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Leone JP, Cole BF, Regan MM, Thürlimann B, Coates AS, Rabaglio M, Giobbie-Hurder A, Gelber RD, Ejlertsen B, Harvey VJ, Neven P, Láng I, Bonnefoi H, Wardley A, Goldhirsch A, Di Leo A, Colleoni M, Vaz-Luis I, Lin NU. Clinical behavior of recurrent hormone receptor-positive breast cancer by adjuvant endocrine therapy within the Breast International Group 1-98 clinical trial. Cancer 2020; 127:700-708. [PMID: 33290610 DOI: 10.1002/cncr.33318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endocrine therapy resistance is a major cause of distant recurrence (DR) in hormone receptor-positive breast cancer. This study evaluated differences in survival after DR in patients treated with different adjuvant endocrine therapy regimens in the Breast International Group (BIG) 1-98 trial. METHODS BIG 1-98 compared 5 years of adjuvant treatment among 4 arms: tamoxifen (T), letrozole (L), tamoxifen followed by letrozole (TL), and letrozole followed by tamoxifen (LT). After a median follow-up of 8.1 years, 911 of 8010 patients (T, 302; L, 285; TL, 170; and LT, 154) had DR as the site of first recurrence. Univariate and multivariate Cox analyses were performed to determine features associated with post-DR survival. RESULTS The median follow-up time after DR was 59 months (interquartile range, 29-88 months). Among all patients with DR, 38.1% were 65 years old or older at enrollment, 61.9% had tumors larger than 2 cm, and 69.7% were node positive. Neoadjuvant or adjuvant chemotherapy was administered to 35.6% of the patients. There was no difference in post-DR survival by treatment arm (median survival, 20.8 months for T, 17.9 months for L, 17.3 months for TL, and 20.8 months for LT; P = .21). In multivariate analysis, older patients (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.15-1.59) and patients with tumors larger than 2 cm (HR, 1.19; 95% CI, 1.00-1.41), 4 or more positive nodes (HR, 1.31; 95% CI, 1.05-1.64), progesterone receptor (PR)-negative tumors (HR, 1.25; 95% CI, 1.02-1.52), or shorter disease-free survival (DFS) had significantly worse post-DR survival. CONCLUSIONS Treatment with adjuvant T, L, or their sequences was not associated with differences in survival after DR. Significant differences in survival were observed by age, primary tumor size, nodal and PR status, and DFS, and this suggests that traditional baseline high-risk features remain prognostic in the metastatic setting.
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Affiliation(s)
- Jose P Leone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bernard F Cole
- Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont
| | - Meredith M Regan
- International Breast Cancer Study Group Statistical Center, Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Beat Thürlimann
- Kantonsspital St. Gallen, St. Gallen, Switzerland.,International Breast Cancer Study Group and Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Alan S Coates
- International Breast Cancer Study Group and University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Rabaglio
- International Breast Cancer Study Group Coordinating Center, Bern, Switzerland.,Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Anita Giobbie-Hurder
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Richard D Gelber
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Bent Ejlertsen
- Department of Oncology, Centre for Cancer and Organ Diseases, University of Copenhagen, Copenhagen, Denmark
| | - Vernon J Harvey
- Regional Cancer and Blood Service, Auckland City Hospital, Auckland, New Zealand
| | - Patrick Neven
- Department of Oncology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Istvan Láng
- Oncology Clinic, Istenhegyi Géndiagnosztika Private Health Center, Budapest, Hungary
| | - Herve Bonnefoi
- Department of Medical Oncology, Bergonié Institute, Bordeaux, France
| | - Andrew Wardley
- National Institute for Health Research Manchester Clinical Research Facility at the Christie National Health Service Foundation Trust, Manchester Academic Health Science Centre and Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Aron Goldhirsch
- International Breast Cancer Study Group and Swiss Group for Clinical Cancer Research, Bern, Switzerland.,European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | - Ines Vaz-Luis
- National Institute of Health and Medical Research Unit 981, Gustave Roussy Institute, Villejuif, France
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Nishio E, Hayashi T, Akaza M, Hisatomi Y, Hikichi M, Fujii T, Utsumi T, Harada N, Shimono Y. Upregulation of CIP2A in estrogen depletion-resistant breast cancer cells treated with low-dose everolimus. FEBS Open Bio 2020; 10:2072-2080. [PMID: 32810922 PMCID: PMC7530388 DOI: 10.1002/2211-5463.12956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 07/31/2020] [Accepted: 08/16/2020] [Indexed: 12/31/2022] Open
