Aromatase inhibitor use, side effects and discontinuation rates in gynecologic oncology patients

Aromatase Inhibitor-Associated Distal Radioulnar Joint Instability and Tear of the Extensor Digiti Minimi: A Case Report

ABSTRACT

The addition of aromatase inhibitors has improved cancer-related outcomes in postmenopausal patients with estrogen receptor-positive breast cancer. However, aromatase inhibitor can be associated with a constellation of adverse musculoskeletal effects that comprises bone loss, arthralgia, myalgia, and tendinopathy. This medication complication, known as aromatase inhibitor-associated musculoskeletal syndrome, can limit treatment tolerability in many patients because of the high prevalence of aromatase inhibitor-associated musculoskeletal syndrome among those on aromatase inhibitor. The hand and wrist are the most affected joints in aromatase inhibitor-associated musculoskeletal syndrome, with patients presenting with symmetric arthralgia, stiffness, and tendinopathy. Radioulnar joint subluxation with extensor tendon tear has not been previously reported in patients with aromatase inhibitor-associated musculoskeletal syndrome. This is a case report of a 72-yr-old breast cancer survivor on an aromatase inhibitor presenting with chronic dominant wrist pain, weakness, and 5th digit finger drop. An extensor digitorum minimi tendon tear and radioulnar instability were identified using diagnostic musculoskeletal ultrasonography. This case illustrates the utility of in-office ultrasonography combined with dynamic examination for the often underrecognized pathology associated with aromatase inhibitor-associated musculoskeletal syndrome in breast cancer survivors.

New enantioenriched β-indolyl ketones as aromatase inhibitors: Unraveling heme-ligand interactions by MD simulation and MMPBSA analysis

A series of enantioenriched β-indolyl ketones as aromatase inhibitors (AI) is synthesized through the Michael-type Friedel-Crafts alkylation of indole. A highly efficient bifunctionalized amino catalyst is developed to access structurally diverse β-indolyl ketones in high yields (up to 91%) and excellent enantioselectivity (enantiomeric ratio up to 98:2). All the synthesized compounds demonstrated promising aromatase inhibitory potential, where ortho-substituted analogs (3c and 3e) were found most active with IC50 values of 0.68 and 0.90 µM, respectively. Both of these compounds exhibited significant cytotoxicity (IC50 = 0.34 and 0.37 µM) against the MCF-7 breast cancer cell line in the (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide) assay. Molecular docking studies of the synthesized compounds demonstrate favorable binding interactions with the estrogens controlling CYP19A1 (3EQM) and metabolizing CYP3A4 (5VCC) enzymes. Molecular dynamic (MD) simulation analysis revealed the essentiality of heme-ligand interactions to build a stable protein-ligand complex. An average root mean square deviation of 0.35 nm observed during a 100-ns MD simulation and binding free energy in the range of -190 to -227 kJ/mol calculated by g_mmpbsa analysis authenticated the stability of the 3c-3EQM complex. ADMET and drug-likeness parameters supported the suitability of these indole derivatives as the drug lead to develop potent inhibitors for estrogen-dependent breast cancer.

Aromatase inhibitors as a therapeutic strategy for male prolactinoma resistant to dopamine agonists: a retrospective cohort study and literature review

PURPOSE

To assess the effect of letrozole, an aromatase inhibitor (AI), in patients with resistant prolactinoma that presented an increase in serum prolactin (PRL) levels during testosterone replacement therapy (TRT).

METHODS

A retrospective cohort study in a single tertiary care center. From March 2012 to July 2023, 53 male patients over 18 years with prolactinoma were followed in our Neuroendocrine Unit. Of those, 90.6% presented macroadenomas, 41% of them were resistant to cabergoline and 25% presented persistent hypogonadism to whom TRT was indicated. Among them, five presented a significant increase in PRL levels and AI was initiated. All five patients had resistant prolactinomas. One of them was excluded due to tumor aggressiveness and concomitant use of temozolomide during AI therapy.

RESULTS

Four patients were included in the analysis, with a mean age of 28.5 (± 7.5) years, median prolactin of 1060 (600 to 6700) ng/mL and median of the largest tumor diameter of 3.6 (1.5 to 5) cm at the time of prolactinoma diagnosis. On TRT, all presented an increase in serum PRL levels (231 to 396%), with a subsequent decrease (61 to 93%) after adding AI. During AI treatment for a median time of 60.5 (21 to 120) months, tumor shrinkage was observed in two cases (-8 and -3 mm in the maximum diameter) and tumor stability in the other two. No major side effects occurred and AI was well tolerated.

