Raloxifene as a multifunctional medicine? Current trials will show whether it is effective in both osteoporosis and breast cancer

Pharmacophore mapping of arylbenzothiophene derivatives for MCF cell inhibition using classical and 3D space modeling approaches

Considering the worth of developing non-steroidal estrogen analogs, the present study explores the pharmacophore features of arylbenzothiophene derivatives for inhibitory activity to MCF-7 cells using classical QSAR and 3D space modeling approaches. The analysis shows that presence of phenolic hydroxyl group and ketonic linkage in the basic side chain of 2-arylbenzothiophene core of raloxifene derivatives are crucial. Additionally piperidine ring connected through ether linkage is favorable for inhibition of breast cancer cell line. These features for inhibitory activity are also highlighted through 3D space modeling approach that explored importance of critical inter features distance among HB-acceptor lipid, hydrophobic and HB-donor features in the arylbenzothiophene scaffold for activity.

Interactions of the human cytosolic sulfotransferases and steroid sulfatase in the metabolism of tibolone and raloxifene

Sulfation is important in the metabolism and inactivation of steroidal compounds and hormone replacement therapeutic (HRT) agents in human tissues. Although generally inactive, many steroid sulfates are hydrolyzed to their active forms by sulfatase activity. Therefore, the specific sulfotransferase (SULT) isoforms and the levels of steroid sulfatase (STS) activity in tissues are important in regulating the activity of steroidal and HRT compounds. Tibolone (Tib) is metabolized to three active metabolites and all four compounds are readily sulfated. Tib and the Delta4-isomer are sulfated at the 17beta-OH group by SULT2A1 and the 17-sulfates are resistant to hydrolysis by human placental STS. 3alpha-OH and 3beta-OH Tib can form both 3- and 17-monosulfates as well as disulfates. Only the 3beta-sulfates are susceptible to STS hydrolysis. Raloxifene monosulfation was catalyzed by at least seven SULT isoforms and SULT1E1 also synthesizes raloxifene disulfate. SULT1E1 forms both monosulfates in a ratio of approximately 8:1 with the more abundant monosulfate migrating on HPLC identical to the SULT2A1 synthesized monosulfate. The raloxifene monosulfate formed by both SULT isoforms is sensitive to STS hydrolysis whereas the low abundance monosulfate formed by SULT1E1 is resistant. The benzothiophene sulfates of raloxifene and arzoxifene were hydrolyzed by STS whereas the raloxifene 4'-phenolic sulfate was resistant. These results indicate that tissue specific expression of SULT isoforms and STS could be important in the inactivation and regeneration of the active forms of HRT agents.

Sulfation of raloxifene and 4-hydroxytamoxifen by human cytosolic sulfotransferases

Raloxifene and 4-hydroxytamoxifen (4-OHT) are important estrogen-related drugs used in the treatment of osteoporosis and breast cancer. Sulfation is involved in the metabolism and inactivation of both compounds in human tissues, although the sulfotransferase (SULT) isoforms involved in their conjugation have not been well described. The ability of seven expressed SULT isoforms to sulfate raloxifene and 4-OHT was investigated. Raloxifene was conjugated by all seven SULT isoforms tested, whereas 4-OHT was conjugated only by SULTs 1A1, 1E1, and 2A1. Characterization of raloxifene and 4-OHT sulfation demonstrates that sulfation can occur at therapeutic concentrations. SULT1E1 displayed the lowest Km (0.2 microM) for 4-OHT sulfation and SULT2A1 the lowest (0.3 microM) for raloxifene sulfation. SULT1E1 was the only isoform exhibiting detectable levels of raloxifene disulfation activity. Modeling of the interactions of raloxifene in the active site of SULT1E1 indicates that both hydroxyl groups of raloxifene can be readily positioned in proximity to the sulfonyl group of 3'-phosphoadenosine 5'-phosphosulfate and the catalytically important His107 residue. Both raloxifene and 4-OHT sulfation activities were detectable in all human liver cytosols tested. 4-OHT sulfation was detected in cytosol prepared from endometrial biopsies of normal women obtained during the proliferative and secretory phases of the same menstrual cycle. In contrast, raloxifene sulfation was detectable only in secretory phase cytosols in association with SULT1E1 activity. In summary, several human SULT isoforms are capable of sulfating raloxifene and 4-OHT. Tissue-specific expression of the individual SULT isoforms may have important roles in the regulation of the activity of these compounds.

