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Xu Z, Bao J, Jin X, Li H, Fan K, Wu Z, Yao M, Zhang Y, Liu G, Wang D, Yu X, Guo J, Xu R, Gong Q, Wang F, Wang J. The Effects of Cinobufagin on Hepatocellular Carcinoma Cells Enhanced by MRT68921, an Autophagy Inhibitor. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2023; 51:1595-1611. [PMID: 37489112 DOI: 10.1142/s0192415x23500726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Cinobufagin, a cardiotonic steroid derived from toad venom extracts, exhibits significant anticancer properties by inhibiting Na[Formula: see text]/K[Formula: see text]-ATPase in cancer cells. It is frequently used in clinical settings to treat advanced-stage cancer patients, improving their quality of life and survival time. However, its long-term use can result in multidrug resistance to other chemotherapy drugs, and the exact mechanism underlying this effect remains unknown. Therefore, this study explores the molecular mechanism underlying the anticancer effects of cinobufagin in hepatocellular carcinomas (HCCs), specifically in HepG2 and Huh-7 cells. As determined using transcriptome analysis, cinobufagin-triggered protective autophagy suppressed cell apoptosis in liver cancer HepG2 and Huh-7 cells by inhibiting the phosphoinositide-3-Kinase (PI3K)-AKT serine/threonine kinase (AKT)-mammalian target of rapamycin (mTOR) pathway. Cinobufagin-inhibited cell proliferation, induced apoptosis, and generated cell autophagy by upregulating the expression of MAP1 light chain 3 protein II, Beclin1, and autophagy-related protein 12-5. In addition, the autophagy inhibitor MRT68921 improved the antiproliferative and proapoptotic effects of cinobufagin in the studied cell lines. Overall, this study suggests that combining cinobufagin with an autophagy inhibitor can effectively treat HCC, providing a potential strategy for cancer therapy.
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Affiliation(s)
- Zhongwei Xu
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Jun Bao
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Xiaohan Jin
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Heng Li
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Kaiyuan Fan
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Zhidong Wu
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Min Yao
- Department of Internal Medicine, Tianjin Armed Police Corps Hospital, Tianjin 300126, P. R. China
| | - Yan Zhang
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Gang Liu
- Xinjiang General Corps Hospital, Chinese People's Armed Police Force, Urumqi, Xinjiang 839001, P. R. China
| | - Dan Wang
- Xinjiang General Corps Hospital, Chinese People's Armed Police Force, Urumqi, Xinjiang 839001, P. R. China
| | - Xiaoping Yu
- Xinjiang General Corps Hospital, Chinese People's Armed Police Force, Urumqi, Xinjiang 839001, P. R. China
| | - Jia Guo
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Ruicheng Xu
- Central Laboratory, Logistics University of Chinese People's Armed Police Force, Tianjin 300309, P. R. China
| | - Qian Gong
- Department of Clinical Laboratory, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, P. R. China
| | - Fengmei Wang
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin 300170, P. R. China
| | - Jin Wang
- Department of Clinical Laboratory, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, P. R. China
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Yao X, Hu Q, Liu X, Ling Q, Leng Y, Zhao H, Yu P, Ma J, Zhao Y, Liu M, Yang R. Atrial fibrillation and breast cancer—Vicious twins? A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1113231. [PMID: 36970342 PMCID: PMC10036368 DOI: 10.3389/fcvm.2023.1113231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
BackgroundEpidemiological studies suggest a bidirectional association between atrial fibrillation and breast cancer. This study aimed to conduct a meta-analysis to elucidate the prevalence of atrial fibrillation among breast cancer patients, and the bidirectional association between atrial fibrillation and breast cancer.MethodsPubMed, the Cochrane Library, and Embase were searched to identify studies reporting the prevalence, incidence, and bidirectional association between atrial fibrillation and breast cancer. The study was registered with PROSPERO (CRD42022313251). Levels of evidence and recommendations were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).ResultsTwenty-three studies (17 retrospective cohort studies, 5 case-control studies and 1 cross-sectional study) involving 8,537,551 participants were included. Among patients with breast cancer, the prevalence of atrial fibrillation was 3% (11 studies; 95% CI: 0.6 to 7.1%) and the incidence was 2.7% (6 studies; 95% CI: 1.1 to 4.9%). Breast cancer was associated with increased risk of atrial fibrillation (5 studies; hazard ratio [HR]: 1.43, 95% CI: 1.12 to 1.82, I2 = 98%). Atrial fibrillation was also significantly associated elevated risk of breast cancer (5 studies HR: 1.18, 95% CI: 1.14 to 1.22, I2 = 0%). Grade assessment shown low certainty of the evidence for the risk of atrial fibrillation and moderate certainty of the evidence for the risk of breast cancer.ConclusionAtrial fibrillation is not uncommon in patients with breast cancer and vice versa. There is a bidirectional association between atrial fibrillation (low certainty) and breast cancer (moderate certainty).
