefore, understanding the molecular mechanisms causing treatment resistance is critical for developing highly effective therapies and improving patient survival. This review focuses on the key mechanisms that contribute to anti-estrogen therapy resistance and potential new treatment strategies alone and in combination with anti-estrogen drugs to improve the survival of BC patients.

Sleep disturbances and restless legs syndrome in postmenopausal women with early breast cancer given adjuvant aromatase inhibitor therapy

INTRODUCTION

Whether adjuvant therapy with aromatase inhibitors (AIs) causes sleep disturbances or not in postmenopausal women with early breast cancer (EBC) is still a controversial issue.

METHODS

Between March 2014 and November 2017, validated questionnaires for assessing insomnia, anxiety, depression, quality of life (QoL) and restless legs syndrome (RLS) were administered to 160 EBC patients at baseline and after 3, 6, 12, and 24 months of AI therapy.

RESULTS

AI therapy significantly decreased the patients' QoL, but did not influence insomnia, anxiety or depression. However, it significantly increased the frequency and severity of RLS. Patients with RLS at baseline (19%) or who developed RLS during AI therapy (26.3%) reported statistically lower quality of sleep, higher anxiety and depression, and worse QoL compared to patients who never reported RLS (54.7%).

CONCLUSION

Although AI therapy does not affect sleep quality, it may increase RLS frequency. The presence of RLS could identify a group of EBC patients who may benefit from psychological support.

Five decades of progress in surgical oncology: Breast

Surgery remains the single most effective treatment for breast cancer but coincident with a deeper understanding of tumor biology and advances in multidisciplinary care (encompassing breast imaging, systemic adjuvant therapy, radiotherapy, and genomics) continues to de-escalate, supported by strong level I data. We have moved from mastectomy to breast conservation, and from routine axillary dissection to sentinel lymph node biopsy to selective omission of axillary node staging altogether. We have further de-escalated through consensus over margin width in breast conservation, through improvements in neoadjuvant therapy, and by demonstrating no benefit for upfront surgery in patients with stage IV disease. For patients with ipsilateral breast tumor recurrence, reconservation surgery and reirradiation are promising. Cell cycle and immune checkpoint inhibitors, when added to conventional systemic therapy, have now moved beyond stage IV disease to phase III trials in the adjuvant and neoadjuvant settings, promising even further de-escalation of surgery. Finally, with genomic profiling we are moving away from the primacy of axillary node status for prognostication and into a new era allowing prediction of response to therapy.

Breast cancer: an up-to-date review and future perspectives

Breast cancer is the most common cancer worldwide. The occurrence of breast cancer is associated with many risk factors, including genetic and hereditary predisposition. Breast cancers are highly heterogeneous. Treatment strategies for breast cancer vary by molecular features, including activation of human epidermal growth factor receptor 2 (HER2), hormonal receptors (estrogen receptor [ER] and progesterone receptor [PR]), gene mutations (e.g., mutations of breast cancer 1/2 [BRCA1/2] and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [PIK3CA]) and markers of the immune microenvironment (e.g., tumor-infiltrating lymphocyte [TIL] and programmed death-ligand 1 [PD-L1]). Early-stage breast cancer is considered curable, for which local-regional therapies (surgery and radiotherapy) are the cornerstone, with systemic therapy given before or after surgery when necessary. Preoperative or neoadjuvant therapy, including targeted drugs or immune checkpoint inhibitors, has become the standard of care for most early-stage HER2-positive and triple-negative breast cancer, followed by risk-adapted post-surgical strategies. For ER-positive early breast cancer, endocrine therapy for 5-10 years is essential. Advanced breast cancer with distant metastases is currently considered incurable. Systemic therapies in this setting include endocrine therapy with targeted agents, such as CDK4/6 inhibitors and phosphoinositide 3-kinase (PI3K) inhibitors for hormone receptor-positive disease, anti-HER2 targeted therapy for HER2-positive disease, poly(ADP-ribose) polymerase inhibitors for BRCA1/2 mutation carriers and immunotherapy currently for part of triple-negative disease. Innovation technologies of precision medicine may guide individualized treatment escalation or de-escalation in the future. In this review, we summarized the latest scientific information and discussed the future perspectives on breast cancer.

Comprehensive Transcriptomic and Proteomic Analyses Identify a Candidate Gene Set in Cross-Resistance for Endocrine Therapy in Breast Cancer

Endocrine therapy (ET) of selective estrogen receptor modulators (SERMs), selective estrogen receptor downregulators (SERDs), and aromatase inhibitors (AIs) has been used as the gold standard treatment for hormone-receptor-positive (HR+) breast cancer. Despite its clinical benefits, approximately 30% of patients develop ET resistance, which remains a major clinical challenge in patients with HR+ breast cancer. The mechanisms of ET resistance mainly focus on mutations in the ER and related pathways; however, other targets still exist from ligand-independent ER reactivation. Moreover, mutations in the ER that confer resistance to SERMs or AIs seldom appear in SERDs. To date, little research has been conducted to identify a critical target that appears in both SERMs/SERDs and AIs. In this study, we conducted comprehensive transcriptomic and proteomic analyses from two cohorts of The Cancer Genome Atlas Breast Invasive Carcinoma (TCGA-BRCA) to identify the critical targets for both SERMs/SERDs and AIs of ET resistance. From a treatment response cohort with treatment response for the initial ET regimen and an endocrine therapy cohort with survival outcomes, we identified candidate gene sets that appeared in both SERMs/SERDs and AIs of ET resistance. The candidate gene sets successfully differentiated progress/resistant groups (PD) from complete response groups (CR) and were significantly correlated with survival outcomes in both cohorts. In summary, this study provides valuable clinical implications for the critical roles played by candidate gene sets in the diagnosis, mechanism, and therapeutic strategy for both SERMs/SERDs and AIs of ET resistance for the future.

