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Huang S, Wu Z, Chen Y, Li H, Zou L, Teichmann AT, Luo Y, Zhang L, Gao L. Dermal repeated dose toxicity study of the anti-breast cancer drug Formestane cream in Bama minipig. Food Chem Toxicol 2023:113927. [PMID: 37406756 DOI: 10.1016/j.fct.2023.113927] [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: 04/25/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023]
Abstract
Formestane (4-OHA) has been proven to be highly effective with high systemic tolerability in treating ER+ breast cancer. However, its intramuscular administration and associated side effects make it unsuitable for adjuvant treatment, leading to its withdrawal from the market. In contrast, Formestane cream may offer a solution by providing a more convenient route of administration and retaining its tumor-shrinking effects. This suggests that 4-OHA cream could have promising clinical applications. However, before clinical application, it is necessary to evaluate the potential toxicity of the cream in animals. This study evaluated the toxicity of 4-OHA cream on female Bama minipigs in vivo by analyzing hematology, biochemistry, and histopathology. The results showed that there was no significant difference between the cream-treated group and the control normal group for each parameter analyzed, indicating that 4-OHA cream was non-dermal toxic to minipigs. This finding provides a basis for the safe clinical use of the cream.
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Affiliation(s)
- Shiyao Huang
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China; Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Ziming Wu
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China; Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Youyou Chen
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Han Li
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China; Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Linglin Zou
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Alexander T Teichmann
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Yao Luo
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Lifeng Zhang
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Lanyang Gao
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China; Metabolic Hepatobiliary and Pancreatic Diseases Key Laboratory of Luzhou City, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China.
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Gao L, Zhu L, Shen C, Hou X, Chen Y, Zou L, Qiang H, Teichmann AT, Fu W, Luo Y. The transdermal cream of Formestane anti-breast cancer by controlling PI3K-Akt pathway and the tumor immune microenvironment. Front Immunol 2023; 14:1041525. [PMID: 37056757 PMCID: PMC10087521 DOI: 10.3389/fimmu.2023.1041525] [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: 09/11/2022] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundTreatment of ER+ breast cancer with intramuscular formulation of Formestane (4-OHA) shrinks the tumor within weeks. Since the tedious way of intramuscular administration and side effects are not suited for adjuvant treatment, Formestane was withdrawn from the market. A new transdermal formulation of 4-OHA cream may overcome the defects and retain the effect of shrinking the breast cancer tumor. However, the effects of 4-OHA cream on breast cancer need further confirmatory studies.MethodsIn this work, in vivo, the influence of 4-OHA cream on breast cancer was evaluated using the mode of 7,12-dimethylbenz(a)anthracene (DMBA) induced rat mammary cancer. We explored the common molecule mechanisms of action of 4-OHA cream and its injection formulation on breast cancer through RNA- sequencing-based transcriptome analysis and several biochemical experiments.ResultsThe results showed that the cream substantially reduced the entire quantity, size, and volum of tumors in DMBA-treated rats consistent with 4-OHA injection, and indicated that there were comprehensive signals involved in 4-OHA antitumor activity, such as ECM-receptor interaction, focal adhesion, PI3K-Akt signaling pathway, and proteoglycans in cancer. In addition, we observed that both 4-OHA formulations could enhance immune infiltration, especially CD8+ T cells, B cells, natural killer cells, and macrophages infiltration, in the DMBA-induced mammary tumor tissues. The antitumor effects of 4-OHA partly depended on these immune cells.Conclusion4-OHA cream could inhibit breast cancer growth as its injection formulation and may provide a new way for neoadjuvant treatment of ER+ breast cancer.
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Affiliation(s)
- Lanyang Gao
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Lei Zhu
- West China Hospital, Sichuan University, Chengdu, China
| | - Chen Shen
- West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoming Hou
- West China Hospital, Sichuan University, Chengdu, China
| | - Youyou Chen
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Linglin Zou
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Huiyan Qiang
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Alexander T. Teichmann
- Sichuan Provincial Center for Gynaecology and Breast Disease, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Wenguang Fu
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
- *Correspondence: Yao Luo, ; Wenguang Fu,
| | - Yao Luo
- West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yao Luo, ; Wenguang Fu,
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Yin F, Wang S, Hou C, Zhang Y, Yang Z, Wang X. Development and validation of nomograms for predicting overall survival and cancer specific survival in locally advanced breast cancer patients: A SEER population-based study. Front Public Health 2022; 10:969030. [PMID: 36203704 PMCID: PMC9530359 DOI: 10.3389/fpubh.2022.969030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023] Open
Abstract
Background For patients with locally advanced breast cancer (LABC), conventional TNM staging is not accurate in predicting survival outcomes. The aim of this study was to develop two accurate survival prediction models to guide clinical decision making. Methods A retrospective analysis of 22,842 LABC patients was performed from 2010 to 2015 using the Surveillance, Epidemiology and End Results (SEER) database. An additional cohort of 200 patients from the Binzhou Medical University Hospital (BMUH) was analyzed. The least absolute shrinkage and selection operator (LASSO) regression was used to screen for variables. The identified variables were used to build a survival prediction model. The performance of the nomogram models was assessed based on the concordance index (C-index), calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA). Results The LASSO analysis identified 9 variables in patients with LABC, including age, marital status, Grade, histological type, T-stage, N-stage, surgery, radiotherapy, and chemotherapy. In the training cohort, the C-index of the nomogram in predicting the overall survival (OS) was 0.767 [95% confidence intervals (95% CI): 0.751-0.775], cancer specific survival (CSS) was 0.765 (95% CI: 0.756-0.774). In the external validation cohort, the C-index of the nomogram in predicting the OS was 0.858 (95% CI: 0.812-0.904), the CSS was 0.866 (95% CI: 0.817-0.915). In the training cohort, the area under the receiver operator characteristics curve (AUC) values of the nomogram in prediction of the 1, 3, and 5-year OS were 0.836 (95% CI: 0.821-0.851), 0.769 (95% CI: 0.759-0.780), and 0.750 (95% CI: 0.738-0.762), respectively. The AUC values for prediction of the 1, 3, and 5-year CSS were 0.829 (95% CI: 0.811-0.847), 0.769 (95% CI: 0.757-0.780), and 0.745 (95% CI: 0.732-0.758), respectively. Results of the C-index, ROC curve, and DCA demonstrated that the nomogram was more accurate in predicting the OS and CSS of patients compared with conventional TNM staging. Conclusion Two prediction models were developed and validated in this study which provided more accurate prediction of the OS and CSS in LABC patients than the TNM staging. The constructed models can be used for predicting survival outcomes and guide treatment plans for LABC patients.
