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Buijs SM, Koolen SLW, Mathijssen RHJ, Jager A. Tamoxifen Dose De-Escalation: An Effective Strategy for Reducing Adverse Effects? Drugs 2024; 84:385-401. [PMID: 38480629 PMCID: PMC11101371 DOI: 10.1007/s40265-024-02010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 05/19/2024]
Abstract
Tamoxifen, a cornerstone in the adjuvant treatment of estrogen receptor-positive breast cancer, significantly reduces breast cancer recurrence and breast cancer mortality; however, its standard adjuvant dose of 20 mg daily presents challenges due to a broad spectrum of adverse effects, contributing to high discontinuation rates. Dose reductions of tamoxifen might be an option to reduce treatment-related toxicity, but large randomized controlled trials investigating the tolerability and, more importantly, efficacy of low-dose tamoxifen in the adjuvant setting are lacking. We conducted an extensive literature search to explore evidence on the tolerability and clinical efficacy of reduced doses of tamoxifen. In this review, we discuss two important topics regarding low-dose tamoxifen: (1) the incidence of adverse effects and quality of life among women using low-dose tamoxifen; and (2) the clinical efficacy of low-dose tamoxifen examined in the preventive setting and evaluated through the measurement of several efficacy derivatives. Moreover, practical tools for tamoxifen dose reductions in the adjuvant setting are provided and further research to establish optimal dosing strategies for individual patients are discussed.
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Affiliation(s)
- Sanne M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands.
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, PO Box 2040, 3015 CN, Rotterdam, The Netherlands
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2
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Lazzeroni M, Puntoni M, Provinciali N, Webber TB, Briata IM, D'Amico M, Giuliano S, Siri G, Cagnacci S, DeCensi A. Estimating the magnitude of clinical benefit of systemic therapy in patients with DCIS or pre-invasive disease of the breast. Breast 2020; 48 Suppl 1:S39-S43. [PMID: 31839158 DOI: 10.1016/s0960-9776(19)31121-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The challenge of effective management of ductal carcinoma in situ (DCIS) and other pre-malignant disorders of the breast is to select patients who will not progress to invasive carcinoma from those at the highest risk who require radiotherapy and/or endocrine therapy to minimize the risk of a subsequent invasive recurrence. Although IBIS-II and NSABP-B35 DCIS phase III trials proved that tamoxifen 20 mg/day and anastrozole reduce the risk of ipsilateral and contralateral events, the toxicities of both drugs have hampered the drug uptake by high-risk women. We recently reported results of a 3-year placebo-controlled trial of low-dose (5 mg/d) tamoxifen in 500 women with intraepithelial neoplasia (70% DCIS). At a median follow-up of 5 years, women randomly assigned to low-dose tamoxifen had half the number of subsequent diagnoses of DCIS or invasive cancer compared with those randomly assigned to placebo but no increase in thromboembolic events or endometrial cancers. The 5-year number needed to treat was 22 (95% CI, 20-27). Our attention is now focused on prognostic and predictive markers to identify patients who can derive the greatest benefits from low dose tamoxifen, such as for instance the expression of 23 genes involved in cell cycle progression (CCP). In conclusion, we endorse an active treatment of DCIS as the standard of care.
