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Dai S, Wu X, Huang X, Li J, Wang X, Wang S, Tang J, Shi Y, Xie X, Xu F, Liu P, Huang J, Xie X, An X, Chen M, Hong R, Xia W, Zheng Q, Jiang K, Zhong Y, Yuan Z, Huang Y, Bi X, Xue C. Clinical significance of serum estradiol monitoring in women receiving adjuvant aromatase inhibitor for hormone receptor-positive early breast cancer. Breast 2024; 78:103818. [PMID: 39357125 PMCID: PMC11480241 DOI: 10.1016/j.breast.2024.103818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 08/05/2024] [Accepted: 09/28/2024] [Indexed: 10/04/2024] Open
Abstract
PURPOSE The limited understanding of long-term estradiol (E2) suppression poses challenges to the effectiveness of adjuvant therapy with aromatase inhibitors (AI), necessitating comprehensive serum E2 monitoring to address this issue. Therefore, our objective was to investigate serum E2 levels in women undergoing adjuvant AI treatment and evaluate the significance of such monitoring. PATIENTS AND METHODS In this prospective cohort study, we recruited women who had received adjuvant AI treatment, including those who underwent ovarian function suppression (OFS). Serum E2 levels were measured using high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). The primary endpoint was the proportion of women with E2 levels exceeding 2.72 pg/mL, indicating inadequate suppression achieved with AI therapy. RESULTS A total of 706 patients were enrolled, including 482 women with OFS in combination with AI. Among them, 116 women (16.4 %) exhibited E2 levels exceeding 2.72 pg/mL. The majority of serum E2 elevations (77.6 %) occurred within the first two years of initiating endocrine therapy. Younger age, no prior chemotherapy, shorter duration of the current treatment regimen, and lower follicle stimulating hormone (FSH) levels were associated with inadequate E2 suppression. Serum E2 concentrations demonstrated dynamic variations and occasional rebound following adjuvant AI therapy. CONCLUSIONS Despite receiving adjuvant AI treatment for nearly two years, a certain proportion of patients failed to achieve the adequate threshold of E2 suppression. Our findings emphasize the significance of monitoring serum E2 levels during adjuvant AI therapy, particularly within the first two years. Further research is imperative to facilitate a more comprehensive comprehension of E2 monitoring.
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Affiliation(s)
- Shuqin Dai
- Department of Medicine Laboratory, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xingping Wu
- Department of Medicine Laboratory, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xuefang Huang
- Department of Clinic, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jibin Li
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xi Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Shusen Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jun Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yanxia Shi
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xiaoming Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Fei Xu
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Peng Liu
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jiajia Huang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xinhua Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xin An
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Meiting Chen
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Rouxi Hong
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Wen Xia
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Qiufan Zheng
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Kuikui Jiang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yongyi Zhong
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Zhongyu Yuan
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yuanyuan Huang
- Department of VIP Inpatient, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xiwen Bi
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Cong Xue
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China.
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Gao L, Gao L, Huang S, Sun L, Li M, Shen C, Chen Y, Tan R, Chen Y, Zhan C, Wieland FH, Liu Y, Zhang Y, Luo Y. Nanoemulsion-based transdermal delivery of third-generation steroidal and non-steroidal aromatase inhibitors in preclinical models. Cell Prolif 2024:e13753. [PMID: 39343994 DOI: 10.1111/cpr.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 09/04/2024] [Accepted: 09/14/2024] [Indexed: 10/01/2024] Open
Abstract
Aromatase inhibitors are effective in treating hormone receptor-positive breast cancer, particularly in postmenopausal women. However, the challenges of inconsistent dissolution, variable absorption and side effects with oral administration persist. To address these issues, transdermal delivery has emerged as a viable alternative. In our study, we have developed nanoemulsion-based transdermal creams containing third-generation aromatase inhibitors Exemestane (EXE) or Letrozole (LE) and evaluated their toxicity, anti-tumour effects and androgenic potency using preclinical models including Bama minipigs, DMBA-induced breast cancer rats and orchidectomized male rats. The results of our study are significant, suggesting that both creams effectively penetrated the skin, demonstrating an impressive anti-breast cancer effect. Importantly, EXE cream had no organ toxicity at the tested dose, providing a reassuring safety profile for its use. In contrast, LE cream displayed reversible toxicity from drug molecule itself in animals at the given dose, dissipating after 3 weeks of withdrawal and recovery. This study establishes a solid foundation for the safe clinical use of third-generation aromatase inhibitors. It highlights transdermal creams as a promising drug delivery carrier for administering them.