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Affiliation(s)
- Fangxu Yin
- Department of Thyroid and Breast Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Song Wang
- Department of Thyroid and Breast Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Chong Hou
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, China
| | - Yiyuan Zhang
- Department of Reproductive Endocrinology, Affiliated Reproductive Hospital of Shandong University, Jinan, China
| | - Zhenlin Yang
- Department of Thyroid and Breast Surgery, Binzhou Medical University Hospital, Binzhou, China,*Correspondence: Zhenlin Yang
| | - Xiaohong Wang
- Department of Thyroid and Breast Surgery, Binzhou Medical University Hospital, Binzhou, China,Xiaohong Wang
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Mehmood S, Faheem M, Ismail H, Farhat SM, Ali M, Younis S, Asghar MN. ‘Breast Cancer Resistance Likelihood and Personalized Treatment Through Integrated Multiomics’. Front Mol Biosci 2022; 9:783494. [PMID: 35495618 PMCID: PMC9048735 DOI: 10.3389/fmolb.2022.783494] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/14/2022] [Indexed: 12/24/2022] Open
Abstract
In recent times, enormous progress has been made in improving the diagnosis and therapeutic strategies for breast carcinoma, yet it remains the most prevalent cancer and second highest contributor to cancer-related deaths in women. Breast cancer (BC) affects one in eight females globally. In 2018 alone, 1.4 million cases were identified worldwide in postmenopausal women and 645,000 cases in premenopausal females, and this burden is constantly increasing. This shows that still a lot of efforts are required to discover therapeutic remedies for this disease. One of the major clinical complications associated with the treatment of breast carcinoma is the development of therapeutic resistance. Multidrug resistance (MDR) and consequent relapse on therapy are prevalent issues related to breast carcinoma; it is due to our incomplete understanding of the molecular mechanisms of breast carcinoma disease. Therefore, elucidating the molecular mechanisms involved in drug resistance is critical. For management of breast carcinoma, the treatment decision not only depends on the assessment of prognosis factors but also on the evaluation of pathological and clinical factors. Integrated data assessments of these multiple factors of breast carcinoma through multiomics can provide significant insight and hope for making therapeutic decisions. This omics approach is particularly helpful since it identifies the biomarkers of disease progression and treatment progress by collective characterization and quantification of pools of biological molecules within and among the cancerous cells. The scrupulous understanding of cancer and its treatment at the molecular level led to the concept of a personalized approach, which is one of the most significant advancements in modern oncology. Likewise, there are certain genetic and non-genetic tests available for BC which can help in personalized therapy. Genetically inherited risks can be screened for personal predisposition to BC, and genetic changes or variations (mutations) can also be identified to decide on the best treatment. Ultimately, further understanding of BC at the molecular level (multiomics) will define more precise choices in personalized medicine. In this review, we have summarized therapeutic resistance associated with BC and the techniques used for its management.
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Affiliation(s)
- Sabba Mehmood
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
- *Correspondence: Sabba Mehmood, ; Muhammad Nadeem Asghar,
| | - Muhammad Faheem
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Hammad Ismail
- Department of Biochemistry & Biotechnology University of Gujrat, Gujrat, Pakistan
| | - Syeda Mehpara Farhat
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mahwish Ali
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Sidra Younis
- Department of Biological Sciences, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Muhammad Nadeem Asghar
- Department of Medical Biology, University of Québec at Trois-Rivieres, Trois-Rivieres, QC, Canada
- *Correspondence: Sabba Mehmood, ; Muhammad Nadeem Asghar,
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Bahrami N, Jabeen S, Tahiri A, Sauer T, Ødegård HP, Geisler SB, Gravdehaug B, Reitsma LC, Selsås K, Kristensen V, Geisler J. Lack of cross-resistance between non-steroidal and steroidal aromatase inhibitors in breast cancer patients: the potential role of the adipokine leptin. Breast Cancer Res Treat 2021; 190:435-449. [PMID: 34554372 PMCID: PMC8558290 DOI: 10.1007/s10549-021-06399-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/11/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The aromatase inactivator exemestane may cause clinical disease stabilization following progression on non-steroidal aromatase inhibitors like letrozole in patients with metastatic breast cancer, indicating that additional therapeutic effects, not necessarily related to estrogen-suppression, may be involved in this well-known "lack of cross-resistance". METHODS Postmenopausal women with ER positive, HER-2 negative, locally advanced breast cancer were enrolled in the NEOLETEXE-trial and randomized to sequential treatment starting with either letrozole (2.5 mg o.d.) or exemestane (25 mg o.d.) followed by the alternative aromatase inhibitor. Serum levels of 54 cytokines, including 12 adipokines were assessed using Luminex xMAP technology (multiple ELISA). RESULTS Serum levels of leptin were significantly decreased during treatment with exemestane (p < 0.001), regardless whether exemestane was given as first or second neoadjuvant therapy. In contrast, letrozole caused a non-significant increase in serum leptin levels in vivo. CONCLUSIONS Our findings suggest an additional and direct effect of exemestane on CYP-19 (aromatase) synthesis presumably due to effects on the CYP19 promoter use that is not present during therapy with the non-steroidal aromatase inhibitor letrozole. Our findings provide new insights into the influence of clinically important aromatase inhibitors on cytokine levels in vivo that contribute to the understanding of the clinically observed lack of cross-resistance between non-steroidal and steroidal aromatase inhibitors in breast cancer patients. TRIAL REGISTRATION Registered on March 23rd 2015 in the National trial database of Norway (Registration number: REK-SØ-84-2015).