Factors influencing the initiation of adjuvant endocrine therapy in patients with estrogen receptor-positive ductal carcinoma in situ: a single institution experience

Purpose

This study evaluates whether race, socioeconomic status, insurance type, oncological provider type, and prior cancer treatment are associated with the suggestion and acceptance of hormonal therapy in patients with estrogen receptor (ER)-positive Ductal carcinoma in situ (DCIS). This study also assesses whether disparities exist pertaining to prescription of such medications.

Methods

This single-center retrospective study included 111 patients diagnosed with DCIS between 2020 and 2021. Data collected included race, type of insurance, prescribing providers, and socioeconomic status. We used zip codes to identify the poverty levels in these areas as published in the United States Census Bureau and stratified the patients into quartiles accordingly. Chi-Square statistics were used to calculate significance levels.

Results

There was no significant correlation between the intake of hormonal therapy and race (p = 0.60), insurance (p = 0.50), socioeconomic (p = 0.58), or providers (p = 0.99). 79.3% of women were offered endocrine therapy. Of those who were offered endocrine therapy, 70.8% accepted. Of patients not on hormonal therapy, 45.8% were not recommended the medications by their provider, and 54.2% declined treatment when offered.

Conclusion

In this study, patients’ demographics and providers were not associated with adjuvant hormonal therapy initiation in DCIS. Our results show that abstaining from endocrine therapy in DCIS patients is both due to lack of provider recommendation and patient rejection of these medications. The wide variation in hormonal therapy treatment among ER-positive DCIS patients suggests a need for improved provider-patient communication regarding the risks and benefits of endocrine therapy in order to ensure a shared decision-making process.

Determining the Optimal Cut-Off Values of Serum E2 and FSH for Evaluating the Menopausal Status of Breast Cancer Patients in a Southern Chinese Population

Background

Chemotherapy-induced amenorrhea (CIA) is one of universal phenomena in breast cancer (BC) patients, and it causes difficulties in evaluating the actual menopausal status which is important for the oncologists to choose appropriate treatment. Currently, serum estradiol (E2) and follicle-stimulating hormone (FSH) levels are the most commonly used clinical parameters for the assessment of menopausal status in BC patients. However, the optimal cut-off points of serum E2 and FSH have little been explored in southern Chinese population.

Objective

This study is aimed to determine the optimal cut-off values of the serum E2 and FSH levels for evaluating the menopausal status of BC patients in a southern Chinese population.

Methods

A retrospective analysis was done among a total of 206 patients with BC from a southern Chinese area. The data of serum E2, FSH, and luteinizing hormone (LH) levels were collected and analyzed for the comparison purpose. The receiver-operating curve (ROC) was generated to assess the specificity and sensitivity of the three biomarkers in discriminating the menopausal status of BC patients. The optimal cut-off values were determined according to the Youden index and then compared with the recommended reference values by the Chinese Anti-cancer Association (CACA) and those recommended by the manufacturers.

Results

The areas under the ROC curves (AUCs) of E2, FSH, and LH were 0.846 (95% CI: 0.790-0.903), 0.781 (95% CI: 0.714-0.847) and 0.608 (95% CI: 0.526-0.690), respectively. The optimal cut-off values were 130.0 pg/mL for E2, 23.325 IU/L for FSH, and 11.625 IU/L for LH with a maximum of the Youden index. When E2, FSH, and LH were used in combination for ROC analysis, the AUC increased to 0.847 (95% CI: 0.790-0.904), which was higher than that of any other biomarker alone. In this study, the sensitivity and specificity of E2 and FSH were 91.6% and 73.70% and 94.4% and 58.6%, respectively, in comparison with 85.0% and 75.80% and 76.6% and 65.7% according to the CACA-recommended cut-off points, or 92.5% and 68.7% and 96.3% and 53.5% according to the manufacturer recommended cut-off points.

Conclusion

Considering the sensitivity and specificity of serum E2 and FSH for assessing the menopausal status, the optimal cut-off values determined in the present study were similar to the manufacturer's recommendations, but obviously superior to the cut-off points suggested by CACA. These cut-off points calculated in this study seem to be valuable in southern Chinese population and might be used by clinicians to make a correct medical decision for BC patients who would benefit from endocrine therapy of aromatase inhibitor (AI).

The Effect of Anastrozole on the Lipid Profile: Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

We aimed to investigate the impact of anastrozole administration on the traditional components of the lipid profile (ie, total cholesterol [TC], LDL-C, HDL-C, and triglycerides [TGs]) by means of a systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched the PubMed/Medline, Scopus, Embase, and Web of Science databases for relevant randomized controlled trials published in the English language until January 18, 2022. The weighted mean difference (WMD) and 95% CIs were calculated using a random-effects model (DerSimonian and Laird methods).

FINDINGS

Anastrozole administration significantly lowered TC concentrations when the treatment duration was ≤3 months (WMD = -2.73 mg/dL; 95% CI, -5.09 to -0.38 mg/dL; P = 0.02) and when the baseline TC concentration was ≥200 mg/dL (WMD = -3.64 mg/dL; 95% CI, -6.30 to -0.98 mg/dL; P = 0.007). HDL-C levels decreased after anastrozole administration when the treatment duration was >3 months (WMD = -1.67 mg/dL; 95% CI, -3.24 to -0.10 mg/dL; P = 0.03). Anastrozole administration had no impact on TG or LDL-C values.