Current comprehensive assessment and management of women at increased risk for breast cancer

The potential for reducing the risk of breast cancer through selective estrogen receptor modulators, aromatase inhibitors, and surgery has generated interest in the use of quantitative models of risk assessment. With the addition of ductal lavage cytology to traditional epidemiologic risk factors, a discovery of cellular atypia can result in refinement of assigned risk values, while simultaneously optimizing patient selection for selective estrogen receptor modulators utilization. In view of increasing complexity in this arena, a Risk Assessment Working Group was formed to outline management strategies for the patient at an elevated risk for the development of breast cancer. No longer a statistical exercise, quantitative risk assessment is part of basic breast care and comprehensive management includes a discussion of the following: ductal lavage for improved risk stratification, multiple options for risk reduction, and high risk surveillance strategies that might incorporate investigational imaging protocols.

Management of the menopause in cancer survivors

The consequences of premature menopause are of great importance to cancer survivors. Oestrogen replacement therapy (with and without added progestins) is the most extensively researched agent for the treatment and prevention of menopausal problems. While this may be appropriate for symptom control in patients with tumours that are not hormone responsive, patients with hormone dependent tumours will require safe and effective alternative treatments for menopausal symptoms. This paper will discuss both the short-term and long-term consequences of the menopause in cancer survivors and will also offer various management strategies.

Selective estrogen receptor modulators as a new therapeutic drug group: concept to reality in a decade

This article provides an overview of the historical development, current research, clinical benefits, and potential future applications of the selective estrogen receptor modulators (SERMs), tamoxifen and raloxifene. The understanding of the mechanism of action of SERMs led not only to the development of tamoxifen, the first widely used antiestrogen for breast cancer treatment, but also to its application as a chemopreventive agent. The SERM principle of antiestrogenic actions in the breast but estrogenlike actions in bone is reviewed in clinical practice through analysis of the current applications and the potential for expanding the role of SERMs. The current view of the molecular mechanism of SERM action is summarized to identify potential target sites for future research. The clinical success of tamoxifen and raloxifene for the prevention and treatment of breast cancer and osteoporosis, respectively, has encouraged the development of a range of new agents that target breast cancer, osteoporosis, coronary heart disease, and endometrial safety.

A new day dawns: women without oestrogen or is a balance best?

Building on the 30-year success story with tamoxifen, the question now is whether one agent can be used for treatment and prevention or should new medicines be targeted to specific applications? The early results with anastrozole suggest it could replace tamoxifen for treatment and should be tested as a preventive. Unfortunately, long-term testing of aromatase inhibitors will be required to avoid concerns about osteoporosis, Alzheimer's disease and coronary heart disease. Most importantly, the knowledge gained with tamoxifen has resulted in a new generation of selective oestrogen receptor modulators that can be used to prevent osteoporosis, breast cancer and uterine cancer. It is now clear that strategies utilising aromatase inhibitors and selective oestrogen receptor modulators will provide much needed options for individualised treatments.