Abstract
Everolimus (EVE), an inhibitor of mammalian target of rapamycin, is an emerging second‐line therapeutic option for hormone therapy‐resistant breast cancers. However, some patients do not respond to EVE, whereas in others it exacerbates the disease. Cellular inhibitor of protein phosphatase 2A (CIP2A) is a human oncoprotein that can promote cancer cell growth and apoptosis resistance. Although CIP2A is upregulated in hormone‐related cancers, such as breast cancer, little is known about potential anti‐tumor effects of downregulating CIP2A. As a model to study the resistance of breast cancer cells to hormone treatment, we previously established clones of long‐term estrogen depletion‐resistant MCF‐7 (LTED) cells. Here, we selected three clones highly responsive to EVE and three clones poorly responsive to EVE. When cells were treated with EVE, CIP2A mRNA expression was decreased in highly responsive EVE clones (DC‐cells) whereas it was increased in poorly responsive EVE clones (IC‐cells). Using Kaplan–Meier survival plots, we report that high expression of CIP2A was associated with significantly reduced overall survival in patients with luminal A breast cancer. In IC‐cells, cell growth was enhanced upon EVE treatment whereas an EVE range of 0.1–100 nm decreased growth in DC‐cells. The mRNA expression of genes involved in epithelial–mesenchymal transition (EMT) such as CDH1, CLDN3, and CK19 was significantly decreased in IC‐cells, but remained unchanged in DC‐cells. These findings highlight a relationship between CIP2A and EMT in the intrinsic resistance of hormone therapy‐resistant breast cancers to EVE.
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Affiliation(s)
- Eiji Nishio
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takanori Hayashi
- Department of Biochemistry, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mao Akaza
- Department of Biochemistry, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yukiko Hisatomi
- Department of Biochemistry, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masahiro Hikichi
- Department of Breast Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takuma Fujii
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Toshiaki Utsumi
- Department of Breast Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Nobuhiro Harada
- Department of Biochemistry, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yohei Shimono
- Department of Biochemistry, Fujita Health University School of Medicine, Toyoake, Japan
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Chottanapund S, Van Duursen MBM, Navasumrit P, Hunsonti P, Timtavorn S, Ruchirawat M, Van den Berg M. Anti-aromatase effect of resveratrol and melatonin on hormonal positive breast cancer cells co-cultured with breast adipose fibroblasts. Toxicol In Vitro 2014; 28:1215-21. [PMID: 24929094 DOI: 10.1016/j.tiv.2014.05.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/27/2014] [Accepted: 05/29/2014] [Indexed: 12/29/2022]
Abstract
Targeting the estrogen pathway has been proven effective in the treatment for estrogen receptor positive breast cancer. There are currently two common groups of anti-estrogenic compounds used in the clinic; Selective Estrogen Receptor Modulators (SERMs, e.g. tamoxifen) and Selective Estrogen Enzyme Modulators (SEEMs e.g. letrozole). Among various naturally occurring, biologically active compounds, resveratrol and melatonin have been suggested to act as aromatase inhibitors, which make them potential candidates in hormonal treatment of breast cancer. Here we used a co-culture model in which we previously demonstrated that primary human breast adipose fibroblasts (BAFs) can convert testosterone to estradiol, which subsequently results in estrogen receptor-mediated breast cancer T47D cell proliferation. In the presence of testosterone in this model, we examined the effect of letrozole, resveratrol and melatonin on cell proliferation, estradiol (E2) production and gene expression of CYP19A1, pS2 and Ki-67. Both melatonin and resveratrol were found to be aromatase inhibitors in this co-culture system, albeit at different concentrations. Our co-culture model did not provide any indications that melatonin is also a selective estrogen receptor modulator. In the T47D-BAF co-culture, a melatonin concentration of 20 nM and resveratrol concentration of 20 μM have an aromatase inhibitory effect as potent as 20 nM letrozole, which is a clinically used anti-aromatase drug in breast cancer treatment. The SEEM mechanism of action of especially melatonin clearly offers potential advantages for breast cancer treatment.