IMPLICATIONS

Anastrozole administration in humans can decrease TC and HDL-C levels but has no effect on LDL-C or TG concentrations.

Aromatase inhibitors and contralateral breast cancer in BRCA mutation carriers

BACKGROUND

Deleterious BRCA mutations confer a significant lifetime risk of breast cancer (BC) as well as contralateral BC (CBC) in patients who do not undergo prophylactic mastectomy. Prior reports have suggested that tamoxifen reduces the risk of CBC in BRCA mutation carriers. Whether aromatase inhibitors (AI) have the same effect is unknown.

METHODS

This is a retrospective review of patients diagnosed with non-metastatic ER+ BC between 2004 and 2014 with known BRCA mutation status. Patients were followed from primary diagnosis until CBC diagnosis or death. Median follow-up was 11.5 years. Risk of CBC was evaluated as time to event.

RESULTS

935 subjects were included in this analysis, with 53 BRCA1 mutation carriers, and 94 BRCA2 mutation carriers. Median age at diagnosis was 42.7 years. Seventy-two percent (676) received tamoxifen and 43% (405) received AI. A total of 66 CBCs occurred, of which 10% (15/147) occurred in BRCA mutation carriers vs 6.5% (51/788) in BRCA wild type. Multivariate analyses indicated that BRCA status and AI use were significantly associated with CBC risk. AI use resulted in a significant reduction in risk of CBC (HR 0.44, p = 0.004) regardless of the BRCA mutation status. Tamoxifen use was not associated with reduced risk of CBC.

CONCLUSIONS

This is the first report showing that AIs reduce the risk of CBC in BRCA mutation carriers. The potential role of AIs as chemoprevention should be validated in larger independent cohorts.

Oral Health in Breast Cancer Women with Vitamin D Deficiency: A Machine Learning Study

Breast cancer (BC) survivors treated with aromatase inhibitors (AIs) commonly show several pathological issues, including poor oral health, bone health impairment, and vitamin D deficiency. However, to date, oral health issues in BC survivors treated with AIs have been poorly investigated and their relationship with vitamin D deficiency are far from being understood. This study aimed to evaluate the correlation between oral health and vitamin D status in BC survivors undergoing treatment with AIs through a machine learning approach. In this cross-sectional study, we included post-menopausal BC women with vitamin D deficiency undergoing AIs therapy. The outcome measures were the following: oral health indexes as the Decayed, Missing, and Filled Permanent Teeth Index (DMFT); serum levels of 25(OH)D₃; Bone Mineral Density (BMD); and the diagnosis of osteoporosis. We included 41 post-menopausal BC women, mean aged 66.10 ± 8.47 years, with mean serum levels of vitamin D of 14.63 ± 6.62 ng/mL. Furthermore, 56.10% of patients had a diagnosis of osteoporosis and 36.59% were osteopenic. DMFT was significantly related to smoking (p-value = 0.005) and dental floss use (p-value = 0.001). There was a significant correlation between DMFT and vitamin D levels (Pearson’s r: −0.73; p-value = 0.001). The regression machine learning model showed that vitamin D status and the use of dental floss were the most relevant variables in terms of correlation with DMFT. In conclusion, vitamin D deficiency, inadequate use of dental floss, and smoking had a negative impact on oral health in BC women. Thus, vitamin D deficiency screening and supplementation and a prompt oral rehabilitation plan should be suggested and implemented in the complex treatment framework of BC survivors undergoing treatment with AIs.

Preventing late recurrence in hormone receptor-positive early breast cancer: a review

Late recurrences are a key challenge for patients with early-stage oestrogen receptor-positive breast cancer, with the risk of disease relapse continuing steadily from 5 to more than 20 years after diagnosis. Five years of adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor was shown many years ago to improve survival. More recently, the trials of extended adjuvant endocrine therapy for more than 5 years have shown a further small gain, but with an associated small risk of increased long-term toxicity including bone loss, cardiovascular impairment and impaired quality of life. This review describes the efficacy and safety of extended endocrine therapy, the optimal selection criteria for patient benefit and the potential for novel agents to improve long-term outcomes.

Recent insights into the effects of metabolism on breast cancer cell dormancy

Breast cancer (BC) remains the most common cancer, as well as the leading cause of cancer mortality in women worldwide [1]. Approximately 30% of patients with early-stage BC experience metastasis or a recurrent form of the disease [2]. The phenomenon of BC dormancy, where metastasised cancer cells remain in a quiescent phase at their disseminated location and for unknown reasons can become actively proliferative again, further adds to BC’s clinical burden with treatment at this secondary stage typically proving futile. An emerging avenue of research focuses on the metabolic properties of dormant BC cells (BCCs) and potential metabolic changes causing BCCs to enter/exit their quiescent state. Here we explore several studies that have uncovered changes in carbon metabolism underlying a dormant state, with conflicting studies uncovering shifts towards both glycolysis and/or oxidative phosphorylation. This review highlights that the metabolic states/shifts of dormant BCCs seem to be dependent on different BC subtypes and receptor status; however, more work needs to be done to fully map these differences. Building on the research that this review outlines could provide new personalised therapeutic possibilities for BC patients.

Breast Cancer Epidemiology and Contemporary Breast Cancer Care: A Review of the Literature and Clinical Applications

Substantial progress has been made in contemporary breast cancer care, resulting in a consistently declining breast cancer mortality rate and an improvement in quality of life. Advancements include deescalation of therapy in low-risk populations and refining systemic therapy options. Research into molecular biomarkers continues to evolve and holds the promise of achieving the goal of precision medicine, while guidelines for supportive care and survivorship have been created to address the needs of an ever-increasing number of breast cancer survivors. A collaborative, multidisciplinary team approach is essential for patients and survivors to achieve optimal outcomes and enjoy productive high-quality lives. Gynecologists, in particular, play a key role in screening and survivorship care.

