Therapeutic effects of the aromatase inhibitor fadrozole hydrochloride in advanced breast cancer

Towards understanding aromatase inhibitory activity via QSAR modeling

Aromatase is a rate-limiting enzyme for estrogen biosynthesis that is overproduced in breast cancer tissue. To block the growth of breast tumors, aromatase inhibitors (AIs) are employed to bind and inhibit aromatase in order to lower the amount of estrogen produced in the body. Although a number of synthetic aromatase inhibitors have been released for clinical use in the treatment of hormone-receptor positive breast cancer, these inhibitors may lead to undesirable side effects (e.g. increased rash, diarrhea and vomiting; effects on the bone, brain and heart) and therefore, the search for novel AIs continues. Over the past decades, there has been an intense effort in employing medicinal chemistry and quantitative structure-activity relationship (QSAR) to shed light on the mechanistic basis of aromatase inhibition. To the best of our knowledge, this article constitutes the first comprehensive review of all QSAR studies of both steroidal and non-steroidal AIs that have been published in the field. Herein, we summarize the experimental setup of these studies as well as summarizing the key features that are pertinent for robust aromatase inhibition.

Estrogen receptor agonists/antagonists in breast cancer therapy: A critical review

Estrogens display intriguing tissue selective action that is of great biomedical importance in the development of optimal therapeutics for the prevention and treatment of breast cancer. There are also strong evidences to show that both endogenous and exogenous estrogens are involved in the pathogenesis of breast cancer. Tamoxifen has been the only drug of choice for more than 30years to treat patients with estrogen related (ER) positive breast tumors. There is a need therefore, for identifying newer, potential and novel candidates for breast cancer. Keeping this in view, the present review focuses on selective estrogen receptor modulators and estrogen antagonists such as sulfatase and aromatase inhibitors involved in breast cancer therapy. A succinct and critical overview of the structure of estrogen receptors, their signaling and involvement in breast carcinogenesis are herein described.

Effects of bisphenol A and fadrozole exposures on cyp19a1 expression in the Murray rainbowfish, Melanotaenia fluviatilis

Several endocrine-disrupting chemicals (EDCs) have been attributed to the alteration of reproduction in fish through disrupting endogenous sex steroidogenic pathways including aromatisation of androgens to oestrogen by CYP19 aromatase. Here we investigate this hypothesis in adult male and female Melanotaenia fluviatilis by examining the mRNA expression of cyp19a1 isoforms after exposure for ≤96 h to two EDCs with contrasting modes of action: one a weak oestrogen mimic, bisphenol A [BPA (100 or 500 μg/L)], and the other a nonsteroidal aromatase inhibitor, fadrozole [FAD (10 or 50 µg/L)]. The results suggest that BPA did not affect cyp19a1a expression significantly at both concentrations, whereas 50 µg/L of FAD significantly upregulated its expression in ovary. In contrast, BPA exposures increased expression of cyp19a1b in brain of both males and females, whilst FAD had contrasting effects in brain: It increased in males but decreased in females. Similar contrasting responses of cyp19a1b were induced by BPA in gonads: upregulation in ovary and downregulation in testis. FAD did not have a significant effect on gonadal expression of cyp19a1b. Collectively, the results suggest that BPA and FAD can disrupt cyp19a1b activity more readily than can cyp19a1a, albeit with contrasting effects in either a tissue- or sex-specific context that is conceivably consistent with their (BPA and FAD) opposing modes of action. Enhanced spatial and temporal sensitivity of cyp19a1b compared with cyp19a1a suggests that brain sex of fish is more susceptible to disruption by environmental pollutants such as BPA and FAD. Therefore, we propose that the response of cyp19a1b in brain tissue of M. fluviatilis is a more suitable indicator of oestrogenic pollution in the aquatic environment.

Aromatase inhibitors for treatment of advanced breast cancer in postmenopausal women

BACKGROUND

Endocrine therapy removes the influence of oestrogen on breast cancer cells and so hormonal treatments such as tamoxifen, megestrol acetate and medroxyprogesterone acetate have been in use for many years for advanced breast cancer. Aromatase inhibitors (AIs) inhibit oestrogen synthesis in the peripheral tissues and have a similar tumour-regressing effect to other endocrine treatments. Aminoglutethimide was the first AI in clinical use and now the third generation AIs, anastrozole, exemestane and letrozole, are in current use. Randomised trial evidence on response rates and side effects of these drugs is still limited.

OBJECTIVES

To compare AIs to other endocrine therapy in the treatment of advanced breast cancer in postmenopausal women.

SEARCH STRATEGY

For this update, the Cochrane Breast Cancer Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) and relevant conference proceedings were searched (to 30 June 2008).