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Affiliation(s)
- Suthat Chottanapund
- Division of Environmental Toxicology, Chulabhorn Graduate Institute, Bangkok, Thailand; Laboratory of Environmental Toxicology, Chulabhorn Research Institute, Bangkok, Thailand; Center of Excellence on Environmental Health, Toxicology and Management of Chemicals, Bangkok, Thailand; Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Thailand.
| | - M B M Van Duursen
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Panida Navasumrit
- Division of Environmental Toxicology, Chulabhorn Graduate Institute, Bangkok, Thailand; Laboratory of Environmental Toxicology, Chulabhorn Research Institute, Bangkok, Thailand; Center of Excellence on Environmental Health, Toxicology and Management of Chemicals, Bangkok, Thailand
| | - Potchanee Hunsonti
- Laboratory of Environmental Toxicology, Chulabhorn Research Institute, Bangkok, Thailand
| | - Supatchaya Timtavorn
- Laboratory of Environmental Toxicology, Chulabhorn Research Institute, Bangkok, Thailand
| | - Mathuros Ruchirawat
- Division of Environmental Toxicology, Chulabhorn Graduate Institute, Bangkok, Thailand; Laboratory of Environmental Toxicology, Chulabhorn Research Institute, Bangkok, Thailand; Center of Excellence on Environmental Health, Toxicology and Management of Chemicals, Bangkok, Thailand
| | - Martin Van den Berg
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
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Lintermans A, Laenen A, Van Calster B, Van Hoydonck M, Pans S, Verhaeghe J, Westhovens R, Henry NL, Wildiers H, Paridaens R, Dieudonné AS, Leunen K, Morales L, Verschueren K, Timmerman D, De Smet L, Vergote I, Christiaens MR, Neven P. Prospective study to assess fluid accumulation and tenosynovial changes in the aromatase inhibitor-induced musculoskeletal syndrome: 2-year follow-up data. Ann Oncol 2013; 24:350-355. [PMID: 23038762 DOI: 10.1093/annonc/mds290] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aromatase inhibitors (AIs) frequently lead to the AI-induced musculoskeletal syndrome (AIMSS). Looking into its pathophysiology, 6 months of AI therapy thickens the tendon sheath with intra-articular fluid (IAF) retention and loss of grip strength. We here report 24-month follow-up data. PATIENTS AND METHODS A prospective cohort study of 33 postmenopausal breast cancer patients received adjuvant endocrine therapy; 27 received an AI and 6 received tamoxifen. At baseline, 6 and 24 months patients had a rheumatologic examination, including a grip strength test, and magnetic resonance imaging of both hands and wrists. The primary end point was tenosynovial changes; secondary end points were changes in morning stiffness, grip strength and IAF. RESULTS Twenty-three AI and 5 tamoxifen patients completed all investigations. Between month 6 and 24, IAF further increased in AI users (P = 0.04) but not in tamoxifen users, and grip strength further decreased in both groups. The worsened tenosynovial changes were strongly correlated with a decrease in grip strength. At 24 months, morning stiffness continued to be present in over a third of AI users. CONCLUSION AIMSS represents a substantial problem in breast cancer patients. It is associated with tenosynovial changes, IAF retention, joint stiffness and loss of grip strength that do not improve with prolonged use.
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Affiliation(s)
- A Lintermans
- Department of Obstetrics and Gynecology, KU Leuven, Leuven.