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Affiliation(s)
- Lanyang Gao
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
- School of Chemical Science and Engineering, Tongji University, Shanghai, China
| | - Lin Gao
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Shiyao Huang
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Lei Sun
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Mei Li
- Department of Laboratory Medicine/Sichuan Medical Laboratory Clinical Medicine Research Center, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Shen
- Department of Laboratory Medicine/Sichuan Medical Laboratory Clinical Medicine Research Center, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, China
| | - Youyou Chen
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Ruihao Tan
- School of Chemical Science and Engineering, Tongji University, Shanghai, China
| | - Yuji Chen
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Chengguo Zhan
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Frank Heinrich Wieland
- Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, Academician (Expert) Workstation of Sichuan Province, Department of General Surgery (Hepatopancreatobiliary Surgery), Fundamental and Clinical Research on Mental Disorders Key Laboratory of Luzhou, The Affiliated Hospital Southwest Medical University, Luzhou, China
| | - Yingying Liu
- School of Chemistry and Chemical Engineering, Frontiers Science Center for Transformative Molecules and National Center for Translational Medicine (Shanghai), Shanghai Jiao Tong University, Shanghai, China
| | - Yinan Zhang
- School of Chemical Science and Engineering, Tongji University, Shanghai, China
| | - Yao Luo
- Department of Laboratory Medicine/Sichuan Medical Laboratory Clinical Medicine Research Center, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, China
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Bertelsen BE, Almås B, Fjermeros K, Viste K, Geisler SB, Sauer T, Selsås K, Geisler J. Superior suppression of serum estrogens during neoadjuvant breast cancer treatment with letrozole compared to exemestane. Breast Cancer Res Treat 2024; 206:347-358. [PMID: 38649619 PMCID: PMC11182829 DOI: 10.1007/s10549-024-07313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE The aromatase inhibitor letrozole and the aromatase inactivator exemestane are two of the most pivotal cancer drugs used for endocrine treatment of ER-positive breast cancer in all phases of the disease. Although both drugs inhibit CYP19 (aromatase) and have been used for decades, a direct head-to-head, intra-patient-cross-over comparison of their ability to decrease estrogen synthesis in vivo is still lacking. METHODS Postmenopausal breast cancer patients suitable for neoadjuvant endocrine therapy were randomized to receive either letrozole (2.5 mg o.d.) or exemestane (25 mg o.d.) for an initial treatment period, followed by a second treatment period on the alternative drug (intra-patient cross-over study design). Serum levels of estrone (E1), estradiol (E2), letrozole, exemestane, and 17-hydroxyexemestane were quantified simultaneously using a novel, ultrasensitive LC-MS/MS method established in our laboratory. RESULTS Complete sets of serum samples (baseline and during treatment with letrozole or exemestane) were available from 79 patients, including 40 patients starting with letrozole (cohort 1) and 39 with exemestane (cohort 2). Mean serum estrone and estradiol levels in cohort 1 were 174 pmol/L and 46.4 pmol/L at baseline, respectively. Treatment with letrozole suppressed serum E1 and E2 to a mean value of 0.2 pmol/L and 0.4 pmol/L (P < 0.001). After the cross-over to exemestane, mean serum levels of E1 and E2 increased to 1.4 pmol/L and 0.7 pmol/L, respectively. In cohort 2, baseline mean serum levels of E1 and E2 were 159 and 32.5 pmol/L, respectively. Treatment with exemestane decreased these values to 1.8 pmol/L for E1 and 0.6 pmol/L for E2 (P < 0.001). Following cross-over to letrozole, mean serum levels of E1 and E2 were significantly further reduced to 0.1 pmol/L and 0.4 pmol/L, respectively. Serum drug levels were monitored in all patients throughout the entire treatment and confirmed adherence to the protocol and drug concentrations within the therapeutic range for all patients. Additionally, Ki-67 values decreased significantly during treatment with both aromatase inhibitors, showing a trend toward a stronger suppression in obese women. CONCLUSION To the best of our knowledge, we present here for the first time a comprehensive and direct head-to-head, intra-patient-cross-over comparison of the aromatase inhibitor letrozole and the aromatase inactivator exemestane concerning their ability to suppress serum estrogen levels in vivo. All in all, our results clearly demonstrate that letrozole therapy results in a more profound suppression of serum E1 and E2 levels compared to exemestane.
