Does obesity interfere with anastrozole treatment? Positive association between body mass index and anastrozole plasma levels

Comparing long-term prognosis following different surgical methods in patients with early stage breast cancer and obesity: a retrospective cohort study in China

OBJECTIVE

Breast-conserving therapy (BCT) includes breast-conserving surgery (BCS) combined with radiation therapy (RT). RT plays a crucial role in improving the prognosis of patients who undergo BCS. However, obesity is a potential risk factor for resistance to radiation. The aim of this study was to evaluate any difference in the long-term prognosis of patients with early stage breast cancer and obesity treated with BCT or total mastectomy (TM).

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective cohort study involving 1125 patients diagnosed with early stage breast cancer and obesity at the Shanghai Cancer Center of Fudan University from 2013 to 2016.

OUTCOME MEASURES

Obesity in the Chinese population was defined as a body mass index ≥28 kg/m2. Surgical options included BCT and TM. The primary survival outcomes were overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS). Inverse probability of treatment weighting (IPTW) was used to control for the impact of confounding factors on prognosis.

RESULTS

The median follow-up times in the BCT group and TM group without postoperative RT were 51.1 months (IQR of 40.6-68.1 months) and 61.8 months (IQR of 46.5-76.7 months), respectively. After IPTW, the baseline data were balanced. Compared with those in the TM cohort, patients in the whole IPTW cohort in the BCT cohort had worse DFS (HR 4.280, 95% CI 2.180 to 8.400; p<0.001), RFS (HR 4.380, 95% CI 2.370 to 8.120; p<0.001) and OS (HR 3.590, 95% CI 1.620 to 7.950; p=0.002).

CONCLUSION

In patients with early stage breast cancer and obesity, TM is associated with better survival outcomes than BCT.

Dispersive liquid-liquid microextraction followed by sweeping micellar electrokinetic chromatography-tandem mass spectrometry for determination of six breast cancer drugs in human plasma

Herein, we have developed a novel method of aqueous-sample dispersive liquid-liquid microextraction (AqS-DLLME) followed by sweeping micellar electrokinetic chromatography-tandem mass spectrometry (MEKC-MS/MS) for simultaneous determination of breast cancer drugs letrozole, anastrozole, palbociclib, ribociclib, abemaciclib, and fulvestrant in human plasma. Coupling of MEKC to MS was possible due to the use of ammonium perfluorooctanoate (APFO) as a volatile surfactant. The MEKC and MS conditions were optimized to achieve a fast, sensitive, selective, and green analysis enabling full separation of the analytes within 16 min. Electrophoretic buffer was 125 mM APFO at apparent pH 10.5 in 32 % MeOH, while sheath liquid was 70 % MeOH with 0.2 % formic acid, delivered at 10 µL/min. Excellent extraction recoveries from plasma ranging from 89.4 to 104.9 % were obtained with a combination of protein precipitation and DLLME. The developed method was validated according to the ICH guidelines. Remarkable selectivity, accuracy (bias < 6.7 %), precision (RSD < 15.8 %), and stability (bias < 10.4 %) with insignificant matrix effect (RSD < 14.0 %) and no carry-over were obtained over a wide range of concentrations. Linearity with inter-day slope RSD lower than 8.7 % was demonstrated. With this method, very low concentrations could be detected after the injection of only 68.7 nL of the sample. The method was applied to plasma samples from six women currently receiving breast cancer treatment. Determined concentrations of the drugs of interest agreed with concentrations found in clinical studies, thus proving the suitability of the developed method for therapeutic drug monitoring as a superior alternative to published LC-MS methods.

Impact of sex hormones dysregulation and adiposity on the outcome of postmenopausal breast cancer patients

Epidemiological studies demonstrated that, in postmenopausal women, high circulating levels of testosterone, especially when associated with weight gain, positively correlated with an increased risk of breast cancer because of the augmented production of oestrogen via testosterone aromatization in the adipose tissue. Besides, growing evidence suggests that sulfatase can increase the tissue concentration of bioactive estradiol through the reconversion of estrone sulfate, thus providing a favourable milieu for epithelial cells expressing the oestrogen receptor. In this review, we will discuss how the "obesity-insulin-testosterone" connection and the abnormal production of bioactive oestrogen - as a result of the conversion of the androgens by aromatase and the estrone reconversion by sulfatase-, may affect the response to hormone therapy and the outcome of postmenopausal breast cancer patients, and how a combined therapy including metformin, anti-inflammatory drugs, and aromatase/sulfatase inhibitors could successfully improve patient's outcome.

