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Fasching PA, Hack CC, Nabieva N, Maass N, Aktas B, Kümmel S, Thomssen C, Wolf C, Kolberg HC, Brucker C, Janni W, Dall P, Schneeweiss A, Marme F, Sütterlin MW, Ruebner M, Theuser AK, Kellner S, Hofmann NM, Böhm S, Almstedt K, Lück HJ, Schmatloch S, Kalder M, Uleer C, Jurhasz-Böss I, Hanf V, Jackisch C, Müller V, Rack B, Belleville E, Wallwiener D, Rody A, Rauh C, Bayer CM, Uhrig S, Goossens C, Huebner H, Brucker SY, Hein A, Fehm TN, Häberle L. Prognostic impact of selection criteria of current adjuvant endocrine therapy trials NATALEE and monarchE in postmenopausal HRpos/HER2neg breast cancer patients treated with upfront letrozole. Eur J Cancer 2024; 209:114239. [PMID: 39059184 DOI: 10.1016/j.ejca.2024.114239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/02/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The monarchE and NATALEE trials demonstrated the benefit of CDK4/6 inhibitor (CDK4/6i) therapy in adjuvant breast cancer (BC) treatment. Patient selection, based on clinical characteristics, delineated those at high (monarchE) and high/intermediate recurrence risk (NATALEE). This study employed a historical patient cohort to describe the proportion and prognosis of patients eligible for adjuvant CDK4/6i trials. METHODS Between 2009 and 2011, 3529 patients were enrolled in the adjuvant PreFace clinical trial (NCT01908556). Eligibility criteria included postmenopausal patients with hormone receptor-positive (HRpos) BC for whom a five-year upfront therapy with letrozole was indicated. Patients were categorized into prognostic groups according to monarchE and NATALEE inclusion criteria, and their invasive disease-free survival (iDFS) and overall survival (OS) were assessed. RESULTS Among 2891 HRpos patients, 384 (13.3 %) met the primary monarchE inclusion criteria. The majority (n = 261) qualified due to having ≥ 4 positive lymph nodes. For NATALEE, 915 out of 2886 patients (31.7 %) met the eligibility criteria, with 126 patients (13.7 %) being node-negative. Patients from monarchE with ≥ 4 positive lymph nodes and NATALEE with stage III BC exhibited the poorest prognosis (3-year iDFS rate 0.87). Patients ineligible for the trials demonstrated prognoses similar to the most favorable patient groups within the eligibility criteria. CONCLUSION Patient populations eligible for monarchE and NATALEE trials differed. Nearly a third of the postmenopausal HRpos population, previously under upfront letrozole treatment, met the NATALEE prognostic eligibility criteria. As certain eligible groups had a prognosis similar to non-eligible patients, it might be interesting to explore additional patient groups for CDK4/6i therapy.
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Affiliation(s)
- Peter A Fasching
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Carolin C Hack
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Naiba Nabieva
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bahriye Aktas
- Department of Gynecology, University Hospital Leipzig, Leipzig, Germany
| | - Sherko Kümmel
- Interdisziplinäres Brustzentrum an den Kliniken Essen-Mitte, Essen, Germany
| | - Christoph Thomssen
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | - Cosima Brucker
- Department of Gynecology and Obstetrics, University Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Peter Dall
- Department of Obstetrics and Gynecology, Municipal Clinical Center, Lüneburg, Germany
| | - Andreas Schneeweiss
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Frederik Marme
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc W Sütterlin
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Ruebner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Sara Kellner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Sybille Böhm
- Institut für Frauengesundheit GmbH, Erlangen, Germany
| | - Katrin Almstedt
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; Department of Obstetrics and Gynecology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | | | | | - Matthias Kalder
- Department of Gynecology and Obstetrics, University Hospital Gießen and Marburg, Marburg, Germany
| | - Christoph Uleer
- Gyn.-onkologische Gemeinschaftspraxis Hildesheim, Hildesheim, Germany
| | - Ingolf Jurhasz-Böss
- Department of Obstetrics and Gynecology, Freiburg University Hospital, Freiburg, Germany
| | - Volker Hanf
- Frauenklinik, Klinikum Fürth, Fürth, Germany
| | | | - Volkmar Müller
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Brigitte Rack
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | | | - Diethelm Wallwiener
- Department of Obstetrics and Gynecology, University of Tuebingen, Tuebingen, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Rauh
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; Department of Gynecology, University Hospital Inselspital Bern, Bern, Switzerland
| | - Christian M Bayer
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; WMC HEALTHCARE GmbH, München, Germany
| | - Sabrina Uhrig
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Chloë Goossens
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hanna Huebner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sara Y Brucker
- Department of Obstetrics and Gynecology, University of Tuebingen, Tuebingen, Germany
| | - Alexander Hein
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Tanja N Fehm
- Department of Gynecology and Obstetrics, University Hospital Düsseldorf, Düsseldorf, Germany; Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf, Düsseldorf, Germany
| | - Lothar Häberle
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; Biostatistics Unit, Erlangen University Hospital, Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Germany
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Douglas E, Levine B, Ansari A, Ansley K, Melin S, Park CJ, Richardson K, Hatcher S, D'Agostino RB, Jordan JH, Thomas A. Impact of Anti-Estrogen Therapy on Early Cardiovascular Referrals, Tests and Medications in Premenopausal Women with Operable Breast Cancer. Clin Breast Cancer 2024; 24:e289-e296. [PMID: 38458842 PMCID: PMC11162933 DOI: 10.1016/j.clbc.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/11/2024] [Accepted: 02/11/2024] [Indexed: 03/10/2024]
Abstract
INTRODUCTION Premenopausal women with high-risk hormone receptor (HR)-positive breast cancer often receive ovarian function suppression (OFS) and anti-estrogen therapy which induces near complete estrogen deprivation (NCED). This treatment improves recurrence-free survival but may increase cardiovascular risk. We sought to identify patterns of cardiovascular care and outcomes in premenopausal women with operable breast cancer. METHODS Premenopausal women ≤ 50 years of age with stage I-III HR-positive or triple negative breast cancer (TNBC) were identified by retrospective review. We categorized women into 3 groups based on anti-estrogen therapy approach: NCED (HR + OFS), anti-estrogen therapy without OFS (HRnoOFS), and no anti-estrogen therapy (TNBC). Baseline characteristics, post-diagnosis cardiovascular events and cardiovascular actions (tests, referrals and medications) were recorded. Categorical variables were compared among the groups using chi-square and Fisher's exact tests; continuous outcomes were compared using ANOVA. RESULTS 82, 83, and 52 women were identified in the HR + OFS, HRnoOFS, and TNBC groups respectively; mean follow-up was 5.0 years. Mean number of cardiovascular actions per year were highest in the HR + OFS group compared with HRnoOFS and TNBC groups (0.35 vs. 0.20 and 0.27, respectively; P = .036). The HR + OFS group had significantly more referrals and tests per year than the other groups. Cardiovascular medication initiation did not differ among groups. CONCLUSIONS In this early follow-up period, there were meaningful numbers of cardiovascular actions, with women on NCED experiencing the most per year. Future work should seek to further understand the impact of anti-estrogen therapy on the cardiovascular health of premenopausal women and test strategies to mitigate cardiotoxicity.
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Affiliation(s)
- Emily Douglas
- Section on Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Beverly Levine
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ahmer Ansari
- Section on Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Katherine Ansley
- Section on Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Susan Melin
- Section on Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Carolyn J Park
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Karl Richardson
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Sarah Hatcher
- Division of Medical Oncology, Department of Internal Medicine, Duke University, Durham, NC, USA; Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Ralph B D'Agostino
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jennifer H Jordan
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA; Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Alexandra Thomas
- Division of Medical Oncology, Department of Internal Medicine, Duke University, Durham, NC, USA; Duke Cancer Institute, Duke University, Durham, NC, USA.
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Taguchi T, Matsushima H, Kodama S, Okubo N, Ito T, Ludwikowska M, Fukumoto S, Matsumoto T. Osteoporotic fracture risk in women with breast cancer treated with aromatase inhibitors: a health insurance claims database study in Japan. Expert Opin Pharmacother 2024; 25:325-334. [PMID: 38588537 DOI: 10.1080/14656566.2024.2340712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hormone therapy with aromatase inhibitors (AIs) for estrogen receptor-dependent breast cancer may expose patients to an increased osteoporosis risk. This study was performed to estimate fracture risk in women with breast cancer to whom AIs were prescribed in Japan. METHODS This retrospective study used data from the Japanese Medical Data Vision database. Women with breast cancer prescribed AIs over a 12-month period were identified and matched to women not prescribed AIs using a propensity score. Fracture rates were estimated by a cumulative incidence function and compared using a cause-specific Cox hazard model. The proportion of women undergoing bone density tests was retrieved. RESULTS For all fractures sites combined, cumulative fracture incidence at 10 years was 0.19 [95%CI: 0.16-0.22] in women prescribed AIs and 0.18 [95%CI: 0.15-0.21] without AIs. AI prescription was not associated with any changes in risk (adjusted hazard ratio: 1.08 [95%CI: 0.99-1.17] p = 0.08). Women prescribed AI more frequently underwent bone density testing (31.9% [95% CI: 31.2%; 32.6%] versus 2.2% [95% CI: 2.0%; 2.4%]). CONCLUSIONS The anticipated association between AI exposure and osteoporotic fracture risk in Japanese women with breast cancer was not seen clearly.
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Affiliation(s)
- Tetsuya Taguchi
- Division of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Sho Kodama
- Primary Medical Science Department, Medical Affairs Division, Japan Business Unit, Daiichi Sankyo Co., Ltd ., Tokyo, Japan
| | - Naoki Okubo
- Data Intelligence Department, Global DX, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Tetsuo Ito
- Primary Medical Science Department, Medical Affairs Division, Japan Business Unit, Daiichi Sankyo Co., Ltd ., Tokyo, Japan
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Hack CC, Maass N, Aktas B, Kümmel S, Thomssen C, Wolf C, Kolberg HC, Brucker C, Janni W, Dall P, Schneeweiss A, Marme F, Ruebner M, Theuser AK, Hofmann NM, Böhm S, Almstedt K, Kellner S, Nabieva N, Gass P, Sütterlin MW, Lück HJ, Schmatloch S, Kalder M, Uleer C, Juhasz-Böss I, Hanf V, Jackisch C, Müller V, Rack B, Belleville E, Wallwiener D, Rody A, Rauh C, Bayer CM, Uhrig S, Goossens C, Huebner H, Brucker SY, Häberle L, Fehm TN, Hein A, Fasching PA. Long-term Follow-up and Safety of Patients after an Upfront Therapy with Letrozole for Early Breast Cancer in Routine Clinical Care - The PreFace Study. Geburtshilfe Frauenheilkd 2024; 84:185-195. [PMID: 38344045 PMCID: PMC10853028 DOI: 10.1055/a-2238-3153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/21/2023] [Indexed: 05/02/2024] Open
Abstract
Introduction Adjuvant treatment of patients with early-stage breast cancer (BC) should include an aromatase inhibitor (AI). Especially patients with a high recurrence risk might benefit from an upfront therapy with an AI for a minimum of five years. Nevertheless, not much is known about the patient selection for this population in clinical practice. Therefore, this study analyzed the prognosis and patient characteristics of postmenopausal patients selected for a five-year upfront letrozole therapy. Patients and Methods From 2009 to 2011, 3529 patients were enrolled into the adjuvant phase IV PreFace clinical trial (NCT01908556). Postmenopausal hormone receptor-positive BC patients, for whom an upfront five-year therapy with letrozole (2.5 mg/day) was indicated, were eligible. Disease-free survival (DFS), overall survival (OS) and safety in relation to patient and tumor characteristics were assessed. Results 3297 patients started letrozole therapy. The majority of patients (n = 1639, 57%) completed the five-year treatment. 34.5% of patients continued with endocrine therapy after the mandated five-year endocrine treatment. Five-year DFS rates were 89% (95% CI: 88-90%) and five-year OS rates were 95% (95% CI: 94-96%). In subgroup analyses, DFS rates were 83%, 84% and 78% for patients with node-positive disease, G3 tumor grading, and pT3 tumors respectively. The main adverse events (any grade) were pain and hot flushes (66.8% and 18.3% of patients). Conclusions The risk profile of postmenopausal BC patients selected for a five-year upfront letrozole therapy showed a moderate recurrence and death risk. However, in subgroups with unfavorable risk factors, prognosis warrants an improvement, which might be achieved with novel targeted therapies.