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Affiliation(s)
- Xiongda Yao
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qingwen Hu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong, China
| | - Qing Ling
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yurong Leng
- The Affiliated Stomatological Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huilei Zhao
- Department of Anesthesiology, The Third Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Peng Yu
- Department of Endocrine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Yujie Zhao
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Menglu Liu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Renqiang Yang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- *Correspondence: Renqiang Yang
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Ion Channels, Transporters, and Sensors Interact with the Acidic Tumor Microenvironment to Modify Cancer Progression. Rev Physiol Biochem Pharmacol 2021; 182:39-84. [PMID: 34291319 DOI: 10.1007/112_2021_63] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Solid tumors, including breast carcinomas, are heterogeneous but typically characterized by elevated cellular turnover and metabolism, diffusion limitations based on the complex tumor architecture, and abnormal intra- and extracellular ion compositions particularly as regards acid-base equivalents. Carcinogenesis-related alterations in expression and function of ion channels and transporters, cellular energy levels, and organellar H+ sequestration further modify the acid-base composition within tumors and influence cancer cell functions, including cell proliferation, migration, and survival. Cancer cells defend their cytosolic pH and HCO3- concentrations better than normal cells when challenged with the marked deviations in extracellular H+, HCO3-, and lactate concentrations typical of the tumor microenvironment. Ionic gradients determine the driving forces for ion transporters and channels and influence the membrane potential. Cancer and stromal cells also sense abnormal ion concentrations via intra- and extracellular receptors that modify cancer progression and prognosis. With emphasis on breast cancer, the current review first addresses the altered ion composition and the changes in expression and functional activity of ion channels and transporters in solid cancer tissue. It then discusses how ion channels, transporters, and cellular sensors under influence of the acidic tumor microenvironment shape cancer development and progression and affect the potential of cancer therapies.
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Tai CJ, Yang YH, Tseng TG, Chang FR, Wang HC. Association Between Digoxin Use and Cancer Incidence: A Propensity Score-Matched Cohort Study With Competing Risk Analysis. Front Pharmacol 2021; 12:564097. [PMID: 33867973 PMCID: PMC8044813 DOI: 10.3389/fphar.2021.564097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 02/22/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Previous studies neglected death as a critical competing risk while estimating the cancer risk for digoxin users. Therefore, the current study aims to assess the effectiveness of digoxin on cancer prevention by competing risk analysis. Methods: We performed a population-based retrospective cohort study using the Taiwan National Health Insurance Research database between 1998 and 2010. After one-to-one propensity score-matching from 36,160 patients with defined criteria, we enrolled 758 patients both in digoxin and β-blocker group for further analysis. Results: The results showed that the digoxin group had higher all-cause mortality than the β-blocker group in the 4- year (10.4 vs. 4.9%) and 8 years (13.6 vs. 7.0%) follow-up. The subdistribution HR of cancer incidence in the digoxin group compared to the β-blocker group was 1.99 (95% confidence interval [CI]: 1.22–3.01) and 1.46 (95% CI: 1.01–2.15) in the 4 years and 8 years follow-up, respectively. Conclusions: The result of our study showed the usage of digoxin has no benefit in cancer prevention compared with β-blocker. The possibility of β-blocker as a new drug candidate for cancer prevention needs further clinical evaluation. The current study also emphasized the necessity of competing risk analysis applying to similar clinical researches.
