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Tesch ME, Zheng Y, Rosenberg SM, Poorvu PD, Ruddy KJ, Tamimi R, Schapira L, Peppercorn J, Borges V, Come SE, Snow C, Bhasin S, Partridge AH. Estrogen levels in young women with hormone receptor-positive breast cancer on ovarian function suppression therapy. NPJ Breast Cancer 2024; 10:67. [PMID: 39090124 PMCID: PMC11294545 DOI: 10.1038/s41523-024-00680-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 07/22/2024] [Indexed: 08/04/2024] Open
Abstract
Ovarian function suppression (OFS) benefits young women with hormone receptor (HR)-positive breast cancer but they are at risk for ovarian function breakthrough. We assessed endocrine effects of gonadotropin-releasing hormone agonist (GnRHa) treatment in a prospective cohort of patients aged ≤ 40 years with HR-positive breast cancer. Plasma estradiol (E2), estrone, and follicule-stimulating hormone (FSH) levels were measured from blood samples drawn 1 and 4 years after diagnosis. Patient characteristics, invasive breast cancer-free survival (iBCFS), and overall survival (OS) were compared between those with and without E2 > 2.72 pg/mL during GnRHa treatment. Among eligible patients, 54.7% (46/84) and 60% (15/25) had E2 > 2.72 pg/mL at 1 and 4 years, respectively. Factors associated with E2 > 2.72 pg/mL at 1 year were no prior chemotherapy (P = 0.045) and tamoxifen use (P = 0.009). After a median follow-up of 7 years, among patients with stage I-III breast cancer (N = 74), iBCFS events were seen in 6 (8.1%) with E2 > 2.72 pg/mL and 5 (6.8%) with E2 ≤ 2.72 pg/mL (P = 0.893). Among patients with de novo metastatic breast cancer (N = 12), 6 (50%) with E2 > 2.72 pg/mL and 3 (25%) with E2 ≤ 2.72 pg/mL died during follow-up (P = 0.052). Larger studies exploring the clinical implications of incomplete E2 suppression by GnRHa are needed to ensure optimal OFS treatment strategies are being employed for this population.
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Affiliation(s)
- Megan E Tesch
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yue Zheng
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Philip D Poorvu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | - Jeffrey Peppercorn
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Steven E Come
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Craig Snow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Shalender Bhasin
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Jiang M, Chen W, Hu Y, Chen C, Li H. Adjuvant ovarian suppression for premenopausal hormone receptor-positive breast cancer: A network meta-analysis. Medicine (Baltimore) 2021; 100:e26949. [PMID: 34414958 PMCID: PMC8376312 DOI: 10.1097/md.0000000000026949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 07/23/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ovarian function suppressor (OFS) plus either tamoxifen (TAM) or aromatase inhibitor (AI) could improve the survival outcome for premenopausal hormone receptor-positive (HR+) breast cancer. However, the optimal OFS-based regimen and medication duration remain uncertain. This article aims to systematically evaluate the OFS-based adjuvant endocrine therapy for premenopausal breast cancer. METHODS We searched several public databases from January 1980 to November 2020. A random model was adopted in this meta-analysis. We used the hazard ratio (HR) with a 95% confidence interval (CI) for the statistical analysis of efficacy. The primary outcome measures included overall survival and disease-free survival. RESULTS A total of 32 articles with 37,224 cases were included in this network meta-analysis. OFS+TAM improved 5-year disease-free survival (HR -0.09, 95% CI -0.16 to -0.01) and 5-year overall survival (HR -0.18, 95% CI -0.33 to -0.03) compared with TAM monotherapy. For OFS+AI, although the 5-year disease-free survival was improved (HR -0.18, 95% CI -0.29 to -0.08), the 5-year overall survival was not improved (HR -0.13, 95% CI -0.43 to 0.18). In subgroup analysis, both OFS+AI and OFS+TAM showed a protective effect in stage I-III patients compared with stage I-II patients. For the course of therapy, OFS+TAM for 2-years could achieve clinical benefit and the best course of therapy of OFS+AI still waits for further study. CONCLUSIONS OFS+TAM might be a better option than OFS+AI for premenopausal intensive adjuvant endocrine therapy. Stage III patients are more suitable for the OFS-based therapy. For the medication duration, the 2-years course of OFS+TAM could be effective. This analysis provides helpful information for selecting therapeutic regimen in intensive adjuvant endocrine therapy and identifying the target population.
