The Modern Landscape of Endocrine Therapy for Premenopausal Women with Breast Cancer

Adjuvant Endocrine Therapy in Premenopausal Women With Hormone Receptor-Positive Early-Stage Breast Cancer: Risk Stratification in a Real-World Setting

BACKGROUND

Ovarian function suppression (OFS) and hormone therapy (HT) represent an adjuvant option in premenopausal hormone receptor-positive early breast cancer (HR+EBC). The SOFT-TEXT trials showed improved outcomes upon receiving aromatase inhibitors (AIs)/OFS.

METHODS

In order to estimate the magnitude of absolute improvements, we conducted a retrospective study applying composite risk (CR) to 237 premenopausal HR+EBC patients.

RESULTS

Overall, 119 of these received tamoxifen (T)/OFS and 118 received AIs/OFS. The median age was 45 years (ys). After a median follow up of 65 months, recurrence was 6.7% in T patients and 10.2% in AI ones. CR (cutoff: 2.67) and ET duration (five-year cutoff) was found to have a significant impact on DFS. Invasive disease-free survival (IDFS) at 5 ys amounted to 82.9% for a CR>2.67 and 95% with CR

CONCLUSION

In a real-world setting, treatment options for premenopausal patients who are candidates for HT and OFS should take risk status into account. Therefore, every effort should be made to maintain patient adherence to treatment in order to manage toxicities and improve outcomes.

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Key Words

• Adjuvant hormone therapy
• Aromatase inhibitors
• Breast cancer
• Ovarian function suppression
• Tamoxifen

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Affiliation(s)

Raffaella D'Onofrio Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
Claudia Omarini Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy
Angela Toss Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
Isabella Sperduti Biostatistics Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
Federico Piacentini Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy
Monica Barbolini Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
Laura Cortesi Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
Elena Barbieri Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
Elisa Pettorelli Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
Chiara Chiavelli Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy; Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
Massimo Dominici Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
Luca Moscetti Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy.

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Diagnosis and Treatment of Breast Cancer in Young Women

OPINION STATEMENT

Despite the increase of breast cancer incidence with age, approximately 7 to 10% ofwomen diagnosed with breast cancer are younger than the age 40. This subgroup ofpatients has different risk factors, tumour biology, clinical outcomes, and specific psy- chosocial issues, such as fertility preservation, family planning, and job reintegration. However, age alone should not be the main consideration when choosing the aggressive- ness of the treatment, as other factors must be considered, including the biologic aggressiveness of the tumour, potential long-term toxicities, and the preferences of the patient. Fertility preservation techniques should be discussed with the patient before starting any cancer treatment. Despite the significant percentage of breast cancer patients younger than age 40, fewclinical studies have specifically investigated disease characteristics and outcomes of this population, and most therapies routinely administered to these younger women were tested in older patients. Moreover, young women who have breast cancer are at a greater risk of sexual and psychological distress, and clinicians should address these issues in order to properly support patients during the long diagnostic and therapeutic journey. Consequently, it is essential to follow diagnostic and treatment guidelines specificallyaddressed to young women. Additional specific procedures should be followed to treat pregnant patients with breast cancer.

Aromatase inhibitors in premenopausal women with breast cancer: the state of the art and future prospects

Approximately 11% of patients with breast cancer (bca) are diagnosed before menopause, and because in most of those patients the tumour expresses a hormone receptor, treatment with endocrine interventions can be applied in any setting of disease (early or advanced). In the past, hormonal treatment consisted only of the estrogen receptor modulator tamoxifen, associated with luteinizing hormone-releasing hormone (lhrh); more recently, aromatase inhibitors (ais) have come into widespread use. The ais interfere with the last enzymatic step of estrogen synthesis in which androgens are converted into estrogens. Initially, the ais were used alone in postmenopausal patients to prevent disease recurrence, but together with lhrh analogs, they can be used in premenopausal patients to produce better estrogen suppression than can be achieved with tamoxifen plus a lhrh analog. Using a systematic review of the scientific literature (prospective and retrospective studies), we set out to assess the efficacy of ais compared with other endocrine therapy in various disease settings (neoadjuvant, adjuvant, metastatic).