CONCLUSION

AI might be an option for men with resistant prolactinoma who have an increase in PRL levels on TRT. Nevertheless, prospective randomized clinical trials are needed to ensure efficacy and security for this approach.

Polypharmacy, over-the-counter medications, and aromatase inhibitor adherence in early-stage breast cancer

PURPOSE

Polypharmacy is associated with negative health outcomes and decreased medication adherence. Polypharmacy is common in cancer populations, but few studies have evaluated the relationship between polypharmacy and aromatase inhibitor (AI) adherence. No studies have evaluated the relationship between over-the-counter (OTC) supplements and AI adherence. Our primary hypothesis was that polypharmacy would be associated with increased risk of premature AI discontinuation.

METHODS

This exploratory analysis used data from the Exemestane and Letrozole Pharmacogenetics (ELPh) trial, a prospective, multicenter, randomized controlled trial that enrolled participants from 2005 to 2009. Included patients were female, postmenopausal, with stage 0-III breast cancer, who had completed indicated chemotherapy, surgery, and radiation. Participants were randomized to adjuvant exemestane or letrozole and completed serial clinical examinations and questionnaires for two years. Concomitant medication data were collected prospectively. Cox proportion models were used for statistical analysis of the relationship between polypharmacy, OTCs, medication class, and AI adherence.

RESULTS

In the 490 analyzed participants, use of any prescription medications at baseline was associated with decreased risk of premature AI discontinuation (HR 0.56, p = 0.02). Use of selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs) at baseline was associated with decreased risk of premature AI discontinuation (HR 0.67, p = 0.04). Use of any OTCs was not associated with AI discontinuation.

CONCLUSION

Baseline use of prescription medications but not OTCs was associated with increased AI persistence. Future research is needed to understand how this can be utilized to promote AI adherence.

Dual aromatase-steroid sulfatase inhibitors (DASI's) for the treatment of breast cancer: a structure guided ligand based designing approach

Dual aromatase-steroid sulfatase inhibitors (DASIs) lead to significant deprivation of estrogen levels as compared to a single target inhibition and thereby exhibited an additive or synergistic effect in the treatment of hormone-dependent breast cancer (HDBC). Triazole-bearing DASI's having structural features of clinically available aromatase inhibitors are identified as lead structures for optimization as DASI's. To identify the spatial fingerprints of target-specific triazole as DASI's, we have performed molecular docking assisted Gaussian field-based comparative 3D-QSAR studies on a dataset with dual aromatase-STS inhibitory activities. Separate contours were generated for both aromatase and steroid sulphates showing respective pharmacophoric structural requirements for optimal activity. These developed 3D-QSAR models also showed good statistical measures with the excellent predictive ability with PLS-generated validation constraints. Comparative steric, electrostatic, hydrophobic, HBA, and HBD features were elucidated using respective contour maps for selective target-specific favourable activity. Furthermore, the molecular docking was used for elucidating the mode of binding as DASI's along with the MD simulation of 100 ns revealed that all the protease-ligand docked complexes are overall stable as compared to reference ligand (inhibitor ASD or Irosustat) complex. Further, the MM-GBSA study revealed that compound 24 binds to aromatase as well as STS active site with relatively lower binding energy than reference complex, respectively. A comparative study of these developed multitargeted QSAR models along with molecular docking and dynamics study can be employed for the optimization of drug candidates as DASI's.Communicated by Ramaswamy H. Sarma.

The impact of adjuvant antihormonal therapy versus observation on recurrence of borderline ovarian tumors: A retrospective cohort study

Objectives

Adjuvant management of borderline ovarian tumors (BOT) after surgical diagnosis and staging is not standardized. While many patients undergo observation alone, some providers have introduced the use of adjuvant antihormonal therapy for BOT, extrapolating from studies suggesting improvement in progression-free survival in the low-grade serous ovarian carcinoma population. We hypothesized that adjuvant antihormonal therapy after surgical diagnosis of BOT would improve progression-free survival compared to surveillance alone.

Methods

This is a retrospective review of BOT at one academic institution over thirteen years comparing management with antihormonal therapy, including aromatase inhibitors, progestins, and selective estrogen receptor modulators, to surveillance alone. Patients with concurrent malignancy were excluded. Data were abstracted from electronic medical records. Groups were compared by bivariate statistics.