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Affiliation(s)
- Mengjie Jiang
- Department of Radiotherapy, First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Wuzhen Chen
- Department of Breast Surgery (Surgical Oncology), Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, Hangzhou, China
| | - Yujie Hu
- Department of Radiotherapy, First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Chao Chen
- Department of Radiotherapy, First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Huafeng Li
- Department of Radiotherapy, First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
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Burns E, Koca E, Xu J, McLean E, Lee R, Patel T, Chang J, Niravath P. Measuring Ovarian Escape in Premenopausal Estrogen Receptor-Positive Breast Cancer Patients on Ovarian Suppression Therapy. Oncologist 2021; 26:e936-e942. [PMID: 33594769 DOI: 10.1002/onco.13722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/05/2021] [Indexed: 01/25/2023] Open
Abstract
PURPOSE This study evaluated the proportion of premenopausal women who experience persistent ovarian escape (OE) while receiving ovarian suppression (OS) therapy for estrogen receptor-positive (ER+) breast cancer treatment. The study also examined clinical factors that may predispose to higher risk of persistent OE. MATERIALS AND METHODS This was a retrospective, "real-world" study to evaluate premenopausal women receiving adjuvant endocrine OS therapy. The primary objective was to measure the percentage of persistent OE within the first 3 months of OS injections (using either leuprolide or goserelin). The secondary objective was to associate baseline clinical data (age, body mass index [BMI], and previous chemotherapy) with the probability of OE. RESULTS Of the 46 patients included in this analysis, 11 (23.9%) women did not achieve OS within 3 months. Three women (6.5%) remained in OE at 12 months. Older age (odds ratio, 0.86; confidence interval, 0.76-0.98, p = .024) was associated with lower chance of developing OE. BMI, previous chemotherapy, and drug used (tamoxifen versus aromatase inhibitor) did not correlate with the likelihood of OE in this patient cohort. CONCLUSION Among the premenopausal women who did not attain complete ovarian suppression, young age was a significant risk factor for likelihood of OE. Although the clinical relevance of this finding is not yet known, it should prompt further studies to determine whether inadequate OS is associated with higher recurrence risk for patients with ER+ breast cancer. IMPLICATIONS FOR PRACTICE Because up to a quarter of premenopausal women do not attain adequate ovarian suppression within the first 3 months of gonadotropin-releasing hormone (GnRH) agonist therapy, bloodwork should be checked to ascertain hormone levels prior to starting aromatase inhibitor therapy, and at regular intervals, for these women.
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Affiliation(s)
- Ethan Burns
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Emre Koca
- Department of Hematology and Medical Oncology, Houston Methodist Cancer Center, Houston, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Edward McLean
- Houston Methodist Department of Pharmacy, Houston, Texas
| | - Rosetta Lee
- Houston Methodist Department of Pharmacy, Houston, Texas
| | - Tejal Patel
- Department of Hematology and Medical Oncology, Houston Methodist Cancer Center, Houston, Texas, USA
| | - Jenny Chang
- Department of Hematology and Medical Oncology, Houston Methodist Cancer Center, Houston, Texas, USA
| | - Polly Niravath
- Department of Hematology and Medical Oncology, Houston Methodist Cancer Center, Houston, Texas, USA
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Venturelli M, Guaitoli G, Omarini C, Moscetti L. Spotlight on triptorelin in the treatment of premenopausal women with early-stage breast cancer. BREAST CANCER-TARGETS AND THERAPY 2018; 10:39-49. [PMID: 29551913 PMCID: PMC5844254 DOI: 10.2147/bctt.s137508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Endocrine treatment represents the cornerstone of endocrine-sensitive premenopausal early breast cancer. The estrogen blockade plays a leading role in the therapeutic management of hormone receptor-positive breast cancer together with surgery, radiotherapy, and selective antiestrogen treatments. For several years, selective estrogen receptor modulators, such as tamoxifen, have represented the mainstay of therapy. The role of amenorrhea has been extensively elucidated in the past year: the benefit observed with chemotherapy-induced amenorrhea has strengthened its therapeutic role. Luteinizing hormone-releasing hormone (LHRH) has been introduced in oncology practice to induce amenorrhea in order to increase the advantage obtained from endocrine treatment. Triptorelin is one of the most widely used LHRH analogs currently available in clinical practice. It was recently investigated in two major clinical trials that studied the role of complete estrogen blockade in the premenopausal setting. Both showed the clinical benefit due to ovarian suppression treatment, primarily in high-risk patients. Furthermore, triptorelin and other LHRH analogs have recently been investigated in the attempt to preserve the ovarian function in young patients. The medical treatment of early breast cancer is always evolving in the effort to search for safe and efficacious treatments. The role of LHRH analogs is actually well recognized as contributing to the improvement of the medical treatment of premenopausal women with early breast cancer.
