Extended Adjuvant Endocrine Therapy in Breast Cancer: Evidence and Update - A Review

Design, synthesis and antiproliferative activity of raloxifene/histone deacetylase inhibitor hybrids in breast cancer

Antiestrogen/histone deacetylase inhibitor (HDACi) hybrids were designed by merging structures of raloxifene with suberoylanilide hydroxamic acid, incorporating the HDACi unit into the phenolic ring of the antiestrogen. These hybrids were synthesized with a range of HDACi chain lengths and assessed for bifunctionality. Four hybrids, 21 (YW471), 22 (YW490), 27(YW486), and 28 (YW487) showed good potency both as antiestrogens in a BRET assay and in a fluorometric HDACi assay. The antiproliferative activity of the hybrids was demonstrated in both ER+ MCF7 and ER- MDA-MB-231 breast cancer cell lines.

Selecting postoperative adjuvant systemic therapy for early-stage breast cancer: An updated assessment and systematic review of leading commercially available gene expression assays

Gene expression assays (GEAs) can guide treatment for early-stage breast cancer. Several large prospective randomized clinical trials, and numerous additional studies, now provide new information for selecting an appropriate GEA. This systematic review builds upon prior reviews, with a focus on five widely commercialized GEAs (Breast Cancer Index®, EndoPredict®, MammaPrint®, Oncotype DX®, and Prosigna®). The comprehensive dataset available provides a contemporary opportunity to assess each GEA's utility as a prognosticator and/or predictor of adjuvant therapy benefit.

Comparative efficacy and safety of extended adjuvant endocrine therapy for hormone receptor-positive early breast cancer: a Bayesian network meta-analysis

PURPOSE

Optimal extended adjuvant endocrine therapy (ET) duration and strategy for hormone receptor-positive (HR +) early breast cancer remain unclear. In this network meta-analysis (NMA), the efficacy and safety of all available extended adjuvant ETs were compared and ranked.

METHODS

PubMed, Embase, and Cochrane Library and abstracts presented at ASCO, SABCS, and ESMO were searched on March 5, 2022. Fourteen randomized controlled trials (RCTs) comprising eight extended adjuvant ETs for HR + breast cancer and 38,070 patients were analyzed. Main outcomes were disease-free survival (DFS), overall survival (OS), grade ≥ 3 adverse events (AEs), and contralateral breast cancer (CBC). Direct and indirect comparisons were integrated via Bayesian NMA. Hierarchical cluster analysis was performed to jointly rank efficacy and safety outcomes.

RESULTS

Compared with that of 5 year ET, extended 10 year aromatase inhibitor (AI) treatment provided the greatest DFS benefit (HR = 0.45, 95%CrI 0.23-0.83), whereas no strategy differed significantly in terms of the other main outcomes. Extended 10 year AI treatment was the preferred strategy for DFS improvement and CBC prevention (surface under the cumulative ranking curve: 93.51% and 91.29% probability, respectively). All strategies had comparable safeties (grade ≥ 3 AEs). Compared with that of 5 year ET, 10 year extended AI significantly increased arthralgia (OR = 1.65, 95%CrI 1.02-2.93) and osteoporosis (OR = 3.33, 95%CrI 1.19-9.68).

CONCLUSION

Extended 10 year AI therapy may be optimal for HR + early breast cancer given its relatively high efficacy and safety.

The role of trust in the acceptance of adjuvant endocrine therapy in breast cancer patients

OBJECTIVE

Despite adjuvant endocrine therapy (AET) considerably reducing mortality and recurrence in hormonal receptor-positive (HR+) breast cancer (BC) patients, acceptance of AET remains an issue. The reasoning behind the lack of acceptance is complex and multifactorial, and some associated risk factors have been previously analyzed. Our study aims to assess women's beliefs and concerns toward AET and women's trust in the treating physician, focusing on determining the importance of these factors in the acceptance of AET.

METHODS

Out of n = 539, n = 269 women with HR + BC participated in a cross-sectional online survey. The main study variables were AET necessity beliefs and concerns (Beliefs about Medicines Questionnaire) and the trust in treating physicians. A binary hierarchical logistic regression was applied to predict AET acceptance.

RESULTS

We did not observe a meaningful mean difference in the necessity beliefs between women who accepted versus refused AET by the time of study conduct. Women with ongoing AET intake indicated significantly higher trust in their treating physician (d = 0.57) and have lower concerns (d = -1.65) regarding AET than women who had declined or discontinued AET prematurely. Results of the logistic regression demonstrated that after adjusting for clinical factors (e.g., prognosis, age), higher trust and lower concerns significantly increased the likelihood of accepting AET treatment.

CONCLUSIONS

Our results demonstrate the importance of discussing potential concerns regarding AET and establishing a trustful patient-physician relationship, which outweighs non-modifiable factors such as cancer prognosis.

