Toremifene is an effective and safe alternative to tamoxifen in adjuvant endocrine therapy for breast cancer: results of four randomized trials

Comparison of effects of tamoxifen and Toremifene on hepatic function and serum lipids in breast cancer patients during adjuvant endocrine therapy

To investigate the effects of tamoxifen (TAM) and toremifene (TOR) on hepatic function and serum lipid levels in breast cancer patients receiving adjuvant endocrine therapy. The clinical data of 597 early breast cancer patients treated at the First Affiliated Hospital of Nanjing Medical University between January 2016 and December 2022 were collected. All the patients received standard adjuvant endocrine therapy with TAM or TOR after chemotherapy. Hepatic function and serum lipid data of all patients before and at 6 months and 1, 2, and 3 years after the treatment were collected retrospectively and analyzed statistically. There: no negative effect on hepatic function was observed in patients treated with either TAM or TOR. The triglyceride levels in both groups increased during treatment, and the effect of TAM on improving total cholesterol levels was stronger. Total cholesterol levels were not affected by time or treatment regimen. The low-density lipoprotein cholesterol levels decreased in both groups, and the effect was similar between groups. TAM can decrease the high-density lipoprotein cholesterol levels, whereas TOR can increase the high-density lipoprotein cholesterol levels, and there was a significant difference between groups. In the postoperative adjuvant endocrine therapy, TOR and TAM will not negatively impact the hepatic function of breast cancer patients, and TOR is better than TAM in the management of serum lipids; therefore, it may be a better choice for clinical medication.

Thrombosis of acute superior mesenteric artery in a patient with breast cancer receiving toremifene therapy: a case report and literature review

It is widely recognized that cancer itself is related to increased risk of thromembolism. Venous thromboembolism is relatively common in breast cancer patients, but arterial thrombosis, especially acute superior mesenteric artery thrombosis (SMAT) associated with chemotherapy or endocrinotherapy, rarely occurs in breast cancer patients. There were few reports about acute SMAT in cancer patients who underwent chemotherapy, but no reports of acute SMAT caused by endocrine-therapy. We reported a 54-year-old patient with acute SMAT during toremifene treatment after breast cancer surgery. She underwent 4 cycles chemotherapy of TC regimen, then accepted toremifen endocrinotherapy because of positive estrogen receptor. She suffered from acute SMAT after 2 months toremifen treatment. Therefore, we consider that this case of acute SMAT may be a rare adverse event of toremifen. In view of the high risk and rarity of acute SMAT caused by toremifene, we suggest that except for venous thrombosis, arterial thrombosis in special position (ATSP) should be kept in mind during use of toremifene. Once a thrombotic event occurs, toremifene should be stopped immediately.

Toremifene, an Alternative Adjuvant Endocrine Therapy, Is Better Than Tamoxifen in Breast Cancer Patients with CYP2D6*10 Mutant Genotypes

PURPOSE

Tamoxifen showed individual differences in efficacy under different CYP2D6*10 genotypes. Our study evaluated the prognosis of tamoxifen or toremifene in hormone receptor (HR)-positive breast cancer patients under different genotypes.

MATERIALS AND METHODS

CYP2D6*10 genotypes of HR-positive breast cancer patients were determined by Sanger sequencing, and all the patients were divided into tamoxifen group or toremifene group.

RESULTS

A total of 268 patients with HR-positive breast cancer were studied. The median follow-up time was 72.0 months (range, 5.0 to 88.0 months). Of these, 88 (32.9%), 114 (42.5%), and 66 (24.6%) patients had C/C, C/T, and T/T genotypes, respectively. Among patients who received tamoxifen (n=176), the 5-year disease-free survival (DFS) rate in patients with C/C and C/T genotype was better than that in patients with T/T genotype, and the difference was statistically significant (p < 0.001 and p=0.030, respectively). In patients receiving toremifene, CYP2D6*10 genotype was not significantly associated with DFS (p=0.325). Regardless of genotypes, the 5-year DFS rate was higher in patients treated with toremifene than in patients with tamoxifen (91.3% vs. 80.0%, p=0.011). Compared with tamoxifen, toremifene remained an independent prognostic marker of DFS in multivariate analysis (hazard ratio, 0.422; p=0.021). For all the 180 patients with CYP2D6*10 C/T and T/T genotypes, the 5-year DFS rate was significantly higher in the toremifene group than in the tamoxifen group (90.8% vs. 70.1%, p=0.003).

CONCLUSION

Toremifene may be an alternative adjuvant endocrine therapy for patients with CYP2D6*10 mutant genotypes.