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Affiliation(s)
- Marta Venturelli
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - Giorgia Guaitoli
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - Claudia Omarini
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - Luca Moscetti
- Division of Medical Oncology, Department of Oncology and Hematology, Azienda Ospedaliero Universitaria Policlinico di Modena, Modena, Italy
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Sverrisdottir A, Nystedt M, Johansson H, Fornander T. Adjuvant goserelin and ovarian preservation in chemotherapy treated patients with early breast cancer: results from a randomized trial. Breast Cancer Res Treat 2009; 117:561-7. [PMID: 19153828 DOI: 10.1007/s10549-009-0313-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
Abstract
The purpose of this randomized study was to examine if goserelin concomitant to CMF-chemotherapy as adjuvant treatment for premenopausal breast cancer, protects the ovaries from premature failure. A total of 285 premenopausal breast cancer patients, in a randomized adjuvant trial (Zoladex in premenopausal patients (ZIPP)), were assigned to a study on ovarian function. Node positive patients were assigned to CMF-(cyclophosphamide, methotrexate and 5-fluorouracil) chemotherapy in addition to endocrine therapy. All patients were randomly assigned to receive 2 years of goserelin, goserelin plus tamoxifen, tamoxifen alone or no endocrine treatment. We studied, if menses were affected in the treatment groups, up to 36 months after randomization. One year after completed CMF- and endocrine therapy, 36% of the women in the goserelin group reported menses, compared to 7% in the goserelin plus tamoxifen group, 13% in the tamoxifen group and 10% of the controls. Among women treated with goserelin, there was a statistically significant increase in the proportion of menstruating women, 1 year after completed treatment compared to at 24 months of treatment (P = 0.006), in contrast to all other treatment groups, who were unchanged or more often amenorrheic. In our study, there is some evidence of protective effect of goserelin on ovarian function in CMF treated women. This effect was not observed in the combined tamoxifen and goserelin treatment.
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Affiliation(s)
- A Sverrisdottir
- Departments of Oncology, Karolinska Institute and University Hospital, Stockholm, Sweden.
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Cheung KL. Endocrine therapy for breast cancer: an overview. Breast 2007; 16:327-43. [PMID: 17499991 DOI: 10.1016/j.breast.2007.03.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 03/19/2007] [Accepted: 03/22/2007] [Indexed: 01/08/2023] Open
Abstract
Endocrine therapy for breast cancer has been established in the adjuvant treatment for primary disease and in the treatment of advanced disease. The ER remains the best predictor of response although other factors exist and need to be identified. Pharmacological manipulation has been replacing ablative procedures. Tamoxifen used to be the most popular agent of choice and promising new agents include the pure anti-oestrogens and the third generation selective aromatase inhibitors. Ongoing and future studies will optimise treatment in established areas and will exploit its potential roles in preoperative use and chemoprevention.