Outcomes for Patients with Residual Stage II/III Breast Cancer Following Neoadjuvant Chemotherapy (AFT-01)

INTRODUCTION

Pathologic complete response (pCR) after neoadjuvant chemotherapy has a demonstrated survival advantage; however, outcomes for non-pCR by receptor status are less understood. We sought to evaluate survival and distant recurrence by receptor status for patients with residual stage II/III breast cancer.

METHODS

A stage-stratified random sample of 11,366 patients with stage II-III breast cancer in 2006-2007 was selected from 1217 facilities in the National Cancer Database for a Commission on Cancer Special Study. We identified patients with residual pathologic stage II/III cancer who received standard of care therapy based on receptor status. Distant recurrence and 5-year survival were abstracted and Kaplan-Meier curves were generated by receptor status. Multivariable Cox regression was used to estimate hazard ratios for death and distant recurrence.

RESULTS

A total of 734 patients had residual disease; 58%, 28%, and 14% were ER or PR+/Her2neu-, ER and PR-/Her2neu-, and Her2neu+ (any ER/PR), respectively. ER and PR-/Her2neu- cancers had the poorest 5-year overall (52% vs. 82% for Her2neu+ and ER or PR+/Her2neu-, p < 0.0001) and distant recurrence-free survival (57% vs. 72% Her2neu+ and 77% ER or PR+/Her2neu, p < 0.0001). Cox regression models demonstrated a higher likelihood of distant recurrence and death for patients with ER and PR-/Her2neu- disease (HR 2.25, 95% CI 1.56-3.24 and HR 3.19, 95% CI 2.20-4.64 respectively) compared with ER or PR+/Her2neu-.

CONCLUSIONS

Patients with residual ER and PR-/Her2neu- cancer have a significant risk of distant recurrence and mortality compared with other breast cancer types, supporting the consideration for additional adjuvant therapy and novel clinical trials in this cohort. Trial registry number ClinicalTrials.gov identifier NCT02171078.

Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor-Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database

PURPOSE

Deintensification of adjuvant therapy is being considered for older women with early-stage, biologically favorable breast cancer. Although radiation therapy (RT) can be omitted in some cases, toxicity from hormone therapy (HT) is not trivial, and adherence rates vary. We hypothesized that adjuvant RT alone would produce survival outcomes comparable to those with adjuvant HT alone among elderly patients treated with lumpectomy.

METHODS AND MATERIALS

We searched the National Cancer Database (2010-2014) for healthy women (aged ≥70 years, Charlson/Deyo [CD] score 0-1) with T1N0 hormone-receptor-positive, HER-2-negative breast cancer treated with lumpectomy and adjuvant HT or RT. Propensity scores were used to match patients for analysis.

RESULTS

We identified 2995 patients (median age, 78 years), most (81%) with a CD score of 0, clinical stage IA (77%), of whom 65% received HT alone and 35% received RT only after lumpectomy. On multivariate analysis of the matched cohort, older age (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.07-1.13; P < .001), CD score 1 (HR 1.92; 95% CI 1.37-2.70; P = .0002), and living in a metropolitan (vs urban) area (HR 3.09; 95% CI 1.43-6.67; P = .004) were associated with inferior overall survival (OS), whereas treatment with HT (vs RT) was not (HR 1.13; 95% CI 0.85-1.49; P = .406). At a median follow-up of 45 months, no difference was found in OS between HT versus RT cohorts (85% and 86%, respectively; P = .44).

CONCLUSIONS

For healthy, older women with biologically favorable breast cancer treated with lumpectomy, adjuvant RT or HT is associated with equivalent 5-year OS rates. A randomized controlled trial is warranted to explore these adjuvant monotherapy options in elderly patients with hormone receptor-positive breast cancer.

Synthesis of New Dihydroquinopimaric Acid Analogs with Nitrile Groups as Apoptosis-Inducing Anticancer Agents

BACKGROUND

Cyan-containing compounds are of great interest as potential anticancer agents. Terpenoids can severe as a natural matrix for the development of promising derivatives with antitumor activity.

METHODS

The 2-cyanoethoxy methyl dihydroquinopimarate derivatives (5-9) were synthesized by the reaction of the intermediates (1-4) with acrylonitrile in the presence of alkali (30% KOH solution) using triethylbenzylammonium chloride. The cytotoxicity evaluation was carried out according to the National Cancer Institute (NCI) Protocol, while apoptosis was studied by flow cytometric analysis of Annexin V and 7-aminoactinomycin D staining and cell cycle was analyzed using the method of propidium iodide staining.