SELECTION CRITERIA

Randomised controlled trials in postmenopausal women comparing the effects of any AI versus other endocrine therapy, no endocrine therapy, or a different AI in the treatment of advanced (metastatic) breast cancer. Non-English language publications, comparisons of the same AI at different doses, AIs used as neoadjuvant treatment, or outcomes not related to tumour response were excluded.

DATA COLLECTION AND ANALYSIS

Data from published trials were extracted independently by two review authors and cross-checked by a third. Hazard ratios (HR) were derived for analysis of time-to-event outcomes (overall and progression-free survival). Odds ratios (OR) were derived for objective response, clinical benefit, and toxicity.

MAIN RESULTS

Thirty-seven trials were identified, 31 of which were included in the main analysis of any AI versus any other treatment (11,403 women). No trials were excluded due to inadequate allocation concealment. The pooled estimate showed a significant survival benefit for treatment with an AI over other endocrine therapies (HR 0.90, 95% CI 0.84 to 0.97). A subgroup analysis of the three commonly prescribed AIs (anastrozole, exemestane, letrozole) also showed a similar survival benefit (HR 0.88, 95% CI 0.80 to 0.96). There were very limited data to compare one AI with a different AI, but these suggested an advantage for letrozole over anastrozole.AIs have a different toxicity profile to other endocrine therapies. For those currently prescribed, and for all AIs combined, they had similar levels of hot flushes and arthralgia; increased risks of rash, nausea, diarrhoea and vomiting; but a 71% decreased risk of vaginal bleeding and 47% decrease in thromboembolic events compared with other endocrine therapies.

AUTHORS' CONCLUSIONS

In women with advanced (metastatic) breast cancer, aromatase inhibitors including those in current clinical use show a survival benefit when compared to other endocrine therapy.

Aromatase inhibitors for treatment of advanced breast cancer in postmenopausal women

BACKGROUND

Hormonal treatments for advanced or metastatic breast cancer, such as tamoxifen and the progestins megestrol acetate and medroxyprogesterone acetate, have been in use for many years. Aromatase inhibitors (AIs) are a class of compounds that systemically inhibit oestrogen synthesis in the peripheral tissues. Aminoglutethimide was the first AI in clinical use (first generation) and had a similar tumour-regressing effect to other endocrine treatments, which showed the potential of this alternative type of therapy. Other AIs have since been developed and the third generation AIs anastrozole, exemestane and letrozole are in current use. Randomised evidence on response rates and side effects of these drugs is still limited.

OBJECTIVES

To compare aromatase inhibitors to other endocrine therapy in the treatment of advanced breast cancer in postmenopausal women.

SEARCH STRATEGY

The Cochrane Breast Cancer Group Specialised Register was searched on 3 December 2004 using the codes for "advanced" and "endocrine therapy". Details of the search strategy applied to create the Register and the procedure used to code references are described in the Cochrane Breast Cancer Group module on The Cochrane Library. The search was updated to 30 September 2005 and additional publications were included. Experts were consulted to determine that no relevant studies had been excluded.

SELECTION CRITERIA

Randomised trials comparing the effects of any aromatase inhibitor versus other endocrine therapy, no endocrine therapy or a different aromatase inhibitor in the treatment of advanced (metastatic) breast cancer.

DATA COLLECTION AND ANALYSIS

Data from published trials were extracted by two independent review authors. A third independent author then carried out a further cross check for accuracy and consistency. Hazard ratios (HR) were derived for analysis of time-to-event outcomes (overall and progression-free). Odds ratios (OR) were derived for objective response and clinical benefit (both analysed as dichotomous variables). Toxicity data were extracted where present and treatments were compared using odds ratios. All but one of the studies included data on one or more of the following outcomes: overall survival, progression-free survival, clinical benefit and objective response.

MAIN RESULTS

Thirty studies were identified, twenty five of which were included in the main analysis of any AI versus any other treatment (9416 women). The pooled estimate showed a significant survival benefit for treatment with an AI over other endocrine therapies (HR 0.89, 95%CI 0.82 to 0.96). A subgroup analysis of the three commonly prescribed AIs (anastrozole, exemestane, letrozole) also showed a similar survival benefit (HR 0.88, 95%CI 0.80 to 0.96). The results for progression-free survival, clinical benefit and objective response were not statistically significant and there was statistically significant heterogeneity across types of AI. There were very limited data to compare one AI with a different AI, but these suggested an advantage for letrozole over anastrozole. All the trials of AIs used exclusively as first-line therapy were against tamoxifen. There was an advantage to treatment with AIs in terms of progression-free survival (HR 0.78, 95% CI 0.70 to 0.86) and clinical benefit (OR 0.70, 95% CI 0.51 to 0.97) but not overall survival or objective response. There was considerable heterogeneity across studies when considering clinical benefit (P = 0.001). Use of an AI as second-line therapy showed a significant benefit in terms of overall survival (HR 0.80, 95% CI 0.66 to 0.96) but not for progression-free survival (HR 1.08, 95% CI 0.89 to 1.31), clinical benefit (OR 1.00, 95% CI 0.87 to 1.14) or objective response (OR 0.96, 95% CI 0.81 to 1.14). This is difficult to interpret due to the extreme heterogeneity across AIs for progression-free survival but not the other endpoints.AIs have a different toxicity profile to other endocrine therapies. For all AIs combined, they had similar levels of hot flushes (especially when compared to tamoxifen) and arthralgia, increased risks of nausea, diarrhoea and vomiting, but a decreased risk of vaginal bleeding and thromboembolic events compared with other endocrine therapies. A similar pattern of risks and benefits was still seen when analyses were limited to the currently most-prescribed third generation AIs.