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Affiliation(s)
- K L Cheung
- Division of Breast Surgery, University of Nottingham, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
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7
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Klem J, Moore Z, Peck S, Tripathy D, O'Shaughnessy J. 2007 Highlights from: The 29th Annual San Antonio Breast Cancer Symposium; San Antonio, TX, December 2006. Clin Breast Cancer 2007. [DOI: 10.1016/s1526-8209(11)70741-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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8
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Lee JS, Chang MA, Ko BK, Hong SJ, Kim HJ, Son BH, Kim SB, Ahn JH, Kwack BS, Ahn SH. Experience of Ovarian Function Suppression Therapy: Endocrine Response Preand Perimenopausal Korean Breast Cancer Patients in the Adjuvant Setting. J Breast Cancer 2007. [DOI: 10.4048/jbc.2007.10.2.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jung Sun Lee
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Mi Ae Chang
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Bo-kyoung Ko
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Soo Jung Hong
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Hee Jeong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Byung Ho Son
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Sung Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | - Jin Hee Ahn
- Department of Oncology, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
| | | | - Sei-Hyung Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea
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9
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Jackisch C, Schneeweiss A. Adjuvant Endocrine Therapy in Pre- and Postmenopausal Patients. Breast Care (Basel) 2006. [DOI: 10.1159/000094756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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10
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Forward DP, Cheung KL, Jackson L, Robertson JFR. Clinical and endocrine data for goserelin plus anastrozole as second-line endocrine therapy for premenopausal advanced breast cancer. Br J Cancer 2004; 90:590-4. [PMID: 14760369 PMCID: PMC2409605 DOI: 10.1038/sj.bjc.6601557] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
A total of 16 premenopausal women with metastatic breast cancer (N=13) or locally advanced primary breast cancer (N=3) were treated with a combination of a gonadotropin-releasing hormone agonist goserelin, and a selective aromatase inhibitor anastrozole. All had previously been treated with goserelin and tamoxifen. In all, 12 patients (75%) achieved objective response or durable stable disease at 6 months, with a median duration of remission of 17+ months (range 6–47 months). Four patients still have clinical benefit. Introduction of goserelin and tamoxifen resulted in an 89% reduction in mean oestradiol levels (pretreatment vs 6 months=224 vs 24 pmol l−1) (P<0.0001). Substitution of tamoxifen by anastrozole on progression resulted in a further 76% fall (to 6 pmol l−1 at 3 months) (P<0.0001). Treatment with goserelin and tamoxifen led to a 90% fall in the mean follicle-stimulating hormone (P<0.001). This was reversed once therapy was changed to goserelin and anastrozole. A similar initial reduction was seen in the mean luteinising hormone levels, but substitution of tamoxifen by anastrozole on progression resulted in no significant change. Goserelin and tamoxifen did not lead to any significant change in testosterone and androstenedione levels. The combined use of goserelin and anastrozole as second-line endocrine therapy produces a significant clinical response of worthwhile duration, with demonstrable endocrine changes, in premenopausal women with advanced breast cancer, and offers them another therapeutic option. Further studies involving more patients and longer follow-up are indicated.
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Affiliation(s)
- D P Forward
- Professorial Unit of Surgery, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - K L Cheung
- Professorial Unit of Surgery, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
- Professorial Unit of Surgery, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. E-mail:
| | - L Jackson
- Professorial Unit of Surgery, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - J F R Robertson
- Professorial Unit of Surgery, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
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11
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Robertson JFR, Blamey RW. The use of gonadotrophin-releasing hormone (GnRH) agonists in early and advanced breast cancer in pre- and perimenopausal women. Eur J Cancer 2003; 39:861-9. [PMID: 12706354 DOI: 10.1016/s0959-8049(02)00810-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Gonadotrophin-releasing hormone (GnRH) agonists, in particular goserelin ('Zoladex'), are increasingly being used for the treatment of breast cancer in women with functioning ovaries. They act by downregulating pituitary GnRH receptors, thereby suppressing the release of luteinising hormone (LH) and follicle stimulating hormone (FSH), which, in turn, reduce the main source of oestradiol production in the ovaries. GnRH agonists have been shown to be as effective therapeutically as surgical ovarian ablation in pre- and perimenopausal women with advanced breast cancer. The combination of a GnRH agonist such as goserelin with the peripheral oestrogen antagonist, tamoxifen, may be used to produce 'combined oestrogen blockade'. In advanced breast cancer, this regimen prolongs progression-free survival and increases both the response rate and duration relative to the use of a GnRH agonist alone. In patients with early breast cancer, the addition of goserelin to 'standard treatment' (i.e. surgery+/-tamoxifen, chemotherapy or radiotherapy) results in a significant benefit in recurrence-free survival and overall survival. This benefit was most apparent in patients with oestrogen receptor (ER) +ve tumours. Goserelin, when used either alone or in combination with tamoxifen as an adjuvant systemic therapy in women with ER +ve tumours, has been shown in clinical trials to produce recurrence-free survival rates equivalent to cytotoxic chemotherapy such as cyclophosphamide, methotrexate, 5-fluorouracil (CMF). Evidence suggests that at least part of the effect of adjuvant cytotoxic chemotherapy in premenopausal women is produced by ovarian ablation. Endocrine therapy with goserelin or goserelin plus tamoxifen should now be considered a treatment option in the management of premenopausal women with ER +ve early breast cancer.