| | - A Laenen
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven; Leuven Cancer Institute (LKI), KU Leuven, Leuven
| | - B Van Calster
- Leuven Cancer Institute (LKI), KU Leuven, Leuven; Department of Development and Regeneration, KU Leuven, Leuven
| | | | - S Pans
- Department of Radiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - J Verhaeghe
- Department of Obstetrics and Gynecology, KU Leuven, Leuven
| | | | - N L Henry
- Breast Oncology Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, USA
| | - H Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, KU Leuven, Leuven; Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
| | - R Paridaens
- Department of General Medical Oncology, University Hospitals Leuven, KU Leuven, Leuven; Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
| | - A S Dieudonné
- Department of Obstetrics and Gynecology, KU Leuven, Leuven
| | - K Leunen
- Department of Obstetrics and Gynecology, KU Leuven, Leuven; Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
| | - L Morales
- Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
| | | | - D Timmerman
- Department of Obstetrics and Gynecology, KU Leuven, Leuven
| | - L De Smet
- Orthopedic Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - I Vergote
- Department of Obstetrics and Gynecology, KU Leuven, Leuven; Leuven Cancer Institute (LKI), KU Leuven, Leuven
| | - M R Christiaens
- Department of Obstetrics and Gynecology, KU Leuven, Leuven; Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
| | - P Neven
- Department of Obstetrics and Gynecology, KU Leuven, Leuven; Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven
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Shibahara Y, Miki Y, Ishida T, Nakamura Y, Suzuki T, Ohuchi N, Sasano H. Immunohistochemical analysis of aromatase in metastatic lymph nodes of breast cancer. Pathol Int 2012; 63:20-8. [DOI: 10.1111/pin.12015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/08/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Yukiko Shibahara
- Department of Pathology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Yasuhiro Miki
- Department of Pathology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Takanori Ishida
- Division of Surgical Oncology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Yasuhiro Nakamura
- Department of Pathology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Takashi Suzuki
- Department of Pathology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Noriaki Ohuchi
- Division of Surgical Oncology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
| | - Hironobu Sasano
- Department of Pathology; Tohoku University Graduate School of Medicine; Sendai; Miyagi; Japan
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Rizzoli R, Body JJ, DeCensi A, Reginster JY, Piscitelli P, Brandi ML. Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper. Osteoporos Int 2012; 23:2567-76. [PMID: 22270857 DOI: 10.1007/s00198-011-1870-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/05/2011] [Indexed: 10/14/2022]
Abstract
UNLABELLED Aromatase inhibitors (AIs) are widely used in women with breast cancer, but they are known to increase bone loss and risk of fractures. Based on available evidence and recommendations, an ESCEO working group proposes specific guidance for the prevention of AIs-induced bone loss and fragility fractures. INTRODUCTION Aromatase inhibitors (AIs) are now the standard treatment for hormone receptor-positive breast cancer. However, deleterious effects of AIs on bone health have been reported. An ESCEO working group proposes guidance for the prevention of bone loss and fragility fractures in post-menopausal women with breast cancer receiving AIs. METHODS A panel of experts addressed the issue of skeletal effects of AIs and effectiveness of antifracture therapies for the prevention of AI-induced bone loss and fractures. Recommendations by national and international organizations, and experts' opinions on this topic were evaluated. RESULTS All aromatase inhibitors are associated with negative effects on the skeleton, resulting in bone loss and increased risk of fragility fractures. Current guidelines suggest approaches that differ both in terms of drugs proposed for fracture prevention and duration of treatment. CONCLUSION The ESCEO working group recommends that all AI-treated women should be evaluated for fracture risk. Besides general recommendations, zoledronic acid 4 mg i.v. every 6 months, denosumab s.c., or possibly oral bisphosphonates should be administered for the entire period of AI treatment to all osteoporotic women (T-score hip/spine <-2.5 or ≥ 1 prevalent fragility fracture), to women aged ≥ 75 irrespective of BMD, and to patients with T-score <-1.5 + ≥ 1 clinical risk factor or T-score <-1.0 + ≥ 2 clinical risk factors. Alternatively, therapy could be considered in patients with a FRAX-determined 10-year hip fracture probability ≥ 3%.
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Affiliation(s)
- R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Body JJ. Aromatase inhibitors-induced bone loss in early breast cancer. BONEKEY REPORTS 2012; 1:201. [PMID: 24936287 PMCID: PMC4056949 DOI: 10.1038/bonekey.2012.201] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/26/2012] [Indexed: 12/31/2022]
Abstract
Women with breast cancer have an increased prevalence and incidence of fractures. This increased risk of fracture has become most evident following the use of aromatase inhibitors (AIs) as standard adjuvant therapy. AI-induced bone loss occurs at more than twice the rate of physiologic postmenopausal bone loss. Moreover, peripheral quantitative computed tomography data indicate that effects of AIs on bone strength and on cortical bone have been substantially underestimated by dual-energy X-ray absorptiometry. All AIs have been associated with an increased fracture risk. The incidence of fractures is at least 33-43% higher in AI-treated patients than in tamoxifen-treated patients, and this increase in fracture risk is maintained at least for the duration of AI therapy. Over the last few years, clinical trials have established the effectiveness of bisphosphonates and denosumab to preserve and even increase bone mineral density (BMD) during adjuvant AIs. Most data have been obtained with zoledronic acid administered twice a year, which effectively maintains or increases BMD in women receiving AIs. In addition, zoledronic acid has been shown to delay disease recurrence and maybe prolong survival in women with hormone-responsive tumors, thereby providing an adjuvant antitumor benefit besides preserving BMD. It is likely that a combined fracture risk assessment will more accurately identify women with breast cancer who require bone protective therapy. The FRAX tool probably underestimates the net increase in fracture risk due to AI therapy. Recent guidelines for the prevention of AI-induced bone loss have adequately considered the presence of several established clinical risk factors for fractures, in addition to BMD, when selecting patients to be treated with inhibitors of bone resorption.