AUTHORS' CONCLUSIONS

In women with advanced (metastatic) breast cancer, aromatase inhibitors including those in current clinical use show a survival benefit when compared to other endocrine therapy.

Differential expression pattern and steroid hormone sensitivity of SNAP-25 and synaptoporin mRNA in the telencephalic song control nucleus HVC of the zebra finch

Gonadal steroid hormones play an important role in the process of sexual differentiation of brain areas and behavior such as singing and song learning in songbirds. These hormones affect behavior controlling circuits on both the gross morphological and ultrastructural levels. Here we study whether the expression of genes coding for synaptic proteins is sensitive to gonadal steroid hormones and whether such altered expression coincides with changes in brain area size. We treated adult male zebra finches with the aromatase inhibitor fadrozole, to reduce estrogen synthesis and analyzed the mRNA expression of the synaptic proteins synaptoporin (SPO) and synaptosomal-associated protein 25 kDa (SNAP-25) in song control areas and surrounding tissues of adult male zebra finches. SPO and SNAP-25 are differently expressed throughout the song system. Generally, the telencephalic song nuclei expressed SNAP-25 at high intensity whereas SPO expression was area-specific. Elevated levels of SNAP-25 mRNA were present in the nucleus hyperstriatalis ventrale pars caudale (HVC) and in the robust nucleus of the archistriatum (RA). SPO mRNA was found in moderate levels in the HVC, in low levels in the lateral nucleus magnocellularis (lMAN) and Area X, and was absent in the RA. The treatment significantly increased the mRNA level of SPO in the HVC, whereas SNAP-25 expression level was not affected. These expression patterns are not explained by the decrease of HVC volume after treatment. The decreased HVC size is not area-specific but correlates with an overall reduction in size and an overall increase in cell density of the forebrain.

Comprehensive pharmacology and clinical efficacy of aromatase inhibitors

The goal of hormone therapy is to deprive breast tumours of estrogens, since estrogens have been implicated in the development or progression of tumours. This can be accomplished by the use of antiestrogens that block estrogen action or by inhibiting aromatase, the enzyme that catalyses the final and rate-limiting step in estrogen biosynthesis. A number of steroidal and nonsteroidal compounds have been developed as aromatase inhibitors. This review highlights the valuable role that a few of these aromatase inhibitors have played, and continue to play, in the treatment of breast cancer. Following background information regarding the biochemistry of aromatase, the rationale for its inhibition, and an outline of the test systems for evaluating and characterising aromatase inhibitors, the discussion focuses on the new generation of aromatase inhibitors that are in clinical trials or clinically available. Specifically, it discusses the pharmacology and clinical efficacy of formestane, exemestane, rogletimide, fadrozole, vorozole, anastrozole and letrozole. The role of these agents as the optimal second-line agents (after tamoxifen) for the treatment of advanced breast cancer has been established; their prospects in other clinical settings and as potential breast cancer chemopreventives are warranted but are yet to be fully determined.

Aromatase inhibitors and their use in the adjuvant setting

Over the past decade several novel aromatase inhibitors have been introduced into clinical practice. The discovery of these drugs followed on from the observation that the main mechanism of action of aminoglutethemide was via inhibition of the enzyme aromatase, thereby reducing peripheral levels of estradiol in post-menopausal patients. The second-generation drug 4-hydroxyandrostenedione was introduced in 1990, and although its use was limited by its need to be given parenterally, it was found to be a well-tolerated form of endocrine therapy. The third-generation inhibitors include vorozole, letrozole, anastrozole and exemestane, the former three being non-steroidal inhibitors, the latter being a steroidal inhibitor. All these compounds are capable of reducing estrogen levels to within 5%-10% of baseline levels compared with 20%-30% base line levels in the case of 4-hydroxyandrostenedione. Studies are currently in progress to determine the value of these third-generation aromatase inhibitors in the adjuvant setting. These studies include head-to-head comparison of aromatase inhibitor with tamoxifen, sequential aromatase inhibitor after tamoxifen and first-line aromatase inhibitor followed by adjuvant tamoxifen. Current issues revolve around the toxicity of these compounds in terms of effects on the cardiovascular system and bone.