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Affiliation(s)
- Nazli Bahrami
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.,Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Shakila Jabeen
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Andliena Tahiri
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | | | - Berit Gravdehaug
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | | | - Knut Selsås
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Vessela Kristensen
- Department of Clinical Molecular Biology (EPIGEN), Akershus University Hospital, Lørenskog, Norway.,Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Luque-Bolivar A, Pérez-Mora E, Villegas VE, Rondón-Lagos M. Resistance and Overcoming Resistance in Breast Cancer. BREAST CANCER-TARGETS AND THERAPY 2020; 12:211-229. [PMID: 33204149 PMCID: PMC7666993 DOI: 10.2147/bctt.s270799] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
The incidence and mortality of breast cancer (BC) have increased in recent years, and BC is the main cause of cancer-related death in women worldwide. One of the most significant clinical problems in the treatment of patients with BC is the development of therapeutic resistance. Therefore, elucidating the molecular mechanisms involved in drug resistance is critical. The therapeutic decision for the management of patients with BC is based not only on the assessment of prognostic factors but also on the evaluation of clinical and pathological parameters. Although this has been a successful approach, some patients relapse and/or eventually develop resistance to treatment. This review is focused on recent studies on the possible biological and molecular mechanisms involved in both response and resistance to treatment in BC. Additionally, emerging treatments that seek to overcome resistance and reduce side effects are also described. A greater understanding of the mechanisms of action of treatments used in BC might contribute not only to the enhancement of our understanding of the mechanisms involved in the development of resistance but also to the optimization of the existing treatment regimens.
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Affiliation(s)
- Andrea Luque-Bolivar
- School of Biological Sciences, Universidad Pedagógica y Tecnológica de Colombia, Tunja 150003, Colombia
| | - Erika Pérez-Mora
- School of Biological Sciences, Universidad Pedagógica y Tecnológica de Colombia, Tunja 150003, Colombia
| | | | - Milena Rondón-Lagos
- School of Biological Sciences, Universidad Pedagógica y Tecnológica de Colombia, Tunja 150003, Colombia
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Bahrami N, Chang G, Kanaya N, Sauer T, Park D, Loeng M, Gravdehaug B, Chen S, Geisler J. Changes in serum estrogenic activity during neoadjuvant therapy with letrozole and exemestane. J Steroid Biochem Mol Biol 2020; 200:105641. [PMID: 32151708 DOI: 10.1016/j.jsbmb.2020.105641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 12/29/2022]
Abstract
The aromatase inhibitors (AIs), letrozole (Femar®/Femara®) and exemestane (Aromasin®), are widely used to treat estrogen receptor (ER) positive breast cancer in postmenopausal patients. In the setting of metastatic breast cancer, these drugs may be used after another causing new responses in selected patients after progressing on the first choice. The precise explanation for this "lack of cross resistance" is still missing. NEOLETEXE is a neoadjuvant, randomized, open-label, cross-over trial. Postmenopausal patients with ER-positive, HER-2 negative, locally advanced breast cancer were enrolled. All patients were randomized to treatment starting with either letrozole or exemestane for at least 2 months followed by another 2 months on the alternative AI. The total estrogenic activities in blood samples were determined using the AroER tri-screen assay developed in the Chen laboratory. Using this highly sensitive assay, estrogenic activity was detected at three time points for all patients. Importantly, a significantly higher total estrogenic activity was found during therapy with exemestane compared to letrozole in 21 out of 26 patients. When letrozole was included in the AroER tri-screen assay, the estrogenic activities in most samples collected during exemestane treatment were further reduced, suggesting that low levels of androgens remained in specimens obtained after exemestane treatment. Our results suggest the AroER tri-screen to be a very sensitive method to estimate the overall estrogen-mediated activity in human samples even during therapy with highly potent aromatase inhibitors. In the present study, serum estrogen activity was significantly higher during exemestane therapy when compared to letrozole therapy.
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Affiliation(s)
- Nazli Bahrami
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway; Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Gregory Chang
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Noriko Kanaya
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Campus AHUS, Norway
| | - Daehoon Park
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Marie Loeng
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
| | - Berit Gravdehaug
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Shiuan Chen
- Department of Cancer Biology, Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Campus AHUS, Norway.
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Bahrami N, Sauer T, Engebretsen S, Aljabri B, Bemanian V, Lindstrøm J, Lüders T, Kristensen V, Lorentzen A, Loeng M, Ødegård HP, Kvaløy JØ, Vestøl IB, Geisler SB, Gravdehaug B, Gundersen JM, Geisler J. The NEOLETEXE trial: a neoadjuvant cross-over study exploring the lack of cross resistance between aromatase inhibitors. Future Oncol 2019; 15:3675-3682. [DOI: 10.2217/fon-2019-0258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The aromatase inhibitor letrozole (Femar®/Femara®) and the aromatase inactivator exemestane (Aromasin®) differ in their biochemical effect on the aromatase enzyme. Letrozole is a competitive aromatase inhibitor while exemestane binds irreversibly to the aromatase enzyme. This pharmacological difference is of clinical interest since a lack of cross-resistance has been documented. It has been demonstrated in several clinical trials that exemestane may cause a disease regression following resistance to nonsteroidal aromatase inhibitors. The exact mechanism(s) behind this phenomenon is yet unknown. Here, we present the NEOLETEXE trial with the aim of exploring the individual mechanisms involved behind the observed lack of cross resistance. Clinical trial registration: The trial has been approved by the Regional Ethics Committee of South-East Norway (project number 2015/84).