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Affiliation(s)
- J F R Robertson
- Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
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12
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Featherstone CJ, Harnett AN, Brunt AM, Johnson L. Methods of ovarian suppression used in the UK. Breast 2002; 11:23-9. [PMID: 14965641 DOI: 10.1054/brst.2001.0356] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2000] [Revised: 04/18/2001] [Accepted: 04/30/2001] [Indexed: 11/18/2022] Open
Abstract
Ovarian suppression in the management of breast cancer has had a resurgence in the 1990s. In view of the development of luteinizing hormone-releasing hormone (LHRH) analogues and advances in laparoscopic surgery, we wished to determine whether more consultants are considering these methods for achieving ovarian suppression than radiotherapy. A questionnaire was designed to determine the current practice of consultants in the UK and to discover who is involved in making this decision. It was distributed via the Adjuvant Breast Cancer (ABC) trials office to consultants who enter patients into the ABC premenopausal trial. Seventy-four (72%) questionnaires were analysed. The preferred method of treatment was radiotherapy in 60%, surgery in 30% and LHRH analogues in 9%. Seventy-three per cent of consultants were using more than one technique but did not always involve the patient in the decision-making process to determine which treatment modality to use. Radiotherapy techniques used included using bony landmarks for field borders (46%), using a standard field size (20%) or using ultrasound localization (15%).
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Abstract
Combination endocrine therapy has long been sought after as a means to better treat breast cancer. Agents that suppress estrogen production are given with agents that suppress estrogenic activity at the cellular level. Historically, these combinations have resulted in initial improvements in response rates, but relapse-free and overall survival were not significantly improved. Also, the increased toxicity seen with these regimens was limiting. New endocrine therapies with more potent activity and less toxicity have led to a resurgence of this idea in the management of breast cancer. Complete estrogen blockade has been compared with single-agent treatments in many different settings. The endocrine effects of this type of therapy are intriguing, but apparently do not readily predict a clinical advantage. The combination of an aromatase inhibitor and an antiestrogen, despite pharmacokinetic interactions, may prove to be beneficial. Results from ongoing trials are eagerly awaited to further address this question in postmenopausal breast cancer patients. For premenopausal breast cancer patients the options are more complex. Clinical outcomes with leutinizing hormone releasing hormone (LHRH) agonists plus aromatase inhibitors are limited to very small phase II studies and are not clearly superior to single-agent therapy. Clinical data in the metastatic setting with premenopausal patients favor the use of an LHRH agonist with tamoxifen over the use of an LHRH agonist alone. However, a similar comparison with tamoxifen alone is lacking with only one trial including this as a treatment arm. Adjuvant therapy with this combined endocrine approach (LHRH agonist plus antiestrogen) has been more extensively studied, but lacks crucial comparisons necessary for making complex treatment decisions. Hopefully, through investigative diligence and ingenuity this issue can be adequately understood. However, many exciting new agents are on the horizon that offer hope to further advance the progress made to date although further confounding the questions already answered.
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Affiliation(s)
- L B Michaud
- The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA
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14
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Klijn JG, Blamey RW, Boccardo F, Tominaga T, Duchateau L, Sylvester R. Combined tamoxifen and luteinizing hormone-releasing hormone (LHRH) agonist versus LHRH agonist alone in premenopausal advanced breast cancer: a meta-analysis of four randomized trials. J Clin Oncol 2001; 19:343-53. [PMID: 11208825 DOI: 10.1200/jco.2001.19.2.343] [Citation(s) in RCA: 329] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The logic behind the application of luteinizing hormone-releasing hormone (LHRH) agonists in combination with tamoxifen in premenopausal women is that LHRH agonists on the one hand suppress the tamoxifen-induced stimulation of the pituitary-ovarian function and, on the other hand, seem as effective as surgical castration. This meta-analysis combines all randomized evidence to compare the combined treatment with LHRH agonist alone with respect to overall survival, progression-free survival, and objective response in premenopausal women with advanced breast cancer. PATIENTS AND METHODS Four clinical trials randomizing a total of 506 premenopausal women with advanced breast cancer to LHRH agonist alone or to the combined treatment of LHRH agonist plus tamoxifen were identified. Meta-analytic techniques were used to analyze individual patient data from these trials. RESULTS With a median follow-up of 6.8 years, there was a significant survival benefit (stratified log-rank test, P = .02; hazards ratio [HR] = 0.78) and progression-free survival benefit (stratified log-rank test, P = .0003; HR = 0.70) in favor of the combined treatment. The overall response rate was significantly higher on combined endocrine treatment (stratified Mantel Haenszel test, P = .03; odds ratio = 0.67). CONCLUSION The combination of LHRH agonist plus tamoxifen is superior to LHRH agonist alone in premenopausal women with advanced breast cancer. Therefore, if a premenopausal woman with advanced breast cancer is thought to be suitable for endocrine treatment, it is proposed that the combination of a LHRH agonist plus tamoxifen be considered as the new standard treatment.