Chemoprevention with antiestrogens: the beginning of the end for breast cancer. Daniel G. Miller Lecture

In the 1960s, compounds known as nonsteroidal antiestrogens were identified as potential contraceptives, but the drugs caused the induction of ovulation in subfertile women. Tamoxifen and clomiphene were marketed for this indication. However, tamoxifen was advanced for the treatment of breast cancer in the 1970s through a close cooperation between the laboratory and the clinical trials community. The extensive use of long-term adjuvant tamoxifen has resulted in saving the lives of 400,000 women with breast cancer. Tamoxifen is a selective estrogen receptor modulator (SERM) that produces antiestrogenic actions in the breast but estrogen-like actions in bone and lowers serum cholesterol. These properties not only allowed the application of tamoxifen as the first chemopreventive in high-risk pre- and postmenopausal women but also the development of raloxifene to prevent osteoporosis with the potential to prevent breast cancer in postmenopausal women. The future development of SERMs holds the promise of preventing osteoporosis and coronary heart disease as well as breast and endometrial cancer.

Effect of selective estrogen receptor modulators on reproductive tissues other than endometrium

The objective of this paper is to review the published and unpublished knowledge of the effect of selective estrogen receptor modulators on reproductive tissues other than endometrium. Pharmaceutical companies developing or marketing selective estrogen receptor modulators (SERMs) were identified. The investigators at each company responsible for the conduct of investigational trials were contacted and queried about reports of adverse events in any ongoing or completed trials involving SERMs produced by their company. Levormeloxifene and idoxifene trials noted a higher proportion of surgery for pelvic organ prolapse in treated versus untreated women. The development of these pharmaceutical agents was discontinued, primarily for endometrial concerns. However, pelvic organ prolapse was reported to the FDA as an adverse event associated with both drugs. Study weaknesses preclude a definitive association between the agents and pelvic organ prolapse. The treated groups were not necessarily similar for confounding factors such as age, parity, obesity, cigarette smoking, and other risk factors for pelvic organ prolapse. Tamoxifen and raloxifene increase hot flash intensity and frequency. Ovarian cyst formation and uterine fibroid growth have also been reported with some SERMs. The identification and assessment of the impact of current and future SERMs on the pelvic floor and other genital tissues will be important to understanding their potential long-term application in disease treatment and prevention.

Progress in the prevention of breast cancer: concept to reality

In 1936, Professor Antoine Lacassagne suggested that breast cancer could be prevented by developing drugs to block estrogen action in the breast. Jensen discovered the physiologic target, the estrogen receptor, that regulates estrogen action in its target tissues and Lerner discovered the first nonsteroidal antiestrogen MER25. However, the success of tamoxifen as a treatment of breast cancer opened the door for the testing of the worth of tamoxifen to reduce breast cancer incidence in high-risk women. In 1998, Fisher showed that tamoxifen could reduce breast cancer incidence by 50%. Nevertheless, only half the women who develop breast cancer have risk factors other than age, so what can be done for women without risk factors? The recognition that nonsteroidal antiestrogens have the ability to modulate estrogen action selectively has advanced the design and development of new drug for multiple diseases. Tamoxifen and raloxifene maintain bone density and raloxifene is now used to prevent osteoporosis and is being tested as a preventive for coronary heart disease and breast cancer. The drug group is now known as selective estrogen receptor modulators (SERMs) and the challenge is to design new agents for multiple applications. If the 20th century was the era of chemotherapy, the 21st century will be the era of chemoprevention.

Tamoxifen: a personal retrospective

Tamoxifen, originally described as an anti-oestrogen and antifertility agent in the rat, is now a pioneering medicine for the treatment and prevention of breast cancer. Its success is the result of an effective collaboration between laboratory research and clinical trial processes. However, this drug is more than just an anti-oestrogen to treat breast cancer. Laboratory and clinical research defined the concept of selective oestrogen receptor modulation in the 1980s. Non-steroidal anti-oestrogens show oestrogen-like activity in bones and lower cholesterol, but block oestrogen action in the breast and uterus. This realisation led to the development of chemical cousins, known as selective oestrogen receptor modulators. One of these compounds, raloxifene, is used for the prevention of osteoporosis, but is currently being tested as a preventive for breast cancer.