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Affiliation(s)
- Nazli Bahrami
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Department of Breast & Endocrine Surgery (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Torill Sauer
- Department of Pathology (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Norway
| | - Siri Engebretsen
- Department of Breast & Endocrine Surgery (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Belal Aljabri
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Vahid Bemanian
- Department of Gene Technology (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Jonas Lindstrøm
- Health Services Research Center (AHUS), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Norway
| | - Torben Lüders
- Department of Clinical Molecular Biology (AHUS/EpiGen), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Norway
| | - Vessela Kristensen
- Department of Clinical Molecular Biology (AHUS/EpiGen), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Norway
| | - Annika Lorentzen
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Marie Loeng
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Hilde Presterud Ødegård
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Jan Øyvind Kvaløy
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Ingeborg Berge Vestøl
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Stephanie Beate Geisler
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Berit Gravdehaug
- Department of Breast & Endocrine Surgery (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Joanna Majak Gundersen
- Department of Breast & Endocrine Surgery (AHUS), Akershus University Hospital, Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital (AHUS), Lørenskog, Norway
- Translational Cancer Research Group, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Norway
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The beneficial androgenic action of steroidal aromatase inactivators in estrogen-dependent breast cancer after failure of nonsteroidal drugs. Cell Death Dis 2019; 10:494. [PMID: 31235695 PMCID: PMC6591174 DOI: 10.1038/s41419-019-1724-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 11/08/2022]
Abstract
Direct treatment of ER (+) breast cancer with Formestane diminishes the tumor within weeks. This is unlikely due to lack of estrogens alone. We proposed that it is the negative influence of androgens on the growth of ER(+) breast cancer. We investigated the influence of Formestane and Exemestane and of their major androgenic metabolites 4-hydroxytestosterone and 17-hydroexemestane on the proliferation of MCF-7 cells and ZR-75-1 cells. Inhibitory effects could be prevented by antiandrogens and siRNA. Activation of the AR in MCF-7 and U2-OS cells was tested by reporter gene assays. In vivo androgenicity was evaluated using the Hershberger assay. Influence on the cell cycle was demonstrated by flow-cytometry. Influence of androgens on the activity of CCND1 was demonstrated by Chip-qPCR. Antitumor activity was determined by topical treatment of DMBA tumors. We found that breast cancer cells can metabolize Formestane and Exemestane to androgenic compounds which inhibit proliferation. This can be explained by hindering the accessibility of CCND1 by histone modification. Androgenic metabolites can abolish the growth of DMBA-tumors and prevent the appearance of new tumors. The lack of cross-resistance between steroidal and nonsteroidal aromatase inhibitors is due to inhibitory effects of androgenic steroidal metabolites on the production of cyclin D1. These sterols not only inhibit proliferation of cancer cells but can also stop the growth of DMBA cancers upon direct absorption into the tumor. The quick and considerable effect on ER(+) tumors may open a new avenue for neodjuvant treatment.
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Kümler I, Knoop AS, Jessing CAR, Ejlertsen B, Nielsen DL. Review of hormone-based treatments in postmenopausal patients with advanced breast cancer focusing on aromatase inhibitors and fulvestrant. ESMO Open 2016; 1:e000062. [PMID: 27843622 PMCID: PMC5070302 DOI: 10.1136/esmoopen-2016-000062] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/12/2016] [Accepted: 05/13/2016] [Indexed: 12/14/2022] Open
Abstract
Background Endocrine therapy constitutes a central modality in the treatment of oestrogen receptor (ER)-positive advanced breast cancer. Purpose To evaluate the evidence for endocrine treatment in postmenopausal patients with advanced breast cancer focusing on the aromatase inhibitors, letrozole, anastrozole, exemestane and fulvestrant. Methods A review was carried out using PubMed. Randomised phase II and III trials reporting on ≥100 patients were included. Results 35 trials met the inclusion criteria. If not used in the adjuvant setting, a non-steroid aromatase inhibitor was the optimal first-line option. In general, the efficacy of the different aromatase inhibitors and fulvestrant was similar in tamoxifen-refractory patients. A randomised phase II trial of palbociclib plus letrozole versus letrozole alone showed significantly increased progression-free survival (PFS) when compared with endocrine therapy alone in the first-line setting (20.2 vs 10.2 months). Furthermore, the addition of everolimus to exemestane in the Breast Cancer Trials of OraL EveROlimus-2 (BOLERO-2) study resulted in an extension of median PFS by 4.5 months after recurrence/progression on a non-steroid aromatase inhibitor. However, overall survival was not significantly increased. Conclusion Conventional treatment with an aromatase inhibitor or fulvestrant may be an adequate treatment option for most patients with hormone receptor-positive advanced breast cancer. Mammalian target of rapamycin (mTOR) inhibition and cyclin-dependent kinase 4/6 (CDK4/6) inhibition might represent substantial advances for selected patients in some specific settings. However, there is an urgent need for prospective biomarker-driven trials to identify patients for whom these treatments are cost-effective.
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Affiliation(s)
- Iben Kümler
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
| | - Ann S Knoop
- Department of Oncology , Finsen Centre, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Christina A R Jessing
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
| | - Bent Ejlertsen
- Department of Oncology , Finsen Centre, Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Dorte L Nielsen
- Department of Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
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11
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Yadav MR, Barmade MA, Tamboli RS, Murumkar PR. Developing steroidal aromatase inhibitors-an effective armament to win the battle against breast cancer. Eur J Med Chem 2015; 105:1-38. [DOI: 10.1016/j.ejmech.2015.09.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 01/05/2023]
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Zucchini G, Geuna E, Milani A, Aversa C, Martinello R, Montemurro F. Clinical utility of exemestane in the treatment of breast cancer. Int J Womens Health 2015; 7:551-63. [PMID: 26064072 PMCID: PMC4455847 DOI: 10.2147/ijwh.s69475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Breast cancer is the most prevalent cancer in women, causing a significant mortality worldwide. Different endocrine strategies are available for the treatment of hormone-sensitive breast cancer, including antiestrogen tamoxifen and fulvestrant, as well as third-generation aromatase inhibitors (AIs), such as letrozole, anastrozole, and exemestane. In this review, we will focus on exemestane, its clinical use, and its side effects. Exemestane is a steroidal third-generation AI now used in all treatment settings for breast cancer. In the metastatic disease, it has been extensively investigated as the first-, second-, and further-line treatment and it is now registered for the treatment of postmenopausal women with advanced estrogen-receptor-positive breast cancer whose disease has progressed following antiestrogen therapy. A potential lack of cross-resistance with nonsteroidal AIs has been described, giving additional therapeutic opportunities in sequences of endocrine agents. Exemestane is also approved for the adjuvant treatment of postmenopausal early breast cancer, either as upfront monotherapy for 5 years, as a switch following 2–3 years of tamoxifen, or as extended therapy beyond 5 years of adjuvant treatment. New promising data also showed a beneficial effect in young premenopausal early breast cancer patients, when administered together with ovarian suppression. Interesting results have also emerged when exemestane has been investigated as neodjuvant treatment as well as preventive agent in healthy women at high risk for breast cancer. Exemestane is generally well tolerated, with a side effect profile similar to that of other AIs, including menopausal symptoms, arthralgia, and bone loss. In conclusion, exemestane can be considered an effective and well-tolerated endocrine treatment option for all stages of breast cancer.