Crosstalk between ferroptosis and steroid hormone signaling in gynecologic cancers

Ferroptosis is a novel types of regulated cell death and is widely studied in cancers and many other diseases in recent years. It is characterized by iron accumulation and intense lipid peroxidation that ultimately inducing oxidative damage. So far, signaling pathways related to ferroptosis are involved in all aspects of determining cell fate, including oxidative phosphorylation, metal-ion transport, energy metabolism and cholesterol synthesis progress, et al. Recently, accumulated studies have demonstrated that ferroptosis is associated with gynecological oncology related to steroid hormone signaling. This review trends to summarize the mechanisms and applications of ferroptosis in cancers related to estrogen and progesterone, which is expected to provide a theoretical basis for the prevention and treatment of gynecologic cancers.

Recent Advancement in the One-Pot Synthesis of the Tri-Substituted Methanes (TRSMs) and Their Biological Applications

The history of tri-substituted methanes (TRSMs) in chemical industries is much older. Tri-substituted methanes were previously used as dyes in the chemical industries. Still, there is a significant surge in researchers' interest in them due to their wide range of bioactivities. Tri-substituted methane derivatives show a wide range of biological activities like anti-tumor, antimicrobial, antibiofilm, antioxidant, anti-inflammatory, anti-arthritic activities. Due to the wide range of medicinal applications shown by tri-substituted methanes, most of the methodologies reported in the literature for the synthesis of TRSMs are focused on the one-pot method. This review explored the recently reported one-pot processes for synthesizing tri-substituted methanes and their various medicinal applications. Based on the substitution attached to the -CH carbon, this review categorizes them into two major classes: (I) symmetrical and (II) unsymmetrical trisubstituted methanes. In addition, this review gives an insight into the growing opportunities for the construction of trisubstituted scaffolds via one-pot methodologies. To the best of our knowledge, no one has yet reported a review on the one-pot synthesis of TRSMs. Therefore, here we present a brief literature review of the synthesis of both symmetrical and unsymmetrical TRSMs covering various one-pot methodologies along with their medicinal applications.

Chinese breast cancer patients with CYP2D6*10 mutant genotypes have a better prognosis with toremifene than with tamoxifen

Purpose

To evaluate the prognosis of estrogen receptor‐positive breast cancer patients with CYP2D6*10 mutant genotypes under tamoxifen or toremifen therapy.

Methods

Estrogen receptor‐positive breast cancer patients were selected and CYP2D6*10 genotypes (C/C, C/T, and T/T) were determined by Sanger sequencing. Patients were divided into tamoxifen, toremifene, or tamoxifen + toremifene groups according to prior therapy. The correlation between CYP2D6*10 genotype and disease‐free survival was analyzed.

Results

In total, 293 estrogen receptor‐positive breast cancer patients treated with tamoxifen or toremifene between 2008 and 2017 were studied. Median follow‐up was 39 months (10–141). Of these, 107 (36.52%), 112 (38.23%), and 74 (25.26%) patients had C/C, C/T, and T/T genotypes, respectively. Genotype was significantly associated with disease‐free survival in tamoxifen patients. Patients with C/T and T/T genotypes showed worse disease‐free survival than patients with a C/C genotype. Genotype and disease‐free survival in toremifene and tamoxifen+toremifene patients were not correlated. Of patients with a C/T genotype, toremifene or tamoxifen+toremifene groups showed better disease‐free survival than tamoxifen patients. Although disease‐free survival of patients with a T/T genotype in the three groups was not statistically different, tamoxifen patients showed worse disease‐free survival. There was no correlation between different treatments and disease‐free survival in patients with a C/C genotype. Cox proportional hazard analysis revealed toremifene patients had a better prognosis than tamoxifen patients; toremifene was an independent protective factoremifene for disease‐free survival.

Conclusions

Tamoxifen was less effective in patients with CYP2D6*10 C/T and T/T genotypes. Estrogen receptor‐positive breast cancer patients with a CYP2D6*10 mutation genotype have a better prognosis with toremifen than tamoxifen.

A prospective, randomized study of Toremifene vs. tamoxifen for the treatment of premenopausal breast cancer: safety and genital symptom analysis

BACKGROUND

Toremifene (TOR) is a selective oestrogen receptor modulator (SERM) and has comparable efficacy to that of tamoxifen (TAM) in breast cancer patients. Herein, we compared the safety of TOR to that of TAM in the adjuvant treatment of premenopausal breast cancer.

METHODS

This was a prospective randomized and open-label clinical study. Premenopausal patients with hormonal receptor (HR)-positive early breast cancer were randomly assigned (1:1) to receive TOR) or TAM treatment. The follow-up period was 1 year. The primary end point was the incidence of ovarian cysts, and secondary end points were the incidence of endometrial thickening, changes in female hormones, the incidence of fatty liver, changes in the modified Kupperman index (mKMI) and changes in quality of life.