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Affiliation(s)
- Carolin C. Hack
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bahriye Aktas
- Department of Gynecology, University Hospital Leipzig, Leipzig, Germany
| | - Sherko Kümmel
- Interdisziplinäres Brustzentrum an den Kliniken Essen-Mitte, Essen, Germany
| | - Christoph Thomssen
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | - Cosima Brucker
- Department of Gynecology and Obstetrics, University Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Peter Dall
- Department of Obstetrics and Gynecology, Municipal Clinical Center, Lüneburg, Germany
| | - Andreas Schneeweiss
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Frederik Marme
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Ruebner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Sybille Böhm
- Institut für Frauengesundheit GmbH, Erlangen, Germany
| | - Katrin Almstedt
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Obstetrics and Gynecology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Sara Kellner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Naiba Nabieva
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Paul Gass
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Marc W. Sütterlin
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | | | - Matthias Kalder
- Department of Gynecology and Obstetrics, University Hospital Gießen and Marburg, Marburg, Germany
| | - Christoph Uleer
- Gyn.-onkologische Gemeinschaftspraxis Hildesheim, Hildesheim, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Freiburg University Hospital, Freiburg, Germany
| | - Volker Hanf
- Frauenklinik, Klinikum Fürth, Fürth, Germany
| | | | - Volkmar Müller
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Brigitte Rack
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | | | - Diethelm Wallwiener
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Rauh
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Gynecology, University Hospital Inselspital Bern, Bern, Switzerland
| | - Christian M. Bayer
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- WMC HEALTHCARE GmbH, München, Germany
| | - Sabrina Uhrig
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Chloë Goossens
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hanna Huebner
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sara Y. Brucker
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Lothar Häberle
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Biostatistics Unit, Erlangen University Hospital, Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Tanja N. Fehm
- Department of Gynecology and Obstetrics, University Hospital Düsseldorf, Düsseldorf, Germany
- Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf, Düsseldorf, Germany
| | - Alexander Hein
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Peter A. Fasching
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Wadasadawala T, Joshi S, Rath S, Popat P, Sahay A, Gulia S, Bhargava P, Krishnamurthy R, Hoysal D, Shah J, Engineer M, Bajpai J, Kothari B, Pathak R, Jaiswal D, Desai S, Shet T, Patil A, Pai T, Haria P, Katdare A, Chauhan S, Siddique S, Vanmali V, Hawaldar R, Gupta S, Sarin R, Badwe R. Tata Memorial Centre Evidence Based Management of Breast cancer. Indian J Cancer 2024; 61:S52-S79. [PMID: 38424682 DOI: 10.4103/ijc.ijc_55_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT The incidence of breast cancer is increasing rapidly in urban India due to the changing lifestyle and exposure to risk factors. Diagnosis at an advanced stage and in younger women are the most concerning issues of breast cancer in India. Lack of awareness and social taboos related to cancer diagnosis make women feel hesitant to seek timely medical advice. As almost half of women develop breast cancer at an age younger than 50 years, breast cancer diagnosis poses a huge financial burden on the household and impacts the entire family. Moreover, inaccessibility, unaffordability, and high out-of-pocket expenditure make this situation grimmer. Women find it difficult to get quality cancer care closer to their homes and end up traveling long distances for seeking treatment. Significant differences in the cancer epidemiology compared to the west make the adoption of western breast cancer management guidelines challenging for Indian women. In this article, we intend to provide a comprehensive review of the management of breast cancer from diagnosis to treatment for both early and advanced stages from the perspective of low-middle-income countries. Starting with a brief introduction to epidemiology and guidelines for diagnostic modalities (imaging and pathology), treatment has been discussed for early breast cancer (EBC), locally advanced, and MBC. In-depth information on loco-regional and systemic therapy has been provided focusing on standard treatment protocols as well as scenarios where treatment can be de-escalated or escalated.
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Affiliation(s)
- Tabassum Wadasadawala
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Shalaka Joshi
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sushmita Rath
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Palak Popat
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Ayushi Sahay
- Department of Pathology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Seema Gulia
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Prabhat Bhargava
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Revathy Krishnamurthy
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Dileep Hoysal
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jessicka Shah
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Mitchelle Engineer
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Bhavika Kothari
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Rima Pathak
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Dushyant Jaiswal
- Department of Plastic Surgery, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sangeeta Desai
- Department of Pathology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Tanuja Shet
- Department of Pathology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Asawari Patil
- Department of Pathology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Trupti Pai
- Department of Pathology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Purvi Haria
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Aparna Katdare
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sonal Chauhan
- Department of Radiology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Shabina Siddique
- Department of Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Vaibhav Vanmali
- Department of Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Rohini Hawaldar
- Department of Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Rajiv Sarin
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Rajendra Badwe
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Zagami P, Trapani D, Nicolò E, Corti C, Valenza C, Criscitiello C, Curigliano G, Carey LA. Cardiotoxicity of Agents Used in Patients With Breast Cancer. JCO Oncol Pract 2024; 20:38-46. [PMID: 37983586 PMCID: PMC10827297 DOI: 10.1200/op.23.00494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 11/22/2023] Open
Abstract
Cancer and cardiovascular diseases are the two major causes of mortality, morbidity, and disability worldwide. The improvement in effective therapeutic options for the management of breast cancer (BC) has led to an increased number of BC survivors, who can experience long-term toxicities from cancer treatments. Adverse events including cardiovascular toxicities must be considered in light of effectiveness of recently approved drugs for BC treatment, including elacestrant, tucatinib, neratinib, olaparib, the immune checkpoint inhibitors, trastuzumab deruxtecan, or sacituzumab govitecan. Many cancer drugs affect the cardiovascular system with a range of clinical manifestations. Prompt diagnosis and treatment as well as a multidisciplinary approach involving a cardio-oncologist is optimal for management of these cardiovascular events.
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Affiliation(s)
- Paola Zagami
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Dario Trapani
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Eleonora Nicolò
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Chiara Corti
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Carmine Valenza
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Carmen Criscitiello
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Curigliano
- Department of Oncology and Hematology, University of Milano, Milan, Italy
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Lisa Anne Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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7
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Thomas A, O'Connell NS, Douglas E, Hatcher S, Park CJ, Dent S, Ansley K, Klem I, Bansal R, Westbrook K, Hundley WG, Bottinor W, Hackney MH, Richardson KM, Sirkisoon SR, D'Agostino RB, Jordan JH. Cardiovascular impact of near complete estrogen deprivation in premenopausal women with breast cancer: The CROWN study. Am Heart J 2024; 267:33-43. [PMID: 37890547 PMCID: PMC10976295 DOI: 10.1016/j.ahj.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/18/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023]
Abstract
Survival with operable breast cancer has improved markedly in recent decades, however, treatment-related cardiovascular toxicities threaten to offset these gains. Ovarian function suppression paired with aromatase inhibition, for premenopausal women with hormone receptor (HR)-positive breast cancer, is a newer widely adopted therapy with the potential for significant long-term cardiovascular toxicity. Abrupt estrogen deprivation for non-cancer reasons is associated with accelerated coronary artery disease. Women with breast cancer treated with aromatase inhibition in addition to ovarian function suppression experience a dual hit with regards to estrogen exposure. The CaRdiac Outcomes With Near-complete estrogen deprivation (CROWN) study seeks to understand the early, subclinical natural history of cardiovascular compromise in young women undergoing near-complete estrogen deprivation (NCED) therapy. It is critical to understand the early subclinical development of cardiovascular disease to identify a window for therapeutic intervention before overt cardiovascular events occur. This three-site regional study (Atrium Health Wake Forest, Duke, and Virginia Commonwealth University) uses serial stress cardiac magnetic resonance (CMR) imaging and cardiac computed tomography angiography (CCTA) obtained during the initial two years of NCED therapy to study myocardial prefusion reserve (MPR), large cardiovascular vessel changes, left ventricular function, and other cardiovascular parameters. The CROWN cohort will consist of 90 premenopausal women with breast cancer, 67 with HR-positive disease receiving NCED and 23 comparators with HR-negative disease. Participants will undergo three annual CMR scans and 2 CCTA scans during the 2-year study period. After initial activation hurdles, accrual has been brisk, and the study is expected to complete accrual in December 2024. Efforts are in place to encourage participant retention with the study primary outcome, change in MPR between the two groups, to be reported in 2026 to 2027. The results of this study will enable premenopausal women with breast cancer to balance the health burdens of cancer at a young age and treatment-related cardiovascular morbidity. Finally, the tools developed here can be utilized to study cardiovascular risk across a range of cancer types and cancer therapies with the ultimate goals of both developing generalizable risk stratification tools as well as validating interventions which prevent overt cardiovascular compromise.
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Affiliation(s)
- Alexandra Thomas
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Emily Douglas
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Sarah Hatcher
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Carolyn J Park
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC
| | - Katherine Ansley
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC
| | - Rani Bansal
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC
| | - Kelly Westbrook
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC
| | - W Gregory Hundley
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Wendy Bottinor
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Mary Helen Hackney
- Division of Hematology, Oncology and Palliative Care, Massey Comprehensive Cancer Center, Virginia Commonwealth University, Richmond, VA
| | - Karl M Richardson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sherona R Sirkisoon
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Ralph B D'Agostino
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Jennifer H Jordan
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA; Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA.
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Generali D, Berardi R, Caruso M, Cazzaniga M, Garrone O, Minchella I, Paris I, Pinto C, De Placido S. Aromatase inhibitors: the journey from the state of the art to clinical open questions. Front Oncol 2023; 13:1249160. [PMID: 38188305 PMCID: PMC10770835 DOI: 10.3389/fonc.2023.1249160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
Breast cancer is a major cause of death among females. Great advances have been made in treating this disease, and aromatase inhibitors (AIs) have been recognized as the cornerstone. They are characterized by high efficacy and low toxicity. The authors reviewed the available literature and defined state-of-the-art AI management. This study was designed to assist clinicians in addressing the need to equally weigh patients' needs and disease control rates in their everyday clinical practice. Today, AIs play a central role in the treatment of hormone receptor-positive breast cancer. In this study, an expert panel reviewed the literature on the use of AIs, discussing the evolution of their use in various aspects of breast cancer, from pre- and postmenopausal early breast cancer to metastatic breast cancer, along with their management regarding efficacy and toxicity. Given the brilliant results that have been achieved in improving survival in everyday clinical practice, clinicians need to address their concerns about therapy duration and the adverse effects they exert on bone health, the cardiovascular system, and metabolism. Currently, in addition to cancer treatment, patient engagement is crucial for improving adherence to therapy and supporting patients' quality of life, especially in a selected subset of patients, such as those receiving an extended adjuvant or combination with targeted therapies. A description of modern technologies that contribute to this important goal is provided.
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Affiliation(s)
- Daniele Generali
- Breast Cancer Unit, Azienda Socio Sanitaria Territoriale di Cremona, Cremona, Italy
- Department of Medical, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Rossana Berardi
- Medical Oncology, Azienda Ospedaliera Universitaria (AOU) delle Marche, University Politecnica delle Marche, Ancona, Italy
| | - Michele Caruso
- Humanitas Istituto Clinico Catanese, Breast Centre Humanitas Catania, Catania, Italy
| | - Marina Cazzaniga
- School of Medicine and Surgery University of Milano Bicocca, Milan, Italy
- Phase 1 Research Unit, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - Ornella Garrone
- Medical Oncology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Minchella
- Division of Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Ida Paris
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Comprehensive Cancer Centre, Azienda Unità Sanitaria Locale - Istituto di Ricerca e Cura a Carattere Scientifico (AUSL-IRCCS) di Reggio Emilia, Reggio Emilia, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Pandey S, Kalaria A, Jhaveri KD, Herrmann SM, Kim AS. Management of hypertension in patients with cancer: challenges and considerations. Clin Kidney J 2023; 16:2336-2348. [PMID: 38046043 PMCID: PMC10689173 DOI: 10.1093/ckj/sfad195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 12/05/2023] Open
Abstract
The survival rates of many cancers have significantly improved due to recent advancements in cancer screening and therapeutics. Although better cancer outcomes are encouraging, additional health challenges have surfaced, the utmost of which is the burden imposed by various cardiovascular and renal toxicities of anticancer therapies. To improve the overall outcome of patients with cancer, it is essential to understand and manage these treatment-related adverse effects. The cardiovascular side effects of antineoplastic therapies are well-known and include left ventricular dysfunction, heart failure, myocardial ischaemia, QT prolongation, arrhythmia and hypertension. Among these, hypertension is the most common complication, prevalent in about 40% of all cancer patients, yet frequently overlooked and undertreated. This review explores the intricate connection between cancer and hypertension and provides distinct approaches to diagnosing, monitoring and managing hypertension in patients with cancer. We also outline the challenges and considerations that are relevant to the care of patients receiving anticancer drugs with prohypertensive potential.
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Affiliation(s)
- Shubhi Pandey
- Department of Internal Medicine, Calhoun Cardiology Center, University of Connecticut Health, Farmington, CT, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Amar Kalaria
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Agnes S Kim
- Department of Internal Medicine, Calhoun Cardiology Center, University of Connecticut Health, Farmington, CT, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
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10
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Uhelski ACR, Blackford AL, Sheng JY, Snyder C, Lehman J, Visvanathan K, Lim D, Stearns V, Smith KL. Factors associated with weight gain in pre- and post-menopausal women receiving adjuvant endocrine therapy for breast cancer. J Cancer Surviv 2023:10.1007/s11764-023-01408-y. [PMID: 37261654 DOI: 10.1007/s11764-023-01408-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Weight gain after breast cancer poses health risks. We aimed to identify factors associated with weight gain during adjuvant endocrine therapy (AET). METHODS Women initiating AET enrolled in a prospective cohort. Participants completed FACT-ES plus PROMIS pain interference, depression, anxiety, fatigue, sleep disturbance and physical function measures at baseline, 3, 6, 12, 24, 36, 48 and 60 months. Treatment-emergent symptoms were defined as changes in scores in the direction indicative of worsening symptoms that exceeded the minimal important difference at 3 and/or 6 months compared to baseline. We used logistic regression to evaluate associations of clinicodemographic features and treatment-emergent symptoms with clinically significant weight gain over 60 months (defined as ≥ 5% compared to baseline) in pre- and post-menopausal participants. RESULTS Of 309 participants, 99 (32%) were pre-menopausal. The 60 months cumulative incidence of clinically significant weight gain was greater in pre- than post-menopausal participants (67% vs 43%, p < 0.001). Among pre-menopausal participants, treatment-emergent pain interference (OR 2.49), aromatase inhibitor receipt (OR 2.8), mastectomy, (OR 2.06) and White race (OR 7.13) were associated with weight gain. Among post-menopausal participants, treatment-emergent endocrine symptoms (OR 2.86), higher stage (OR 2.25) and White race (OR 2.29) were associated with weight gain while treatment-emergent physical function decline (OR 0.30) was associated with lower likelihood of weight gain. CONCLUSIONS Weight gain during AET is common, especially for pre-menopausal women. Clinicodemographic features and early treatment-emergent symptoms may identify at risk individuals. IMPLICATIONS FOR CANCER SURVIVORS Patients at risk for weight gain can be identified early during AET. CLINICAL TRIALS GOV IDENTIFIER NCT01937052, registered September 3, 2013.