Therapeutic Drug Monitoring of Oral Anti-Hormonal Drugs in Oncology

Oral anti-hormonal drugs are essential in the treatment of breast and prostate cancer. It is well known that the interpatient variability in pharmacokinetic exposure is high for these agents and exposure-response relationships exist for many oral anti-hormonal drugs. Yet, they are still administered at fixed doses. This could lead to underdosing and thus suboptimal efficacy in some patients, while other patients could be overdosed resulting in unnecessary side effects. Therapeutic drug monitoring (TDM), individualized dosing based on measured blood concentrations of the drug, could therefore be a valid option to further optimize treatment. In this review, we provide an overview of relevant clinical pharmacokinetic and pharmacodynamic characteristics of oral anti-hormonal drugs in oncology and translate these into practical guidelines for TDM. For some agents, TDM targets are not well established yet and as a reference the median pharmacokinetic exposure could be targeted (exemestane: minimum plasma concentration (C_min) 4.1 ng/mL and enzalutamide: C_min 11.4 mg/L). However, for most drugs, exposure-efficacy analyses could be translated into specific targets (abiraterone: C_min 8.4 ng/mL, anastrozole: C_min 34.2 ng/mL, and letrozole: C_min 85.6 ng/mL). Moreover, prospective clinical trials have shown TDM to be feasible for tamoxifen, for which the exposure-efficacy threshold of its active metabolite endoxifen is 5.97 ng/mL. Based on the available data, we therefore conclude that individualized dosing based on drug concentrations is feasible and promising for oral anti-hormonal drugs and should be developed further and implemented into clinical practice.

Anastrozole Aromatase Inhibitor Plasma Drug Concentration Genome-Wide Association Study: Functional Epistatic Interaction Between SLC38A7 and ALPPL2

Anastrozole is a widely prescribed aromatase inhibitor for the therapy of estrogen receptor positive (ER+) breast cancer. We performed a genome‐wide association study (GWAS) for plasma anastrozole concentrations in 687 postmenopausal women with ER+ breast cancer. The top single‐nucleotide polymorphism (SNP) signal mapped across SLC38A7 (rs11648166, P = 2.3E‐08), which we showed to encode an anastrozole influx transporter. The second most significant signal (rs28845026, P = 5.4E‐08) mapped near ALPPL2 and displayed epistasis with the SLC38A7 signal. Both of these SNPs were cis expression quantitative trait loci (eQTL)s for these genes, and patients homozygous for variant genotypes for both SNPs had the highest drug concentrations, the highest SLC38A7 expression, and the lowest ALPPL2 expression. In summary, our GWAS identified a novel gene encoding an anastrozole transporter, SLC38A7, as well as epistatic interaction between SNPs in that gene and SNPs near ALPPL2 that influenced both the expression of the transporter and anastrozole plasma concentrations.

Omega-3 fatty acid use for obese breast cancer patients with aromatase inhibitor-related arthralgia (SWOG S0927)

PURPOSE

Although aromatase inhibitors (AIs) prolong survival in post-menopausal breast cancer (BC) patients, AI-associated arthralgia can lead to discontinuation. Obese patients have higher rates of AI arthralgia than non-obese patients, but treatment options are limited. Omega-3 fatty acid (O3-FA) treatment for AI arthralgia has produced mixed results.

METHODS

We performed an exploratory analysis of SWOG S0927, a multicenter randomized placebo-controlled trial of O3-FA use for AI arthralgia. Post-menopausal women with stage I-III BC taking an AI were randomized to 24 weeks of O3-FAs or placebo. Brief Pain Inventory (BPI) questionnaires and fasting serum were collected at baseline, 12, and 24 weeks. The BPI assessment included worst pain, average pain, and pain interference scores (range 0-10).

RESULTS

Among the 249 participants, 139 had BMI < 30 kg/m² (56%) and 110 had BMI ≥ 30 kg/m² (44%). Among obese patients, O3-FA use was associated with significantly lower BPI worst pain scores at 24 weeks compared with placebo (4.36 vs. 5.70, p = 0.02), whereas among non-obese patients, there was no significant difference in scores between treatment arms (5.27 vs. 4.58, p = 0.28; interaction p = 0.05). Similarly, O3-FA use was associated with lower BPI average pain and pain interference scores at 24 weeks compared with placebo among obese patients, but no significant difference between treatment arms in non-obese patients (interaction p = 0.005 and p = 0.01, respectively).

CONCLUSIONS

In obese BC patients, O3-FA use was associated with significantly reduced AI arthralgia compared to placebo.