RESULTS

There were 92 patients in the final analysis. The incidences of ovarian cysts were 42.6% in the TOR group and 51.1% in the TAM group (p = 0.441). Forty-one patients (87.2%) in the TOR group and 36 patients (80.0%) in the TAM group experienced endometrial thickening (p = 0.348). The proportions of patients with fatty liver were 31.9% in the TOR group and 26.7% in the TAM group (p = 0.581). No significant differences in the mKMI or quality of life were observed between the two groups.

CONCLUSIONS

TOR and TAM have similar side effects on the female genital system and quality of life in premenopausal early breast cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02344940. Registered 26 January 2015 (retrospectively registered).

Network-based drug repurposing for novel coronavirus 2019-nCoV/SARS-CoV-2

Human coronaviruses (HCoVs), including severe acute respiratory syndrome coronavirus (SARS-CoV) and 2019 novel coronavirus (2019-nCoV, also known as SARS-CoV-2), lead global epidemics with high morbidity and mortality. However, there are currently no effective drugs targeting 2019-nCoV/SARS-CoV-2. Drug repurposing, representing as an effective drug discovery strategy from existing drugs, could shorten the time and reduce the cost compared to de novo drug discovery. In this study, we present an integrative, antiviral drug repurposing methodology implementing a systems pharmacology-based network medicine platform, quantifying the interplay between the HCoV-host interactome and drug targets in the human protein-protein interaction network. Phylogenetic analyses of 15 HCoV whole genomes reveal that 2019-nCoV/SARS-CoV-2 shares the highest nucleotide sequence identity with SARS-CoV (79.7%). Specifically, the envelope and nucleocapsid proteins of 2019-nCoV/SARS-CoV-2 are two evolutionarily conserved regions, having the sequence identities of 96% and 89.6%, respectively, compared to SARS-CoV. Using network proximity analyses of drug targets and HCoV-host interactions in the human interactome, we prioritize 16 potential anti-HCoV repurposable drugs (e.g., melatonin, mercaptopurine, and sirolimus) that are further validated by enrichment analyses of drug-gene signatures and HCoV-induced transcriptomics data in human cell lines. We further identify three potential drug combinations (e.g., sirolimus plus dactinomycin, mercaptopurine plus melatonin, and toremifene plus emodin) captured by the "Complementary Exposure" pattern: the targets of the drugs both hit the HCoV-host subnetwork, but target separate neighborhoods in the human interactome network. In summary, this study offers powerful network-based methodologies for rapid identification of candidate repurposable drugs and potential drug combinations targeting 2019-nCoV/SARS-CoV-2.

CYP2D6*10 pharmacogenetic-guided SERM could be a cost-effective strategy in Chinese patients with hormone receptor-positive breast cancer

Aim: To assess the cost-effectiveness of CYP2D6*10 genetic testing for the management of Chinese women with hormone receptor-positive (HR+) breast cancer treated with selective estrogen receptor modulator. Methods: A Markov model was developed to evaluate a total expected cost and an incremental cost-effectiveness ratio (ICER). Robustness of the model was addressed in one-way analyses and probabilistic sensitivity analysis. Results: The cost of strategies of tamoxifen, toremifene without genotyping and the strategy base on CYP2D6*10 genotype were $63,879.19, $90,156.60 and $95,021.41, and the quality-adjusted life years gained are 8.1588, 12.89687 and 13.85911, respectively. The incremental cost-effectiveness ratio of the CYP2D6*10 testing versus toremifene were 5,055.74221/quality-adjusted life year, respectively. Conclusion: CYP2D6*10 pharmacogenetic-guided selective estrogen receptor modulator can be a cost-effective strategy in the Chinese patients with hormone receptor-positive breast cancer.

Clinical significance of fatty liver disease induced by tamoxifen and toremifene in breast cancer patients

BACKGROUND AND AIM

The aim of this study was to identify the effect of selective estrogen receptor modulator (SERM) on non-alcoholic fatty liver disease (NAFLD) in Asian women.

METHODS

We retrospectively evaluated fatty liver development and/or serum alanine aminotransferase (ALT) elevation during SERM treatment in 1061 women who were diagnosed and treated with breast cancer in 2005 at Asan Medical Center.