Use of an alfa-lipoic, Methylsulfonylmethane, Boswellia serrata and Bromelain dietary supplement (OPERA®) for aromatase inhibitors-related arthralgia management (AIA): a prospective phase II trial (NCT04161833)

Aromatase Inhibitors (AIs) are recommended for the adjuvant treatment of hormone receptor positive breast cancer in both high-risk pre-menopausal and post-menopausal population; arthralgia is the main cause of discontinuation of therapy and affects up to 25% of population on AI treatment. The objective of the study was to prospectively evaluate OPERA® (GAMFARMA srl, Milan, Italy), a new dietary supplement where α-Lipoic acid, Boswellia serrata, Methylsulfonylmethane and Bromelain are combined in a single hard-gelatin capsule to be taken once a day. Fifty-three patients with arthralgia (NCI-CTCAE v4.0 grade ≥ 1) occurring during AI therapy were enrolled. All patients received OPERA® from enrollment (T0) up to sixth months (T3). Patients' AI-related arthralgia was evaluated every two months with VAS Scale, PRAI questionnaire, and CTCAE scale. Primary endpoint was the number of patients with symptom resolution (G0) at T3 if compared to T0, according to CTCAE and VAS scale. Secondary endpoints were decrease in arthralgia intensity measured with PRAI score at T3 compared to baseline, safety of OPERA® and rate of AI interruption. Treatment with OPERA® supplement was overall well tolerated; no relevant toxicities related to OPERA® intake were reported. Seven subjects (13.2%) were not included in the final analysis because of consent withdrawal. 46 participants were eligible for final analysis. According to CTCAE scale, 10 out of 46 patients reported symptoms resolution at 6-month follow-up from the time of enrollment T0 (p = 0.0009). According to VAS score, 5 patients reported complete resolution of symptoms at T3 if compared to baseline starting situation T0 (p = 0.0222). Analysis of PRAI score showed a significant reduction in arthralgia-related pain perceived (p = 0.0001). OPERA® was able to reduce the intensity of arthralgia related to AI therapy. Randomized, double-blind studies are warranted to confirm the effectiveness of this dietary supplement.

A look at current and potential treatment approaches for hormone receptor-positive, HER2-negative early breast cancer

The heterogeneity of hormone receptor (HR)-positive, HER2-negative early breast cancers reinforces the importance of individualized, risk-adapted treatment approaches. Numerous factors contribute to the risk for recurrence, including clinical tumor features, individual biomarkers, and genomic risk. Current standard approaches for patients with HR-positive, HER2-negative, early stage disease focus on endocrine therapy and chemotherapy. The specific treatment regimen and duration of adjuvant therapy should be selected based on accurate risk assessment, tolerability of available therapies, and consideration for patient preferences. For patients with high-risk features, such as highly proliferative tumors, large tumor size, and significant nodal involvement, the risk for recurrence remains clinically significant despite appropriate adjuvant treatment with current standards of care. This has driven investigation into novel treatment approaches, including the addition of cyclin-dependent kinase 4 and 6 inhibitors to adjuvant endocrine therapy. Cyclin-dependent kinase 4 and 6 inhibition has demonstrated significant efficacy in patients with high-risk, HR-positive, HER2-negative, nonmetastatic breast cancer and now offers a new strategy to greatly improve outcomes in this difficult to treat patient population.; LAY SUMMARY: Hormone receptor (HR)-positive, HER2-negative early breast cancers are highly diverse and need to be managed differently for individual patients. The use of adjuvant endocrine therapy and chemotherapy should be driven by a patient's risk for recurrence, preferences, and risk for side effects. Patients with high-risk tumors have a persistently elevated risk for recurrence despite current standards of care. Emerging cyclin-dependent kinase 4 and 6 inhibitors are highly effective when added to endocrine therapy in high-risk, HR-positive early breast cancer and have the potential to improve patient outcomes in this difficult to treat patient population.

Efficacy and Safety of Initial 5 Years of Adjuvant Endocrine Therapy in Postmenopausal Hormone Receptor-Positive Breast Cancer: A Systematic Review and Network Meta-Analysis

Purpose: To identify the optimal initial 5 years of adjuvant endocrine therapy for hormone receptor-positive postmenopausal early breast cancer (EBC) patients.

Methods: We conducted a systematic search of the PubMed, Web of Science, and EMBASE to obtain relevant studies published between January 2000 and January 2022. Randomized clinical trials assessing the efficacy and safety of initial 5 years of adjuvant endocrine therapy were included. The primary outcomes were disease-free survival and overall survival and the secondary outcome was severe adverse effects (SAEs). A Bayesian network meta-analysis was carried out to indirectly compare all regimens and the value of surface under the cumulative ranking curve (SUCRA) was used to obtain rankings.

Results: Eleven studies with 49,987 subjects were included. For DFS, exemestane (EXE) [hazard ratio (HR) 0.91, 95% confidence interval (95%CI) 0.87–0.96], anastrozole (ANA) (0.94, 0.90–0.97), letrozole (LET) (0.93, 0.89–0.97), tamoxifen (TAM) followed by EXE (0.91, 0.87–0.96), and TAM followed by ANA (0.92, 0.87–0.98) were more favorable than TAM, with TAM followed by EXE ranking as the first of SUCRA. For OS, only TAM followed by ANA showed significant superiority than TAM (HR 0.91, 95%CI 0.86–0.97) and ranked as the first of SUCRA. For SAEs, EXE (HR 1.72, 95%CI 1.04–2.98), ANA (1.58, 1.03–2.43), and LET (1.63, 1.02–2.57) showed greater associations with bone fracture than TAM. However, no significant difference in the incidences of cardiac events, thromboembolic events, and cerebrovascular events was found among all comparisons.