New 4-methylidene sterols from the marine sponge Theonella swinhoei

A series of 4-methylidene sterols including three new compounds 1-3, were isolated from the marine sponge Theonella swinhoei. The structures of new compounds were determined on the basis of spectroscopic analyses. Compounds 3, 5, and 6 showed cytotoxicities against U937, MCF-7, and PC-9 cancer cells with IC₅₀ in the range of 1.6-8.8 μM. The new compound 3 exhibited remarkable proapoptotic activity in breast cancer cells. Mechanically, 3 significantly triggered reactive oxygen species (ROS) accumulation resulting in apoptosis and DNA damage in breast cancer cells.

Clinical implications of tumor necrosis factor receptor 2 in breast cancer

Tumor necrosis factor receptor 2 (TNFR2) is a member of the tumor necrosis factor receptor family. Its high expression and oncogenic roles have been reported in several types of tumors in previous years. However, the clinical implication of TNFR2 in breast cancer (BC) tissue (i.e., not soluble TNFR2 in blood or genetic variation of TNFR2) has not been reported. In the present study, TNFR2 expression was detected in BC tissue using immunohistochemistry and, to the best of our knowledge, it was confirmed for the first time that TNFR2 was positively associated with increased tumor size, advanced clinical stage and higher pathological grade. Survival analysis revealed that TNFR2 was positively associated with shorter overall survival (OS) time and disease-free survival (DFS) time. In addition, univariate regression analysis demonstrated that TNFR2 expression (P=0.045), tumor size (P<0.0001), clinical stage (P<0.0001), pathological grade (P=0.002), estrogen and progesterone receptor and human epidermal growth factor receptor 2 (HER2) triple-status (P=0.001) all had a significant impact on the OS rate of patients with BC. TNFR2 expression (P=0.017), age (P=0.011), menopausal status (P<0.0001), tumor size (P=0.016), clinical stage (P=0.005), pathological grade (P=0.002) and estrogen/progesterone receptor and HER2 triple-status (P=0.008) were all shown to significantly impact the DFS rate of patients with BC. Multivariate regression analysis showed that only clinical stage (P=0.024), estrogen and progesterone receptor status and HER2 status (P=0.009) had a significant impact on the OS rate of patients with BC, while TNFR2 expression (P=0.043) and menopausal status (P=0.033) were shown to significantly impact the DFS rate of patients with BC. These data indicated that TNFR2 may perform important roles in the progression and prognosis of BC. This enriches previous understanding about TNFR2 in BC.

Family-building After Breast Cancer: Considering the Effect on Adherence to Adjuvant Endocrine Therapy

Adherence to endocrine therapy (ET) is a longstanding problem in breast cancer (BC) survivorship care, particularly among younger women. Younger patients have reported lower ET initiation rates and greater rates of early discontinuation and are considered an "at risk" group for nonadherence. For women who hope to have children in the future, concerns about premature menopause and the implications of postponing childbearing for the 5 to 10 years of ET are widespread. Preliminary evidence suggests that prioritizing fertility, along with concerns about side effects, leads to ET noninitiation and early discontinuation. Clinical efforts to improve adherence might need to consider patients' family-building goals during the course of treatment and to appropriately counsel patients according to their priorities and family-building intentions. Educational materials about family building after cancer are still not consistently available or provided. Helping patients to access trusted informational resources and decision support tools, in conjunction with medical counseling, will promote informed decisions regarding ET adherence and pregnancy that are medically appropriate. Such shared patient-provider decision-making about ET adherence and pregnancy could help to maximize patient autonomy by incorporating their values, preferences, and priorities into decisions, using providers' medical expertise.

Body mass index and aromatase inhibitors: a step forward in individualizing therapy for breast cancer patients?

INTRODUCTION

Progress made in breast cancer management along with treatment-related symptoms has drawn a lot of attention from both scientists and clinicians. Establishing predictive factors for treatment response facilitate tailoring of therapy to each individual patient and leads to a reduction in unnecessary treatments. Body mass index is confirmed to be a risk factor for breast cancer development as well as for disease recurrence, which additionally negatively influence the overall survival. Due to the increased level of fatty tissue in obese and overweight patients, their total level of body aromatase is elevated. This lead to the hypothesis about a worse response to aromatase inhibitors in these groups as compared to normal weight patients, due to incomplete aromatase blockage and thus higher peripheral androgen aromatization.

AREAS COVERED

This review aims to summarize the data from clinical trials assessing the effect of BMI on response to AI-based therapy in the setting of breast cancer. Expert commentary: Our conclusion made on the data available to date does not exclude BMI from the list of potential predictive factors however further research in this area is warranted.