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Affiliation(s)
- Giorgia Zucchini
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | - Elena Geuna
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | - Andrea Milani
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
| | | | | | - Filippo Montemurro
- Investigative Clinical Oncology, Fondazione del Piemonte per l'Oncologia-Candiolo Cancer Institute (IRCCs), Candiolo, Italy
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Shioi Y, Kashiwaba M, Inaba T, Komatsu H, Sugai T, Wakabayashi G. Long-term complete remission of metastatic breast cancer, induced by a steroidal aromatase inhibitor after failure of a non-steroidal aromatase inhibitor. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:85-9. [PMID: 24587856 PMCID: PMC3936946 DOI: 10.12659/ajcr.890023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/08/2013] [Indexed: 11/11/2022]
Abstract
Patient: Female, 56 Final Diagnosis: Breast cancer Symptoms: Solid mass in the right breast Medication: Exemestane Clinical Procedure: — Specialty: Oncology
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Affiliation(s)
- Yoshihiro Shioi
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | | | - Toru Inaba
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | - Hideaki Komatsu
- Department of Surgery, Iwate Medical University, Morioka, Japan
| | - Tamotsu Sugai
- Department of Pathology, Iwate Medical University, Morioka, Japan
| | - Go Wakabayashi
- Department of Surgery, Iwate Medical University, Morioka, Japan
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Van Asten K, Neven P, Lintermans A, Wildiers H, Paridaens R. Aromatase inhibitors in the breast cancer clinic: focus on exemestane. Endocr Relat Cancer 2014; 21:R31-49. [PMID: 24434719 DOI: 10.1530/erc-13-0269] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Breast cancer is the most prevalent type of cancer in women and responsible for significant female cancer-related mortality worldwide. In the Western world, over 80% of breast cancers are hormone-receptor positive for which endocrine therapy is administered. The main anti-estrogen treatments in use consist of selective estrogen-receptor modulators, such as tamoxifen, and third-generation aromatase inhibitors (AIs), such as exemestane, letrozole, and anastrozole. In this review, the focus will lie on exemestane, its clinical use, and its side-effect profile. Exemestane is the only third-generation steroidal AI. Its efficacy as a first-line treatment in metastatic breast cancer has been demonstrated. Therefore, exemestane could be considered a valid first-line therapeutic option, but it also can be used in second-line or further situations. Exemestane is mostly used as part of sequential adjuvant treatment following tamoxifen, but in this setting it is also active in monotherapy. Furthermore, this AI has been studied in the neoadjuvant setting as presurgical treatment, and even as chemoprevention in high-risk healthy postmenopausal women. It may reverse side effects of tamoxifen, such as endometrial changes and thromboembolic disease but may also cause some inconvenient side effects itself. Additionally, there is a lack of total cross-resistance between exemestane and nonsteroidal AIs as far as their anti-tumoral efficacy is concerned; moreover the two classes of AIs display a nontotal overlapping toxicity profile. Taking together, exemestane can be considered as a useful treatment option at all stages of breast cancer.
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Affiliation(s)
- Kathleen Van Asten
- KU Leuven, Department of Oncology, Leuven, Belgium University Hospitals Leuven, Department of Gynecology and Obstetrics, Leuven, Belgium University Hospitals Leuven, Department of General Medical Oncology, Leuven, Belgium
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Palmieri C, Patten DK, Januszewski A, Zucchini G, Howell SJ. Breast cancer: current and future endocrine therapies. Mol Cell Endocrinol 2014; 382:695-723. [PMID: 23933149 DOI: 10.1016/j.mce.2013.08.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 12/29/2022]
Abstract
Endocrine therapy forms a central modality in the treatment of estrogen receptor positive breast cancer. The routine use of 5 years of adjuvant tamoxifen has improved survival rates for early breast cancer, and more recently has evolved in the postmenopausal setting to include aromatase inhibitors. The optimal duration of adjuvant endocrine therapy remains an active area of clinical study with recent data supporting 10 years rather than 5 years of adjuvant tamoxifen. However, endocrine therapy is limited by the development of resistance, this can occur by a number of possible mechanisms and numerous studies have been performed which combine endocrine therapy with agents that modulate these mechanisms with the aim of preventing or delaying the emergence of resistance. Recent trial data regarding the combination of the mammalian target of rapamycin (mTOR) inhibitor, everolimus with endocrine therapy have resulted in a redefinition of the clinical treatment pathway in the metastatic setting. This review details the current endocrine therapy utilized in both early and advanced disease, as well as exploring potential new targets which modulate pathways of resistance, as well as agents which aim to modulate adrenal derived steroidogenic hormones.
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Affiliation(s)
- Carlo Palmieri
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool L69 3GA, UK; Liverpool & Merseyside Breast Academic Unit, The Linda McCartney Centre, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; Academic Department of Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wiral CH63 4JY, UK.