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Affiliation(s)
- Anna-Carson Rimer Uhelski
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Hematology/Oncology Fellowship Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Jennifer Y Sheng
- Johns Hopkins Women's Malignancies Disease Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claire Snyder
- Johns Hopkins Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Lehman
- Johns Hopkins Women's Malignancies Disease Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kala Visvanathan
- Johns Hopkins Women's Malignancies Disease Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Cancer Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Lim
- Division of Biostatistics and Bioinformatics, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Division of Statistics, Collaborative Inc., WCG, Washington, DC, USA
| | - Vered Stearns
- Johns Hopkins Women's Malignancies Disease Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Under Armour Breast Health Innovation Center, The Skip Viragh Outpatient Cancer, Building 201 North Broadway Viragh 10th floor, Room 10291, Baltimore, MD, 21287, USA.
| | - Karen Lisa Smith
- Johns Hopkins Women's Malignancies Disease Group, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- AstraZeneca, Gaithersburg, MD, USA
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11
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Skafida E, Andrikopoulou A, Terpos E, Markellos C, Moustafa S, Pectasides D, Dimopoulos MA, Zagouri F, Vassilopoulos D. Impact of CDK4/6 Inhibitors on Aromatase Inhibitor-Associated Musculoskeletal Syndrome (AIMSS) in the Adjuvant Setting. Breast J 2023; 2023:3614296. [PMID: 37293258 PMCID: PMC10247331 DOI: 10.1155/2023/3614296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 09/20/2022] [Accepted: 03/28/2023] [Indexed: 06/10/2023]
Abstract
Background Third-generation aromatase inhibitors (AIs) are the mainstay of treatment in hormone receptor (HR)-positive breast cancer. Even though it is considered to be a well-tolerated therapy, AI-induced musculoskeletal symptoms are common and may be accused for treatment discontinuation. Recently, selective cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors changed the therapeutic setting, and currently, ribociclib, palbociclib, and abemaciclib are all approved in combination with nonsteroidal AIs in patients with ER-positive, HER2-negative advanced or metastatic breast cancer. This systematic review aims to identify the frequency of aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) in the adjuvant setting in patients under AI monotherapy compared to patients under combination therapy with AIs and CDK4/6 inhibitors and demonstrate the underlying mechanism of action. Methods This study was performed in accordance with PRISMA guidelines. The literature search and data extraction from all randomized clinical trials (RCTs) were done by two independent investigators. Eligible articles were identified by a search of MEDLINE and ClinicalTrial.gov database concerning the period 2000/01/01-2021/05/01. Results Arthralgia was reported in 13.2 to 68.7% of patients receiving AIs for early-stage breast cancer, while arthralgia induced by CDK4/6 inhibitors occurred in a much lower rate [20.5-41.2%]. Bone pain (5-28.7% vs. 2.2-17.2%), back pain (2-13.4% vs. 8-11.2%), and arthritis (3.6-33.6% vs. 0.32%) were reported less frequently in patients receiving the combination of CDK4/6 inhibitors with ET. Conclusions CDK4/6 inhibitors might have a protective effect against joint inflammation and arthralgia occurrence. Further studies are warranted to investigate arthralgia incidence in this population.
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Affiliation(s)
- Efthymia Skafida
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | | | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Christos Markellos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Savvina Moustafa
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Pectasides
- Oncology Section, Second Department of Internal Medicine, Hippokration Hospital, Athens, Greece
| | | | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
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12
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Luyendijk M, Jager A, Buijs SM, Siesling S, Groot CAUD, Blommestein HM. Cost-Effectiveness Analysis of MammaPrint ® to Guide the Use of Endocrine Therapy in Patients with Early-Stage Breast Cancer. PHARMACOECONOMICS 2023:10.1007/s40273-023-01277-4. [PMID: 37245167 DOI: 10.1007/s40273-023-01277-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Gene expression profiling tests can predict the risk of disease recurrence and select patients who are expected to benefit from therapy, while allowing other patients to forgo therapy. For breast cancers, these tests were initially designed to tailor chemotherapy decisions, but recent evidence suggests that they may also guide the use of endocrine therapy. This study evaluated the cost effectiveness of a prognostic test, MammaPrint®, to guide the use of adjuvant endocrine therapy in patients eligible according to Dutch treatment guidelines. METHODS We constructed a Markov decision model to calculate the lifetime costs (in 2020 Euros) and effects (survival and quality-adjusted life-years) of MammaPrint® testing versus usual care (endocrine therapy for all patients) in a simulated cohort of patients. The population of interest includes patients for whom MammaPrint® testing is currently not indicated, but for whom it may be possible to safely omit endocrine therapy. We applied both a health care perspective and a societal perspective and discounted costs (4%) and effects (1.5%). Model inputs were obtained from published research (including randomized controlled trials), nationwide cancer registry data, cohort data and publicly available data sources. Scenario and sensitivity analyses were conducted to explore the impact of uncertainty around input parameters. Additionally, threshold analyses were performed to identify under which circumstances MammaPrint® testing would be cost effective. RESULTS Adjuvant endocrine therapy guided by MammaPrint® resulted in fewer side effects, more (quality-adjusted) life-years (0.10 and 0.07 incremental QALYS and LYs, respectively) and higher costs (€18,323 incremental costs) compared with the usual care strategy in which all patients receive endocrine therapy. While costs for hospital visits, medication costs and productivity costs were somewhat higher in the usual care strategy, these did not outweigh costs of testing in the MammaPrint® strategy. The incremental cost-effectiveness ratio was €185,644 per QALY gained from a healthcare perspective and €180,617 from a societal perspective. Sensitivity and scenario analyses showed that the conclusions remained the same under changed input parameters and assumptions. Our results show that MammaPrint® can become a cost-effective strategy when either the price of the test is reduced (> 50%), or the proportion of patients for which treatment is altered (i.e. those with ultra-low risk) increases to > 26%. CONCLUSION Standard MammaPrint® testing to guide the use of endocrine therapy in our simulated patient population appears not to be a cost-effective strategy compared with usual care. The cost effectiveness of the test can be improved by reducing the price or preselecting a population more likely to benefit from the test.
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Affiliation(s)
- Marianne Luyendijk
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, P.O. Box 19079, 3501 DB, Utrecht, The Netherlands.
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sanne M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, P.O. Box 19079, 3501 DB, Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, P.O. BOX 217, 7500 AE, Enschede, the Netherlands
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR, Rotterdam, The Netherlands
| | - Hedwig M Blommestein
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR, Rotterdam, The Netherlands
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13
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Pandey P, Sharma A, Gogia A. Bone health in breast cancer. Curr Probl Cancer 2023; 47:100959. [PMID: 37236055 DOI: 10.1016/j.currproblcancer.2023.100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/09/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023]
Abstract
Early breast cancer is among the most common cancers worldwide. Recent advances continue to improve outcomes and increase long-term survivorship. However, therapeutic modalities are deleterious for patients' bone health. While antiresorptive therapy may partially negate this, consequent reduction in rates of fragility fractures remains unproven. Selective prescription of bisphosphonates or denosumab may be an amicable middle ground. Recent evidence also suggests a possible role of osteoclast inhibitors as adjuvant therapy, but the evidence is modest at best. In this narrative clinical review, we explore the impact of various adjuvant modalities on bone mineral density and fragility fracture rates of early breast cancer survivors. We also review optimal patient selection for antiresorptive agents, their impact on rates of fragility fractures, and the possible role of these agents as adjuvant therapy.
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Affiliation(s)
- Praful Pandey
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Sharma
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India.
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14
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Souwer ETD, Sanchez-Spitman A, Moes DJAR, Gelderblom H, Swen JJ, Portielje JEA, Guchelaar HJ, van Gelder T. Tamoxifen pharmacokinetics and pharmacodynamics in older patients with non-metastatic breast cancer. Breast Cancer Res Treat 2023; 199:471-478. [PMID: 37067610 PMCID: PMC10175413 DOI: 10.1007/s10549-023-06925-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/16/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND We aimed to study the pharmacokinetics and -dynamics of tamoxifen in older women with non-metastatic breast cancer. METHODS Data for this analysis were derived from the CYPTAM study (NTR1509) database. Patients were stratified by age (age groups < 65 and 65 and older). Steady-state trough concentrations were measured of tamoxifen, N-desmethyltamoxifen, 4-hydroxy-tamoxifen, and endoxifen. CYP2D6 and CYP3A4 phenotypes were assessed for all patients by genotyping. Multiple linear regression models were used to analyze tamoxifen and endoxifen variability. Outcome data included recurrence-free survival at time of tamoxifen discontinuation (RFSt) and overall survival (OS). RESULTS 668 patients were included, 141 (21%) were 65 and older. Demographics and treatment duration were similar across age groups. Older patients had significantly higher concentrations of tamoxifen 129.4 ng/ml (SD 53.7) versus 112.2 ng/ml (SD 42.0) and endoxifen 12.1 ng/ml (SD 6.6) versus 10.7 ng/ml (SD 5.7, p all < 0.05), independently of CYP2D6 and CYP3A4 gene polymorphisms. Age independently explained 5% of the variability of tamoxifen (b = 0.95, p < 0.001, R2 = 0.051) and 0.1% of the variability in endoxifen concentrations (b = 0.45, p = 0.12, R2 = 0.007). Older patients had worse RFSt (5.8 versus 7.3 years, p = 0.01) and worse OS (7.8 years versus 8.7 years, p = 0.01). This was not related to differences in endoxifen concentration (HR 1.0, 95% CI 0.96-1.04, p = 0.84) or CYP polymorphisms. CONCLUSION Serum concentrations of tamoxifen and its demethylated metabolites are higher in older patients, independent of CYP2D6 or CYP3A4 gene polymorphisms. A higher bioavailability of tamoxifen in older patients may explain the observed differences. However, clinical relevance of these findings is limited and should not lead to a different tamoxifen dose in older patients.
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Affiliation(s)
- E T D Souwer
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.
| | - A Sanchez-Spitman
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - J J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - H J Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - T van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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15
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Zhang X, Gunda A, Kranenbarg EMK, Liefers GJ, Savitha BA, Shrivastava P, Serkad CPVK, Kaur T, Eshwaraiah MS, Tollenaar RAEM, van de Velde CJH, Seynaeve CMJ, Bakre M, Kuppen PJK. Ten-year distant-recurrence risk prediction in breast cancer by CanAssist Breast (CAB) in Dutch sub-cohort of the randomized TEAM trial. Breast Cancer Res 2023; 25:40. [PMID: 37060036 PMCID: PMC10103430 DOI: 10.1186/s13058-023-01643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/30/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Hormone receptor (HR)-positive, HER2/neu-negative breast cancers have a sustained risk of recurrence up to 20 years from diagnosis. TEAM (Tamoxifen, Exemestane Adjuvant Multinational) is a large, multi-country, phase III trial that randomized 9776 women for the use of hormonal therapy. Of these 2754 were Dutch patients. The current study aims for the first time to correlate the ten-year clinical outcomes with predictions by CanAssist Breast (CAB)-a prognostic test developed in South East Asia, on a Dutch sub-cohort that participated in the TEAM. The total Dutch TEAM cohort and the current Dutch sub-cohort were almost similar with respect to patient age and tumor anatomical features. METHODS Of the 2754 patients from the Netherlands, which are part of the original TEAM trial, 592 patients' samples were available with Leiden University Medical Center (LUMC). The risk stratification of CAB was correlated with outcomes of patients using logistic regression approaches entailing Kaplan-Meier survival curves, univariate and multivariate cox-regression hazards model. We used hazard ratios (HRs), the cumulative incidence of distant metastasis/death due to breast cancer (DM), and distant recurrence-free interval (DRFi) for assessment. RESULTS Out of 433 patients finally included, the majority, 68.4% had lymph node-positive disease, while only a minority received chemotherapy (20.8%) in addition to endocrine therapy. CAB stratified 67.5% of the total cohort as low-risk [DM = 11.5% (95% CI, 7.6-15.2)] and 32.5% as high-risk [DM = 30.2% (95% CI, 21.9-37.6)] with an HR of 2.90 (95% CI, 1.75-4.80; P < 0.001) at ten years. CAB risk score was an independent prognostic factor in the consideration of clinical parameters in multivariate analysis. At ten years, CAB high-risk had the worst DRFi of 69.8%, CAB low-risk in the exemestane monotherapy arm had the best DRFi of 92.7% [vs CAB high-risk, HR, 0.21 (95% CI, 0.11-0.43), P < 0.001], and CAB low-risk in the sequential arm had a DRFi of 84.2% [vs CAB high-risk, HR, 0.48 (95% CI, 0.28-0.82), P = 0.009]. CONCLUSIONS Cost-effective CAB is a statistically robust prognostic and predictive tool for ten-year DM for postmenopausal women with HR+/HER2-, early breast cancer. CAB low-risk patients who received exemestane monotherapy had an excellent ten-year DRFi.