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Affiliation(s)
- Jean-Jacques Body
- CHU Brugmann, Department of Medicine, Université Libre de Bruxelles, Brussels, Belgium
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Shibahara Y, Miki Y, Onodera Y, Hata S, Chan MSM, Yiu CCP, Loo TY, Nakamura Y, Akahira JI, Ishida T, Abe K, Hirakawa H, Chow LWC, Suzuki T, Ouchi N, Sasano H. Aromatase inhibitor treatment of breast cancer cells increases the expression of let-7f
, a microRNA targeting CYP19A1. J Pathol 2012; 227:357-66. [DOI: 10.1002/path.4019] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 02/07/2012] [Accepted: 02/21/2012] [Indexed: 12/11/2022]
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Cohen MH, Johnson JR, Justice R, Pazdur R. Approval summary: letrozole (Femara® tablets) for adjuvant and extended adjuvant postmenopausal breast cancer treatment: conversion of accelerated to full approval. Oncologist 2011; 16:1762-70. [PMID: 22089970 DOI: 10.1634/theoncologist.2011-0287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
On April 30, 2010, the U.S. Food and Drug Administration converted letrozole (Femara®; Novartis Pharmaceuticals Corporation, East Hanover, NJ) from accelerated to full approval for adjuvant and extended adjuvant (following 5 years of tamoxifen) treatment of postmenopausal women with hormone receptor-positive early breast cancer. The initial accelerated approvals of letrozole for adjuvant and extended adjuvant treatment on December 28, 2005 and October 29, 2004, respectively, were based on an analysis of the disease-free survival (DFS) outcome of patients followed for medians of 26 months and 28 months, respectively. Both trials were double-blind, multicenter studies. Both trials were unblinded early when an interim analysis showed a favorable letrozole effect on DFS. In updated intention-to-treat analyses of both trials, the risk for a DFS event was lower with letrozole than with tamoxifen (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.77-0.99; p = .03) in the adjuvant trial and was lower than with placebo (HR, 0.89; 95% CI, 0.76-1.03; p = .12) in the extended adjuvant trial. The latter analysis ignores the interim switch of 60% of placebo-treated patients to letrozole. Bone fractures and osteoporosis were reported more frequently following treatment with letrozole whereas tamoxifen was associated with a higher risk for endometrial proliferation and endometrial cancer. Myocardial infarction was more frequently reported with letrozole than with tamoxifen, but the incidence of thromboembolic events was higher with tamoxifen than with letrozole. Lipid-lowering medications were required for 25% of patients on letrozole and 16% of patients on tamoxifen.
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Affiliation(s)
- Martin H Cohen
- Office of Oncology Drug Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993-0002, USA.