RESULTS

45 of 618 SERM-treated patients with normal ALT at baseline experienced ALT elevation during SERM treatment. Among the 112 SERM-treated patients who underwent liver imaging test, fatty liver was observed in 47 and both fatty liver and ALT elevation developed in 16 of 102 SERM-treated patients with normal baseline ALT. The cumulative rates of ALT elevation (10.7 vs. 4.3%; P = 0.002), fatty liver (48.5 vs. 20.9%; P < 0.001), and both fatty liver and ALT elevation (17.7 vs. 7.1%; P = 0.02) at 60 months were significantly higher in the SERM group than non-SERM group. By multivariate analysis, SERM treatment increased the risk of ALT elevation (hazard ratio [HR], 2.20; P = 0.01), fatty liver development (HR, 3.59; P < 0.001), and both fatty liver and ALT elevation (HR, 4.98; P = 0.01). After discontinuation of SERM, elevated serum ALT normalized in 39 (92.9%) and there were no instances of liver-related death or progression to liver cirrhosis in patients who experienced fatty liver or ALT elevation.

CONCLUSIONS

Although SERM treatment is significantly associated with NAFLD in Asian women, considering the tolerability and reversibility of NAFLD induced by SERM, it can be continued with liver function monitoring in relevant patients.

Association between bone mineral density and type 1 diabetes mellitus: a meta-analysis of cross-sectional studies

A few studies have investigated the relationship between type 1 diabetes mellitus (T1DM) and bone mineral density (BMD) values. This meta-analysis was performed to explore differences between T1DM and healthy individuals in BMD values measured at five bone sites.We searched the database of PubMed for cross-sectional studies about the association of T1DM and BMD, and a meta-analysis was conducted.The results suggested significant association between T1DM and decreased BMD values of total body. The pooled mean differences (MDs) were -0.06 [95% confidence interval (CI): -0.11, -0.01] for all people. As for the association between T1DM and spine BMD values, the pooled MDs were -0.04 (95% CI: -0.07, -0.01) for males and -0.03 (95% CI: -0.06, 0.00) for females <20 years old. As for femur BMD values, the pooled MDs were -0.06 (95% CI: -0.13, 0.00) for all people, -0.03 (95% CI: -0.06, -0.01) for females and -0.04(95% CI: -0.05, -0.02) for males. As for hip BMD values, the pooled MDs were -0.06 (95% CI: -0.08, -0.04) for females. As for forearm BMD values, the pooled MDs were -0.01 (95% CI: -0.02, 0.00) for females.The results of this meta-analysis suggest the overall association between T1DM and reduced BMD values. Notably, the influence of T1DM on BMD seems to depend on gender or patient's age. Reduced BMD values may occur early after T1DM diagnosis. Future clinical and basic research studies are needed to further understand the mechanisms of decreased BMD values in T1DM patients.

Toremifene for breast cancer: a review of 20 years of data

Endocrine therapy is a cornerstone of medical treatment for estrogen receptor-positive breast cancer. The discovery of selective estrogen receptor modulators (SERMs) > 40 years ago represented a revolutionary advance in the treatment of breast cancer. As a therapeutic class, SERMs have either estrogenic or antiestrogenic activity, depending on the target tissue and the hormonal environment. In breast tissue, SERMs are antiestrogenic, making them a major treatment option for women with hormone-sensitive breast cancer. Toremifene citrate was developed > 20 years ago with the goal of achieving efficacy similar to that of tamoxifen and with an improved safety profile. Although studies to date have not confirmed a clear safety advantage or disadvantage for toremifene, clinical data support the efficacy and safety of toremifene for the treatment of breast cancer in postmenopausal patients. Toremifene also has a pharmacokinetic profile and metabolic pathway different from that of tamoxifen, which may provide a therapeutic advantage in certain patients. In addition, because of the selective estrogenic effects of SERMs in bone and on lipid levels along with a different side effect profile compared with the aromatase inhibitors (AIs), toremifene is a viable option to the AIs for some patients. Despite a number of clinical trials and over 500,000 patient years of use, many oncologists have limited familiarity with toremifene data. This article will examine the rationale for the use of toremifene in the treatment of women with breast cancer and review data from 20 years of clinical experience with this agent.

Intraoperative ultrasound guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis

Purpose

Margin status is one of the most important predictors of local recurrence after breast conserving surgery (BCS). Intraoperative ultrasound guidance (IOUS) has the potential to improve surgical accuracy for breast cancer. The purpose of the present meta-analysis was to determine the efficacy of IOUS in breast cancer surgery and to compare the margin status to that of the more traditional Guide wire localization (GWL) or palpation-guidance.

Methods

We searched the database of PubMed for prospective and retrospective studies about the impact of IOUS on margin status of breast cancer, and a meta-analysis was conducted.