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Affiliation(s)
- J G Klijn
- Dr Daniel den Hoed Kliniek and University Hospital, Rotterdam, The Netherlands
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Abstract
This review reassesses the role of hormonal therapy in breast cancer specifically the sequential or concurrent use of endocrine therapy and the combined use of chemotherapy with endocrine therapy. In advanced disease the sequential use of hormone therapies is generally recommended rather than the combined use of various hormonal agents, though combination hormonal therapy offers advantages in certain subsets of patients. The efficacy of combined chemo-endocrine therapy is questionable. Chemotherapy with estrogenic recruitment is an attractive but still experimental concept. However, in an adjuvant setting there is evidence that combined chemo-endocrine therapy causes a significant increase in disease-free and/or overall survival, particularly in postmenopausal patients with estrogen receptor(ER)-positive tumors. While hormonal treatment strategies have clearly benefitted from randomized studies, data regarding optimal endocrine therapy are still insufficient.
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O'Boyle CJ, O'Hanlon DM, Kerin MJ, Barry MK, Given HF. Laparoscopic oophorectomy: a prospective evaluation in pre-menopausal breast cancer with particular reference to incidence and severity of menopausal symptoms. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:491-3. [PMID: 8903491 DOI: 10.1016/s0748-7983(96)92911-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Laparoscopic oophorectomy offers potential advantages over other methods of ovarian ablation. In this prospective study the technique, complications and side-effects have been assessed in 69 consecutive patients. Menopausal symptoms were assessed using two scoring systems - the Kupperman index and the Women's Health Questionnaire. The serum beta oestradiol levels fell rapidly post-operatively (from 540 pmol/l to 25 pmol/l within 1 month). Menopausal symptoms were mild in 75% of patients and severe in none. Complications occurred in three patients. Laparoscopic oophorectomy has an important role to play in the management of pre-menopausal breast cancer and this study confirms that is well tolerated and gives good short-term results.
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Affiliation(s)
- C J O'Boyle
- Department of Surgery, University College Hospital, National Breast Cancer Research Institute, Galway, Ireland
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Abstract
An antiestrogen is a compound that blocks the action of estrogen. Most synthetic antiestrogens have agonistic or antagonistic activity depending on the tissue and the endogenous estrogen mileu. The triphenylethylene derivatives, clomiphene and tamoxifen, are the antiestrogens in greatest clinical use. Their biologic effects, clinical indications, and risks are reviewed. Novel antiestrogens which are beginning to be studied clinically include the benzothiophene derivative, raloxifene and the "pure" antiestrogens such as ICI 182,780. New clinical indications for existing compounds as well as the development of novel antiestrogens may lead to better treatment options for endocrine-dependent conditions.
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Affiliation(s)
- V L Baker
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
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Jordan VC, Catherino WH, Wolf DM. A mutant receptor as a mechanism of drug resistance to tamoxifen treatment. Ann N Y Acad Sci 1995; 761:138-47. [PMID: 7625717 DOI: 10.1111/j.1749-6632.1995.tb31375.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- V C Jordan
- Robert H. Lurie Cancer Center, Northwestern University Medical School, Chicago, Illinois 60611, USA
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19
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Jonat W, Kaufmann M, Blamey RW, Howell A, Collins JP, Coates A, Eiermann W, Jänicke F, Njordenskold B, Forbes JF. A randomised study to compare the effect of the luteinising hormone releasing hormone (LHRH) analogue goserelin with or without tamoxifen in pre- and perimenopausal patients with advanced breast cancer. Eur J Cancer 1995; 31A:137-42. [PMID: 7718316 DOI: 10.1016/0959-8049(94)00415-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The use of goserelin with or without tamoxifen was investigated in a randomised multicentre study involving 318 pre- and perimenopausal advanced breast cancer patients. With a median follow-up of 93 weeks, 31% of goserelin-treated patients had objective responses (UICC criteria) compared with 38% of goserelin plus tamoxifen-treated patients (P = 0.24). There was a modest benefit in favour of combination therapy in time to progression (P = 0.03) but not in survival (P = 0.25). Median follow-up for survival was 117.5 weeks. Median times for disease progression and survival were 23 and 127 weeks in the goserelin alone group and 28 and 140 weeks in the combination group, respectively. In 115 patients with skeletal metastases only, significant differences in favour of combination therapy were seen in response rate, time to progression and survival. Both treatments were well tolerated and no additional safety issues were associated with combination therapy.