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Affiliation(s)
- Chi-Jung Tai
- Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Family Medicine, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Yi-Hsin Yang
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Tzyy-Guey Tseng
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Rong Chang
- Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Marine Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung, Taiwan.,Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Chun Wang
- Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Marine Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung, Taiwan.,Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Pederson PJ, Cai S, Carver C, Powell DR, Risinger AL, Grkovic T, O'Keefe BR, Mooberry SL, Cichewicz RH. Triple-Negative Breast Cancer Cells Exhibit Differential Sensitivity to Cardenolides from Calotropis gigantea. JOURNAL OF NATURAL PRODUCTS 2020; 83:2269-2280. [PMID: 32649211 PMCID: PMC7540184 DOI: 10.1021/acs.jnatprod.0c00423] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Triple-negative breast cancers (TNBC) are aggressive and heterogeneous cancers that lack targeted therapies. We implemented a screening program to identify new leads for subgroups of TNBC using diverse cell lines with different molecular drivers. Through this program, we identified an extract from Calotropis gigantea that caused selective cytotoxicity in BT-549 cells as compared to four other TNBC cell lines. Bioassay-guided fractionation of the BT-549 selective extract yielded nine cardenolides responsible for the selective activity. These included eight known cardenolides and a new cardenolide glycoside. Structure-activity relationships among the cardenolides demonstrated a correlation between their relative potencies toward BT-549 cells and Na+/K+ ATPase inhibition. Calotropin, the compound with the highest degree of selectivity for BT-549 cells, increased intracellular Ca2+ in sensitive cells to a greater extent than in the resistant MDA-MB-231 cells. Further studies identified a second TNBC cell line, Hs578T, that is also highly sensitive to the cardenolides, and mechanistic studies were conducted to identify commonalities among the sensitive cell lines. Experiments showed that both cardenolide-sensitive cell lines expressed higher mRNA levels of the Na+/Ca2+ exchanger NCX1 than resistant TNBC cells. This suggests that NCX1 could be a biomarker to identify TNBC patients that might benefit from the clinical administration of a cardiac glycoside for anticancer indications.
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Affiliation(s)
- Petra J Pederson
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, Texas 78229, United States
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, Texas 78229, United States
| | - Shengxin Cai
- Natural Products Discovery Group, Institute for Natural Products Applications and Research Technologies, Stephenson Life Science Research Center, University of Oklahoma, Norman, Oklahoma 73019, United States
- Department of Chemistry & Biochemistry, Stephenson Life Science Research Center, University of Oklahoma, Norman, Oklahoma 73019, United States
| | - Chase Carver
- Department of Cellular and Integrative Physiology, University of Texas Health Science Center, San Antonio, Texas 78229, United States
| | - Douglas R Powell
- Department of Chemistry & Biochemistry, Stephenson Life Science Research Center, University of Oklahoma, Norman, Oklahoma 73019, United States
| | - April L Risinger
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, Texas 78229, United States
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, Texas 78229, United States
| | - Tanja Grkovic
- Natural Products Support Group, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland 21702, United States
| | - Barry R O'Keefe
- Natural Products Branch, Developmental Therapeutics Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Frederick, Maryland 21702, United States
- Molecular Targets Program, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Susan L Mooberry
- Department of Pharmacology, University of Texas Health Science Center, San Antonio, Texas 78229, United States
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, Texas 78229, United States
| | - Robert H Cichewicz
- Natural Products Discovery Group, Institute for Natural Products Applications and Research Technologies, Stephenson Life Science Research Center, University of Oklahoma, Norman, Oklahoma 73019, United States