Results

Of the 13 studies included, 8 were eligible for the impact of IOUS on margin status of non-palpable breast cancers, 4 were eligible for palpable breast cancers, and 1 was for both non-palpable and palpable breast cancers. The rate of negative margins of breast cancers in IOUS group was significantly higher than that in control group without IOUS (risk ratio (RR)  = 1.37, 95% confidence interval (CI)  = 1.18–1.59 from 7 prospective studies, odds ratio (OR)  = 2.75, 95% CI  = 1.66–4.55 from 4 retrospective studies). For non-palpable breast cancers, IOUS-guidance enabled a significantly higher rate of negative margins than that of GWL-guidance (RR  = 1.26, 95% CI  = 1.09–1.46 from 6 prospective studies; OR  = 1.45, 95% CI  = 0.86–2.43 from 2 retrospective studies). For palpable breast cancers, relative to control group without IOUS, the RR for IOUS associated negative margins was 2.36 (95% CI  = 1.26–4.43) from 2 prospective studies, the OR was 2.71 (95% CI  = 1.25–5.87) from 2 retrospective studies.

Conclusion

This study strongly suggests that IOUS is an accurate method for localization of non-palpable and palpable breast cancers. It is an efficient method of obtaining high proportion of negative margins and optimum resection volumes in patients undergoing BCS.

Hormone-related pharmacokinetic variations associated with anti-breast cancer drugs

INTRODUCTION

Breast cancer is the most common female cancer, with more than one million new patients diagnosed annually worldwide. Generally speaking, there are three types of drugs used in management of breast cancer namely: hormonal treatment, chemotherapeutic agents and target-based agents. There is increasing evidence that hormones play an important role in development of both hormone-dependent and hormone-independent breast cancers.

AREAS COVERED

This review summarizes the pharmacokinetics of various types of drugs used to treat breast cancer. Furthermore, the authors discuss hormone-related variations including: the menstrual status, gender and exogenous hormones influencing drug absorption, distribution, metabolism or excretion (ADME). The authors also describe the physiological factors such as body weight and age that affect the pharmacokinetics of several drugs.

EXPERT OPINION

The factors affecting the pharmacokinetics of anti-breast cancer drugs are multifaceted. Hormones appear to be a key factor determining the pharmacokinetics (and efficacy) of hormonal therapy due to their role in cancer progression. In chemotherapy, the effects of hormones on the drug pharmacokinetics are possibly mediated through P-glycoprotein (P-gp) efflux and/or cytochrome P450 metabolism. In many cases, dosing regimen should be adjusted for drugs used in treatment of breast cancers based on the hormone levels in the body.

Propofol combined with traditional sedative agents versus propofol- alone sedation for gastrointestinal endoscopy: a meta-analysis

OBJECTIVE

To assess the efficacy and safety of sedation of propofol combined with traditional sedative agents (PTSA) for gastrointestinal endoscopy, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing PTSA with propofol-alone sedation.

MATERIAL AND METHODS

RCTs comparing the effects of PTSA and propofol alone during gastrointestinal endoscopy were found on MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE. Cardiopulmonary complications (i.e., hypoxia, hypotension, arrhythmia, and apnea), total dose of propofol used and amnesia were assessed.

RESULTS

Nine original RCTs investigating a total of 1,505 patients, of whom, 805 received PTSA sedation and 700 received propofol-alone sedation, met the inclusion criteria. Compared with propofol-alone sedation, the pooled relative risk with the use of PTSA sedation for developing hypoxia, hypotension, arrhythmias, and apnea for all the procedures combined was 0.93 (95% CI, 0.30-2.92), 1.32 (95% CI, 0.38-4.64), 2.61 (95% CI, 0.23-29.29) and 2.81 (95% CI, 0.27-29.07), with no significant difference between the groups. The pooled mean difference in total dose of propofol used was -40.01 (95% CI, -78.96 to -1.05), which showed a significant reduction with use of PTSA sedation. The pooled relative risk for amnesia was 0.97 (95% CI, 0.88-1.07), suggesting no significant difference between the groups.

CONCLUSIONS

PTSA sedation during gastrointestinal endoscopy could significantly reduce the total dose of propofol, but without benefits of lower risk of cardiopulmonary complications compared with propofol-alone sedation.

Effects of toremifene versus tamoxifen on breast cancer patients: a meta-analysis