| | - Darren K Patten
- Department of Surgery, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Adam Januszewski
- Department of Medical Oncology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Giorgia Zucchini
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Sacha J Howell
- The University of Manchester, Institute of Cancer Studies, Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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16
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Lee JK, Im SA, Lee D, Kim JY, Lim Y, Lee E, Moon HG, Kim TY, Han SW, Oh DY, Lee SH, Han W, Kim DW, Kim TY, Noh DY. Efficacy of exemestane in korean patients with metastatic breast cancer after failure of nonsteroidal aromatase inhibitors. J Breast Cancer 2013; 16:66-71. [PMID: 23593084 PMCID: PMC3625772 DOI: 10.4048/jbc.2013.16.1.66] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 01/05/2013] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Exemestane has shown good efficacy and tolerability in postmenopausal women with hormone receptor-positive metastatic breast cancer. However, clinical outcomes in Korean patients have not yet been reported. METHODS Data on 112 postmenopausal women with metastatic breast cancer were obtained retrospectively. Clinicopathological characteristics and treatment history were extracted from medical records. All patients received 25 mg exemestane daily until objective disease progression. Progression-free survival (PFS) was the primary endpoint, and secondary endpoints were overall survival (OS), objective response rate (ORR), and clinical benefit rate (CBR=complete response+partial response+stable disease for 6 months). RESULTS The median age of the subjects was 55 years (range, 28-76 years). Exemestane treatment resulted in a median PFS of 5.7 months (95% confidence interval [CI], 4.4-7.0 months) and median OS of 21.9 months (95% CI, 13.6-30.3 months). ORR was 6.4% and CBR was 46.4% for the 110 patients with evaluable lesions. Symptomatic visceral disease was independently associated with shorter PFS (hazard ratio, 3.611; 95% CI, 1.904-6.848; p<0.001), compared with bone-dominant disease in a multivariate analysis of PFS after adjusting for age, hormone receptor, human epidermal growth factor receptor 2, Ki-67 status, dominant metastasis site, and sensitivity to nonsteroidal aromatase inhibitor (AI) treatment. Sensitivity to previous nonsteroidal AI treatment was not associated with PFS, suggesting no cross-resistance between exemestane and nonsteroidal AIs. CONCLUSION Exemestane was effective in postmenopausal Korean women with hormone receptor-positive metastatic breast cancer who failed previous nonsteroidal AI treatment.
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Affiliation(s)
- June Koo Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Aromatase inhibitors in the treatment of elderly women with metastatic breast cancer. Breast 2013; 22:142-149. [PMID: 23321585 DOI: 10.1016/j.breast.2012.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 10/26/2012] [Accepted: 12/17/2012] [Indexed: 11/22/2022] Open
Abstract
The proportion of elderly women in the population is rising, and in tandem, the incidence of breast cancer rises with age. Because of health and tolerability concerns, as well as life expectancy, physicians may be reluctant to advise a standard treatment regimen for elderly patients with metastatic breast cancer. To elucidate this issue, we performed a literature review of clinical studies that included women with metastatic breast cancer who were over the age of 65. Our results show that although little clinical evidence exists, what is available suggests that standard treatment is tolerated and beneficial for patients meeting certain criteria. A geriatric assessment may identify specific patient groups (independent, dependent, or frail) and thereby guide treatment. Treatment recommendations for elderly patients with metastatic breast cancer are sparse, although first-line endocrine treatment, usually aromatase inhibitors or tamoxifen, is recommended for hormone-sensitive disease. In general, the evidence from clinical studies suggests that aromatase inhibitors are more effective than either tamoxifen or megestrol acetate as first- or second-line treatment in postmenopausal women with metastatic breast cancer. Ultimately, quality of life, treatment effects, and comorbidities are important aspects in this population and may guide treatment choice. To provide evidence-based treatment guidance, future clinical trials should include more patients over the age of 65 years.
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Miller WR, Larionov AA. Understanding the mechanisms of aromatase inhibitor resistance. Breast Cancer Res 2012; 14:201. [PMID: 22277572 PMCID: PMC3496110 DOI: 10.1186/bcr2931] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aromatase inhibitors (AIs) have a central role in the treatment of breast cancer; however, resistance is a major obstacle to optimal management. Evidence from endocrine, molecular and pathological measurements in clinical material taken before and after therapy with AIs and data from clinical trials in which AIs have been given as treatment either alone or in combination with other targeted agents suggest diverse causes for resistance. These include inherent tumour insensitivity to oestrogen, ineffective inhibition of aromatase, sources of oestrogenic hormones independent of aromatase, activation of signalling by non-endocrine pathways, enhanced cell survival and selection of hormone-insensitive cellular clones during treatment.
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19
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Schneider R, Barakat A, Pippen J, Osborne C. Aromatase inhibitors in the treatment of breast cancer in post-menopausal female patients: an update. BREAST CANCER-TARGETS AND THERAPY 2011; 3:113-25. [PMID: 24367181 DOI: 10.2147/bctt.s22905] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Estrogen and its metabolites play a significant role in the proliferation of hormone receptor-positive breast cancer. In postmenopausal women, aromatase inhibitors can significantly reduce estrogen levels by blocking enzyme-mediated estrogen synthesis within tissues. Third-generation aromatase inhibitors have now surpassed tamoxifen as first-line therapy for postmenopausal women with metastatic, hormone receptor-positive, breast cancer, showing improved response rates and time to progression. Aromatase inhibitors have shown incremental improvements in disease-free survival, lower local recurrence rates, lower metastatic recurrence rates, and a lower incidence of contralateral breast cancer over tamoxifen when used in the adjuvant setting. Aromatase inhibitors are recommended to be used as adjuvant therapy within the first 5 years of hormonal therapy and may be used either upfront for 5 years or sequenced with tamoxifen. No superiority of one aromatase inhibitor over another has yet been shown. The side effect profiles of aromatase inhibitors have some key differences compared with tamoxifen. These differences may influence treatment choices as well as impact compliance.