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Affiliation(s)
- Xi Zhang
- Department of Surgery, Leiden University Medical Center (LUMC), Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Aparna Gunda
- OncoStem Diagnostics Pvt Ltd, #4, Raja Ram Mohan Roy Road, Aanand Tower, 2nd Floor, Bangalore, 560027, India
| | | | - Gerrit-Jan Liefers
- Geriatric Oncology Research Group, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Payal Shrivastava
- OncoStem Diagnostics Pvt Ltd, #4, Raja Ram Mohan Roy Road, Aanand Tower, 2nd Floor, Bangalore, 560027, India
| | | | - Taranjot Kaur
- OncoStem Diagnostics Pvt Ltd, #4, Raja Ram Mohan Roy Road, Aanand Tower, 2nd Floor, Bangalore, 560027, India
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center (LUMC), Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Cornelis J H van de Velde
- Department of Surgery, Leiden University Medical Center (LUMC), Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | | | - Manjiri Bakre
- OncoStem Diagnostics Pvt Ltd, #4, Raja Ram Mohan Roy Road, Aanand Tower, 2nd Floor, Bangalore, 560027, India.
| | - Peter J K Kuppen
- Department of Surgery, Leiden University Medical Center (LUMC), Albinusdreef 2, Leiden, 2333 ZA, The Netherlands.
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16
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Alfaris I, Asselah J, Aziz H, Bouganim N, Mousavi N. The Cardiovascular Risks Associated with Aromatase Inhibitors, Tamoxifen, and GnRH Agonists in Women with Breast Cancer. Curr Atheroscler Rep 2023; 25:145-154. [PMID: 36848014 DOI: 10.1007/s11883-023-01085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease accounts for up to 10% of all-cause mortality in women with a diagnosis of breast cancer, and the causes for this are multifaceted. Many women at risk of or with a diagnosis of breast cancer are on endocrine-modulating therapies. It is therefore important to understand the effect of hormone therapies on cardiovascular outcomes in breast cancer patients to mitigate against any adverse effects and to identify those most at risk so that they can be proactively managed. Here we discuss the pathophysiology of these agents, their effect on the cardiovascular system, and the latest evidence on their cardiovascular risks association. RECENT FINDINGS Tamoxifen appears to be cardioprotective during treatment but not over the longer term, while the effect of AIs on cardiovascular outcomes remains controversial. Heart failure outcomes remain understudied, and the cardiovascular effects of gonadotrophin-releasing hormone agonists (GNRHa) in women need further research, especially since data from men with prostate cancer have indicated an increased risk of cardiac events in GNRHa users. There remains a need for a greater understanding of the effects of hormone therapies on cardiovascular outcomes in breast cancer patients. Further areas of research in this area include developing evidence to better define the optimal preventive and screening methods for cardiovascular effects and the risk factors for patients on hormonal therapies.
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Affiliation(s)
- Ibrahim Alfaris
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada.
| | - Jamil Asselah
- Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Haya Aziz
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Nathaniel Bouganim
- Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Negareh Mousavi
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada
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17
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Zagami P, Nicolò E, Corti C, Valenza C, Curigliano G. New Concepts in Cardio-Oncology. Cancer Treat Res 2023; 188:303-341. [PMID: 38175351 DOI: 10.1007/978-3-031-33602-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Cancer and cardiovascular disease are the two major causes of morbidity and mortality in worldwide. Discovering new therapeutic agents for the management of breast cancer (BC) has increased the numbers of cancer survivors but with the risk of cardiovascular adverse events (CV-AEs). All drugs can potentially damage the cardiovascular system, with different types of clinical manifestations from ischemic myocardial disease to vasculitis, thrombosis or pericarditis. An early detection of CV-AEs guarantees an earlier treatment, which is associated with better outcomes. Cardio-oncology field enlarged its studies to improve prevention, monitoring and treatment of all cardiotoxic manifestations related to old or modern oncological agents. A multidisciplinary approach with a close partnership between oncologists and cardiologists is essential for an optimal management and therapeutic decision-making. The aim of this chapter is to review all types of cardiotoxic manifestations related to novel and old agents approved for treatment of BC patients including chemotherapy, anti-HER2 agents, cyclin-dependent kinase 4/6 inhibitors, PolyADP-ribose polymerase (PARP) inhibitors, antiangiogenic drugs and immunotherapy. We also focused our discussion on prevention, monitoring, treatment, and management of CV-AEs.
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Affiliation(s)
- Paola Zagami
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy.
- Department of Oncology and Hematology, University of Milano, Milan, Italy.
| | - Eleonora Nicolò
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Chiara Corti
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Carmine Valenza
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
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18
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Kearns AE. Managing Bone Health in Breast Cancer. Endocr Pract 2022; 29:408-413. [PMID: 36509360 DOI: 10.1016/j.eprac.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Osteoporosis is a common condition that can be caused or exacerbated by estrogen deficiency. METHODS This narrative review will discuss optimizing bone health in the setting of adjuvant endocrine treatments for hormone receptor-positive breast cancer and the current use of antiresorptive agents as adjuvant therapy and as bone modifying agents. RESULTS Adjuvant endocrine treatments for hormone receptor-positive breast cancer (tamoxifen and aromatase inhibitors) affect bone health. The exact effect depends on the agent used and the menopausal state of the woman. Antiresorptive medications for osteoporosis, bisphosphonates and denosumab, lower the risk of bone loss from aromatase inhibitors. Use of bisphosphonates as adjuvant treatment in breast cancer, regardless of hormone receptor status, is increasing because of benefits seen to cancer relapse and survival. CONCLUSION Optimizing bone health in women with breast cancer during and after cancer treatment is informed by an understanding of breast cancer treatment and its skeletal effect.
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Affiliation(s)
- Ann E Kearns
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota.
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19
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McGuinness S, Hughes L, Moss‐Morris R, Hunter M, Norton S, Moon Z. Adherence to adjuvant endocrine therapy among White British and ethnic minority breast cancer survivors in the United Kingdom. Eur J Cancer Care (Engl) 2022; 31:e13722. [PMID: 36255032 PMCID: PMC9787781 DOI: 10.1111/ecc.13722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Around half of women do not take adjuvant endocrine therapy (AET) as prescribed. Research suggests that adherence rates vary across ethnic groups. This study compared AET adherences rates in White British women and women from minority ethnic groups in the United Kingdom. METHODS This is an observational study with 2001 breast cancer survivors recruited from outpatient clinics. Eligible women were diagnosed with primary breast cancer and prescribed AET within the last 3 years. Adherence was measured using the Medication Adherence Rating Scale. Eligible women were asked to complete a questionnaire pack that collected sociodemographic data such as age, relationship status and ethnicity. Independent samples t tests and χ2 tests were used to compare White British women and women from minority ethnic groups on self-reported adherence to AET. RESULTS Of White British women, 27.8% were classed as non-adherent, compared to 44.4% of women from minority ethnic groups. A logistic regression controlling for relevant demographics indicated that women from minority ethnic groups had a significantly higher risk of non-adherence than women who were White British (odds ratio = 1.50, p = 0.03) CONCLUSION: Rates of non-adherence to AET are higher in women from minority ethnic groups, which may contribute towards racial disparities in breast cancer outcomes. Research with larger and more diverse samples is needed to explore this further and to investigate the psychosocial factors driving differences in adherence.
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Affiliation(s)
- Serena McGuinness
- Faculty of Nursing Midwifery and Palliative CareKing's College LondonLondonUK
| | - Lyndsay Hughes
- Psychology Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College London, Guy's HospitalLondonUK
| | - Rona Moss‐Morris
- Psychology Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College London, Guy's HospitalLondonUK
| | - Myra Hunter
- Psychology Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College London, Guy's HospitalLondonUK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College London, Guy's HospitalLondonUK,Centre for Rheumatic DiseasesKing's College London, Weston Education CentreLondonUK
| | - Zoe Moon
- Centre for Behavioural Medicine, School of PharmacyUniversity College LondonLondonUK
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20
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Adjuvant aromatase inhibitor therapy and early markers for cardiovascular disease in breast cancer survivors. Breast Cancer Res Treat 2022; 196:591-602. [PMID: 36181605 DOI: 10.1007/s10549-022-06714-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/14/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Aromatase inhibitors (AIs) are an important component of the adjuvant treatment of hormone receptor positive breast cancer (BC) but concerns regarding their cardiovascular safety remain. In this cross-sectional study nested in a breast cancer cohort, we investigated the association between AI exposure and early markers for cardiovascular disease in BC survivors. METHODS The study population consisted of 569 women, who were 5-7 years (n = 277) or 10-12 years (n = 292) after BC diagnosis. All participants underwent carotid ultrasound, skin autofluorescence measurement and laboratory evaluation. To quantify AI exposure, we obtained the AI ratio by dividing the duration of AI use by the total duration of endocrine therapy (ET). Patients were classified according to their AI ratio into low (no ET or AI ratio < 0.40), intermediate (0.40 ≤ AI ratio ≤ 0.60) or high AI exposure (AI ratio > 0.60). The association between AI ratio and carotid intima media thickness (cIMT), advanced glycation end products (AGEs) and the presence of dyslipidemia was assessed using linear and logistic regression. RESULTS Median age at study visit was 55.5 years (range 45.2-63.8). Forty percent (n = 231) of the study population had used AIs, of whom the majority sequentially with tamoxifen; median duration of AI use was 3.0 years. Mean cIMT and mean AGEs did not differ across AI exposure groups in univariable and multivariable analysis. The occurrence of dyslipidemia did not vary across AI exposure groups. Intermediate AI exposure was associated with more frequent occurrence of the combined endpoint (elevated cIMT, elevated AGEs and/or dyslipidemia). This association, however, was not present in the group with highest AI exposure. CONCLUSION AI exposure was not associated with cIMT, AGEs or the presence of dyslipidemia. These results do not prompt a change in current clinical practice, although further research is warranted to validate our findings over time and in different BC populations. Trial registration number (clinicaltrials.gov): NCT02485626, June 30, 2015.
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21
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Vliek SB, Noordhoek I, Meershoek-Klein Kranenbarg E, van Rossum AGJ, Dezentje VO, Jager A, Hokken JWE, Putter H, van der Velden AWG, Hendriks MP, Bakker SD, van Riet YEA, Tjan-Heijnen VCG, Portielje JEA, Kroep JR, Nortier JWR, van de Velde CJH, Linn SC. Daily Oral Ibandronate With Adjuvant Endocrine Therapy in Postmenopausal Women With Estrogen Receptor-Positive Breast Cancer (BOOG 2006-04): Randomized Phase III TEAM-IIB Trial. J Clin Oncol 2022; 40:2934-2945. [PMID: 35442755 DOI: 10.1200/jco.21.00311] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/14/2022] [Accepted: 03/09/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE For postmenopausal patients with breast cancer, previous subgroup analyses have shown a modest benefit from adjuvant bisphosphonate treatment. However, the efficacy of oral nitrogen-containing bisphosphonates such as ibandronate is unclear in this setting. TEAM-IIB investigates adjuvant ibandronate in postmenopausal women with estrogen receptor-positive (ER+) breast cancer. METHODS TEAM-IIB is a randomized, open-label, multicenter phase III study. Postmenopausal women with stage I-III ER+ breast cancer and an indication for adjuvant endocrine therapy (ET) were randomly assigned 1:1 to 5 years of ET with or without oral ibandronate 50 mg once daily for 3 years. Major ineligibility criteria were bilateral breast cancer, active gastroesophageal problems, and health conditions that might interfere with study treatment. Primary end point was disease-free survival (DFS), analyzed in the intention-to-treat population. RESULTS Between February 1, 2007, and May 27, 2014, 1,116 patients were enrolled, 565 to ET with ibandronate (ibandronate arm) and 551 to ET alone (control arm). Median follow-up was 8.5 years. DFS was not significantly different between the ibandronate and control arms (HR, 0.97; 95% CI, 0.76 to 1.24; log-rank P = .811). Three years after random assignment, DFS was 94% in the ibandronate arm and 91% in the control arm. Five years after random assignment, this was 89% and 86%, respectively. In the ibandronate arm, 97/565 (17%) of patients stopped ibandronate early because of adverse events. Significantly more patients experienced GI issues, mainly dyspepsia, in the ibandronate arm than in the control arm (89 [16%] and 54 [10%], respectively; P < .003). Eleven patients in the ibandronate arm developed osteonecrosis of the jaw. CONCLUSION In postmenopausal women with ER+ breast cancer, adjuvant ibandronate 50 mg once daily does not improve DFS and should not be recommended as part of standard treatment regimens.
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Affiliation(s)
- Sonja B Vliek
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Iris Noordhoek
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Annelot G J van Rossum
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Vincent O Dezentje
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Agnes Jager
- Dutch Breast Cancer Research Group, Amsterdam, the Netherlands
| | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, the Netherlands
| | - Sandra D Bakker
- Department of Internal Medicine, Zaans Medical Centre, Zaandam, the Netherlands
| | - Yvonne E A van Riet
- Department of Surgical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan W R Nortier
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
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22
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Gupta T, Purington N, Liu M, Han S, Sledge G, Schapira L, Kurian AW. Incident comorbidities after tamoxifen or aromatase inhibitor therapy in a racially and ethnically diverse cohort of women with breast cancer. Breast Cancer Res Treat 2022; 196:175-183. [DOI: 10.1007/s10549-022-06716-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/14/2022] [Indexed: 11/29/2022]
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23
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Xu K, Bayani J, Mallon E, Pond GR, Piper T, Hasenburg A, Markopoulos CJ, Dirix L, Seynaeve CM, van de Velde CJH, Rea DW, Bartlett JMS. Discordance between Immunohistochemistry and Erb-B2 Receptor Tyrosine Kinase 2 mRNA to Determine Human Epidermal Growth Factor Receptor 2 Low Status for Breast Cancer. J Mol Diagn 2022; 24:775-783. [PMID: 35526835 DOI: 10.1016/j.jmoldx.2022.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/02/2022] [Accepted: 04/01/2022] [Indexed: 12/18/2022] Open
Abstract
Novel human epidermal growth factor receptor 2 (HER2)-directed antibody-drug conjugates have demonstrated efficacy in HER2-low expressing breast cancers, which are currently defined as those with immunohistochemistry (IHC) scores of 1+ or 2+ with a negative in situ hybridization assay. However, current HER2 testing methods are designed to identify HER2-amplified tumors with high expression levels. The true definition of HER2-low expressing breast cancers remains controversial. Using quantitative molecular analysis of breast cancers based on RNA expression, the dynamic range of HER2 expression exceeds that detected by in situ IHC approaches. Erb-B2 receptor tyrosine kinase 2 (ERBB2) mRNA expression levels across IHC groups using patient samples derived from the Tamoxifen Exemestane Adjuvant Multicenter Trial were investigated. The standardized mean differences in ERBB2 mRNA scores in log base 2 are 0.47 (95% CI, 0.36-0.57), 0.58 (95% CI, 0.26-0.70), and 0.32 (95% CI, -0.12 to 0.75) when comparing IHC 0+ without staining versus IHC 0+ with some staining, IHC 0+ with some staining versus IHC 1+, and IHC 1+ versus IHC 2+/fluorescence in situ hybridization-negative, respectively. The results showed immunohistochemical methods have a comparatively limited dynamic range for measuring HER2 protein expression. The range of expression based on RNA abundance suggests a molecular method defining HER2-low cancers may better serve the treatment decision needs of this group. Indeed, the validity of RNA abundance to identify HER2-low cancers and predict treatment response needs to be further evaluated by prospective clinical trials.