Toremifene and tamoxifen are both selective estrogen receptor modulators used in the treatment of breast cancer patients. Therefore, we carried out a meta-analysis to achieve a more precise evaluation of the effects of toremifene versus tamoxifen on breast cancer patients, including the efficacy and safety, and the effects on the uterus, lipids, and bone. Comprehensive literature searches were conducted using the electronic databases and reference lists to include randomized controlled trials (RCTs) that compared toremifene with tamoxifen for breast cancer patients. Two reviewers independently selected studies and abstracted data. Data were analyzed by Review Manager, version 5.0. Twenty-three trials (7242 patients) were included. For early stage breast cancer, toremifene was associated with higher 5-year survival rates (OR 1.25, 95 % CI 1.04, 1.50), more vaginal discharge (OR 1. 32, 95 % CI 1.01, 1.73), a greater decrease in serum triglyceride levels (SMD -1.01, 95 % CI -1.89, -0.14), a smaller decrease in LDL cholesterol levels (SMD 0.45, 95 % CI 0.07, 0.84) and in bone mineral density in Ward's triangle (SMD -0.36, 95 % CI -0.71, -0.01), and a greater increase in HDL cholesterol levels (SMD 0.43, 95 % CI 0.08, 0.77) than tamoxifen. For advanced breast cancer patients, toremifene was associated with more vaginal bleeding (OR 0.45, 95 % CI 0.26, 0.80) and a greater decrease in serum triglyceride levels (SMD -1.15, 95 % CI -1.90, -0.39) than tamoxifen. Available evidence showed that toremifene could be an alternative option to tamoxifen for both early and advanced breast cancer patients. However, the methodological quality of the included studies was low. More rigorous RCTs are needed to confirm the results of this meta-analysis in the future.

Efficacy and toxicity of capecitabine-based chemotherapy in patients with metastatic or advanced breast cancer: results from ten randomized trials

OBJECTIVE

The efficacy and adverse effects of capecitabine-based chemotherapy versus other regimens reported in previous trials were discordant. The aim of the present study was to determine the efficacy and toxicity profiles of capecitabine-based chemotherapy versus capecitabine-free regimens in patients with metastatic and/or advanced breast cancer.

METHODS

Randomized trials in which capecitabine-based chemotherapy was compared with capecitabine-free chemotherapy were included by searching the PubMed database. Differences in efficacy and grade 3-4 toxicities between capecitabine-based chemotherapy and other chemotherapy were compared.

RESULTS

Ten randomized controlled trials were included in our meta-analysis. Compared to patients treated with capecitabine-free chemotherapy, patients treated with capecitabine-based chemotherapy did not have a significantly different complete response (odds ratio (OR): 1.25, 95% confidence interval (CI): 0.87-1.79, p = 0.231), partial response (OR: 1.16, 95% CI: 0.95-1.41, p = 0.147), and overall response (OR: 1.21, 95% CI: 1.00-1.47, p = 0.053). Compared to the capecitabine-free group, less hematological toxicity and more gastrointestinal toxicity occurred in patients treated with capecitabine-based chemotherapy, including neutropenia (OR: 0.34, 95% CI: 0.19-0.59, p <0.001), anemia (OR: 0.41, 95% CI: 0.20-0.85, p = 0.016), leukocytopenia (OR: 0.50, 95% CI: 0.32-0.78, p = 0.002), and diarrhea (OR: 2.35, 95% CI: 1.62-3.42, p < 0.001). Furthermore, patients in the capecitabine group exhibited a significantly higher rate of grade 3 hand-foot syndrome than the capecitabine-free group (OR: 25.16, 95% CI: 12.27-51.58, p < 0.001).

CONCLUSIONS

The present study suggests that capecitabine-based chemotherapy is as effective as capecitabine-free chemotherapy in patients with metastatic and/or advanced breast cancer with different toxicity profiles. Capecitabine-based chemotherapy may be better tolerated than capecitabine-free chemotherapy. Due to several limitations in our study, future large randomized trials are needed.

Insulin glargine and risk of cancer: a meta-analysis

AIMS

Recently, more and more attention has been drawn on the long-term effects of insulin glargine. Here we strived to estimate the association of cancer occurrence with the use of insulin glargine.

METHODS

We searched all the publications regarding the association between cancer occurrence and the use of insulin glargine using the US National Library of Medicine's PubMed database. Data were independently extracted and analyzed using random or fixed effects meta-analysis depending upon the degree of heterogeneity.

RESULTS

Seven cohort studies were included in the meta-analysis. Cancer occurrence had no significant difference in glargine-treated patients compared to patients treated with other insulins (RR=0.86, 95% CI=0.69-1.07, p=0.17, P(heterogeneity)<0.00001). In our subgroup analysis, glargine, compared to other insulins, did not increase the risk of breast cancer (RR=1.14, 95% CI=0.65-2.02, p=0.65, P(heterogeneity)=0.002), prostate cancer (RR=1.00, 95% CI=0.79-1.26, p=0.99, P(heterogeneity)=0.78), pancreatic cancer (RR=0.57, 95% CI=0.14-2.35, p=0.44, P(heterogeneity)=0.0002) and gastrointestinal cancer (RR=0.80, 95% CI=0.62-1.02, p=0.07, P(heterogeneity)=0.86).

CONCLUSIONS

This meta-analysis of open-label studies does not support an increased cancer risk in patients treated with insulin glargine. The result provides confidence for the development of insulin glargine, but needs confirmation by further clinical studies.