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Affiliation(s)
- Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Matteo Puntoni
- Clinical Trial Office, E.O. Ospedali Galliera, Genoa, Italy
| | | | | | | | - Mauro D'Amico
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Silvia Giuliano
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Giacomo Siri
- Clinical Trial Office, E.O. Ospedali Galliera, Genoa, Italy
| | - Sara Cagnacci
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
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3
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Skandarajah AR, Thomas S, Shackleton K, Chin-Lenn L, Lindeman GJ, Mann GB. Patient and medical barriers preclude uptake of tamoxifen preventative therapy in women with a strong family history. Breast 2017; 32:93-97. [DOI: 10.1016/j.breast.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 01/26/2023] Open
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4
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Lazzeroni M, Dunn BK, Pruneri G, Jereczek-Fossa BA, Orecchia R, Bonanni B, DeCensi A. Adjuvant therapy in patients with ductal carcinoma in situ of the breast: The Pandora's box. Cancer Treat Rev 2017; 55:1-9. [PMID: 28262606 DOI: 10.1016/j.ctrv.2017.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 12/23/2022]
Abstract
Most patients with ductal carcinoma in situ of the breast (DCIS) are eligible for breast conservation treatment. The key management decision is whether to add radiotherapy and/or endocrine therapy to minimize the risk of a subsequent recurrence. Recent analyses indicating a lack of benefit in terms of breast cancer-associated mortality have suggested that more conservative approaches, omitting adjuvant therapy or even surgery, may be advisable in selected patients. These mortality observations are directly influenced by widespread use of mammographic screening which has opened a Pandora's box of subclinical DCIS and early invasive lesions. Confusion as to how aggressively such possibly indolent lesions should be treated has led to misunderstandings among patients and medical professionals. While awaiting further prospective evidence from clinical trials, we endorse an active treatment of DCIS as the standard of care. Our rationale is twofold: invasive recurrences are associated with an increase in breast cancer mortality, which is not the only relevant endpoint for DCIS. The benefit of complete surgical excision, adjuvant radiotherapy and endocrine treatment in preventing recurrence and invasive progression has been demonstrated in DCIS. The challenge now is how to identify DCIS patients who will not progress to invasive carcinoma even without complete excision and, at the other extreme, those patients at the highest risk who require mastectomy for local control. The current controversies over whether and which adjuvant therapy should be implemented can at least in part be addressed by developing effective doctor-patient communications that enable mutual understanding about the management of this biologically heterogeneous disease.
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Affiliation(s)
- Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Barbara K Dunn
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD 20892, USA
| | - Giancarlo Pruneri
- Pathology, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Roberto Orecchia
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Andrea DeCensi
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom.
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5
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Chemoprevention. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Graffeo R, Livraghi L, Pagani O, Goldhirsch A, Partridge AH, Garber JE. Time to incorporate germline multigene panel testing into breast and ovarian cancer patient care. Breast Cancer Res Treat 2016; 160:393-410. [DOI: 10.1007/s10549-016-4003-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/23/2016] [Indexed: 02/07/2023]
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7
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Toss A, Palazzo J, Berger A, Guiles F, Sendecki JA, Simone N, Anne R, Avery T, Jaslow R, Lazar M, Tsangaris T, Cristofanilli M. Clinical-pathological features and treatment modalities associated with recurrence in DCIS and micro-invasive carcinoma: Who to treat more and who to treat less. Breast 2016; 29:223-30. [PMID: 27506636 DOI: 10.1016/j.breast.2016.07.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 12/28/2022] Open
Abstract
The primary aim in the management of DCIS is the prevention of recurrence and contralateral tumor. Risk factors for DCIS recurrence and appropriate treatments are still widely debated. Adjuvant therapies after surgical resection reduce recurrences and contralateral disease, but these treatments have significant financial costs, side effects and there is a group of low-risk patients who would not gain additional benefit. The aim of our analysis was to identify clinical-pathological features and treatment modalities associated with recurrence in DCIS and microinvasive carcinoma. In the Thomas Jefferson University Cancer Registry of Philadelphia, we identified 865 patients with DCIS or micro-invasive carcinoma treated between 2003 and 2013. Associations between recurrence and demographic factors (age at diagnosis, ethnicity), biological features (ER, PR and HER2) and treatment modalities (surgery, radiotherapy and endocrine treatment) were assessed. Our single institution register-based study showed that distribution of age at diagnosis and biological features did not significantly differ among ethnic groups. Younger women and micro-invasive carcinoma patients were more likely to undergo mastectomy, while African Americans were more likely to take endocrine therapy and undergo radiotherapy. In our sample only ER/PR negative DCIS were associated with significantly higher recurrence rate. Moreover, we reported a high rate of HER2 positive recurrences, suggesting that expression of this oncogene may represent a potential biomarker for DCIS at high risk of recurrence. To better define the molecular profile of the subgroup at worse prognosis might help to identify biomarkers predictive of recurrence or second tumors, identifying patients candidates for more appropriate treatments.