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Affiliation(s)
| | | | - John Pippen
- Medical Oncology, Baylor-Sammons Cancer Center, USA ; Texas Oncology PA, USA ; US Oncology, Dallas, TX, USA
| | - Cynthia Osborne
- Medical Oncology, Baylor-Sammons Cancer Center, USA ; Texas Oncology PA, USA ; US Oncology, Dallas, TX, USA
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20
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Beresford M, Tumur I, Chakrabarti J, Barden J, Rao N, Makris A. A qualitative systematic review of the evidence base for non-cross-resistance between steroidal and non-steroidal aromatase inhibitors in metastatic breast cancer. Clin Oncol (R Coll Radiol) 2010; 23:209-15. [PMID: 21134732 DOI: 10.1016/j.clon.2010.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 10/21/2010] [Accepted: 10/25/2010] [Indexed: 11/16/2022]
Abstract
AIMS The most effective sequence of tamoxifen and both steroidal (SAIs) and non-steroidal aromatase inhibitors (NSAIs) has been extensively studied in the adjuvant setting. However, treatments for women who have failed initial aromatase inhibitor therapy in the metastatic setting have received relatively little attention. A systematic review was undertaken to assess the use of SAIs and NSAIs in metastatic breast cancer. MATERIALS AND METHODS Medline, Embase and the Cochrane library were searched using free text and MeSH terms. Studies assessing the cross-resistance, efficacy and safety of SAIs and NSAIs for postmenopausal women with advanced metastatic breast cancer confirmed by histology/cytology were included. Patients had progressed/relapsed from previous adjuvant, first- or second-line aromatase inhibitor treatment and had undergone treatment with at least two regimens consisting of aminoglutethimide, anastrozole, letrozole and/or exemestane. RESULTS Nine studies reported results for patients treated with an SAI after treatment failure with an NSAI. For SAI after NSAI, clinical benefit was the most frequently reported outcome. The clinical benefit for exemestane (SAI) after any NSAI failure or before treatment ranged from 12% (complete response not recorded, partial response 2%, stable disease 10%) to 55% (complete response 6%, partial response 13%, stable disease 35%) Survival outcomes were infrequently reported; four studies reported disease progression. The time to progression ranged from 3.7 to 5.2 months. Only one study reported a median overall survival with exemestane at 15.2 months. Only one study reported information for an NSAI after SAI and an NSAI followed by another NSAI. DISCUSSION This review suggests that switching from an NSAI to an SAI is a reasonable option. This would be particularly important for patients who would probably respond to further endocrine manoeuvres; strongly oestrogen receptor-positive disease, non-visceral disease, a good prior response or a long duration of response. Further research to optimise the sequence of endocrine therapies in metastatic breast cancer is needed.
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Affiliation(s)
- M Beresford
- Bristol Oncology and Haematology Centre, Horfield Road, Bristol, UK.
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Exemestane as first-line therapy in postmenopausal women with recurrent or metastatic breast cancer. Am J Clin Oncol 2010; 33:314-9. [PMID: 19730353 DOI: 10.1097/coc.0b013e31819fdf9b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antiestrogen therapies generally offer significant disease control to hormone receptor-positive recurrent or metastatic breast cancer patients and are substantially better tolerated than standard chemotherapy regimens, thus representing an attractive first treatment option. The steroidal aromatase inhibitor (AI) exemestane exhibits antitumor effects by lowering full-body estrogen production in postmenopausal women and is an established treatment option for metastatic breast cancer. We review data from 2 recent phase III clinical trials that have confirmed exemestane activity in the first-line metastatic breast cancer setting, with moderate improvements in median progression-free survival (10-12 months) and objective response rates (37%-46%) compared with tamoxifen. The activity of first-line exemestane is comparable with other antiestrogen therapies, including fulvestrant and the nonsteroidal AIs letrozole and anastrozole. Additional findings demonstrating the clinical benefits of exemestane in women who previously progressed on nonsteroidal AIs highlight a partial lack of cross-resistance between these therapies and reinforce the opportunity to use multiple antiestrogen treatments sequentially. Future therapeutic developments in hormone receptor-positive metastatic breast cancer could include combinations with other targeted compounds plus AIs or other antiestrogen-based combinations and the identification of new strategies to evaluate differences among antiestrogen therapies to help optimize the treatment sequence and potential combinations.
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Gerber B, Freund M, Reimer T. Recurrent breast cancer: treatment strategies for maintaining and prolonging good quality of life. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:85-91. [PMID: 20204119 PMCID: PMC2832109 DOI: 10.3238/arztebl.2010.0085] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 06/17/2009] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recurrent breast cancer remains a challenge for interdisciplinary treatment even though new therapeutic options are available. METHODS The PubMed database was selectively searched for articles that appeared from 1999 to 2009 and contained the key words "breast cancer," "recurrence," "metastatic," "advanced," and "treatment". Further sources consulted for this review included the German S3 guideline, the treatment recommendations of the German AGO-Mamma group, the NCCN guidelines, and the Cochrane database. RESULTS Locoregional recurrences are treated with curative intent. Metastatic breast cancer must be treated on an individualized basis: The treatment should be continued as long as its benefits for the individual patient outweigh its adverse side effects. Endocrine treatment is indicated for all patients whose tumors are hormone-receptor positive or of unknown receptor status and who have enough time for a response to be seen. Chemotherapy should be given if the tumor is hormone-receptor negative, if a rapid response is urgently needed, or if endocrine treatment has failed to produce a response. Combination chemotherapy improves response rates and prolongs progression-free survival, yet it does not prolong overall survival in comparison to monochemotherapy. In HER2-positive patients, first-line treatment with trastuzumab and monochemotherapy prolongs overall survival. Other treatment options include angiogenesis inhibitors, various tyrosine kinases inhibitors, radiotherapy, bisphosphonates, surgical or other ablative treatment of metastases, or a combination of these approaches, applied either simultaneously or consecutively. CONCLUSIONS While locoregional recurrences of breast cancer should be treated with curative intent, breast cancer with distant metastases is currently not curable. It is treated with the intention of restoring and maintaining good quality of life and relieving symptoms due to the metastases, rather than prolonging survival.
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Affiliation(s)
- Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt der Hansestadt Rostock, Germany.