- Department of Chemistry & Biochemistry, Stephenson Life Science Research Center, University of Oklahoma, Norman, Oklahoma 73019, United States
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Yokoyama S, Sugimoto Y, Nakagawa C, Hosomi K, Takada M. Integrative analysis of clinical and bioinformatics databases to identify anticancer properties of digoxin. Sci Rep 2019; 9:16597. [PMID: 31719612 PMCID: PMC6851125 DOI: 10.1038/s41598-019-53392-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 10/31/2019] [Indexed: 01/14/2023] Open
Abstract
Cardiac glycosides, such as digoxin, inhibit Na+/K+-ATPases and cause secondary activation of Na+/Ca2+ exchangers. Preclinical investigations have suggested that digoxin may have anticancer properties. In order to clarify the functional mechanisms of digoxin in cancer, we performed an integrative analysis of clinical and bioinformatics databases. The US Food and Drug Administration Adverse Event Reporting System and the Japan Medical Data Center claims database were used as clinical databases to evaluate reporting odds ratios and adjusted sequence ratios, respectively. The BaseSpace Correlation Engine and Connectivity Map bioinformatics databases were used to investigate molecular pathways related to digoxin anticancer mechanisms. Clinical database analyses suggested an inverse association between digoxin and four cancers: gastric, colon, prostate and haematological malignancy. The bioinformatics database analysis suggested digoxin may exert an anticancer effect via peroxisome proliferator-activated receptor α and apoptotic caspase cascade pathways. Our integrative analysis revealed the possibility of digoxin as a drug repositioning candidate for cancers.
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Affiliation(s)
- Satoshi Yokoyama
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashiosaka City, Osaka, 577-8502, Japan.
| | - Yasuhiro Sugimoto
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashiosaka City, Osaka, 577-8502, Japan
| | - Chihiro Nakagawa
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashiosaka City, Osaka, 577-8502, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashiosaka City, Osaka, 577-8502, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashiosaka City, Osaka, 577-8502, Japan
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7
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Grant CV, Carver CM, Hastings SD, Ramachandran K, Muniswamy M, Risinger AL, Beutler JA, Mooberry SL. Triple-negative breast cancer cell line sensitivity to englerin A identifies a new, targetable subtype. Breast Cancer Res Treat 2019; 177:345-355. [PMID: 31230251 DOI: 10.1007/s10549-019-05324-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/15/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Triple-negative breast cancers (TNBCs) represent a heterogeneous group of tumors. The lack of targeted therapies combined with the inherently aggressive nature of TNBCs results in a higher relapse rate and poorer overall survival. We evaluated the heterogeneity of TNBC cell lines for TRPC channel expression and sensitivity to cation-disrupting drugs. METHODS The TRPC1/4/5 agonist englerin A was used to identify a group of TNBC cell lines sensitive to TRPC1/4/5 activation and intracellular cation disruption. Quantitative RT-PCR, the sulforhodamine B assay, pharmacological inhibition, and siRNA-mediated knockdown approaches were employed. Epifluorescence imaging was performed to measure intracellular Ca2+ and Na+ levels. Mitochondrial membrane potential changes were monitored by confocal imaging. RESULTS BT-549 and Hs578T cells express high levels of TRPC4 and TRPC1/4, respectively, and are exquisitely, 2000- and 430-fold, more sensitive to englerin A than other TNBC cell lines. While englerin A caused a slow Na+ and nominal Ca2+ accumulation in Hs578T cells, it elicited rapid increases in cytosolic Ca2+ levels that triggered mitochondrial depolarization in BT-549 cells. Interestingly, BT-549 and Hs578T cells were also more sensitive to digoxin as compared to other TNBC cell lines. Collectively, these data reveal TRPC1/4 channels as potential biomarkers of TNBC cell lines with dysfunctional mechanisms of cation homeostasis and therefore sensitivity to cardiac glycosides. CONCLUSIONS The sensitivity of BT-549 and Hs578T cells to englerin A and digoxin suggests a subset of TNBCs are highly susceptible to cation disruption and encourages investigation of TRPC1 and TRPC4 as potential new biomarkers of sensitivity to cardiac glycosides.