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Affiliation(s)
- Angela Toss
- Department of Medical Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA.
| | - Juan Palazzo
- Department of Pathology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Adam Berger
- Department of Surgery, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Frances Guiles
- Department of Medical Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Jocelyn Andrel Sendecki
- Department of Biostatistics, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Nicole Simone
- Department of Radiation Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Rani Anne
- Department of Radiation Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Tiffany Avery
- Department of Medical Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Rebecca Jaslow
- Department of Medical Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Melissa Lazar
- Department of Surgery, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Theodore Tsangaris
- Department of Surgery, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
| | - Massimo Cristofanilli
- Department of Medical Oncology, Thomas Jefferson University & Kimmel Cancer Center, Philadelphia, PA 19107, USA
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Groom AG, Younis T. Endocrine therapy for breast cancer prevention in high-risk women: clinical and economic considerations. Expert Rev Pharmacoecon Outcomes Res 2016; 16:245-55. [PMID: 26923683 DOI: 10.1586/14737167.2016.1159514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The global burden of breast cancer highlights the need for primary prevention strategies that demonstrate both favorable clinical benefit/risk profile and good value for money. Endocrine therapy with selective estrogen-receptor modulators (SERMs) or aromatase inhibitors (AIs) has been associated with a favorable clinical benefit/risk profile in the prevention of breast cancer in women at high risk of developing the disease. The available endocrine therapy strategies differ in terms of their relative reductions of breast cancer risk, potential side effects, and upfront drug acquisition costs, among others. This review highlights the clinical trials of SERMs and AIs for the primary prevention of breast cancer, and the cost-effectiveness /cost-utility studies that have examined their "value for money" in various health care jurisdictions.
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Affiliation(s)
- Amy G Groom
- a Department of Medicine , Dalhousie University at Queen Elizabeth II Health Sciences Centre , Halifax , Nova Scotia , Canada
| | - Tallal Younis
- a Department of Medicine , Dalhousie University at Queen Elizabeth II Health Sciences Centre , Halifax , Nova Scotia , Canada
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DeCensi A, Thorat MA, Bonanni B, Smith SG, Cuzick J. Barriers to preventive therapy for breast and other major cancers and strategies to improve uptake. Ecancermedicalscience 2015; 9:595. [PMID: 26635899 PMCID: PMC4664508 DOI: 10.3332/ecancer.2015.595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 12/31/2022] Open
Abstract
The global cancer burden continues to rise and the war on cancer can only be won if improvements in treatment go hand in hand with therapeutic cancer prevention. Despite the availability of several efficacious agents, utilisation of preventive therapy has been poor due to various barriers, such as the lack of physician and patient awareness, fear of side effects, and licensing and indemnity issues. In this review, we discuss these barriers in detail and propose strategies to overcome them. These strategies include improving physician awareness and countering prejudices by highlighting the important differences between preventive therapy and cancer treatment. The importance of the agent-biomarker-cohort (ABC) paradigm to improve effectiveness of preventive therapy cannot be overemphasised. Future research to improve therapeutic cancer prevention needs to include improvements in the prediction of benefits and harms, and improvements in the safety profile of existing agents by experimentation with dose. We also highlight the role of drug repurposing for providing new agents as well as to address the current imbalance between therapeutic and preventive research. In order to move the field of therapeutic cancer prevention forwards, engagement with policymakers to correct research imbalance as well as to remove practical obstacles to implementation is also urgently needed.