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Affiliation(s)
- Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | - Bjørg Almås
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | - Kamilla Fjermeros
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Kristin Viste
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | | | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Selsås
- Department of Breast- and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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4
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Johansson H, Guerrieri-Gonzaga A, Gandini S, Bertelsen BE, Macis D, Serrano D, Mellgren G, Lazzeroni M, Thomas PS, Crew KD, Kumar NB, Briata IM, Galimberti V, Viale G, Vornik LA, Aristarco V, Buttiron Webber T, Spinaci S, Brown PH, Heckman-Stoddard BM, Szabo E, Bonanni B, DeCensi A. Alternative dosing regimen of exemestane in a randomized presurgical trial: the role of obesity in biomarker modulation. NPJ Breast Cancer 2024; 10:7. [PMID: 38238336 PMCID: PMC10796398 DOI: 10.1038/s41523-024-00616-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024] Open
Abstract
In a 3-arm presurgical trial, four-six weeks exemestane 25 mg three times/week (TIW) was non-inferior to 25 mg/day (QD) in suppressing circulating estradiol in postmenopausal women with ER-positive breast cancer. Since obesity may decrease exemestane efficacy, we analyzed changes in sex steroids, adipokines, Ki-67, and drug levels in relation to obesity. Postmenopausal women with early-stage ER-positive breast cancer were randomized to either exemestane 25 mg QD (n = 57), 25 mg TIW (n = 57), or 25 mg/week (QW, n = 62) for 4-6 weeks before breast surgery. Serum and tissue pre- and post-treatment biomarkers were stratified by body mass index (BMI)< or ≥30 kg/m2. Post-treatment median exemestane and 17-OH exemestane levels were 5-6 times higher in the QD arm compared to the TIW arm. For obese women, TIW maintained comparable reductions to QD in systemic estradiol levels, although the reduction in estrone was less with the TIW regimen. There was less suppression of SHBG with the TIW versus the QD dose schedule in obese women which should result in less systemic bioavailable estrogens. Metabolically, the effect of the TIW regimen was similar to the QD regimen for obese women in terms of leptin suppression and increase in the adiponectin-leptin ratio. Reduction in tissue Ki-67 was less for obese women on the TIW regimen than QD, although changes were similar for non-obese women. Our findings suggest that TIW exemestane should be explored further for primary cancer prevention in both normal weight and obese cohorts.
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Affiliation(s)
| | | | - Sara Gandini
- IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Debora Macis
- IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | | | | | - Nagi B Kumar
- Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | | | | | | | - Lana A Vornik
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - Powel H Brown
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eva Szabo
- Division of Cancer Prevention, NCI Bethesda, MD, USA
| | | | - Andrea DeCensi
- E.O. Galliera Hospital, Genoa, Italy
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Salmon RJ. [De-escalation in aromatase inhibitors prescription for menopausal women with positive hormonal receptors breast cancer]. Bull Cancer 2023; 110:1084-1085. [PMID: 37507238 DOI: 10.1016/j.bulcan.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Rémy J Salmon
- Clinique Saint-Jean de Dieu, 2, rue Rousselet, Paris, France.
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Khan SA. Breast Cancer Risk Reduction: Current Status and Emerging Trends to Increase Efficacy and Reduce Toxicity of Preventive Medication. Surg Oncol Clin N Am 2023; 32:631-646. [PMID: 37714633 DOI: 10.1016/j.soc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The primary prevention of breast cancer is a worthwhile goal for which the efficacy of antiestrogens is well established. However, implementation has been problematic related to low prioritization by providers and the reluctance of high-risk women to experience medication side effects. Emerging solutions include improved risk estimation through the use of polygenic risk scores and the application of radiomics to screening mammograms; and optimization of medication dose to limit toxicity. The identification of agents to prevent estrogen receptor negative or HER2-positive tumors is being pursued, but personalization of medical risk reduction requires the prediction of tumor subtypes.
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Affiliation(s)
- Seema Ahsan Khan
- Department of Surgery, Feinberg School of Medicine of Northwestern University, 303 East Superior Street, Chicago, IL 60614, USA.
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Fabian CJ, Mudaranthakam DP. Reduced-Frequency Endocrine Therapy and Challenges of Noninferiority Study Designs. JAMA Oncol 2023; 9:672-674. [PMID: 36951870 PMCID: PMC11008220 DOI: 10.1001/jamaoncol.2023.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Affiliation(s)
- Carol J Fabian
- Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City
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