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Affiliation(s)
- Corena V Grant
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA
| | - Chase M Carver
- Department of Cell and Integrative Physiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA
| | - Shayne D Hastings
- Department of Cell and Integrative Physiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA
| | - Karthik Ramachandran
- Department of Medicine, Division of Nephrology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA
| | - Madesh Muniswamy
- Department of Medicine, Division of Nephrology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA
| | - April L Risinger
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA.,Mays Cancer Center, University of Texas Health Science Center at San Antonio, 7979 Wurzbach Rd, San Antonio, TX, USA
| | - John A Beutler
- Molecular Targets Program, Center for Cancer Research, National Cancer Institute, Frederick, MD, USA
| | - Susan L Mooberry
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, USA. .,Mays Cancer Center, University of Texas Health Science Center at San Antonio, 7979 Wurzbach Rd, San Antonio, TX, USA.
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Cancer mortality does not differ by antiarrhythmic drug use: A population-based cohort of Finnish men. Sci Rep 2018; 8:10308. [PMID: 29985440 PMCID: PMC6037774 DOI: 10.1038/s41598-018-28541-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/19/2018] [Indexed: 02/03/2023] Open
Abstract
In-vitro studies have suggested that the antiarrhythmic drug digoxin might restrain the growth of cancer cells by inhibiting Na+/K+-ATPase. We evaluated the association between cancer mortality and digoxin, sotalol and general antiarrhythmic drug use in a retrospective cohort study. The study population consists of 78,615 men originally identified for the Finnish Randomized Study of Screening for Prostate Cancer. Information on antiarrhythmic drug purchases was collected from the national prescription database. We used the Cox regression method to analyze separately overall cancer mortality and mortality from the most common types of cancer. During the median follow-up of 17.0 years after the baseline 28,936 (36.8%) men died, of these 8,889 due to cancer. 9,023 men (11.5%) had used antiarrhythmic drugs. Overall cancer mortality was elevated among antiarrhythmic drug users compared to non-users (HR 1.43, 95% CI 1.34–1.53). Similar results were observed separately for digoxin and for sotalol. However, the risk associations disappeared in long-term use and were modified by background co-morbidities. All in all, cancer mortality was elevated among antiarrhythmic drug users. This association is probably non-causal as it was related to short-term use and disappeared in long-term use. Our results do not support the anticancer effects of digoxin or any other antiarrhythmic drug.
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Chung MH, Wang YW, Chang YL, Huang SM, Lin WS. Risk of cancer in patients with heart failure who use digoxin: a 10-year follow-up study and cell-based verification. Oncotarget 2018; 8:44203-44216. [PMID: 28496002 PMCID: PMC5546474 DOI: 10.18632/oncotarget.17410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 03/30/2017] [Indexed: 12/21/2022] Open
Abstract
Heart failure (HF) is the leading cause of death in the world and digoxin remains one of the oldest therapies for HF. However, its safety and efficacy have been controversial since its initial use and there is uncertainty about its long-term efficacy and safety. Recently, the repositioning of cardiac glycosides is to function in anti-tumor activity via multiple working pathways. It is interesting to compare the potential effects of digoxin in clinical patients and cell lines. First, we analyze patient information retrieved from the National Health Insurance Research database of Taiwan between January 1, 2000 and December 31, 2000. This retrospective study included a study cohort (1,219 patients) and a comparison cohort. Our analytical data suggested that patients taking digoxin are at an increased risk of cancers, including breast, liver, and lung cancers, during the 10-year follow-up period. In contrast to the anti-tumor function of digoxin, we further examined the potential pathway of digoxin via the cell-based strategy using several breast cancer cell lines, including MCF-7, BT-474, MAD-MB-231, and ZR-75-1. Digoxin consistently exerted its cytotoxicity to these four cell lines with various range of concentration. However, the proliferation of ZR-75-1 cells was the only cell lines induced by digoxin and the others were dramatically suppressed by digoxin. The responsiveness of SRSF3 to digoxin might be involved with cell-type differences. In summary, we combined a cohort study for digoxin treatment for HF patients with a cell-based strategy that addresses the translation issue, which revealed the complexity of personalized medicine.