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Affiliation(s)
- W Jonat
- University of Hamburg, Germany
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20
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Bajetta E, Zilembo N, Di Leo A, Buzzoni R, Zampino MG, Biganzoli L, Noberasco C. Hormone therapy in advanced breast carcinoma: present and future trends. Cancer Treat Rev 1994; 20:241-58. [PMID: 8020005 DOI: 10.1016/0305-7372(94)90002-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- E Bajetta
- Division of Medical Oncology B, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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21
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Boccardo F, Rubagotti A, Perrotta A, Amoroso D, Balestrero M, De Matteis A, Zola P, Sismondi P, Francini G, Petrioli R. Ovarian ablation versus goserelin with or without tamoxifen in pre-perimenopausal patients with advanced breast cancer: results of a multicentric Italian study. Ann Oncol 1994; 5:337-42. [PMID: 8075030 DOI: 10.1093/oxfordjournals.annonc.a058837] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Oophorectomy is one of the treatments of choice for premenopausal women with advanced breast cancer. However, in recent years LH-RH analogs have replaced surgical castration (or ovarian irradiation) on the basis of the comparable therapeutic activity shown by these drugs in phase II studies. Moreover, the combination of tamoxifen and LH-RH analogs has gained popularity among clinicians attempting to obtain a 'total estrogen blockade' according to the same rationale previously proposed for advanced prostatic cancer. However, it has thus far not been proven that medical castration is as effective as oophorectomy or ovarian irradiation, nor is there enough evidence that tamoxifen could improve the efficacy of ovarian ablation. PATIENTS AND METHODS Eighty-five perimenopausal patients with estrogen receptor or unknown positive metastatic breast cancer were randomly allocated to receive one of the following treatments: surgical castration (or ovarian irradiation); goserelin; surgical castration (or ovarian irradiation) plus tamoxifen; goserelin plus tamoxifen. The study was performed according to a 2 x 2 factorial randomised design. RESULTS While overall there was no significant difference in the response rates observed after two by two grouping, a trend did favour oophorectomy (or ovarian ablation) with respect to treatment activity. In fact, the best response rate was observed in patients allocated to this treatment (46.6% OR -95% CL: 21.2-72.9) while the lowest rate was observed in patients treated with oophorectomy plus tamoxifen (11.1% OR: CL: -3.4-25.6). Response to goserelin and goserelin plus tamoxifen was 27.2% (+/- 18.6) and 45% (+/- 21.8), respectively. Logistical regression analysis suggested that there might be a different interaction between tamoxifen and goserelin or oophorectomy (ovarian irradiation), respectively. Nevertheless, patient survivals were comparable, irrespective of allocated treatment. This indicates that two by two grouping has some value with respect to treatment efficacy and shows that oophorectomy (or ovarian irradiation) and goserelin have comparable efficacies. Tamoxifen did not improve the efficacy of gonadal ablation, although it did enhance the activity of goserelin treatment. CONCLUSIONS The results of the present study confirm prospectively that the efficacy of chemical castration is comparable to that of oophorectomy (or ovarian irradiation). The concurrent use of tamoxifen can probably enhance the activity of goserelin, but it also induces more side effects. However, it doesn't appear that 'total estrogen blockade' is more effective than gonadal ablation alone. Indeed, the question of whether chemical and surgical castration have the same effect in breast cancer is still open as is the one concerning the interaction between tamoxifen and gonadal ablation. Both questions should be addressed by prospective studies.
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Affiliation(s)
- F Boccardo
- Dept of Medical Oncology II, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
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Iino Y, Wolf DM, Langan-Fahey SM, Johnson DA, Ricchio M, Thompson ME, Jordan VC. Reversible control of oestradiol-stimulated growth of MCF-7 tumours by tamoxifen in the athymic mouse. Br J Cancer 1991; 64:1019-24. [PMID: 1764361 PMCID: PMC1977873 DOI: 10.1038/bjc.1991.457] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We investigated the ability of high concentrations of oestradiol to reverse the growth inhibitory action of tamoxifen on MCF-7 breast cancer cells in vivo. Tamoxifen inhibits the oestradiol stimulated growth of MCF-7 cells in athymic mice. Using a sustained release preparation of tamoxifen we consistently achieved serum concentrations of the drug in the 40 to 50 ng ml-1 range and much higher levels in tissues. These serum levels are sufficient to inhibit the oestrogen stimulated growth of MCF-7 tumours exposed to physiologic (i.e. 300-600 pg ml-1 serum oestradiol concentrations). However, by administering dosages that increase serum oestradiol concentrations to 900-2000 pg ml-1, mimicking the increase often observed clinically in premenopausal women taking tamoxifen, we show that the growth inhibitory action of tamoxifen can be partially reversed. Serum tamoxifen levels were elevated to nearly 400 ng ml-1 by injecting 1 mg day-1 tamoxifen (IP 3 x weekly); this dosage was more effective at inhibiting oestradiol stimulated tumour growth than subcutaneous tamoxifen capsules alone. Our data suggest that at low serum levels tamoxifen may not act optimally. There may be a need to monitor tamoxifen levels in premenopausal patients to ensure that they are high enough not to be overcome by a tamoxifen induced increase in ovarian steroidogenesis.