Conclusion: The sequential use of aromatase inhibitors, which has the best curative effects and relatively mild side effects, may be the optimal treatment mode for hormone receptor-positive postmenopausal EBC patients. In addition, the three kinds of aromatase inhibitors achieved roughly equal efficacy, but caused different types of SAEs.

Systematic Review Registration: [website], identifier [registration number].

Discovery of Thieno[2,3-e]indazole Derivatives as Novel Oral Selective Estrogen Receptor Degraders with Highly Improved Antitumor Effect and Favorable Druggability

Endocrine therapies in the treatment of early and metastatic estrogen receptor α positive (ERα+) breast cancer (BC) are greatly limited by de novo and acquired resistance. Selective estrogen receptor degraders (SERDs) like fulvestrant provide new strategies for endocrine therapy combinations due to unique mechanisms. Herein, we disclose our structure-based optimization of LSZ102 by replacing 6-hydroxybenzothiophene with 6H-thieno[2,3-e]indazole. Subsequent acrylic acid degron modifications led us to identify compound 40 as the preferred candidate. In general, compound 40 showed much better pharmacological profiles than the lead LSZ102, exhibiting growth inhibition of wild-type or tamoxifen-resistant MCF-7 cells, potent ERα degradation, together with superior pharmacokinetic properties, directional target tissue distribution including the brain, and robust antitumor efficacy in the mice breast cancer xenograft model. Currently, 40 is being evaluated in preclinical trials.

Improvement of survival in Korean breast cancer patients over a 14-year period: A large-scale single-center study

Purpose

The aim of this study was to evaluate the chronological changes over 14 years in the survival of Korean patients with breast cancer. We also sought to investigate the factors that may have influenced the changes in survival rate.

Materials and methods

We retrospectively analyzed 17,776 breast cancer patients who were treated at Asan Medical Center between January 2000 and December 2013. Patient information was collected from the Asan database, including age at diagnosis, clinical manifestation, pathology report, types of treatment and modality, types of recurrence, and follow-up period. We classified the patients into two cohorts according to the year of their surgery (P1: 2000–2007 and P2: 2008–2013) and compared survival and recurrence between both cohorts.

Results

We observed that patients treated more recently had better survival outcomes. The 5-year breast cancer-specific survival increased from 94.0% in P1 to 96.6% in P2 (p<0.001), and the 5-year disease-free survival increased from 87.9% in P1 to 91.2% in P2 (p<0.001). When analyzed by type of recurrence, distant metastasis-free survival increased to a significant degree. In subgroup analysis by the subtypes of breast cancer, the survival rates improved in all of the subtypes except triple negative breast cancer, and the improvement was more prominent in subtypes with overexpressed human epidermal growth factor receptor 2.

Conclusion

This study showed improvement in breast cancer survival over the succeeding years, which is consistent with the advancement in systemic therapy.

Study of impacts of brickkiln emanations on soil quality of agriculture lands in selected areas of District Bhimber, Azad Jammu and Kashmir, Pakistan

The pollution is hot issue of current era in world and the current study was carried to explore impacts of brickkilns' emanations on physiochemical properties of agricultural lands from District Bhimber of Azad Jammu and Kashmir (AJK) Pakistan. In this research, various edaphic characteristics: pH, soil organic matter, organic carbon, water holding capacity, cation exchange capacity and heavy metal contamination in soils nearby of brickkilns were determined. The pH of soil ranged from 5.55 to 7.50, soil organic matter was 0.35-0.90% and organic carbon content was 0.65-1.40%. The water holding capacity ranged from 2.10 to 3.20 mgL-1 and carbon exchange capacity was 1250 to 4202 meq/100g. The contamination profile of heavy metal depicted that Pb showed highest conc. 0.065 mg/g followed by Co (0.053 mg/g) and Ni with 0.52 mg/g in the soil. Pb and Cr had high conc. in soil samples around brickkilns due to burning of coal and rubber tyres as fuel. The conc. of sulphate and nitrate ranged from 0.90±0.50 mol L-1 to 4.25±0.65 mol L-1 and 2.30±0.50 mol L-1 to 6.55±0.25 mol L-1, respectively. The fertility of agriculture lands was depicted that edaphic properties were directly related while nutritive features were inversely commensurate to distance from brickkilns. The research proved that emanations of brickkilns causes severe impact on quality of agriculture land, plant growth and its yield. Hence, reclamation measures should be taken to mitigate and/or eradicate nuisance of brickkilns emanations by using environmental friendly strategies.

Therapeutic Targeting of Minimal Residual Disease to Prevent Late Recurrence in Hormone-Receptor Positive Breast Cancer: Challenges and New Approaches

While the majority of breast cancers are diagnosed at a curable stage, approximately 20% of women will experience recurrence at a distant site during their lifetime. These metastatic recurrences are incurable with current therapeutic approaches. Over the past decade, the biologic mechanisms underlying these recurrences have been elucidated, establishing the existence of minimal residual disease in the form of circulating micrometastases and dormant disease, primarily in the bone marrow. Numerous technologies are now available to detect minimal residual disease (MRD) after breast cancer treatment, but it is yet unknown how to best target and eradicate these cells, and whether clearance of detectable disease prior to the formation of overt metastases can prevent ultimate progression and death. Clinical trials to test this hypothesis are challenging due to the rare nature of MRD in the blood and bone marrow, resulting in the need to screen a large number of survivors to identify those for study. Use of prognostic molecular tools may be able to direct screening to those patients most likely to harbor MRD, but the relationship between these predictors and MRD detection is as yet undefined. Further challenges include the lack of a definitive assay for MRD with established clinical utility, difficulty in selecting potential interventions due to limitations in understanding the biology of MRD, and the emotional impact of detecting MRD in patients who have completed definitive treatment and have no evidence of overt metastatic disease. This review provides a roadmap for tackling these challenges in the design and implementation of interventional clinical trials aimed at eliminating MRD and ultimately preventing metastatic disease to improve survival from this disease, with a specific focus on late recurrences in ER+ breast cancer.