RESULTS

Synthesis of new dihydroquinopimaric acid derivatives with nitrile groups was carried out. The obtained cyanoethyl derivatives were converted into tetrazole, amine, oxadiazole and amidoxime analogs. The primary screening for antitumor activity showed the highest cytotoxic potency of the cyanoethyl-substituted compounds. The introduction of cyanoethyl groups at C-1, C-4 and C-1, C-4, C-20 positions of dihydroquinopimaric acid methyl ester provided antiproliferative effect towards the Jurkat, K562, U937, and HeLa tumor cell cultures (CC50=0.045-0.154µM). These nitrile derivatives are effective inducers of tumor cell apoptosis affecting the S and G2 phases of the cell cycle in a dose-dependent manner.

CONCLUSION

The cyanoethyl analogs of dihydroquinopimaric acid reported herein are apoptosis inducers and cytotoxic agents. These findings will be useful for the further design of more potent cytotoxic agents based on natural terpenes.

Locally advanced breast cancer in Brazil: current status and future perspectives

Breast cancer (BC) is the most frequent cancer and the main cause of cancer deaths among women worldwide and in Brazil. A high proportion of patients are diagnosed with locally advanced breast cancer (LABC) in Brazil, mainly due to limited coverage of screening programmes. A disparity in the access to optimal treatment is evident between the public and private health systems which impact patient outcomes. Clinical research is an opportunity for patients, institutions and investigators and therefore should be facilitated through a better regulatory environment. In a country facing a trend of increasing BC incidence for the next years, it is critical to improve BC screening and incorporate new medicines and devices into the public health system to control the burden of LABC.

Prevention of Tamoxifen-related Nonalcoholic Fatty Liver Disease in Breast Cancer Patients

BACKGROUND

Tamoxifen is commonly used to prevent breast cancer recurrence. Studies have confirmed the association between tamoxifen and nonalcoholic fatty liver disease (NAFLD), with the results indicating the need for aggressive management of this side effect. We assessed the potential risk factors for and identified the possible protective factors of tamoxifen-related fatty liver.

MATERIALS AND METHODS

We enrolled patients with a history of breast cancer, aged 20 to 70 years, who had received with tamoxifen treatment within the past 5 years. We obtained the initial data and performed a follow-up blood test and ultrasound examination to compare the differences before and after tamoxifen treatment. The patients were divided into relatively normal and fatty liver groups.

RESULTS

Of the 266 enrolled tamoxifen-treated patients, 143 (53.8%) and 123 (46.2%) were in the relatively normal and fatty liver groups, respectively. The initial body weight (57.6 ± 9.3 kg vs. 60.9 ± 10.3 kg; P = .006) and body mass index (BMI; 23.4 ± 3.8 kg/m² vs. 25.0 ± 4.2 kg/m²; P < .001) were lower in the relatively normal group. An initial BMI of ≥ 22 kg/m² was a potential risk factor for tamoxifen-related NAFLD (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.00-2.48; P = .048). In contrast, a weekly exercise duration of ≥ 150 minutes reduced the risk (HR, 0.47; 95% CI, 0.31-0.69; P < .001).

CONCLUSION

The results from our study suggest that a BMI of ≥ 22 kg/m² is a potential risk factor for tamoxifen-related fatty liver and exercise is a possible protective factor.

ER-positive breast cancer patients with more than three positive nodes or grade 3 tumors are at high risk of late recurrence after 5-year adjuvant endocrine therapy

Purpose

Currently, although several clinical trials available give strong suggestions that extension of endocrine therapy has benefits, the risk level at which patients may benefit from extended endocrine therapy remains uncertain. This study aimed to identify the proportion of patients at a substantial risk of late recurrence after 5-year adjuvant endocrine therapy.

Patients and methods

We reviewed 1,056 female patients with primary breast cancer who underwent curative resection between January 2006 and December 2011. Univariate and multivariate analyses were performed using the Cox proportional hazards regression model to identify prognostic factors.

Results

A total of 327 eligible patients were eventually enrolled in this study. Among them, 42 (12.8%) patients suffered from distant metastasis and 34 (10.4%) patients experienced locoregional recurrence after 5-year adjuvant endocrine therapy. In multivariate analysis, patients with more than three positive nodes (hazard ratio [HR] =2.176, 95% CI=1.071–4.421; P=0.032) and histologic grade 3 disease (HR=2.098, 95% CI=1.300–3.385; P=0.002) were significantly associated with high risk of late recurrence. However, only histologic grade 3 (HR=2.212, 95% CI=1.166–4.194; P=0.015) was significantly associated with high risk of distant metastasis.

Conclusion

Late relapse after completion of 5-year adjuvant endocrine therapy was still common, and grade 3 and more than three positive nodes were the risk factors of late recurrence, while grade 3 was the only risk factor of late distant metastasis. These patients might benefit from extended endocrine therapy.