Estrogen and cancer

Estrogen exhibits a broad spectrum of physiological functions ranging from regulation of the menstrual cycle and reproduction to modulation of bone density, brain function, and cholesterol mobilization. Despite the beneficial actions of endogenous estrogen, sustained exposure to exogenous estrogen is a well-established risk factor for various cancers. We summarize our current understanding of the molecular mechanisms of estrogen signaling in normal and cancer cells and discuss the major challenges to existing antiestrogen therapies.

Phase III randomized trial of toremifene versus tamoxifen for Japanese postmenopausal patients with early breast cancer

BACKGROUND

Toremifene, a selective estrogen receptor modulator, is used as adjuvant therapy for postmenopausal patients with breast cancer in Japan. For Japanese patients, however, only limited data are available on the efficacy and safety profile of toremifene. To establish the long term efficacy and safety of toremifene for Japanese patients, we conducted a prospective, multicenter, randomized phase III trial comparing toremifene and tamoxifen.

PATIENTS AND METHODS

The subjects were postmenopausal Japanese patients who had undergone surgery for node-negative breast cancer. Toremifene or tamoxifen was administered for 2 years. The primary endpoint was demonstration of the non-inferiority of toremifene compared with tamoxifen in respect of 5-year survival. Secondary endpoints were cumulative overall survival, cumulative disease-free survival, effects on lipid profiles, and adverse events.

RESULTS

A total of 253 patients were enrolled. The baseline characteristics of the two treatment groups were well-balanced. Median follow-up was 66.5 months. Five-year survival was similar for toremifene and tamoxifen (97.0 vs. 96.9 %; 90 % confidence interval -3.9 to 4.1), indicating that toremifene is not inferior to tamoxifen for postmenopausal Japanese patients with early breast cancer. Cumulative overall survival and cumulative disease-free survival were also very similar for toremifene and tamoxifen (97.5 vs. 97.3 %, log-rank test P = 0.9458; 88.4 vs. 90.6 %, log-rank test P = 0.3359, respectively). Adverse events in both groups were similar and mostly mild or moderate. Thus, both are equally effective and well tolerated.

CONCLUSION

Our results suggest that the efficacy and safety of toremifene and tamoxifen are equivalent for postmenopausal Japanese patients with early breast cancer.

Toremifene versus tamoxifen for advanced breast cancer

BACKGROUND

Toremifene (TOR) and tamoxifen (TAM) can both be used as treatments for advanced breast cancer.

OBJECTIVES

To compare the efficacy and safety of TOR with TAM in patients with advanced breast cancer.

SEARCH METHODS

The Cochrane Breast Cancer Group's Specialised Register was searched (1 July 2011) using the codes for "toremifene", "fareston", "tamoxifen, "nolvadex, and "breast cancer". We also searched MEDLINE (via PubMed) (from inception to 1 July 2011), EMBASE (via Ovid) (from inception to 1 July 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 7, 2011), and the WHO International Clinical Trials Registry Platform search portal (1 July 2011). In addition, we screened the reference lists of relevant trials or reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the efficacy and safety, or both of TOR with TAM in women with advanced breast cancer. Trials that provided sufficient data on one of the following items: objective response rate (ORR), time to progression (TTP), overall survival (OS), and adverse events, were considered eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Studies were assessed for eligibility and quality. Two review authors independently extracted the following details: first author, publication year, country, years of follow-up, treatment arms, intention-to-treat (ITT) population size, menopausal status of patients, hormone receptor status, response criteria, efficacy and safety outcomes of TOR and TAM arms. Hazard ratios (HR) were derived for time-to-event outcomes, where possible, and response and adverse events were analysed as dichotomous variables. We used a fixed-effect model for meta-analysis unless there was significant between-study heterogeneity.

MAIN RESULTS

A total of 2061 patients from seven RCTs were included for final analysis, with 1226 patients in the TOR group and 835 patients in the TAM group. The ORR for the TOR group was 25.8% (316/1226) whereas, the ORR for the TAM group was 26.9% (225/835). The pooled risk ratio (RR) suggested that the ORRs were not statistically different between the two groups (RR 1.02, 95% confidence interval (CI) 0.88 to 1.18, P = 0.83). The median TTP was 6.1 months for the TOR group and 5.8 months for the TAM group. The median OS was 27.8 months for the TOR group and 27.6 months for the TAM group. There were no significant differences in TTP and OS between the two therapeutic groups (for TTP: HR 1.08, 95% CI 0.94 to 1.24; for OS: HR 1.02, 95% CI 0.86 to 1.20). The frequencies of most adverse events were also similar in the two groups, while headache seemed to occur less in the TOR group than in the TAM group (RR 0.14, 95% CI 0.03 to 0.74, P = 0.02). There was no significant heterogeneity between studies in most of the above meta-analyses. Sensitivity analysis did not alter the results.