Effect of antiresorptive therapy on aromatase inhibitor induced bone loss in postmenopausal women with early-stage breast cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Aromatase inhibitors (AIs) are routinely used to treat postmenopausal women with early-stage breast cancer. Although AIs improve breast cancer outcomes, they increase the risk of osteoporosis and fractures. This systematic review and meta-analysis assesses the effect of antiresorptive drugs on AI induced bone loss in postmenopausal women with non-metastatic breast cancer.

METHODS

We searched four databases until November 4th 2020. We included Randomized controlled trials (RCTs) of antiresorptive drugs in postmenopausal women with breast cancer treated with AI. Two authors screened studies, extracted data and assessed the risk of bias independently and in duplicate.

RESULTS

We identified 14 RCTs: 7 on zoledronic acid, 6 on oral bisphosphonates and 1 on denosumab. The mean difference in bone mineral density (BMD) was 5% at the lumbar spine and 4% at the total hip, at 12 months, favoring zoledronic acid compared to control. The certainty of the evidence was low for lumbar spine and moderate for total hip BMD. Similarly, the mean difference was 3% at the lumbar spine and 2% at the total hip, favoring oral bisphosphonates with moderate certainty. The mean difference was 6% at the lumbar spine, and 4% at the total hip BMD favoring denosumab compared to placebo. In addition, zoledronic acid resulted in a mean difference in bone turnover marker levels of -35-41%, and the relarive risk for morphometric vertebral fractures was 0.7 [0.3-1.4], compared to control. Denosumab reduced fracture incidence by 50% compared to placebo.

CONCLUSION

Evidence suggests a protective effect of antiresorptive drugs on BMD and bone turnover markers in postmenopausal women with non-metastatic breast cancer on AI. However, data on fracture risk reduction remains unclear.

Interstitial lung disorders following postoperative radiotherapy with concurrent or sequential hormonal therapy for breast cancer: a nationwide database study in Japan

BACKGROUND

Hormonal therapy and radiotherapy are conducted concurrently or sequentially after breast cancer surgery. It remains unclear whether concurrent or sequential treatment is safer in terms of lung complications. Using a Japanese nationwide database, this study aimed to compare the occurrence of severe lung complications between concurrent and sequential treatments.

METHODS

We identified patients who underwent partial mastectomy for stage 0-III breast cancer from July 2010 to March 2020 and received adjuvant hormonal therapy and radiotherapy concurrently (n = 1851) or sequentially (n = 18,429). Two propensity score analyses (1:4 matching and overlap weighting) were conducted to compare hospitalization for radiation pneumonitis and pneumonia within 1 year after surgery, and intensive care unit admission and mortality during the hospitalization. We conducted additional analyses stratified by hormonal drugs (aromatase inhibitors and tamoxifen).

RESULTS

The propensity score-matched analysis showed no significant differences in occurrence of hospitalization for radiation pneumonitis (0.27 vs. 0.58%, p = 0.10) and pneumonia (0.16 vs. 0.58%, p = 0.05) between the concurrent and sequential treatments. The overlap propensity score-weighted analysis also showed no significant differences (0.25 vs. 0.56%, p = 0.08 and 0.15 vs. 0.44%, p = 0.06, respectively). Intensive care unit admission and in-hospital mortality did not differ significantly between the two treatments. The stratified analysis showed similar results.

CONCLUSION

Our propensity score analyses revealed no significant differences in severe lung complications between concurrent and sequential hormonal therapy with radiotherapy following breast cancer surgery, regardless of the type of hormonal drugs. Clinicians can provide concurrent or sequential treatment with equivalent attention to early lung complications.

Comparison of StemPrintER with Oncotype DX Recurrence Score for predicting risk of breast cancer distant recurrence after endocrine therapy

OBJECTIVE

Molecular tests predicting the risk of distant recurrence (DR) can be used to assist therapy decision-making in oestrogen receptor-positive (ER+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer patients after considerations of standard clinical markers. The Oncotype DX Recurrence Score (RS) is a widespread tool used for this purpose. Here, we compared the RS with the StemPrintER Risk Score (SPRS), a novel genomic predictor with a unique biological basis in its ability to measure the expression of cancer stemness genes.

MATERIALS AND METHODS

We benchmarked the SPRS vs. RS, alone or in combination with clinicopathological variables expressed by the Clinical Treatment Score (CTS), for the prognostication of DR in a retrospective cohort of 776 postmenopausal patients with ER+/HER2-breast cancer enrolled in the translational arm of the randomised Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial. Likelihood ratio (LR) with χ² test and C-index were used to assess prognostic performance for the entire ten-year follow-up period and in early (0-5 years) and late (5-10 years) intervals.