Plasma metabolic profiling analysis of Cortex Periplocae-induced cardiotoxicity based on UPLC/Q-TOF-MS

Cortex Periplocae is a well-known form of traditional medicine with its unique cardiotonic action, anti-tumor activity and immune regulation effect. However, improper use of Cortex Periplocae often leads to cardiac toxicity, which in the most severe cases can even be life-threatening. Biochemical tests and histopathological examinations are primary methods for clinical trials. However, such approaches are time-consuming, lack specificity and have low sensitivity, which can easily lead to negative results in studies. Therefore, a more scientific and systematic evaluation of Cortex Periplocae cardiotoxicity is particularly important. In this study, we established a method that combines metabonomics with trend analysis of a gavage concentration series to find cardiac toxicity biomarkers of Cortex Periplocae. We created rat cardiotoxicity models, in which the toxicity was caused by Cortex Periplocae. We collected data from rat plasma samples based on metabonomics using ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry (UPLC/Q-TOF-MS). Multiple statistical analyses, such as principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA), were used to examine metabolite profile changes in plasma samples to screen potential cardiotoxicity biomarkers and metabolic pathways. Compared with the control group, after 7 days administration, the pathological sections showed cardiac toxicity. Moreover, some metabolites in the body changed significantly. Receiver operating characteristic curve (ROC) analysis showed that there are 11 metabolites related with cardiac toxicity, which play a role in "phenylalanine, tyrosine and tryptophan biosynthesis"; "phenylalanine metabolism"; "valine, leucine and isoleucine biosynthesis"; "glycerophospholipid metabolism" as well as "pantothenate and CoA biosynthesis". These metabolites can better explain the cardiotoxicity mechanism of Cortex Periplocae and provide a scientific and systematic method to evaluate the cardiotoxicity of Cortex Periplocae.

Obesity and survival in the neoadjuvant breast cancer setting: role of tumor subtype in an ethnically diverse population

BACKGROUND

Obesity may negatively affect survival in breast cancer (BC), but studies are conflicting, and associations may vary by tumor subtypes and race/ethnicity groups.

METHODS

In a retrospective review, we identified 273 women with invasive BC administered Adriamycin/Taxane-based neoadjuvant chemotherapy from 2004 to 2016 with body mass index (BMI) data at diagnosis. Obesity was defined as BMI ≥30. Associations between obesity and event-free survival (EFS), using STEEP events, and overall survival (OS), using all-cause mortality, were assessed overall and stratified by tumor subtype [[Hormone Receptor Positive (HR+)/HER2-, HER2+, and Triple-Negative Breast Cancer (TNBC])] in our diverse population.

RESULTS

Median follow-up was 32.6 months (range 5.7-137.8 months). Overall, obesity was associated with worse EFS (HR 1.71, 95% CI 1.03-2.84, p = 0.04) and a trend towards worse OS (p = 0.13). In HR+/HER2- disease (n = 135), there was an interaction between obesity and hormonal therapy with respect to OS but not EFS. In those receiving tamoxifen (n = 33), obesity was associated with worse OS (HR 9.27, 95% CI 0.96-89.3, p = 0.05). In those receiving an aromatase inhibitor (n = 89), there was no association between obesity and OS. In TNBC (n = 44), obesity was associated with worse EFS (HR 2.62, 95% CI 1.03-6.66, p = 0.04) and a trend towards worse OS (p = 0.06). In HER2+ disease (n = 94), obesity was associated with a trend towards worse EFS (HR 3.37, 95% CI 0.97-11.72, p = 0.06) but not OS. Race/ethnicity was not associated with survival in any subtype, and there were no interactions with obesity on survival.

CONCLUSIONS

Obesity may negatively impact survival, with differences among tumor subtypes.

Can we use gonadotropin plasma concentration as surrogate marker for BMI-related incomplete estrogen suppression in breast cancer patients receiving anastrozole?

BACKGROUND

BMI has been suggested to impact on estrogenic activity in patients receiving anastrozole resulting in a reduced treatment efficacy in obese women. Current evidence in this regard is controversially discussed. Since estradiol is inversely correlated with gonadotropins it can be assumed that an impact of BMI is also reflected by gonadotropin plasma concentrations. We aim at investigating the impact of BMI on the hormonal state of breast cancer (BC) patients receiving anastrozole indicated by LH, FSH and SHBG as well as estradiol.

METHODS

We determined gonadotropin-, estradiol- and anastrozole- serum concentrations from postmenopausal, early stage breast cancer patients receiving upfront anastrozole within routine after care. Gonadotropin plasma concentrations were derived from the routine laboratory examination report. A liquid chromatography tandem mass spectrometry method was used for the measurement of anastrozole serum concentrations. BMI was assessed within the routine after-care check-up.

RESULTS

The overall sample comprised 135 BC patients with a mean age of 65.3 years. BMI was significantly correlated with LH, FSH and SHBG. This association was neither influenced by age nor by anastrozole serum concentrations according to the regression model. Despite aromatase inhibition 12% of patients had detectable estrogen levels in routine quantification.