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Affiliation(s)
- Min-Huey Chung
- Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei 110, Taiwan, Republic of China
| | - Yi-Wen Wang
- Department of Biology and Anatomy, National Defense Medical Center, Taipei City 114, Taiwan, Republic of China
| | - Yung-Lung Chang
- Department of Biochemistry, National Defense Medical Center, Taipei City 114, Taiwan, Republic of China
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei City 114, Taiwan, Republic of China
| | - Wei-Shiang Lin
- Department of Medicine, Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114, Taiwan, Republic of China
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Ameri P, Canepa M, Anker MS, Belenkov Y, Bergler-Klein J, Cohen-Solal A, Farmakis D, López-Fernández T, Lainscak M, Pudil R, Ruschitska F, Seferovic P, Filippatos G, Coats A, Suter T, Von Haehling S, Ciardiello F, de Boer RA, Lyon AR, Tocchetti CG. Cancer diagnosis in patients with heart failure: epidemiology, clinical implications and gaps in knowledge. Eur J Heart Fail 2018; 20:879-887. [PMID: 29464808 DOI: 10.1002/ejhf.1165] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/24/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022] Open
Abstract
Cancer and heart failure (HF) are common medical conditions with a steadily rising prevalence in industrialized countries, particularly in the elderly, and they both potentially carry a poor prognosis. A new diagnosis of malignancy in subjects with pre-existing HF is not infrequent, and challenges HF specialists as well as oncologists with complex questions relating to both HF and cancer management. An increased incidence of cancer in patients with established HF has also been suggested. This review paper summarizes the epidemiology and the prognostic implications of cancer occurrence in HF, the impact of pre-existing HF on cancer treatment decisions and the impact of cancer on HF therapeutic options, while providing some practical suggestions regarding patient care and highlighting gaps in knowledge.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova; and Cardiology Unit, IRCCS Policlinic Hospital San Martino, Genova, Italy
| | - Marco Canepa
- Department of Internal Medicine, University of Genova; and Cardiology Unit, IRCCS Policlinic Hospital San Martino, Genova, Italy
| | - Markus S Anker
- Department of Cardiology (CBF), Charité University Medicine, Berlin, Germany; AND Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia; Department of Internal Medicine & Cardiology; and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), at Charité University Medicine, Berlin, Germany
| | | | | | - Alain Cohen-Solal
- Department of Cardiology, Lariboisière Hospital, Paris, France; U942 INSERM, BIOCANVAS (Biomarqueurs Cardiovasculaires), Paris, France;, Department of Cardiology, University of Paris VII Denis Diderot, Paris, France
| | - Dimitrios Farmakis
- Cardio-Oncology Clinic, Heart Failure Unit, Department of Cardiology, Athens University Hospital 'Attikon', National and Kapodistrian University of Athens, Athens, Greece
| | - Teresa López-Fernández
- Cardio-Oncology Unit, Cardiac Imaging Unit, Department of Cardiology, La Paz University Hospital, IdiPAz, Madrid, Spain
| | - Mitja Lainscak
- Department of Cardiology, Department of Research and Education, General Hospital Celje, Celje, Slovenia, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Radek Pudil
- 1st Department of Medicine - Cardioangiology, Medical Faculty and University Hospital Hradec Kralove, Czech Republic
| | - Frank Ruschitska
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Gerasimos Filippatos
- Cardio-Oncology Clinic, Heart Failure Unit, Department of Cardiology, Athens University Hospital 'Attikon', National and Kapodistrian University of Athens, Athens, Greece
| | - Andrew Coats
- Monash University, Australia and University of Warwick, UK
| | - Thomas Suter
- Department of Cardiology, Cardio-Oncology, Bern University Hospital, Bern, Switzerland
| | - Stephan Von Haehling
- Klinik für Kardiologie und Pneumologie, Herzzentrum Göttingen, Universitätsmedizin Göttingen, Georg-August-Universität, Göttingen, Germany;, Deutsches Zentrum für Herz- und Kreislaufforschung, Standort Göttingen, Göttingen, Germany
| | - Fortunato Ciardiello