RESULTS

In all patients, the SPRS provided significantly more prognostic information than the RS for ten-year DR prognostication (C-index = 0.688, LR-χ² = 33.4 vs. C-index = 0.641, LR-χ² = 22.1) and for late (5-10 years) DR prognostication (C-index = 0.689, LR-χ² = 18.8 vs. C-index = 0.571, LR-χ² = 4.7). The SPRS also provided more prognostic information than the RS when added to the CTS in all patients (CTS + SPRS: LR-Δχ² = 14.9; CTS + RS: LR-Δχ² = 9.7) and in node-negative patients (CTS + SPRS: LR-Δχ² = 11.7; CTS + RS: LR-Δχ² = 6.6).

CONCLUSIONS

In postmenopausal ER+/HER2- breast cancer patients, SPRS provided more prognostic information than RS for DR when used alone or in combination with the CTS. The SPRS could therefore potentially identify high-risk patients, who might benefit from aggressive treatments, from low-risk patients who might safely avoid adjuvant chemotherapy or prolongation of endocrine therapy.

Association of Adjuvant Hormone Therapy Timing With Overall Survival Among Patients With Hormone Receptor-Positive Human Epidermal Growth Factor Receptor-2-Negative Early Breast Cancer Without Chemotherapy

Importance

Studies have shown that delayed initiation of surgery and adjuvant chemotherapy is associated with lower rates of breast cancer survival. However, it remains unclear whether delayed initiation of adjuvant hormone therapy (AHT) is associated with survival.

Objective

To assess the association of time to adjuvant hormone therapy (TTH) with breast cancer survival and evaluate the factors associated with AHT.

Design, Setting, and Participants

This cohort study examined data from the National Cancer Database from 2004 through 2014 to assess the association of TTH (stratified as ≤150 and >150 days) with cancer survival. All patients included were diagnosed with stage I to stage III hormone receptor-positive, human epidermal growth factor receptor-2 (ERBB2; formerly HER2)-negative invasive breast cancer and underwent AHT without chemotherapy. Data were analyzed from April 2019 to May 2020.

Exposures

AHT was administered at different time points following surgical procedures for breast cancer treatment.

Main Outcomes and Measures

An inverse probability of treatment weighting (IPTW) model was constructed to evaluate overall survival by adjusting for treatment facility, patient demographics, tumor characteristics, and treatment; multivariable logistic regression was conducted to assess factors associated with delayed treatment.

Results

A total of 144 103 patients (median [IQR] follow-up, 36.6 months [25.5-49.2 months]; mean [SD] age, 63.7 [11.6] years) were identified, which included 142 916 (99.2%) women, 11 574 (8.0%) Black patients, and 126 013 (87.4%) White patients. Of these, 134 873 patients (93.6%) had a TTH of 150 days or less and 9230 patients (6.4%) had a TTH longer than 150 days. The IPTW-based Cox model demonstrated that patients with delayed AHT (ie, a TTH past 150 days) were associated with decreased survival (hazard ratio [HR], 1.31; 95% CI, 1.26-1.35; P < .001) compared with those receiving the timely treatment (TTH ≤150 days). Several sensitivity analyses (including IPTW with stabilized weight [HR, 1.31; 95% CI, 1.19-1.45; P < .001], propensity score matching [HR, 1.41; 1.13-1.76; P = .002], and propensity score regression adjustment [HR, 1.29; 95% CI, 1.16-1.43; P < .001]) and exploratory subgroup analyses yielded similar trends. Factors associated with delayed AHT included Black racial identity (OR, 1.66; 95% CI, 1.55-1.77), nonprivate insurance (eg, no insurance: OR, 1.46; 95% CI, 1.26-1.70), living in large metropolitan or metropolitan areas (reference vs urban, less urban, or rural: OR, 0.82; 95% CI, 0.76-0.87), treatment in a community hospital (reference vs academic or research: OR, 0.91; 95% CI, 0.84-0.98), Charlson-Deyo Comorbidity Index score 2 or higher (OR, 1.17; 95% CI, 1.04-1.32), poor grade differentiation (OR, 1.42; 95% CI, 1.32-1.53), II and III pathological stage (stage III: OR, 3.13; 95% CI, 2.76-3.54), estrogen receptor-positive (ER+)/progesterone receptor-negative (PR-) or ER-/PR+ (OR, 1.22; 95% CI, 1.13-1.31), receiving breast conservation surgery (reference vs mastectomy: OR, 0.87; 95% CI, 0.79-0.94), and radiotherapy (reference vs no radiotherapy: OR, 0.56; 95% CI, 0.52-0.61).

Conclusions and Relevance

The delay of the initiation of AHT past 150 days was associated with diminished survival in hormone receptor-positive, ERBB2-negative patients with breast cancer who did not receive chemotherapy. Efforts should be made to address factors associated with delayed treatment to improve survival.

How we treat HR-positive, HER2-negative early breast cancer

The present goal of therapy for early hormone receptor-positive (HR+)/human EGF receptor 2-negative (HER2-) BC is to optimize disease-free survival (DFS) and overall survival (OS) rates with the currently available therapies while avoiding any relevant long-term sequalae. Local therapies have evolved toward less aggressive techniques (i.e. breast-preserving surgery, sentinel lymph node biopsy and intraoperative radiotherapy), which significantly reduce the long-term sequalae observed with more radical treatments. Endocrine therapy (ET) is still the cornerstone of adjuvant treatment because it significantly reduces BC relapse and mortality. Adjuvant chemotherapy is today recommended only for a particular subset of patients with a high risk of recurrence with ET alone, identified through genomic assays, age and/or disease stage. Bisphosphonates reduce the risk of bone metastasis and produce a slight although statistically significant improvement in survival in postmenopausal women. The CDK 4/6 inhibitor abemaciclib has been recently approved by the US FDA for patients at high risk of relapse.