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Affiliation(s)
- Keying Xu
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Jane Bayani
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, Ontario, Canada; Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | | | - Gregory R Pond
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Tammy Piper
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, United Kingdom
| | - Annette Hasenburg
- Department of Gynecology and Obstetrics, University Center Mainz, Mainz, Germany
| | | | - Luc Dirix
- Oncology Center, St. Augustinus Hospital, Antwerp, Belgium
| | - Caroline M Seynaeve
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Daniel W Rea
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - John M S Bartlett
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, Ontario, Canada; Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, United Kingdom.
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24
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Boszkiewicz K, Piwowar A, Petryszyn P. Aromatase Inhibitors and Risk of Metabolic and Cardiovascular Adverse Effects in Breast Cancer Patients-A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11113133. [PMID: 35683517 PMCID: PMC9181297 DOI: 10.3390/jcm11113133] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/14/2022] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
Aromatase inhibitors (AIs) have been considered first-line therapy for patients with hormone-dependent breast cancer due to their high efficacy and good tolerability. However, AIs are not free of adverse events, and studies show that therapy with AIs is associated with an increased risk of cardiovascular events and the development of insulin resistance and diabetes. We searched the Cochrane Central Register of Controlled Trials, PubMed and EMBASE up to 27 October 2020 for the prevalence of cardiovascular and/or metabolic adverse effects during treatment with AIs in postmenopausal women with breast cancer. A meta-analysis was performed using a random effects model. Odds ratios and 95% confidence intervals were calculated and illustrated using forest plot charts. We performed separate analyses depending on trial design. Twenty two studies met the inclusion criteria. AIs were associated with a higher risk of cardiovascular events, especially when we compared study arms in which AIs were used (alone or in sequence with TAM) with the arms in which TAM was used alone (OR = 1.16; 95%CI 1.04-1.30) or when comparing patients taking AIs alone to patients taking TAM alone or in sequence with AIs (OR = 1.24; 95%CI 1.11-1.38). A pooled analysis of five trials comparing adjuvant AIs to TAM showed the odds for arterial hypertension being 1.31 times higher for patients taking AIs; however, this did not reach statistical significance (OR = 1.31; 95%CI 0.47-3.65). We have not shown an increased risk of dyslipidemia or weight gain with the use of AIs. Our results suggest that postmenopausal women with breast cancer treated with AIs have an increased risk of cardiovascular events in comparison with TAM, potentially due more to a cardioprotective effect of the latter than the cardiotoxicity of AIs. We were unable to prove a similar association for hypertension, dyslipidemia, hyperglycemia or weight gain. Further high-quality RCTs and post-marketing safety observational studies are needed to definitively evaluate the impact of AIs on metabolic disorders in breast cancer patients.
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Affiliation(s)
- Kamila Boszkiewicz
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
- Correspondence:
| | - Agnieszka Piwowar
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
| | - Paweł Petryszyn
- Department of Clinical Pharmacology, Wroclaw Medical University, Borowska Street 211a, 50-556 Wroclaw, Poland;
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Kirwan CC, Blower EL. Contemporary breast cancer treatment-associated thrombosis. Thromb Res 2022; 213 Suppl 1:S8-S15. [DOI: 10.1016/j.thromres.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/07/2021] [Accepted: 12/24/2021] [Indexed: 10/18/2022]
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Jett S, Malviya N, Schelbaum E, Jang G, Jahan E, Clancy K, Hristov H, Pahlajani S, Niotis K, Loeb-Zeitlin S, Havryliuk Y, Isaacson R, Brinton RD, Mosconi L. Endogenous and Exogenous Estrogen Exposures: How Women's Reproductive Health Can Drive Brain Aging and Inform Alzheimer's Prevention. Front Aging Neurosci 2022; 14:831807. [PMID: 35356299 PMCID: PMC8959926 DOI: 10.3389/fnagi.2022.831807] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/07/2022] [Indexed: 01/14/2023] Open
Abstract
After advanced age, female sex is the major risk factor for late-onset Alzheimer's disease (AD), the most common cause of dementia affecting over 24 million people worldwide. The prevalence of AD is higher in women than in men, with postmenopausal women accounting for over 60% of all those affected. While most research has focused on gender-combined risk, emerging data indicate sex and gender differences in AD pathophysiology, onset, and progression, which may help account for the higher prevalence in women. Notably, AD-related brain changes develop during a 10-20 year prodromal phase originating in midlife, thus proximate with the hormonal transitions of endocrine aging characteristic of the menopause transition in women. Preclinical evidence for neuroprotective effects of gonadal sex steroid hormones, especially 17β-estradiol, strongly argue for associations between female fertility, reproductive history, and AD risk. The level of gonadal hormones to which the female brain is exposed changes considerably across the lifespan, with relevance to AD risk. However, the neurobiological consequences of hormonal fluctuations, as well as that of hormone therapies, are yet to be fully understood. Epidemiological studies have yielded contrasting results of protective, deleterious and null effects of estrogen exposure on dementia risk. In contrast, brain imaging studies provide encouraging evidence for positive associations between greater cumulative lifetime estrogen exposure and lower AD risk in women, whereas estrogen deprivation is associated with negative consequences on brain structure, function, and biochemistry. Herein, we review the existing literature and evaluate the strength of observed associations between female-specific reproductive health factors and AD risk in women, with a focus on the role of endogenous and exogenous estrogen exposures as a key underlying mechanism. Chief among these variables are reproductive lifespan, menopause status, type of menopause (spontaneous vs. induced), number of pregnancies, and exposure to hormonal therapy, including hormonal contraceptives, hormonal therapy for menopause, and anti-estrogen treatment. As aging is the greatest risk factor for AD followed by female sex, understanding sex-specific biological pathways through which reproductive history modulates brain aging is crucial to inform preventative and therapeutic strategies for AD.
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Affiliation(s)
- Steven Jett
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Niharika Malviya
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Eva Schelbaum
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Grace Jang
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Eva Jahan
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Katherine Clancy
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Hollie Hristov
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Silky Pahlajani
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
- Department of Radiology, Weill Cornell Medical College, New York, NY, United States
| | - Kellyann Niotis
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Susan Loeb-Zeitlin
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States
| | - Yelena Havryliuk
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States
| | - Richard Isaacson
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
| | - Roberta Diaz Brinton
- Department of Pharmacology, University of Arizona, Tucson, AZ, United States
- Department of Neurology, University of Arizona, Tucson, AZ, United States
| | - Lisa Mosconi
- Department of Neurology, Weill Cornell Medical College, New York, NY, United States
- Department of Radiology, Weill Cornell Medical College, New York, NY, United States
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Martinez DSL, Noseworthy PA, Akbilgic O, Herrmann J, Ruddy KJ, Hamid A, Maddula R, Singh A, Davis R, Gunturkun F, Jefferies JL, Brown SA. Artificial intelligence opportunities in cardio-oncology: Overview with spotlight on electrocardiography. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 15:100129. [PMID: 35721662 PMCID: PMC9202996 DOI: 10.1016/j.ahjo.2022.100129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 01/21/2023]
Abstract
Cardiovascular disease is a leading cause of death among cancer survivors, second only to cancer recurrence or development of new tumors. Cardio-oncology has therefore emerged as a relatively new specialty focused on prevention and management of cardiovascular consequences of cancer therapies. Yet challenges remain regarding precision and accuracy with predicting individuals at highest risk for cardiotoxicity. Barriers such as access to care also limit screening and early diagnosis to improve prognosis. Thus, developing innovative approaches for prediction and early detection of cardiovascular illness in this population is critical. In this review, we provide an overview of the present state of machine learning applications in cardio-oncology. We begin by outlining some factors that should be considered while utilizing machine learning algorithms. We then examine research in which machine learning has been applied to improve prediction of cardiac dysfunction in cancer survivors. We also highlight the use of artificial intelligence (AI) in conjunction with electrocardiogram (ECG) to predict cardiac malfunction and also atrial fibrillation (AF), and we discuss the potential role of wearables. Additionally, the article summarizes future prospects and critical takeaways for the application of machine learning in cardio-oncology. This study is the first in a series on artificial intelligence in cardio-oncology, and complements our manuscript on echocardiography and other forms of imaging relevant to cancer survivors cared for in cardiology clinical practice.
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Affiliation(s)
- Daniel Sierra-Lara Martinez
- Coronary Care Unit, National Institute of Cardiology/Instituto Nacional de Cardiologia, Ciudad de Mexico, Mexico
| | | | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Wake Forest, NC, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Ashima Singh
- Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert Davis
- Center for Biomedical Informatics, University of Tennessee Health Sciences Center, USA
| | - Fatma Gunturkun
- Center for Biomedical Informatics, University of Tennessee Health Sciences Center, USA
| | - John L. Jefferies
- Division of Cardiovascular Diseases, University of Tennessee Health Sciences Center, USA
- Department of Epidemiology, St. Jude Children's Research Hospital, USA
| | - Sherry-Ann Brown
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Wang Y, Jing F, Wang H. Role of Exemestane in the Treatment of Estrogen-Receptor-Positive Breast Cancer: A Narrative Review of Recent Evidence. Adv Ther 2022; 39:862-891. [PMID: 34989983 DOI: 10.1007/s12325-021-01924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/14/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Breast cancer (BC) is the most common type of cancer diagnosed among women worldwide with an estimated 2.3 million new cases every year. Almost two-thirds of all patients with BC have estrogen receptor-positive (ER+) tumors. In this review, the clinical evidence of exemestane in different treatment settings in ER+ BC is presented and summarized. SEARCH STRATEGY A search strategy with the keywords "breast cancer [MeSH Terms]" AND "exemestane [Title/Abstract]" was devised and a search was performed in PubMed. RESULTS The efficacy of exemestane in different treatment settings has been established by numerous clinical studies. Exemestane is recommended as an adjuvant treatment in postmenopausal women previously treated with tamoxifen in trials comparing 5 years of tamoxifen with 2-3 years of tamoxifen combined with 2-3 years of exemestane, which proved that treatment with exemestane provided better survival outcomes. Similarly, exemestane could be considered as a safe treatment option for neoadjuvant treatment, prevention of chemotherapy, and treatment of advanced BC either alone or in combination with other targeted therapy drugs in both pre- and postmenopausal women. CONCLUSION Exemestane could be considered as a reasonable therapeutic option in the treatment of ER+ BC at any stage in pre- and postmenopausal women.
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Chang WT, Chen PW, Lin HW, Kuo YH, Lin SH, Li YH. Risks of Aromatase Inhibitor-Related Cardiotoxicity in Patients with Breast Cancer in Asia. Cancers (Basel) 2022; 14:cancers14030508. [PMID: 35158776 PMCID: PMC8833815 DOI: 10.3390/cancers14030508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary In Asian breast cancer patients, whether the risks of major adverse cardio- and cerebrovascular events (MACCEs) are different between users of aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs) remains uncertain. In this nationwide cohort study, the risks of MACCEs were significantly higher in users of SERMs compared with users of AIs in those who were at an old age (above 50 years old) or with advanced cancer stage (stage 3–4). Although the choice of hormone therapies is primarily based on the effectiveness regarding cancer survival, AI treatment should be considered for patients for whom the benefits outweigh the risks. Abstract Background: Despite a preferred endocrine therapy for women with estrogen and progesterone receptor-positive breast cancer, aromatase inhibitors (AIs) have been reported to increase risks of cardiovascular events. Given that breast cancer patients in Asia are younger at diagnosis, it is urgent to investigate this safety concern. Methods: Through the Taiwanese National Cohort, we identified breast cancer patients initiating selective estrogen receptor modulators (SERMs) or AIs from 2010 to 2016. Outcomes includes major adverse cardio- and cerebrovascular events (MACCEs). The average follow-up duration was five years. Results: We identified 16,730 breast cancer patients treated with SERMs and 11,728 receiving AIs. The population was older and had more comorbidities in the AI group than in the SERM group. After adjusting for age, cancer stage, cancer therapies, cardiovascular drugs and comorbidities, despite similar risks of MACCEs between AI and SERM users, the risk of HF was significantly higher in patients treated with SERMs after adjusted mortality as a competing risk. When divided by the age of 50 years, despite a similar MACCEs in the younger population, MACCEs remained significantly higher in the older population who received SERMs. Conclusions: In this Asian cohort, we found that among patients of old age or with advanced cancer stage, the use of SERMs was associated with a higher risk of cardiovascular events than the use of AIs.