Overview of a rational approach to design type I 17beta-hydroxysteroid dehydrogenase inhibitors without estrogenic activity: chemical synthesis and biological evaluation

Hormone-sensitive diseases such as breast cancer are health problems of major importance in North America and Europe. Endocrine therapies using antiestrogens for the treatment and the prevention of breast cancer are presently under clinical trials. Antiestrogens are drugs that compete with estrogens for the estrogen receptor without activating the transcription of estrogen-sensitive genes. However, an optimal blockade of estrogen action could ideally be achieved by a dual-action compound that would antagonize the estrogen receptor and inhibit the biosynthesis of estradiol. Type I 17beta-hydroxysteroid dehydrogenase (17beta-HSD) was chosen as a key steroidogenic target enzyme to inhibit the formation of estradiol, which is the most potent estrogen. This article describes a rational approach that could lead to the development of compounds that exhibit both actions. The chemical syntheses of estradiol derivatives bearing a bromoalkyl and a bromoalkylamide side chain at the 16alpha-position are summarized. Two parameters were studied for biological evaluation of our synthetic inhibitors: (1) the inhibition of estrone reduction into estradiol by type I 17beta-HSD, and (2) the proliferative/antiproliferative cell assays performed on the estrogen-sensitive ZR-75-1 breast tumor cell line. First, the substitution of the 16alpha-position of estradiol by bromoalkyl side chain led to potent inhibitors of type I 17beta-HSD, but the estrogenic activity remained. Secondly, an alkylamide functionality at the 16alpha- or 7alpha-position of estradiol cannot abolish the estrogenic activity without affecting considerably the inhibitory potency on type I 17beta-HSD. In conclusion, the best dual-action inhibitor synthesized showed an IC50 of 13 +/- 1 microM for type I 17beta-HSD, while displaying antiestrogenic activity at 1.0 microM. Despite the fact that we did not obtain an ideal dual-action blocker, we have optimized several structural parameters providing important structure-activity relationship.

Other medical management of uterine fibroids

Several medicines are emerging with the potential to treat symptomatic uterine fibroids. Anti-progesterone compounds seem particularly promising. These drugs have been widely used for nearly 20 years and are known to be safe; medical politics have prevented their proper investigation for uterine fibroids. In particular, the value of mifepristone, 50 mg per day for 3 months, seems particularly promising. Further investigation is clearly warranted for this medicine. Several anti-oestrogen compounds have recently become available and may also be useful for the medical treatment of symptomatic uterine fibroids. This includes the possibility of the use of selective oestrogen receptor modulators as well as the prospect of the use of pure anti-oestrogens. On a longer time frame, inhibitors of angiogenesis may be useful. These medicines would act upon the blood supply to uterine fibroids. Physicians also have an obligation to investigate scientifically any promising naturopathic treatment that appears to have possible activity for symptomatic fibroids.

A review of the newer aromatase inhibitors in the management of metastatic breast cancer

BACKGROUND

Breast cancer remains a major cause of morbidity and mortality world-wide. While aminoglutethimide, a first-generation aromatase inhibitor, has equivalent efficacy to first-line tamoxifen in the palliative treatment of metastatic breast cancer, its toxicity profile has relegated this drug to a second- or third-line agent in this setting. Recently, several aromatase inhibitors have been released onto the market while others are in phase II and III clinical trials.

AIM

To review the role of the new aromatase inhibitors in the management of metastatic breast cancer.

METHODS

Current literature, abstracts from meetings and information from pharmaceutical manufacturers have been summarized.

CONTENT

A review of the clinical pharmacology of the new aromatase inhibitors has been provided in addition to a synopsis of phase III clinical studies.

CONCLUSION

The newer aromatase inhibitors have several advantages compared to aminoglutethimide and are a useful addition to the armamentarium of therapies employed in the palliative management of advanced breast cancer.

Breast cancer therapies in development. A review of their pharmacology and clinical potential

Although the management of breast cancer has improved over the past few decades, it remains an important challenge for the clinician. Cytotoxic chemotherapy and hormonotherapy, when given in the adjuvant setting, have a definitive though modest impact on the outcome of early-stage breast cancer. In metastatic disease, these therapies help to provide substantial palliation of symptoms but have a limited impact on survival. The discovery of vinorelbine and the taxanes, paclitaxel and docetaxel, certainly represented the most encouraging clinical development of the 1980s in breast cancer therapy. Several other new cytotoxic agents have been recognised for their potential in the treatment of this disorder. Many of them are only in a very early phase of their clinical development and it remains to be proven that they will have a major role in daily practice in the near future.