- Department of Clinical and Experimental Medicine "Flaviano Magrassi", Luigi Vanvitelli University of Campania, Naples, Italy
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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11
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Cronin-Fenton D, Lash TL, Ahern TP, Damkier P, Christiansen P, Ejlertsen B, Sørensen HT. Concurrent new drug prescriptions and prognosis of early breast cancer: studies using the Danish Breast Cancer Group clinical database. Acta Oncol 2018; 57:120-128. [PMID: 29202630 DOI: 10.1080/0284186x.2017.1407040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Myriad reports suggest that frequently used prescription drugs alter the viability of breast cancer cells in pre-clinical studies. Routine use of these drugs, therefore, may impact breast cancer prognosis, and could have important implications for public health. METHODS The Danish Breast Cancer Group (DBCG) clinical database provides high-quality prospectively collected data on breast cancer diagnosis, treatment, and routine follow-up for breast cancer recurrence. Individual-level linkage of DBCG data to other population-based and medical registries in Denmark, including the Danish National Prescription Registry, has facilitated large population-based pharmacoepidemiology studies. A unique advantage of using DBCG data for such studies is the ability to investigate the association of drugs with breast cancer recurrence rather than breast cancer mortality - which may be misclassified - or all-cause mortality. Here we summarize findings from pharmacoepidemiological studies, based on DBCG data, on the association between routinely used prescription drugs and risk of breast cancer recurrence. RESULTS Our findings suggest that concurrent use of glucocorticoids, ACE inhibitors, aspirin, NSAIDs, selective COX-2 inhibitors, digoxin, and opioids has little impact on breast cancer recurrence. Similarly, patients who use SSRIs concurrently with tamoxifen treatment are not at increased risk of recurrence. In contrast, post-diagnostic use of simvastatin, a lipophilic statin, correlates with a decreased risk of breast cancer recurrence, providing a rationale for a prospective randomized clinical trial investigating simvastatin as an adjuvant therapy for breast cancer. CONCLUSION As a whole, findings of pharmacoepidemiological studies based on DBCG data provide reassurance to physicians and healthcare personnel who provide supportive care during and after cancer (including prescriptions for comedications) and to breast cancer survivors for whom the risk of breast cancer recurrence is a major concern.
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Affiliation(s)
| | - Timothy L. Lash
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas P. Ahern
- Departments of Surgery and Biochemistry, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peer Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
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12
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Durlacher CT, Chow K, Chen XW, He ZX, Zhang X, Yang T, Zhou SF. Targeting Na⁺/K⁺ -translocating adenosine triphosphatase in cancer treatment. Clin Exp Pharmacol Physiol 2016; 42:427-43. [PMID: 25739707 DOI: 10.1111/1440-1681.12385] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/09/2015] [Accepted: 02/21/2015] [Indexed: 12/24/2022]
Abstract
The Na(+) /K(+) -translocating adenosine triphosphatase (ATPase) transports sodium and potassium across the plasma membrane and represents a potential target in cancer chemotherapy. Na(+) /K(+) -ATPase belongs to the P-type ATPase family (also known as E1-E2 ATPase), which is involved in transporting certain ions, metals, and lipids across the plasma membrane of mammalian cells. In humans, the Na(+) /K(+) -ATPase is a binary complex of an α-subunit that has four isoforms (α1 -α4 ) and a β-subunit that has three isoforms (β1 -β3 ). This review aims to update our knowledge on the role of Na(+) /K(+) -ATPase in cancer development and metastasis, as well as on how Na(+) /K(+) -ATPase inhibitors kill tumour cells. The Na(+) /K(+) -ATPase has been found to be associated with cancer initiation, growth, development, and metastasis. Cardiac glycosides have exhibited anticancer effects in cell-based and