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11
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Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. Lancet Oncol 2010; 11:1135-41. [PMID: 21087898 DOI: 10.1016/s1470-2045(10)70257-6] [Citation(s) in RCA: 648] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial was designed to compare the efficacy and safety of anastrozole (1 mg) with tamoxifen (20 mg), both given orally every day for 5 years, as adjuvant treatment for postmenopausal women with early-stage breast cancer. In this analysis, we assess the long-term outcomes after a median follow-up of 120 months. METHODS We used a proportional hazards model to assess the primary endpoint of disease-free survival, and the secondary endpoints of time to recurrence, time to distant recurrence, incidence of new contralateral breast cancer, overall survival, and death with or without recurrence in all randomised patients (anastrozole n=3125, tamoxifen n=3116) and hormone-receptor-positive patients (anastrozole n=2618, tamoxifen n=2598). After treatment completion, we continued to collect data on fractures and serious adverse events in a masked fashion (safety population: anastrozole n=3092, tamoxifen n=3094). This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN18233230. FINDINGS Patients were followed up for a median of 120 months (range 0-145); there were 24,522 woman-years of follow-up in the anastrozole group and 23,950 woman-years in the tamoxifen group. In the full study population, there were significant improvements in the anastrozole group compared with the tamoxifen group for disease-free survival (hazard ratio [HR] 0·91, 95% CI 0·83-0·99; p=0·04), time to recurrence (0·84, 0·75-0·93; p=0·001), and time to distant recurrence (0·87, 0·77-0·99; p=0·03). For hormone-receptor-positive patients, the results were also significantly in favour of the anastrozole group for disease-free survival (HR 0·86, 95% CI 0·78-0·95; p=0·003), time to recurrence (0·79, 0·70-0·89; p=0·0002), and time to distant recurrence (0·85, 0·73-0·98; p=0·02). In hormone-receptor-positive patients, absolute differences in time to recurrence between anastrozole and tamoxifen increased over time (2·7% at 5 years and 4·3% at 10 years) and recurrence rates remained significantly lower on anastrozole than tamoxifen after treatment completion (HR 0·81, 95% CI 0·67-0·98; p=0·03), although the carryover benefit was smaller after 8 years. There was weak evidence of fewer deaths after recurrence with anastrozole compared with tamoxifen treatment in the hormone-receptor-positive subgroup (HR 0·87, 95% CI 0·74-1·02; p=0·09), but there was little difference in overall mortality (0·95, 95% CI 0·84-1·06; p=0·4). Fractures were more frequent during active treatment in patients receiving anastrozole than those receiving tamoxifen (451 vs 351; OR 1·33, 95% CI 1·15-1·55; p<0·0001), but were similar in the post-treatment follow-up period (110 vs 112; OR 0·98, 95% CI 0·74-1·30; p=0·9). Treatment-related serious adverse events were less common in the anastrozole group than the tamoxifen group (223 anastrozole vs 369 tamoxifen; OR 0·57, 95% CI 0·48-0·69; p<0·0001), but were similar after treatment completion (66 vs 78; OR 0·84, 95% CI 0·60-1·19; p=0·3). No differences in non-breast cancer causes of death were apparent and the incidence of other cancers was similar between groups (425 vs 431) and continue to be higher with anastrozole for colorectal (66 vs 44) and lung cancer (51 vs 34), and lower for endometrial cancer (six vs 24), melanoma (eight vs 19), and ovarian cancer (17 vs 28). No new safety concerns were reported. INTERPRETATION These data confirm the long-term superior efficacy and safety of anastrozole over tamoxifen as initial adjuvant therapy for postmenopausal women with hormone-sensitive early breast cancer.
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Lin SX, Chen J, Mazumdar M, Poirier D, Wang C, Azzi A, Zhou M. Molecular therapy of breast cancer: progress and future directions. Nat Rev Endocrinol 2010; 6:485-93. [PMID: 20644568 DOI: 10.1038/nrendo.2010.92] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Breast cancer is a major cause of death in Western women, with a 10% lifetime risk of the disease. Most breast cancers are estrogen-dependent. Molecular therapies for breast cancer have developed rapidly in the past few decades and future treatment strategies are being investigated. The selective estrogen receptor (ER) modulator tamoxifen, which until now has served as a standard therapy, functions not only as an estrogen antagonist but also as an estrogen agonist in terms of bone maintenance. Aromatase inhibitors have performed well in international trials and have become a new standard therapy for estrogen-dependent breast cancer. The systematic study of estrogen activation pathways suggests that the enzymes steroid sulfatase and 17beta-hydroxysteroid dehydrogenase type 1, which both have pivotal roles in estrogen biosynthesis, are promising targets; the results of a phase I trial of steroid sulfatase inhibitors are encouraging. The activity of the human epidermal growth factor receptor (HER) pathway correlates negatively with that of the ER. HER2 is overexpressed in 22% of all breast cancers. In the decade since HER2 began being targeted, the monoclonal antibody trastuzumab has been used as well as pertuzumab and HER2 vaccines. Among the estrogen-independent breast cancers, the basal-like subtype has low survival, and therapeutic improvement is a priority. Crosstalk between ER and HER2 signaling pathways means that combinatory therapies may hold the key to enhancement of treatment responses. Other molecular therapies involving functional genomics and RNA interference studies also hold promise.
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Affiliation(s)
- Sheng-Xiang Lin
- Laboratory of Molecular Endocrinology and Oncology, CHUL (CHUQ) Research Center and Laval University, 2705 Boulevard Laurier, QC G1V 4G2, Canada.
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