Interventions to Improve Bone Mineral Density, Muscle Mass and Fat Mass among Breast Cancer Survivors

Survivors of breast cancer (BC) are at increased risk of chronic diseases due to factors such as low bone mineral density (BMD) and loss of muscle mass (MM) coupled with increased fat mass (FM). It is important to know that healthy behaviors can mitigate the risk of these complications. A narrative review was performed using PubMed and ScienceDirect to identify diet and physical activity (PA) interventions aimed at improving BMD, MM, and/or FM in female BC survivors. Data from 2000 to 2018 were used and 17 diet and/or PA interventions were identified. The duration of interventions was from 3 weeks until 24 months, the smallest sample was 26 women, and the largest was 223. The ranging age of participants was from 46 to 64 years. Studies with a longer duration, in-person modality and/or that used behavioral models showed better results. In BMD, the best results in spine were observed at 24 months in a face-to-face intervention (increase of 3.08%). Regarding MM, the greatest increase was at 26 weeks under Cognitive Behavioral Therapy (CBT) in person (43.8 ± 8.7 to 44.7 ± 8.4 kg, p = 0.04). This approach also showed the greatest decrease in FM from 36.7 to 31.2 kg in 4 months (p ≤ 0.01). Improving BMD and MM and preventing the increase of FM is a challenge for public health. More studies are needed to improve BMD among BC survivors and consider strategies that have yielded better results to promote healthy changes.Key teaching pointsBreast cancer survivors are at increased risk for low bone mineral density, loss of muscle mass, and increased fat mass due to the treatments received; the adoption of a healthy diet and physical activity can mitigate these complications.Of the 17 studies included, 8 used the face-to-face modality, 7 combined face-to-face with phone calls and two studies used only phone calls and email; studies that used the face-to-face modality showed better results.For bone mineral density, the best results were observed in spine at 24 months (increase of 3.08%) in a face-to-face intervention.The greatest increase in muscle mass (43.8 to 44.7 kg) was at 26 weeks in a physical activity intervention; the larger amount of fat mass loss was 5.5 kg in a diet and physical activity intervention. Both results were obtained using the Cognitive Behavioral Therapy (CBT) in person.Lifestyle interventions to maintain or improve bone mineral density, muscle mass and fat mass are effective at least for one of these three variables.

Estrogen and Estrogen Receptor Modulators: Potential Therapeutic Strategies for COVID-19 and Breast Cancer

Owing to the ongoing coronavirus disease 2019 (COVID-19) pandemic, we need to pay a particular focus on the impact of coronavirus infection on breast cancer patients. Approximately 70% of breast cancer patients express estrogen receptor (ER), and intervention therapy for ER has been the primary treatment strategy to prevent the development and metastasis of breast cancer. Recent studies have suggested that selective estrogen receptor modulators (SERMs) are a potential therapeutic strategy for COVID-19. With its anti-ER and anti-viral combined functions, SERMs may be an effective treatment for COVID-19 in patients with breast cancer. In this review, we explore the latent effect of SERMs, especially tamoxifen, and the mechanism between ER and virus susceptibility.

Influence of Estrogen Treatment on ESR1+ and ESR1- Cells in ER+ Breast Cancer: Insights from Single-Cell Analysis of Patient-Derived Xenograft Models

Simple Summary

The benefit of endocrine therapy is normally observed for cancers with 10% or more of cells positive for ER expression. We compared the gene expression profiles in both ESR1⁺ and ESR1^– cells in ER⁺ tumors following estrogen treatment. Our single-cell RNA sequencing analysis of estrogen-stimulated (SC31) and estrogen-suppressed (GS3) patient-derived xenograft models offered an unprecedented opportunity to address the molecular and functional differences between ESR1⁺ and ESR1^– cells. While estrogen should activate ERα and stimulate ESR1⁺ cells, our findings regarding ESR1^– cells were important, indicating that the proliferation of ESR1^– cells in ER⁺ cancer is also influenced by estrogen. Another valuable finding from our studies was that estrogen also upregulated a tumor-suppressor gene, IL-24, only in GS3. Estrogen increased the percentage of cells expressing IL-24, associated with the estrogen-dependent inhibition of GS3 tumor growth.

Abstract

A 100% ER positivity is not required for an endocrine therapy response. Furthermore, while estrogen typically promotes the progression of hormone-dependent breast cancer via the activation of estrogen receptor (ER)-α, estrogen-induced tumor suppression in ER⁺ breast cancer has been clinically observed. With the success in establishing estrogen-stimulated (SC31) and estrogen-suppressed (GS3) patient-derived xenograft (PDX) models, single-cell RNA sequencing analysis was performed to determine the impact of estrogen on ESR1⁺ and ESR1^– tumor cells. We found that 17β-estradiol (E2)-induced suppression of GS3 transpired through wild-type and unamplified ERα. E2 upregulated the expression of estrogen-dependent genes in both SC31 and GS3; however, E2 induced cell cycle advance in SC31, while it resulted in cell cycle arrest in GS3. Importantly, these gene expression changes occurred in both ESR1⁺ and ESR1^– cells within the same breast tumors, demonstrating for the first time a differential effect of estrogen on ESR1^– cells. E2 also upregulated a tumor-suppressor gene, IL-24, in GS3. The apoptosis gene set was upregulated and the G2M checkpoint gene set was downregulated in most IL-24⁺ cells after E2 treatment. In summary, estrogen affected pathologically defined ER⁺ tumors differently, influencing both ESR1⁺ and ESR1^– cells. Our results also suggest IL-24 to be a potential marker of estrogen-suppressed tumors.