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Affiliation(s)
- Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 710402, Taiwan;
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 710301, Taiwan
| | - Po-Wei Chen
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
| | - Hui-Wen Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
| | - Yu-Hsuan Kuo
- Division of Oncology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 710402, Taiwan;
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Correspondence: (S.-H.L.); (Y.-H.L.); Tel.: +886-6-2353535 (ext. 5962) (S.-H.L.); +886-6-2353535 (ext. 2389) (Y.-H.L.); Fax: +886-6-2753834 (Y.-H.L.)
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan;
- Correspondence: (S.-H.L.); (Y.-H.L.); Tel.: +886-6-2353535 (ext. 5962) (S.-H.L.); +886-6-2353535 (ext. 2389) (Y.-H.L.); Fax: +886-6-2753834 (Y.-H.L.)
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Mori H, Saeki K, Chang G, Wang J, Wu X, Hsu PY, Kanaya N, Wang X, Somlo G, Nakamura M, Bild A, Chen S. Influence of Estrogen Treatment on ESR1+ and ESR1- Cells in ER + Breast Cancer: Insights from Single-Cell Analysis of Patient-Derived Xenograft Models. Cancers (Basel) 2021; 13:cancers13246375. [PMID: 34944995 PMCID: PMC8699443 DOI: 10.3390/cancers13246375] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/12/2021] [Accepted: 12/16/2021] [Indexed: 01/07/2023] Open
Abstract
Simple Summary The benefit of endocrine therapy is normally observed for cancers with 10% or more of cells positive for ER expression. We compared the gene expression profiles in both ESR1+ and ESR1– cells in ER+ tumors following estrogen treatment. Our single-cell RNA sequencing analysis of estrogen-stimulated (SC31) and estrogen-suppressed (GS3) patient-derived xenograft models offered an unprecedented opportunity to address the molecular and functional differences between ESR1+ and ESR1– cells. While estrogen should activate ERα and stimulate ESR1+ cells, our findings regarding ESR1– cells were important, indicating that the proliferation of ESR1– cells in ER+ cancer is also influenced by estrogen. Another valuable finding from our studies was that estrogen also upregulated a tumor-suppressor gene, IL-24, only in GS3. Estrogen increased the percentage of cells expressing IL-24, associated with the estrogen-dependent inhibition of GS3 tumor growth. Abstract A 100% ER positivity is not required for an endocrine therapy response. Furthermore, while estrogen typically promotes the progression of hormone-dependent breast cancer via the activation of estrogen receptor (ER)-α, estrogen-induced tumor suppression in ER+ breast cancer has been clinically observed. With the success in establishing estrogen-stimulated (SC31) and estrogen-suppressed (GS3) patient-derived xenograft (PDX) models, single-cell RNA sequencing analysis was performed to determine the impact of estrogen on ESR1+ and ESR1– tumor cells. We found that 17β-estradiol (E2)-induced suppression of GS3 transpired through wild-type and unamplified ERα. E2 upregulated the expression of estrogen-dependent genes in both SC31 and GS3; however, E2 induced cell cycle advance in SC31, while it resulted in cell cycle arrest in GS3. Importantly, these gene expression changes occurred in both ESR1+ and ESR1– cells within the same breast tumors, demonstrating for the first time a differential effect of estrogen on ESR1– cells. E2 also upregulated a tumor-suppressor gene, IL-24, in GS3. The apoptosis gene set was upregulated and the G2M checkpoint gene set was downregulated in most IL-24+ cells after E2 treatment. In summary, estrogen affected pathologically defined ER+ tumors differently, influencing both ESR1+ and ESR1– cells. Our results also suggest IL-24 to be a potential marker of estrogen-suppressed tumors.
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Affiliation(s)
- Hitomi Mori
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Kohei Saeki
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
| | - Gregory Chang
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
| | - Jinhui Wang
- Integrative Genomics Core, Beckman Research Institute of the City of Hope, 655 Huntington Drive, Monrovia, CA 91016, USA; (J.W.); (X.W.)
| | - Xiwei Wu
- Integrative Genomics Core, Beckman Research Institute of the City of Hope, 655 Huntington Drive, Monrovia, CA 91016, USA; (J.W.); (X.W.)
| | - Pei-Yin Hsu
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
| | - Noriko Kanaya
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
| | - Xiaoqiang Wang
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
| | - George Somlo
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA; (G.S.); (A.B.)
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Andrea Bild
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA; (G.S.); (A.B.)
| | - Shiuan Chen
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, 1500 E Duarte Road, Duarte, CA 91010, USA; (H.M.); (K.S.); (G.C.); (P.-Y.H.); (N.K.); (X.W.)
- Correspondence: ; Tel.: +1-626-218-3454; Fax: +1-626-301-8972
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Di Meglio A, Soldato D, Presti D, Vaz-Luis I. Lifestyle and quality of life in patients with early-stage breast cancer receiving adjuvant endocrine therapy. Curr Opin Oncol 2021; 33:553-573. [PMID: 34456250 DOI: 10.1097/cco.0000000000000781] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW A comprehensive approach to survivorship care for women with early-stage, hormone-receptor positive breast cancer should systematically include the proactive assessment and adequate management of endocrine therapy-associated symptoms, in order to assure optimal balance between preserving quality of life (QOL) and maximizing treatment adherence. We reviewed the recent literature focused on lifestyle factors, including physical activity, diet and nutrition, weight management, smoke, and alcohol behavior, and their link with symptomatology and QOL among women receiving adjuvant endocrine therapy. RECENT FINDINGS Recent studies confirm the safety, feasibility, and effectiveness of lifestyle interventions in mitigating several common endocrine therapy-related effects, including musculoskeletal pain, fatigue, and insomnia, and in improving physical and emotional wellbeing as well as overall health-related QOL among women with early-stage breast cancer. SUMMARY Healthy lifestyle behaviors have the potential to modulate the downstream impact of endocrine therapy and improve QOL among women with early-stage breast cancer. Considerations for real-world clinical care implementation emerged, including a need to evaluate the long-term uptake of healthy behaviors and facilitate the postintervention maintenance of an improved lifestyle. Some facilitators to health promotion in breast cancer survivors were also suggested, such as individualized and one-to-one supervised programs, and digital solutions providing real-time feedback, building on personalized, direct patient engagement.
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Affiliation(s)
- Antonio Di Meglio
- Molecular predictors and new targets in oncology, INSERM Unit 981, Gustave Roussy, Villejuif
| | - Davide Soldato
- Molecular predictors and new targets in oncology, INSERM Unit 981, Gustave Roussy, Villejuif.,Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genova, Genova
| | - Daniele Presti
- Molecular predictors and new targets in oncology, INSERM Unit 981, Gustave Roussy, Villejuif.,Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Ines Vaz-Luis
- Molecular predictors and new targets in oncology, INSERM Unit 981, Gustave Roussy, Villejuif
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Burguin A, Diorio C, Durocher F. Breast Cancer Treatments: Updates and New Challenges. J Pers Med 2021; 11:808. [PMID: 34442452 PMCID: PMC8399130 DOI: 10.3390/jpm11080808] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/31/2022] Open
Abstract
Breast cancer (BC) is the most frequent cancer diagnosed in women worldwide. This heterogeneous disease can be classified into four molecular subtypes (luminal A, luminal B, HER2 and triple-negative breast cancer (TNBC)) according to the expression of the estrogen receptor (ER) and the progesterone receptor (PR), and the overexpression of the human epidermal growth factor receptor 2 (HER2). Current BC treatments target these receptors (endocrine and anti-HER2 therapies) as a personalized treatment. Along with chemotherapy and radiotherapy, these therapies can have severe adverse effects and patients can develop resistance to these agents. Moreover, TNBC do not have standardized treatments. Hence, a deeper understanding of the development of new treatments that are more specific and effective in treating each BC subgroup is key. New approaches have recently emerged such as immunotherapy, conjugated antibodies, and targeting other metabolic pathways. This review summarizes current BC treatments and explores the new treatment strategies from a personalized therapy perspective and the resulting challenges.
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Affiliation(s)
- Anna Burguin
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1T 1C2, Canada;
- Cancer Research Center, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
| | - Caroline Diorio
- Cancer Research Center, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
- Department of Preventive and Social Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1T 1C2, Canada
| | - Francine Durocher
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1T 1C2, Canada;
- Cancer Research Center, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
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Bartlett JMS, Bayani J, Kornaga E, Xu K, Pond GR, Piper T, Mallon E, Yao CQ, Boutros PC, Hasenburg A, Dunn JA, Markopoulos C, Dirix L, Seynaeve C, van de Velde CJH, Stein RC, Rea D. Comparative survival analysis of multiparametric tests-when molecular tests disagree-A TEAM Pathology study. NPJ Breast Cancer 2021; 7:90. [PMID: 34238931 PMCID: PMC8266887 DOI: 10.1038/s41523-021-00297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
Multiparametric assays for risk stratification are widely used in the management of both node negative and node positive hormone receptor positive invasive breast cancer. Recent data from multiple sources suggests that different tests may provide different risk estimates at the individual patient level. The TEAM pathology study consists of 3284 postmenopausal ER+ve breast cancers treated with endocrine therapy Using genes comprising the following multi-parametric tests OncotypeDx®, Prosigna™ and MammaPrint® signatures were trained to recapitulate true assay results. Patients were then classified into risk groups and survival assessed. Whilst likelihood χ2 ratios suggested limited value for combining tests, Kaplan-Meier and LogRank tests within risk groups suggested combinations of tests provided statistically significant stratification of potential clinical value. Paradoxically whilst Prosigna-trained results stratified Oncotype-trained subgroups across low and intermediate risk categories, only intermediate risk Prosigna-trained cases were further stratified by Oncotype-trained results. Both Oncotype-trained and Prosigna-trained results further stratified MammaPrint-trained low risk cases, and MammaPrint-trained results also stratified Oncotype-trained low and intermediate risk groups but not Prosigna-trained results. Comparisons between existing multiparametric tests are challenging, and evidence on discordance between tests in risk stratification presents further dilemmas. Detailed analysis of the TEAM pathology study suggests a complex inter-relationship between test results in the same patient cohorts which requires careful evaluation regarding test utility. Further prognostic improvement appears both desirable and achievable.
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Affiliation(s)
- John M S Bartlett
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada.
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Edinburgh Cancer Research Centre, Edinburgh, UK.
| | - Jane Bayani
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Elizabeth Kornaga
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
- Translational Laboratories, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Keying Xu
- Diagnostic Development, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Greg R Pond
- Department of Oncology, McMaster University, Kingston, ON, Canada
| | - Tammy Piper
- Edinburgh Cancer Research Centre, Edinburgh, UK
| | | | - Cindy Q Yao
- Informatics & Computational Biology, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Paul C Boutros
- Informatics & Computational Biology, Ontario Institute for Cancer Research, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Canada
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, USA
| | - Annette Hasenburg
- Dept of Gynecology and Obstetrics, University Center Mainz, Mainz, Germany
| | - J A Dunn
- University of Warwick, Coventry, UK
| | | | - Luc Dirix
- St. Augustinus Hospital, Antwerp, Belgium
| | | | | | - Robert C Stein
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Interactions between cardiology and oncology drugs in precision cardio-oncology. Clin Sci (Lond) 2021; 135:1333-1351. [PMID: 34076246 DOI: 10.1042/cs20200309] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 12/13/2022]
Abstract
Recent advances in treatment have transformed the management of cancer. Despite these advances, cardiovascular disease remains a leading cause of death in cancer survivors. Cardio-oncology has recently evolved as a subspecialty to prevent, diagnose, and manage cardiovascular side effects of antineoplastic therapy. An emphasis on optimal management of comorbidities and close attention to drug interactions are important in cardio-oncologic care. With interdisciplinary collaboration among oncologists, cardiologists, and pharmacists, there is potential to prevent and reduce drug-related toxicities of treatments. The cytochrome P450 (CYP450) family of enzymes and the P-glycoprotein (P-g) transporter play a crucial role in drug metabolism and drug resistance. Here we discuss the role of CYP450 and P-g in drug interactions in the field of cardio-oncology, provide an overview of the cardiotoxicity of a spectrum of cancer agents, highlight the role of precision medicine, and encourage a multidisciplinary treatment approach for patients with cancer.
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Sutton AL, Hagiwara N, Perera RA, Sheppard VB. Assessing Perceived Discrimination as Reported by Black and White Women Diagnosed with Breast Cancer. J Racial Ethn Health Disparities 2021; 8:589-595. [PMID: 32808196 PMCID: PMC7962667 DOI: 10.1007/s40615-020-00817-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Although a number of factors contribute to racial disparities in breast cancer outcomes, perceived discrimination in healthcare may be a key factor that hinders positive interactions and negatively impacts patient outcomes. The goals of our study were to (1) assess the prevalence of perceived discrimination as reported by breast cancer patients and (2) identify factors related to discrimination in women overall as well as by race. DESIGN This study is a secondary analysis of a larger study, "Narrowing the Gaps in Adjuvant Therapy," where a convenience sample of 359 women completed one telephone survey assessing sociodemographics, and attitudes and beliefs concerning breast cancer treatments and care. Chi-square analysis was used to assess the relationship of categorical variables with perceived discrimination, while the F-test was employed for continuous variables. Logistic regression determined predictors of perceived discrimination, a dichotomous variable (none vs. any). RESULTS A majority of women were Black (58%), privately insured (85%), and had at least a Bachelor's degree (48%). Discrimination was reported by 32.4% of women, with significantly more Black women reporting discrimination than White women. Insurance status, attitudes toward treatment, and distress factors were significantly related to perceived discrimination. In the logistic model, women who were less trusting of their providers (OR = 0.863 [0.751, 0.993], p = .021) and Black women (OR = 7.241 [0.751, 0.993], p = .039) were more likely to report incidences of discrimination. CONCLUSIONS Our findings suggest a need to understand Black survivor's experiences with healthcare. Similarly, future work must focus on identifying ways to improve provider trust amongst breast cancer survivors.