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Affiliation(s)
- Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, Genoa 16128, Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Breast Services, Division of Surgery and Interventional Science, Whittington Hospital, Magdala Avenue, London N19 5NF, UK
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Samuel G Smith
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Health Behaviour Research Centre, University College London, London WC1E 7HB, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
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DeCensi A, Puntoni M, Guerrieri-Gonzaga A, Cazzaniga M, Serrano D, Lazzeroni M, Vingiani A, Gentilini O, Petrera M, Viale G, Cuzick J, Bonanni B, Pruneri G. Effect of Metformin on Breast Ductal Carcinoma In Situ Proliferation in a Randomized Presurgical Trial. Cancer Prev Res (Phila) 2015; 8:888-94. [PMID: 26276754 DOI: 10.1158/1940-6207.capr-15-0048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 08/06/2015] [Indexed: 11/16/2022]
Abstract
Metformin is associated with lower breast cancer risk in epidemiologic studies and showed decreased proliferation in HER2-positive breast cancer in a presurgical trial. To provide insight into its preventive potential, we measured proliferation by Ki-67 labeling index (LI) of intraepithelial lesions surrounding breast cancer. We randomly assigned 200 nondiabetic patients diagnosed with invasive breast cancer in core biopsies to metformin, 1,700 mg or placebo once daily for 28 days before surgery. Upon surgery, five to seven specimens of cancer adjacent (≤1 cm) and distant (>1 cm) tissue were screened for LCIS, ductal carcinoma in situ (DCIS), and ductal hyperplasia (DH). The prevalence of LCIS, DCIS, and DH was 4.5% (9/200), 67% (133/200), and 35% (69/200), respectively. Overall, metformin did not affect Ki-67 LI in premalignant disorders. The median posttreatment Ki-67 LI (IQR) in the metformin and placebo arm was, respectively, 15% (5-15) versus 5% (4-6) in LCIS (P = 0.1), 12% (8-20) versus 10% (7-24) in DCIS (P = 0.9), and 3% (1-4) versus 3% (1-4) in DH (P = 0.5). However, posttreatment Ki-67 in HER2-positive DCIS lesions was significantly lower in women randomized to metformin especially when ER was coexpressed: 22% (11-32) versus 35% (30-40) in HER2-positive DCIS (n = 22, P = .06); 12% (7-18) versus 32% (27-42) in ER-positive/HER2-positive DCIS (n = 15, P = .004). Eight of 22 (36%) HER2-positive DCIS were adjacent to HER2-negative invasive breast cancer. In tissue samples obtained following 4 weeks of study drug, proliferation was lower in HER2-positive DCIS for women randomized to metformin versus placebo. An adjuvant trial incorporating metformin in HER2-positive DCIS is warranted.
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Affiliation(s)
- Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy. Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom.
| | - Matteo Puntoni
- Office of the Scientific Director, E.O. Ospedali Galliera, Genoa, Italy
| | | | - Massimiliano Cazzaniga
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Davide Serrano
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Andrea Vingiani
- Division of Pathology, European Institute of Oncology, Milan, Italy
| | - Oreste Gentilini
- Division of Breast Surgery, European Institute of Oncology, Milan, Italy
| | - Marilena Petrera
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Giuseppe Viale
- Division of Pathology, European Institute of Oncology, Milan, Italy. University of Milan, School of Medicine, Milan, Italy
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Giancarlo Pruneri
- Division of Pathology, European Institute of Oncology, Milan, Italy. University of Milan, School of Medicine, Milan, Italy
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Abstract
Pharmacologic interventions for cancer risk reduction involve the chronic administration of synthetic or natural agents to reduce or delay the occurrence of malignancy. Despite the strong evidence for a favorable risk-benefit ratio for a number of agents in several common malignancies such as breast and prostate cancer, the public's attitude toward cancer chemoprevention remains ambivalent, with the issue of toxicity associated with drugs being perceived as the main barrier to widespread use of preventive therapy by high-risk subjects. Among the strategies to overcome such obstacles to preventive therapies, two novel and potentially safer modes of administering agents are discussed in this paper. The first strategy is to lower the dose of drugs that are in common use in the adjuvant setting based on the notion that prevention of cancer cells from developing should require a lower dose than eradicating established tumor cells. A second approach is to adopt an intermittent administration similar to what is used in the chemotherapy setting in an attempt to minimize risks while retaining benefits. This article provides a detailed discussion of the principles and future development of these two approaches in the direction of a precision preventive medicine.
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Affiliation(s)
- Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy.