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A randomized trial exploring the biomarker effects of neoadjuvant sequential treatment with exemestane and anastrozole in post-menopausal women with hormone receptor-positive breast cancer. Breast Cancer Res Treat 2009; 119:155-61. [DOI: 10.1007/s10549-009-0523-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 08/20/2009] [Indexed: 12/26/2022]
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Milani M, Jha G, Potter DA. Anastrozole Use in Early Stage Breast Cancer of Post-Menopausal Women. ACTA ACUST UNITED AC 2009; 1:141-156. [PMID: 19794821 DOI: 10.4137/cmt.s9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The majority of breast cancers express the estrogen receptor and depend on estradiol (E2) for their growth. Hormonal therapy aims at depriving estrogen signaling either by using selective estrogen receptor modulators (SERM)-that interfere with the binding of E2 to its receptor (ER)-or aromatase inhibitors (AI)-that block the aromatase-dependent synthesis of E2. While SERMs are recommended for both pre- and post-menopausal patients, AIs are indicated only for post-menopausal patients. For the past 20 years, the SERM tamoxifen has been considered the "gold standard" for the treatment of hormone receptor positive breast cancers. However, tamoxifen's role is now challenged by third generation AIs, such as anastrozole, which exhibit greater efficacy in the adjuvant setting in several recently reported trials. This review will focus on anastrozole's mechanism of action, dosing, pharmacology, pharmacokinetics, and clinical applications. It will briefly discuss the clinical trials that determined anastrozole's efficacy in the treatment of advanced breast cancer (ABC) and in the neoadjuvant setting. Finally, it will present the clinical trials that established anastrozole as a frontline agent in the treatment of post-menopausal women with hormone receptor positive early breast cancer.
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Affiliation(s)
- Monica Milani
- Department of Medicine, Division of Hematology Oncology and Transplantation, University of Minnesota, Minneapolis, MN, U.S.A
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Gligorov J, Lotz JP. Optimal treatment strategies in postmenopausal women with hormone-receptor-positive and HER2-negative metastatic breast cancer. Breast Cancer Res Treat 2008; 112 Suppl 1:53-66. [PMID: 19101794 DOI: 10.1007/s10549-008-0232-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 10/20/2008] [Indexed: 01/09/2023]
Abstract
Metastatic breast cancer (MBC) is unfortunately still considered incurable; treatment aims to prolong progression-free and overall survival, relieve disease symptoms, and maintain quality of life. Treatment can include endocrine therapy, radiotherapy, chemotherapy, bisphosphonates, and/or targeted therapy; which is used depends on the characteristics of the disease [e.g., hormone receptor status, disease site(s), and response to previous treatment] and the patient (age, comorbidity, and personal preferences). For most patients with hormone-receptor-positive tumors, the first choice of treatment is further endocrine therapy, but endocrine resistance is a common problem in advanced disease. Several novel anticancer agents have been developed with the aim of overcoming endocrine resistance, many of which target intracellular signaling pathways implicated in disease progression or resistance. Among these, inhibitors of growth factor receptor tyrosine kinases and of mammalian target of rapamycin have shown the most promise in clinical trials. Chemotherapy is the cornerstone of MBC treatment in most women. Important considerations when choosing chemotherapy include the choice of agents, and whether to use single-agent or combination therapy. Anthracyclines are one of the most active cytotoxic agents currently used for the treatment of breast cancer, and for many women, further anthracycline therapy at progression or relapse would be the preferred option. However, lifetime exposure to anthracyclines is limited by cumulative cardiotoxicity, which often prevents rechallenge in later lines of therapy. Newer anthracycline formulations have been developed with lower cardiotoxicity than the conventional anthracycline doxorubicin, but these agents still impair cardiac function, and have maximum recommended lifetime doses. Recently, the concomitant use of cardioprotective agents, such as dexrazoxane, has emerged as an effective approach to reducing the cardiotoxic effects of anthracyclines, thus permitting retreatment. Bisphosphonates, which are not associated with the acute toxicities of cytotoxic chemotherapy drugs, are the established standard of care for patients with metastatic bone disease, and have greatly improved outcomes over the last decade. The search is ongoing for novel agents that will, hopefully, bring a cure closer to reality.
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Affiliation(s)
- Joseph Gligorov
- Department of Medical Oncology, CancerEst, APHP Tenon, University of Paris VI, 4 rue de la Chine, 75970, Paris Cedex 20, France.
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Lack of complete cross-resistance between different aromatase inhibitors; a real finding in search for an explanation? Eur J Cancer 2008; 45:527-35. [PMID: 19062270 DOI: 10.1016/j.ejca.2008.10.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 09/23/2008] [Accepted: 10/16/2008] [Indexed: 11/21/2022]
Abstract
While third-generation aromatase inhibitors (anastrozole, letrozole and exemestane) are successfully implemented as adjuvant and first-line therapy for hormone-sensitive breast cancer in postmenopausal women, important questions remain to be addressed. An issue of particular interest is the question about lack of complete cross-resistance between steroidal and non-steroidal compounds. Although the studies reporting this phenomenon in general contain a small number of patients, the findings across the different reports seem consistent. While several potential mechanisms have been suggested, so far we lack scientific proof what mechanisms may be responsible for this finding. Finally, we do not know whether lack of cross-resistance actually signals an improved efficacy for certain compounds or may be due to alternative mechanisms of action. Neither do we know whether some tumours are more sensitive to particular drugs. This paper summarizes clinical findings up to now with respect to lack of cross-resistance and discuss potential mechanisms involved.
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Activity of fulvestrant versus exemestane in advanced breast cancer patients with or without visceral metastases: data from the EFECT trial. Breast Cancer Res Treat 2008; 117:69-75. [DOI: 10.1007/s10549-008-0141-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 07/15/2008] [Indexed: 10/21/2022]
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Geisler J, Helle H, Ekse D, Duong NK, Evans DB, Nordbø Y, Aas T, Lønning PE. Letrozole is Superior to Anastrozole in Suppressing Breast Cancer Tissue and Plasma Estrogen Levels. Clin Cancer Res 2008; 14:6330-5. [DOI: 10.1158/1078-0432.ccr-07-5221] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Iwase H. Current topics and perspectives on the use of aromatase inhibitors in the treatment of breast cancer. Breast Cancer 2008; 15:278-90. [DOI: 10.1007/s12282-008-0071-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/06/2008] [Indexed: 01/15/2023]
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Lønning PE, Geisler J. Experience with Exemestane in the Treatment of Early and Advanced Breast Cancer. Expert Opin Drug Metab Toxicol 2008; 4:987-97. [DOI: 10.1517/17425255.4.7.987] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lønning PE, Geisler J. Indications and limitations of third-generation aromatase inhibitors. Expert Opin Investig Drugs 2008; 17:723-39. [DOI: 10.1517/13543784.17.5.723] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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