CONCLUSION

Obese women have an altered hormonal situation compared to normally weight women under the same dose of anastrozole. Our study findings are a further indicator for the relevance of BMI in regard of anastrozole metabolism and possible estrogenic activity indicated by gonadotropin plasma level.

Polymorphisms in ABCB1 and CYP19A1 genes affect anastrozole plasma concentrations and clinical outcomes in postmenopausal breast cancer patients

AIMS

Anastrozole, an aromatase inhibitor widely used in breast cancer, has recently been indicated to be a P-glycoprotein (ABCB1) substrate. We have aimed to determine whether ABCB1 single-nucleotide polymorphisms (SNPs) can affect anastrozole plasma concentrations in these patients. In addition, we assessed the impact of SNPs in CYP19A1 and TCL1A on the development of arthralgia and cancer recurrence in our series.

METHODS

This study included 110 postmenopausal women with hormone receptor-positive breast cancer. Anastrozole plasma levels were determined by a liquid chromatography-electrospray ionization-quadrupole-time-of-flight mass spectrometry system. Patients were genotyped for SNPs in the ABCB1, TCL1A and CYP19A1 genes to search for associations with pharmacokinetic and pharmacodynamics parameters using logistic regression models.

RESULTS

Anastrozole concentrations showed an almost nine-fold interindividual variability (mean 26.95 ± 11.91 ng ml^-1 ). The ABCB1 2677-TT genotype was associated with higher plasma levels (32.22 ± 12.82 vs. 25.86 ± 11.56 ng ml^-1 for GG/GT subjects; 95% confidence interval: -12.3 to -0.40), whilst the 3435-TT genotype showed a protective effect on the risk of arthralgia (odds ratio = 0.32 [0.11-0.89]; P = 0.029). The CYP19A1 rs1008805 GG genotype was strongly and inversely associated with arthralgia (odds ratio = 0.24 [0.09-0.65], P = 0.004); however, SNPs near the TCL1A gene were not linked to this adverse effect. None of the patients who had cancer recurrence harboured the CYP19A1 rs727479 AA genotype, which, in contrast, was present in 38% of patients who did not relapse (P for trend = 0.031).

CONCLUSION

Our findings indicate that variability in anastrozole plasma levels may be attributable to the status of the ABCB1 gene locus. Furthermore, genetic variants in CYP19A1 were associated with arthralgia and cancer recurrence in our patients.

Body mass index and aromatase inhibitors: a step forward in individualizing therapy for breast cancer patients?

INTRODUCTION

Progress made in breast cancer management along with treatment-related symptoms has drawn a lot of attention from both scientists and clinicians. Establishing predictive factors for treatment response facilitate tailoring of therapy to each individual patient and leads to a reduction in unnecessary treatments. Body mass index is confirmed to be a risk factor for breast cancer development as well as for disease recurrence, which additionally negatively influence the overall survival. Due to the increased level of fatty tissue in obese and overweight patients, their total level of body aromatase is elevated. This lead to the hypothesis about a worse response to aromatase inhibitors in these groups as compared to normal weight patients, due to incomplete aromatase blockage and thus higher peripheral androgen aromatization.

AREAS COVERED

This review aims to summarize the data from clinical trials assessing the effect of BMI on response to AI-based therapy in the setting of breast cancer. Expert commentary: Our conclusion made on the data available to date does not exclude BMI from the list of potential predictive factors however further research in this area is warranted.

Screening and validation for plasma biomarkers of nephrotoxicity based on metabolomics in male rats

Currently, drug-induced nephrotoxicity is widespread and seriously affects human health. However, the conventional indexes of renal function lack sensitivity, leading to a delay in the detection of nephrotoxicity. Therefore, we need to identify more sensitive indexes for evaluating nephrotoxicity. In this study, we used gentamicin (100 mg kg-1), etimicin (100 mg kg-1) and amphotericin B (4 mg kg-1) to establish renal injury models in rats, and we collected information using ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry in the screening stage. Thirteen nephrotoxicity metabolites were selected after multivariate statistical and integration analyses. Then, we conducted trend analysis to select 5 nephrotoxicity biomarkers [thymidine, LysoPC(16:1), LysoPC(18:4), LysoPC(20:5), and LysoPC(22:5)] whose content changed consistently at different timepoints after drug administration. To verify the sensitivity and specificity of these biomarkers for nephrotoxicity, receiver operating characteristic (ROC) and support vector machine (SVM) analyses were applied. The area under the curve of the 5 biomarkers were 0.806-0.901 at the 95% confidence interval according to the ROC analysis. We used the SVM classified model to verify these biomarkers, and the prediction rate was 95.83%. Therefore, the 5 biomarkers have strong sensitivity and high accuracy; these biomarkers are more sensitive indexes for evaluating renal function to identify nephrotoxicity and initiate prompt treatment.