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Affiliation(s)
- Arnethea L Sutton
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, P.O. Box 980149, Richmond, VA, 23219, USA.
| | - Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, P.O. Box 980149, Richmond, VA, 23219, USA
- Office of Health Equity and Disparities Research, Virginia Commonwealth University Massey Cancer Center, Richmond, VA, USA
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Van Dyk K, Joffe H, Carroll JE. Sleep and endocrine therapy in breast cancer. CURRENT OPINION IN ENDOCRINE AND METABOLIC RESEARCH 2021; 18:165-170. [PMID: 34095605 PMCID: PMC8174782 DOI: 10.1016/j.coemr.2021.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sleep disturbances and insomnia are common among breast cancer survivors, and can have a significant effect on quality of life and numerous other significant outcomes. Among risks for sleep disturbance is the introduction of anti-estrogen endocrine therapies. The possible contributing factors to sleep disturbance in endocrine therapy are complex, and include pre-existing sleep disorders, the effects of chemotherapy and other treatments, and concurrent symptoms such as hot flashes. In addition, sleep disturbance in menopause, the natural downregulation of reproductive hormones in older age, is a common occurrence, and can offer a model for understanding the high prevalence of sleep problems in breast cancer survivors on endocrine therapy, as well as suggesting possible treatments such as behavioral interventions and pharmaceuticals. Altogether, significantly more research is needed to better understand and address sleep disturbance in breast cancer survivors on endocrine therapy in order to support quality of life and treatment adherence.
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Affiliation(s)
- Kathleen Van Dyk
- UCLA David Geffen School of Medicine, Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience & Human Behavior, UCLA Jonsson Comprehensive Cancer Center
| | - Hadine Joffe
- Mary Horrigan Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital; Department of Psychiatry, Brigham and Women's Hospital, Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School
| | - Judith E Carroll
- UCLA David Geffen School of Medicine, Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience & Human Behavior, Cousins Center for Psychoneuroimmunology
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Shapiro CL. Bone-modifying Agents (BMAs) in Breast Cancer. Clin Breast Cancer 2021; 21:e618-e630. [PMID: 34045175 DOI: 10.1016/j.clbc.2021.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Abstract
Bone-modifying agents (BMAs) are mainstays in breast cancer and prevent and treat osteoporosis in early-stage disease and reduce skeletal metastases complications in advanced disease. There is some evidence to support that BMA also prevents skeletal metastases and improves overall survival. Bone loss occurs with chemotherapy-induced ovarian failure, gonadotrophin-releasing hormone (GnRH) agonists, and aromatase inhibitors. In some women, the bone loss will be of sufficient magnitude to increase the risks of osteoporosis or fractures. Recommended steps in osteoporosis prevention or treatment include risk factor assessment, taking adequate amounts of calcium and vitamin D3, and periodic evaluations with dual-energy x-ray absorptiometry scanning. If clinically indicated by the T-scores and fracture-risk prediction algorithms treat with oral, IV bisphosphonates or subcutaneous denosumab (DEN). Zoledronic acid (ZA) or DEN reduces skeletal metastases complications, including pathological fracture, spinal cord compression, or the necessity for radiation or surgery to bone. Also, both of these drugs have the side-effect of osteonecrosis at a similar incidence. Monthly administration of ZA or DEN is standard, but several recent randomized trials show noninferiority between ZA monthly and every 3-month ZA. Every 3-month ZA is a new standard of care. Similar trials of the schedule of DEN are ongoing. ZA anticancer effect is only in postmenopausal women or premenopausal women rendered postmenopausal by GnRH agonists or bilateral oopherectomy. High-risk women, either postmenopausal or premenopausal, receiving GnRH/oopherctomy should consider adjuvant ZA. There are insufficient data to support DEN in this setting. Herein, this narrative review covers the mechanism of action of BMA, randomized clinical trials, and adverse events, both common and rare.
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Okwuosa TM, Morgans A, Rhee JW, Reding KW, Maliski S, Plana JC, Volgman AS, Moseley KF, Porter CB, Ismail-Khan R. Impact of Hormonal Therapies for Treatment of Hormone-Dependent Cancers (Breast and Prostate) on the Cardiovascular System: Effects and Modifications: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e000082. [PMID: 33896190 DOI: 10.1161/hcg.0000000000000082] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cardiovascular disease and cancer are the leading causes of death in the United States, and hormone-dependent cancers (breast and prostate cancer) are the most common noncutaneous malignancies in women and men, respectively. The hormonal (endocrine-related) therapies that serve as a backbone for treatment of both cancers improve survival but also increase cardiovascular morbidity and mortality among survivors. This consensus statement describes the risks associated with specific hormonal therapies used to treat breast and prostate cancer and provides an evidence-based approach to prevent and detect adverse cardiovascular outcomes. Areas of uncertainty are highlighted, including the cardiovascular effects of different durations of hormonal therapy, the cardiovascular risks associated with combinations of newer generations of more intensive hormonal treatments, and the specific cardiovascular risks that affect individuals of various races/ethnicities. Finally, there is an emphasis on the use of a multidisciplinary approach to the implementation of lifestyle and pharmacological strategies for management and risk reduction both during and after active treatment.
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Impact of adjuvant endocrine therapy on prognosis in small hormone receptor-positive, HER2-negative early breast cancer. Breast Cancer 2021; 28:1087-1095. [PMID: 33886077 DOI: 10.1007/s12282-021-01245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The efficacy of adjuvant endocrine therapy for hormone receptor-positive breast cancer has been previously established. However, significant adverse events related to endocrine therapy cannot be ignored. T1 breast cancer is expected to have a good prognosis. Therefore, adjuvant endocrine therapy for T1a breast cancer patients is controversial. Thus, in this study, we examined the effect of endocrine therapy on the prognosis of T1N0 hormone receptor-positive, HER2-negative breast cancer patients in each tumor size group, and re-considered the application of endocrine therapy. METHODS We retrospectively obtained clinical and pathological data from medical records of 7635 patients who underwent surgery for breast cancer at Aichi Cancer Hospital between January 2000 and December 2017. The primary end point of our analysis was disease-free survival (DFS). The secondary end points were distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS). The log-rank test, cumulative survival generated curves with Kaplan-Meier methods and the hazard ratio (HR) calculated with a Cox regression model were used to assess the effects of endocrine therapy on prognosis. RESULTS The 5-year DFS was worse in the non-endocrine therapy (non-ET) group (78%) than the endocrine therapy (ET) group (95%) in the T1c population (p < 0.001, HR 0.25). However, there was no statistically significant difference in DFS between the ET and the non-ET groups in T1a (ET 96% vs non-ET 93%, p = 0.9314, HR 0.94) and T1b (ET 96% vs non-ET 93%, p = 0.1481HR 0.53) breast cancer. The OS, DDFS, and BCSS of the patients also showed that endocrine therapy was associated with improvement of the prognosis in the T1c group, but not in the T1a and T1b groups. CONCLUSIONS Adjuvant endocrine therapy may be essential for T1c breast cancer patients. In contrast, this therapy should be discussed for T1a and T1b luminal breast cancer patients under some circumstances, such as suffering from adverse events.
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Cardiovascular toxicity of breast cancer treatment: an update. Cancer Chemother Pharmacol 2021; 88:15-24. [PMID: 33864486 DOI: 10.1007/s00280-021-04254-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
Novel chemotherapeutic agents have marked a new era in oncology during the past decade, prolonging significantly the overall survival of breast cancer patients. Nevertheless, contemporary antineoplastic treatments can frequently cause adverse cardiovascular side effects. Common manifestations of chemotherapy-induced cardiotoxicity include cardiomyopathy, ischemia, conduction disturbances, hypertension and thromboembolic events, while the type of the treatment regimen administered crucially determines clinical outcome. The aim of this literature review is to analyze the incidence and the underlying mechanisms of cardiovascular toxicity caused by agents approved for breast cancer, as well as to describe ways of monitoring and treating the cardiotoxic effects in breast cancer patients. Moreover, our work intends to provide an easy-to-grasp synopsis of recent and clinically meaningful advances in the field.
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Adjuvant endocrine therapy in HER2-positive breast cancer patients: systematic review and meta-analysis. ESMO Open 2021; 6:100088. [PMID: 33735801 PMCID: PMC7988286 DOI: 10.1016/j.esmoop.2021.100088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/13/2021] [Indexed: 01/22/2023] Open
Abstract
Background Approximately 50% of human epidermal growth factor receptor 2 (HER2)-positive breast cancer lesions express hormone receptors. These tumors present a unique therapeutic challenge, and the optimal endocrine therapeutic approach remains controversial. We aimed to study the optimal adjuvant endocrine therapy in this setting, to better establish the basis for clinical recommendations in HER2-positive disease. Methods We conducted a literature search up to May 2020, in which we identified randomized controlled trials (RCTs) that investigated the efficacy of various adjuvant hormonal therapies among premenopausal and postmenopausal patients with hormone receptor (HR)-positive, HER2-positive early breast cancer. Disease-free survival (DFS) was calculated with the random effect model and hazard ratios (HRs) with 95% confidence intervals (CI). Results Six RCTs (N = 5390 patients) were included in the final analysis. There was no significant difference in DFS between adjuvant treatment with aromatase inhibitors and tamoxifen (HR 0.99, 95% CI 0.68-1.44, P = 0.96). Furthermore, after omitting the ALTTO trial, as it did not randomize patients to hormonal therapy, no significant difference was observed between the two protocols (HR 1.06, 95% CI 0.65-1.73, P = 0.81). Conclusion Our study demonstrates similar DFS with tamoxifen and aromatase inhibitors as adjuvant endocrine treatment in HER2-positive HR-positive early-stage breast cancer patients. Future larger prospective studies focusing on the various contemporary endocrine regimens are warranted to validate our findings. Optimal adjuvant endocrine therapy for early-stage breast cancer with co-expression of HER2 and hr is unclear. Our analysis demonstrated no difference in disease-free survival between selected endocrine regimens among these patients. Study strength includes longer follow-up, premenopausal patients and current HER2 regimens and combinations.
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The variant T allele of PvuII in ESR1 gene is a prognostic marker in early breast cancer survival. Sci Rep 2021; 11:3249. [PMID: 33547330 PMCID: PMC7864972 DOI: 10.1038/s41598-021-82002-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 01/11/2021] [Indexed: 11/23/2022] Open
Abstract
The PvuII (rs2234693) Single Nucleotide Polymorphism (SNP) in the gene coding for the estrogen receptor-1 (ESR1), has been found associated with outcome in tamoxifen treated patients with early hormone-receptor positive breast cancer. However, it remains unclear whether this SNP is a predictive marker for tamoxifen efficacy or a prognostic marker for breast cancer outcome. The aim of this study was to examine the prognostic potential of this SNP in postmenopausal early breast cancer patients treated with adjuvant exemestane. Dutch postmenopausal patients randomised to 5 years of adjuvant exemestane of whom tissue was available (N = 807) were selected from the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial database. The SNP rs2234693 in the ESR1 gene was genotyped on DNA from formalin-fixed paraffin embedded (FFPE) tumor tissue using Taqman assays and related to the primary endpoint disease-free survival (DFS) and secondary endpoint overall survival (OS). Survival analyses were performed using Cox regression analysis. In total 805 patients were included in the analyses (median follow up of 5.22 years) and genotypes were obtained in 97% of the samples. The variant T allele of PvuII in ESR1 (rs2234693) was associated with a better DFS (hazard ratio (HR) 0.689, 95% confidence interval (CI) 0.480–0.989, P = 0.044) in univariate analysis only, and a better OS in both univariate (HR 0.616, 95%, CI 0.411–0.923, P = 0.019) and multivariate analyses (HR 0.571, 95% CI 0.380–0.856, P = 0.007), consistent with a prognostic rather than a predictive drug response effect. Variation of PvuII in the ESR1 gene is related to OS in postmenopausal, early HR + breast cancer patients treated with exemestane in the TEAM study. Variation in the ESR1 gene may therefore be a prognostic marker of early breast cancer survival, and warrants further research.
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Dowsett M, Sestak I, Cuzick J. Calibration of CTS5 in Women With Early Estrogen Receptor-Positive Breast Cancer. J Clin Oncol 2021; 39:338-339. [PMID: 33326252 DOI: 10.1200/jco.20.02551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/15/2020] [Indexed: 02/11/2024] Open
Affiliation(s)
- Mitch Dowsett
- Mitch Dowsett, PhD, Ralph Lauren Centre for Breast Cancer Research, Royal Marden Hospital, London, UK and Ivana Sestak, PhD and Jack Cuzick, PhD, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Ivana Sestak
- Mitch Dowsett, PhD, Ralph Lauren Centre for Breast Cancer Research, Royal Marden Hospital, London, UK and Ivana Sestak, PhD and Jack Cuzick, PhD, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Jack Cuzick
- Mitch Dowsett, PhD, Ralph Lauren Centre for Breast Cancer Research, Royal Marden Hospital, London, UK and Ivana Sestak, PhD and Jack Cuzick, PhD, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
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Iwase T, Wang X, Shrimanker TV, Kolonin MG, Ueno NT. Body composition and breast cancer risk and treatment: mechanisms and impact. Breast Cancer Res Treat 2021; 186:273-283. [PMID: 33475878 DOI: 10.1007/s10549-020-06092-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/31/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this review is to clarify the association of body composition with breast cancer risk and treatment, including physiological mechanisms, and to elucidate strategies for overcoming unfavorable body composition changes that relate to breast cancer progression. METHODS We have summarized updated knowledge regarding the mechanism of the negative association of altered body composition with breast cancer risk and treatment. We also review strategies for reversing unfavorable body composition based on the latest clinical trial results. RESULTS Body composition changes in patients with breast cancer typically occur during menopause or as a result of chemotherapy or endocrine therapy. Dysfunction of visceral adipose tissue (VAT) in the setting of obesity underlies insulin resistance and chronic inflammation, which can lead to breast cancer development and progression. Insulin resistance and chronic inflammation are also observed in patients with breast cancer who have sarcopenia or sarcopenic obesity. Nutritional support and a personalized exercise program are the fundamental interventions for reversing unfavorable body composition. Other interventions that have been explored in specific situations include metformin, testosterone, emerging agents that directly target the adipocyte microenvironment, and bariatric surgery. CONCLUSIONS A better understanding of the biology of body composition phenotypes is key to determining the best intervention program for patients with breast cancer.