| | - Andrea DeCensi
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
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12
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Lo AC, Truong PT, Wai ES, Nichol A, Weir L, Speers C, Hayes MM, Baliski C, Tyldesley S. Population-based analysis of the impact and generalizability of the NSABP-B24 study on endocrine therapy for patients with ductal carcinoma in situ of the breast. Ann Oncol 2015; 26:1898-1903. [PMID: 26063632 DOI: 10.1093/annonc/mdv251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/21/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In 1999, the National Surgical Adjuvant Breast and Bowel Project (NSABP)-B24 trial demonstrated that tamoxifen reduced relapse risk in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) and radiotherapy (RT). In 2002, Allred's subgroup analysis showed that tamoxifen mainly benefitted estrogen receptor (ER)-positive disease. This study evaluates the impact and generalizability of these trial findings at the population level. PATIENTS AND METHODS From 1989 to 2009, 2061 women with DCIS underwent BCS + RT in British Columbia. The following cohorts were analyzed: (1) pre-NSABP-B24 era (1989-1998, N = 417); (2) post-NSABP-B24 era (2000-2009, N = 1548). Cohort 2 was further divided into pre- and post-Allred eras. RESULTS Endocrine therapy (ET) was used in 404/2061 (20%) patients. Median age of patients treated with compared with without ET, was 53 versus 57 years, (P < 0.0005). One of 417 (0.2%) versus 399/1548 (26%) patients took ET before versus after NSABP-B24. Among the post-Allred era cohort treated with ET (N = 227), tumors were ER-positive in 65%, ER-negative in 1%, and ER-unknown in 33%; whereas of those treated without ET (N = 801), ER was positive in 43%, negative in 15%, and unknown in 42% (P < 0.0005). On multivariable analysis of the post-NSABP-B24 era, ET was associated with improved event-free survival (EFS) (hazard ratio 0.6; P = 0.02); 5-year EFS were 96.9% with ET versus 94.5% without ET. CONCLUSIONS ET use in DCIS patients treated with BCS + RT increased significantly after the NSABP-B24 study. ER+ disease and younger age were associated with increased ET use. ET was associated with improved EFS, confirming the generalizability of trial data at a population level.
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Affiliation(s)
- A C Lo
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - P T Truong
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Victoria; Breast Cancer Outcomes Unit, Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - E S Wai
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Victoria; Breast Cancer Outcomes Unit, Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - A Nichol
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver; Breast Cancer Outcomes Unit, Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - L Weir
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver; Breast Cancer Outcomes Unit, Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - C Speers
- Breast Cancer Outcomes Unit, Vancouver
| | - M M Hayes
- Department of Pathology, BCCA, Vancouver; Faculty of Medicine, University of BC, Vancouver
| | - C Baliski
- Faculty of Medicine, University of BC, Vancouver; Department of Surgical Oncology, BCCA, Kelowna, Canada
| | - S Tyldesley
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver; Breast Cancer Outcomes Unit, Vancouver; Faculty of Medicine, University of BC, Vancouver.
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13
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Serrano D, Lazzeroni M, Bonanni B. Cancer chemoprevention: Much has been done, but there is still much to do. State of the art and possible new approaches. Mol Oncol 2014; 9:1008-17. [PMID: 25556583 DOI: 10.1016/j.molonc.2014.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 12/14/2022] Open
Abstract
Over the past three decades great efforts have been made in search of cancer chemoprevention strategies. The increase in knowledge of the long process from normal to cancer cell has enabled interventions in terms of lifestyle modifications, natural compounds or drugs to block or reverse the process. Great successes have been achieved, especially for breast and colorectal cancer. However, these strategies have yet to find clinical application on a large scale. In this article we identify the achievements, the pitfalls and the next steps to be taken to improve the efficacy and applicability of chemoprevention strategies. Among the crucial key points to be implemented are educational activities for physicians to appropriately disseminate the aim and indeed the culture of chemoprevention. It is essential to improve the risk-benefit balance, seeking the minimal active doses, intermittent schedules, a better characterization of the risk categories via a more personalized intervention based on individual characteristics, and ensure the containment of costs of public and private health prevention programs.
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Affiliation(s)
- Davide Serrano
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy.
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14
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Toesca A, Botteri E, Lazzeroni M, Vila J, Manika A, Ballardini B, Bettarini F, Guerrieri-Gonzaga A, Bonanni B, Rotmensz N, Viale G, Veronesi P, Luini A, Veronesi U, Gentilini O. Breast conservative surgery for well-differentiated ductal intraepithelial neoplasia: Risk factors for ipsilateral breast tumor recurrence. Breast 2014; 23:829-35. [DOI: 10.1016/j.breast.2014.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/11/2014] [Accepted: 08/31/2014] [Indexed: 11/17/2022] Open
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