Results

We identified 193 patients with BOT. Of these, 17 (8.8%) were treated with adjuvant antihormonal therapy and 24 (12.4%) recurred. Patients treated with antihormonal therapy were more likely to be obese (64.7% vs 37.9%, p = 0.032), have advanced-stage disease (70.6% vs 11.4%, p < 0.001), serous histotype (94.1% vs 59.4%, p = 0.005) or microinvasion (29.4% vs 9.7%, p = 0.030), and less likely to have undergone fertility-sparing surgery (18.8% vs 51.7%, p = 0.012). Use of antihormonal therapy was not associated with a difference in recurrence or survival.

Conclusions

This study is the first retrospective cohort review of adjuvant antihormonal therapy in BOT. We found that adjuvant antihormonal therapy for BOT is not associated with recurrence. While this single institution retrospective cohort study may lack the power to confirm or refute benefit, further studies could evaluate whether a subpopulation exists in whom antihormonal therapy is worthwhile.

Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis

Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.

The role of trust in the acceptance of adjuvant endocrine therapy in breast cancer patients

OBJECTIVE

Despite adjuvant endocrine therapy (AET) considerably reducing mortality and recurrence in hormonal receptor-positive (HR+) breast cancer (BC) patients, acceptance of AET remains an issue. The reasoning behind the lack of acceptance is complex and multifactorial, and some associated risk factors have been previously analyzed. Our study aims to assess women's beliefs and concerns toward AET and women's trust in the treating physician, focusing on determining the importance of these factors in the acceptance of AET.

METHODS

Out of n = 539, n = 269 women with HR + BC participated in a cross-sectional online survey. The main study variables were AET necessity beliefs and concerns (Beliefs about Medicines Questionnaire) and the trust in treating physicians. A binary hierarchical logistic regression was applied to predict AET acceptance.

RESULTS

We did not observe a meaningful mean difference in the necessity beliefs between women who accepted versus refused AET by the time of study conduct. Women with ongoing AET intake indicated significantly higher trust in their treating physician (d = 0.57) and have lower concerns (d = -1.65) regarding AET than women who had declined or discontinued AET prematurely. Results of the logistic regression demonstrated that after adjusting for clinical factors (e.g., prognosis, age), higher trust and lower concerns significantly increased the likelihood of accepting AET treatment.

CONCLUSIONS

Our results demonstrate the importance of discussing potential concerns regarding AET and establishing a trustful patient-physician relationship, which outweighs non-modifiable factors such as cancer prognosis.

Characterization of folic acid-functionalized PLA-PEG nanomicelle to deliver Letrozole: A nanoinformatics study

Effective cancer treatment is currently the number one challenge to human health. To date, several treatment methods have been introduced for cancer cell targeting. Among the proposed new methods for attacking cancer cells, nanotechnology has attracted much attention. Hence, various nanocarriers have been developed for targeted delivery of available drugs and improve their effectiveness against malignant cells. The PLA-PEG functionalised with folic acid (PLA-PEG-FA) is one of the nanocarriers with a limited range of applications for targeting cancer cells. In this investigation, different types of in-silico methods such as molecular docking approach, molecular dynamics simulation and free energy calculations are employed to characterise the carriers studied. The effectiveness of PLA-PEG-FA and PLA-PEG in delivering Letrozole as an aromatase inhibitor in cancer cells is examined. It is found that in the presence of folic acid, the stability and cell membrane permeability of nanomicelle are increased. Therefore, PLA-PEG-FA can be considered as a versatile carrier that can increase the effectiveness of aromatase inhibitors (such as Letrozole) and reduce their side effects.

Aromatase Inhibitor-Associated Musculoskeletal Syndrome: Understanding Mechanisms and Management

Aromatase inhibitors (AIs) are a key component in the chemoprevention and treatment of hormone receptor-positive (HR+) breast cancer. While the addition of AI therapy has improved cancer-related outcomes in the management of HR+ breast cancer, AIs are associated with musculoskeletal adverse effects known as the aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) that limit its tolerability and use. AIMSS is mainly comprised of AI-associated bone loss and arthralgias that affect up to half of women on AI therapy and detrimentally impact patient quality of life and treatment adherence. The pathophysiology of AIMSS is not fully understood though has been proposed to be related to estrogen deprivation within the musculoskeletal and nervous systems. This review aims to characterize the prevalence, risk factors, and clinical features of AIMSS, and explore the syndrome's underlying mechanisms and management strategies.