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Affiliation(s)
- Toshiaki Iwase
- Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, TX, 77030, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Xiaoping Wang
- Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, TX, 77030, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Tushaar Vishal Shrimanker
- Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, TX, 77030, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Mikhail G Kolonin
- Center for Metabolic and Degenerative Diseases, The University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston, TX, 77030, USA
| | - Naoto T Ueno
- Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, TX, 77030, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Gordon-Craig S, Parks RM, Cheung KL. The Potential Use of Tumour-Based Prognostic and Predictive Tools in Older Women with Primary Breast Cancer: A Narrative Review. Oncol Ther 2020; 8:231-250. [PMID: 32700048 PMCID: PMC7366554 DOI: 10.1007/s40487-020-00123-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 01/09/2023] Open
Abstract
A move is under way towards personalised cancer treatment, where tumour biology of an individual patient is examined to give unique predictive and prognostic information. This is extremely important in the setting of older women, who have treatment-specific goals which may differ from their younger counterparts, and may include conservation of quality of life rather than curative intent of treatment. One method employed to assist with this is the use of tumour-based prognostic and predictive tools. This article explores six of the most common tumour-based tools currently available on the market: MammaPrint, Oncotype DX, Mammostrat, Prosigna, EndoPredict, IHC4. The article discusses the creation and validation of these tools, their use and validation in older women, and future directions in the field. With the exception of Oncotype Dx, which has also been licensed for prediction of response from adjuvant chemotherapy, these tools have been licensed for use as prognostic tools only, mainly in the setting of adjuvant therapy following surgery. The evidence base for use in older women is strongest for Mammostrat and PAM50, although overall the evidence is much weaker than that in younger women. Where older women have been included in validation studies, this is often in small numbers, or the exact proportion of older women is unknown. In practice, all six of the tools are recommended to be utilised on surgical excision specimens, as well as in core needle biopsy (CNB) specimens in all of the tools except Mammostrat. This is extremely important in the setting of older women, of whom a large proportion do not undergo surgery. The suggested nature of the sample is formalin-fixed paraffin-embedded in all the tools except MammaPrint, which can also be performed on fresh-frozen samples. Future development of prognostic tools in older women with breast cancer should focus on treatment dilemmas specific to this population. This includes the decision of primary treatment between surgery or endocrine therapy and decisions regarding adjuvant therapy, in particular, chemotherapy.
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Affiliation(s)
- Sophie Gordon-Craig
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
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The Evolving Complexity of Treating Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor-2 (HER2)-Negative Breast Cancer: Special Considerations in Older Breast Cancer Patients-Part I: Early-Stage Disease. Drugs Aging 2020; 37:331-348. [PMID: 32100240 DOI: 10.1007/s40266-020-00748-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The median age for breast cancer diagnosis is 62 years, but a disproportionate number of patients are over the age of 75 years and the majority of those have hormone receptor-positive, human epidermal growth factor receptor-2 (HER2)-negative cancers. This review provides a logical algorithm to guide providers through the many complicated issues involved in adjuvant systemic therapy decisions in older patients with hormone receptor-positive, HER2-negative breast cancer. For this subtype of breast cancer, the mainstay of treatment is surgery and adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor (AI). Adjuvant chemotherapy is added to the treatment regimen when the benefits of treatment are deemed to outweigh the risks, making the risk-benefit discussion particularly important in older women. Traditional tools for cancer risk assessment and genomic expression profiles (GEPs) are under-utilized in older patients, but yield equally useful information about cancer prognosis as they do in younger patients. Additionally, there are tools that estimate life-limiting toxicity risk from chemotherapy and life expectancy, which are both important issues in the risk-benefit discussion. For very low-risk cancers, such as non-invasive and small lymph node (LN)-negative cancers, the benefits of any adjuvant therapy is likely outweighed by the risks, but endocrine therapy might be considered to prevent future new breast cancers. For invasive tumors that are > 5 mm (T1b or larger) or involve LNs, adjuvant endocrine therapy is recommended. Generally, AIs should be included, though tamoxifen is effective and should be offered when AIs are not tolerated. Bone-preserving agents and high-dose vitamin D are options to preserve bone density or treat osteoporosis, especially in older women who are taking AIs. Where the risk-reducing benefit from adjuvant chemotherapy outweighs the toxicity risk, adjuvant chemotherapy should be considered. Adjuvant chemotherapy has similar benefits in older and younger patients and standard regimens are preferred. Several exciting clinic trials are underway and have included older patients, including those adding molecularly targeted agents, cyclin-dependent kinase (CDK) 4/6 inhibitors and everolimus, to endocrine therapy in the adjuvant setting. The high incidence of breast cancer in older women should drive us to design clinical trials for this population and emphasize their inclusion in ongoing trials as much as possible.
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Osteoporosis: A Long-Term and Late-Effect of Breast Cancer Treatments. Cancers (Basel) 2020; 12:cancers12113094. [PMID: 33114141 PMCID: PMC7690788 DOI: 10.3390/cancers12113094] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/07/2020] [Accepted: 10/19/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Osteoporosis is a prevalent condition affecting 200 million individuals world-wide. Estimates are about one in three women will experience a fragility fracture of hip, spine or wrist. Common breast cancer treatments, such as aromatase inhibitors in postmenopausal women and chemotherapy-induced ovarian failure in premenopausal women, cause bone loss that in some women will lead to osteoporosis and fragility fractures. Fragility fractures cause morbidity and mortality and are entirely preventable. Prevention or treatment of osteoporosis includes lifestyle modifications (e.g., reducing smoking and excessive alcohol consumption, and increasing physical activity), taking calcium and vitamin D3, screening for osteoporosis with dual-energy absorptiometry, and treatment, if clinically indicated, with ether oral bisphosphonates, intravenous zoledronic acid, or subcutaneous denosumab. This chapter reviews the pathogenesis of osteoporosis, the magnitude of bone loss related to common breast cancer treatments, osteoporosis risk factor assessment and screening, and the specific drugs to treat or prevent osteoporosis. Abstract Osteoporosis is both a long-term effect (occurs during treatment and extends after treatment) and a late-effect (occurs after treatment ends) of breast cancer treatments. The worldwide prevalence of osteoporosis is estimated to be some 200 million patients. About one in three postmenopausal women will experience an osteoporotic (or fragility) fracture of the hip, spine, or wrist. breast cancer treatments, including gonadotropin-releasing hormone (GnRH) agonists, chemotherapy-induced ovarian failure (CIOF), and aromatase inhibitors (AIs), cause bone loss and increase the risks of osteoporosis. Also, breast cancer is a disease of aging, and most of the “one in eight” lifetime risks of breast cancer are in women in their sixth, seventh, and eighth decades. The majority of women diagnosed with breast cancers today will be long-term survivors and experience personal cures. It is the coalescence of osteoporosis with breast cancer, two common and age-related conditions that make osteoporosis relevant in women with breast cancer throughout the continuum from diagnosis, treatment, and survivorship. It is critical to remember that women (and men) will lose bone after age thirty years. However, only certain women will lose bone of sufficient magnitude to merit treatment with anti-osteoporosis drugs. The narrative review is intended for medical, surgical, radiation oncologists, and other mid-level providers, and provides an overview of bone loss and the prevention and treatment of osteoporosis.
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[Hot flushes and breast cancer with positive hormone receptors: Mechanisms and management]. Bull Cancer 2020; 107:1171-1185. [PMID: 32988609 DOI: 10.1016/j.bulcan.2020.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022]
Abstract
Breast cancer is the most frequently diagnosed cancer in women and the first cause of cancer death in France. Among the different subtypes of breast cancer, the predominant form is characterized by positive hormone receptors (more than 70% of breast cancers). Hormone therapy thus plays a key role in the strategy of management of these cancers both in adjuvant and metastatic situations. The two types of adjuvant hormone therapy used are selective estrogen receptor modulators and aromatase inhibitors. Fulvestrant, an anti-estrogen, is used alone or in combination with other molecules in metastatic situations. Hot flashes are one of the symptoms most frequently reported by patients under hormone therapy. Hormone replacement therapy, which is currently the most effective treatment for hot flashes, is contraindicated in patients with a personal history of breast cancer. Various therapeutic classes of drugs have been tested in this indication but without real efficacy in the various studies carried out to date, and moreover associated with non-negligible side effects. The recent discovery of the implication of the kisspeptin system located at the hypothalamic level in the mechanism of genesis of hot flashes opens the way to possible new symptomatic treatments for hot flashes. Neurokinin 3 receptor antagonists have shown encouraging preliminary results in postmenopausal cancer-free patients and could be considered in patients in hormonal therapy for breast cancer. Broader additional studies are needed to confirm these initial results.
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Zhao F, Wang X, Wang Y, Zhang J, Lai R, Zhang B, Zhou X. The function of uterine UDP-glucuronosyltransferase 1A8 (UGT1A8) and UDP-glucuronosyltransferase 2B7 (UGT2B7) is involved in endometrial cancer based on estrogen metabolism regulation. Hormones (Athens) 2020; 19:403-412. [PMID: 32592099 DOI: 10.1007/s42000-020-00213-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/20/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The progression of endometrial cancer (EC) is closely related to estrogen levels. UDP-glucuronosyltransferases (UGTs) are an essential class of phase II metabolizing enzymes that play a pivotal role in detoxifying steroid hormone. PURPOSE In this study, we aimed to uncover the role of UGTs in estrogen metabolism and the pathogenesis of EC. METHODS A total of 100 unrelated EC patients (mean age 52.15 ± 10.04 y) and 100 healthy subjects (mean age 50.26 ± 8.80 y) were recruited for analysis of the UGT gene polymorphism and estrogen level. In six cases of EC, EC-adjacent tissues and cancer tissues were collected for detection of UGT expression. RESULTS Our results showed that the estrogen homeostasis profile was disturbed in EC patients, with carcinogenic catechol estrogens (4-OHE1, 2-OHE1, 2-OHE2) significantly accumulated in the serum of these patients. Also, levels of estrogen-glucuronides were decreased significantly, and the expression of UGT1A8 and UGT2B7 in uterine tissues was downregulated in EC patients. Consistent with this, we observed that the distribution of genotypes and allele frequencies in UGT1A8 rs1042597 and UGT2B7 rs7439366 was significantly different between EC patients and healthy volunteers. CONCLUSION These results indicated that UGT1A8 and UGT2B7 may contribute to the estrogen signaling pathway and the pathogenesis of EC.
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Affiliation(s)
- Feng Zhao
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, China
| | - Xi Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, China
| | - Yan Wang
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jingbo Zhang
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, China
| | - Ran Lai
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Bei Zhang
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, China
| | - Xueyan Zhou
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, China.
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Paluch-Shimon S, Cherny NI, de Vries EGE, Dafni U, Piccart MJ, Latino NJ, Cardoso F. Application of the ESMO-Magnitude of Clinical Benefit Scale (V.1.1) to the field of early breast cancer therapies. ESMO Open 2020; 5:e000743. [PMID: 32893189 PMCID: PMC7476474 DOI: 10.1136/esmoopen-2020-000743] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/19/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
Click here to listen to the Podcast BACKGROUND: The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated value scale for solid tumour anticancer treatments. Form 1 of the ESMO-MCBS, used to grade therapies with curative intent including adjuvant therapies, has only been evaluated for a limited number of studies. This is the first large-scale field testing in early breast cancer to assess the applicability of the scale to this data set and the reasonableness of derived scores and to identify any shortcomings to be addressed in future modifications of the scale. METHOD Representative key studies and meta-analyses of the major modalities of adjuvant systemic therapy of breast cancer were identified for each of the major clinical scenarios (HER2-positive, HER2-negative, endocrine-responsive) and were graded with form 1 of the ESMO-MCBS. These generated scores were reviewed by a panel of experts for reasonableness. Shortcomings and issues related to the application of the scale and interpretation of results were identified and critically evaluated. RESULTS Sixty-five studies were eligible for evaluation: 59 individual studies and 6 meta-analyses. These studies incorporated 101 therapeutic comparisons, 61 of which were scorable. Review of the generated scores indicated that, with few exceptions, they generally reflected contemporary standards of practice. Six shortcomings were identified related to grading based on disease-free survival (DFS), lack of information regarding acute and long-term toxicity and an inability to grade single-arm de-escalation scales. CONCLUSIONS Form 1 of the ESMO-MCBS is a robust tool for the evaluation of the magnitude of benefit studies in early breast cancer. The scale can be further improved by addressing issues related to grading based on DFS, annotating grades with information regarding acute and long-term toxicity and developing an approach to grade single-arm de-escalation studies.
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Affiliation(s)
| | | | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Urania Dafni
- National and Kapodistrian University of Athens, Athens, Greece; Frontier Science Foundation-Hellas, Athens, Greece
| | - Martine J Piccart
- Université Libre de Bruxelles, Institut Jules Bordet, Bruxelles, Belgium
| | - Nicola Jane Latino
- ESMO-MCBS Working Group, European Society for Medical Oncology, Viganello, Switzerland
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
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