AUTHORS' CONCLUSIONS

TOR and TAM are equally effective and the safety profile of the former is at least not worse than the latter in the first-line treatment of patients with advanced breast cancer. Thus, TOR may serve as a reasonable alternative to TAM when anti-oestrogens are applicable but TAM is not the preferred choice for some reason.

Low-grade endometrial stromal sarcoma developing in a postmenopausal woman under toremifene treatment for breast cancer

Low-grade endometrial stromal sarcoma (ESS) is a rare neoplasm that is generally estrogen-receptor- and progesterone-receptor-positive and develops in premenopausal women. Although tamoxifen treatment is associated with an increased risk of ESS, the effect of other selective estrogen receptor modulators, including toremifene, on the risk of ESS is not clear. A 61-year-old postmenopausal woman was treated with toremifene as an adjuvant therapy for breast cancer. A cystic mass developed during the treatment, with gradual growth in the uterine myometrium. The patient was treated with hysterectomy and bilateral salpingo-oophorectomy, and the tumor was diagnosed as low-grade ESS (stage IA) with estrogen-receptor and progesterone-receptor. The patient discontinued toremifene and has been progression-free for 21 months. Our data suggest that toremifene might be associated with the development of ESS in certain patients through its estrogen-like effects in the uterus.

Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis

Nipple discharge is a common complaint of patients with breast disease. The color of nipple discharge is always the first alarming symptom for patients. It is controversial whether the discharge color is an indicator of an underlying malignancy. The electronic database PubMed was searched for relevant articles. A meta-analysis about the association between the color of nipple discharge and breast cancer risk was conducted. Eight studies, including 3,110 patients, were eligible for this meta-analysis. Compared with patients in non-bloody nipple discharge group (179/1,478), patients in bloody nipple discharge group (404/1,632) had a markedly higher breast cancer risk (OR: 2.27, 95% CI: 1.32-3.89, P < 0.001 for heterogeneity). Compared with patients in clear/serous group (71/575), patients in bloody nipple discharge group (326/1,271) also had a higher risk (OR: 2.49, 95% CI: 1.25-4.93, P = 0.011 for heterogeneity). Furthermore, compared with patients in the colored group (55/448), patients in bloody nipple discharge group (296/1,124) (OR: 2.00, 95% CI: 0.74-5.45, P = 0.009 for heterogeneity) had no significant difference. Besides, there was no significant difference between patients in colored group (55/448) and clear/serous group (61/470) (OR: 1.35, 95% CI: 0.83-2.18, P = 0.707 for heterogeneity). Therefore, bloody nipple discharge could be a predictor of breast cancer risk among different colors of discharges. The symptom of bloody nipple discharge is helpful to the stratification of preoperative patients.

Innegligible musculoskeletal disorders caused by zoledronic acid in adjuvant breast cancer treatment: a meta-analysis

BACKGROUND

Zoledronic acid (ZOL) is widely used for preventing bone loss in early breast cancer patients. However, the adverse effects caused by ZOL itself should not be neglected. Musculoskeletal disorders were common after ZOL administration and distressing to the patients. Up to now, no precise estimation of musculoskeletal disorders has been made.

METHODS

Relevant randomized clinical trials were selected by searching the electronic database PubMed, and a meta-analysis was conducted.

RESULTS

Four trials reported musculoskeletal disorders of ZOL treatment versus no ZOL, including 2684 patients treated with ZOL and 2712 patients without ZOL treatment. Compared to patients without ZOL treatment, patients treated with ZOL had a significantly higher risk of arthralgia (risk ratio (RR): 1.162, 95% confidence interval (CI): 1.096-1.232, P = 0.466 for heterogeneity) and bone pain (RR: 1.257, 95% CI: 1.149-1.376, P = 0.193 for heterogeneity). Three clinical trials reported the complications of upfront versus delayed ZOL treatment, including 1091 patients with upfront ZOL and 1110 patients with delayed ZOL. The rate of bone pain in upfront group (119/824) was significantly higher than that in delayed group (74/836) (RR: 1.284, 95% CI: 1.135-1.453, P = 0.460 for heterogeneity).

CONCLUSIONS

Our meta-analysis suggested that treatment with ZOL was significantly associated to the occurrence of arthralgia and bone pain. Moreover, higher rate of bone pain was observed in patients treated with upfront ZOL compared with delayed ZOL treatment. More attentions should be paid to patients treated with ZOL, especially for immediate ZOL. For patients with low risk of osteoporosis, immediate ZOL may be not needed due to additional musculoskeletal disorders and little benefit. Or it can be stopped after the occurrence of these adverse events.