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Affiliation(s)
- Y Iino
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison 53792
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Abgeschlossene und derzeit laufende adjuvante Therapieprotokolle bei Patienten mit operablem Mammakarzinom. ACTA ACUST UNITED AC 1991. [DOI: 10.1007/bf02658929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dixon AR, Robertson JF, Jackson L, Nicholson RI, Walker KJ, Blamey RW. Goserelin (Zoladex) in premenopausal advanced breast cancer: duration of response and survival. Br J Cancer 1990; 62:868-70. [PMID: 2147110 PMCID: PMC1971509 DOI: 10.1038/bjc.1990.397] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In premenopausal women with advanced breast cancer the luteinising hormone-releasing hormone agonist goserelin (Zoladex, ICI plc) will produce serum levels of oestradiol equivalent to those following surgical oophorectomy or the menopause. This paper reports our further experience of using this drug in 75 premenopausal patients with advanced breast cancer. In addition to response rates, duration of response is reported. An objective response was seen in 25 patients (33%), the median duration of which was in excess of 15 months. Seven patients (9%) showed a complete response to therapy; median duration greater than 37 months. There was no significant difference in time to disease progression (Lee-Desu statistic 18.26, 1 d.f., P = 0.43) and probability of survival (Lee-Desu statistic 3.41, 1 d.f., P = 0.07) between those patients assessed as having either static disease, or those showing a partial response at six months. Response to therapy correlates significantly with the oestrogen receptor status of the primary tumour (X2 = 20.59, 6 d.f., P less than 0.005). The modest side-effects, ease of administration and reversibility make this approach to therapy very attractive. This is to be remembered in that 53% of patients had disease progression whilst receiving goserelin. These patients thus avoided the unnecessary and irreversible morbidity associated with surgical oophorectomy. With the proven efficacy and minimal morbidity associated with goserelin we believe there is no current role for surgical oophorectomy in the management of premenopausal patients with advanced breast cancer.
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Affiliation(s)
- A R Dixon
- Department of Surgery, City Hospital, Nottingham, UK
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Nicholson RI, Walker KJ, Bouzubar N, Wills RJ, Gee JM, Rushmere NK, Davies P. Estrogen deprivation in breast cancer. Clinical, experimental, and biological aspects. Ann N Y Acad Sci 1990; 595:316-27. [PMID: 2142873 DOI: 10.1111/j.1749-6632.1990.tb34305.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The endocrinological and clinical effects of an LH-RH agonist, Zoladex, and an antiestrogen, Nolvadex, in patients with advanced breast cancer are outlined and their potential in the therapy of nonmalignant diseases of the breast and high-risk states is briefly discussed. Additional data are presented to indicate that new antiestrogens are now available for experimental studies that, unlike tamoxifen, do not possess partial estrogen-like activity and that show favorable antitumor properties against DMBA-induced mammary tumors and MCF-7 human breast cancer cells in culture. The lack of agonistic effects of this new class of pharmacological agents now allows a state of total estrogen deprivation to be approached, a previously unobtainable clinical goal.
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Affiliation(s)
- R I Nicholson
- Breast Cancer Units, Tenovus Institute for Cancer Research, University of Wales College of Medicine, Heath Park, Cardiff
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Jordan VC. Long-term adjuvant tamoxifen therapy for breast cancer: the prelude to prevention. Cancer Treat Rev 1990; 17:15-36. [PMID: 2224868 DOI: 10.1016/0305-7372(90)90074-p] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- V C Jordan
- Department of Human Oncology, University of Wisconsin Clinical Cancer Center, Madison 53792
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