mouse studies via inhibition of the Na(+) /K(+) -ATPase and other mechanisms. Na(+) /K(+) -ATPase inhibitors may kill cancer cells via induction of apoptosis and autophagy, radical oxygen species production, and cell cycle arrest. They also modulate multiple signalling pathways that regulate cancer cell survival and death, which contributes to their antiproliferative activities in cancer cells. The clinical evidence supporting the use of Na(+) /K(+) -ATPase inhibitors as anticancer drugs is weak. Several phase I and phase II clinical trials with digoxin, Anvirzel, and huachansu (an intravenous formulated extract of the venom of the wild toad), either alone or more often in combination with other anticancer agents, have shown acceptable safety profiles but limited efficacy in cancer patients. Well-designed randomized clinical trials with reasonable sample sizes are certainly warranted to confirm the efficacy and safety of cardiac glycosides for the treatment of cancer.
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Affiliation(s)
- Cameron T Durlacher
- Department of Pharmaceutical Science, College of Pharmacy, University of South Florida, Tampa, FL, USA
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13
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Karasneh RA, Murray LJ, Mc Menamin ÚC, Hughes CM, Cardwell CR. Digoxin use after diagnosis of breast cancer and survival: a population-based cohort study. Breast Cancer Res Treat 2015; 151:661-9. [PMID: 25975954 DOI: 10.1007/s10549-015-3417-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/30/2022]
Abstract
Digoxin has been shown to have an estrogenic effect and is associated with increased risk of gynecomastia and estrogen-sensitive cancers such as breast and uterus cancer. These findings, particularly recent observations of increased breast cancer risk, raise questions about the safety of digoxin use in breast cancer patients. Therefore, we investigated whether digoxin use after breast cancer diagnosis increased the risk of breast cancer-specific mortality in breast cancer patients. A cohort of 17,842 breast cancer patients newly diagnosed from 1998 to 2009 was identified from English cancer registries (from the National Cancer Data Repository). This cohort was linked to the UK Clinical Practice Research Datalink (to provide digoxin and other prescription records) and to the Office of National Statistics mortality data (to identify breast cancer-specific deaths). Using time-dependent Cox regression models, unadjusted and adjusted hazard ratios (HR) and 95 % confidence intervals (CIs) were calculated for the association between post-diagnostic exposure to digoxin and breast cancer-specific and all-cause mortality. In 17,842 breast cancer patients, there were 2219 breast cancer-specific deaths. Digoxin users appeared to have increased breast cancer-specific mortality compared with non-users (HR 1.73; 95 % CI 1.39-2.15) but this association was entirely attenuated after adjustment for potential confounders (adjusted HR 0.91; 95 % CI 0.72-1.14). In this large population-based breast cancer cohort study, there was little evidence of an increase in breast cancer-specific mortality with digoxin use after diagnosis. These results provide some reassurance that digoxin use is safe in breast cancer patients.
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Affiliation(s)
- Reema A Karasneh
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences Block B, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
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14
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Boursi B, Haynes K, Mamtani R, Yang YX. Digoxin use and the risk for colorectal cancer. Pharmacoepidemiol Drug Saf 2014; 23:1147-53. [PMID: 25263572 DOI: 10.1002/pds.3717] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/08/2014] [Accepted: 08/26/2014] [Indexed: 01/21/2023]
Abstract
PURPOSE Cardiac glycosides affect several pathways central for tumor formation. We sought to evaluate the association between digoxin use and colorectal cancer (CRC) risk. METHODS We conducted a nested case-control study using The Health Improvement Network (THIN), a medical record database representative of the broader UK population. Study cases were defined as those with a diagnostic code for CRC. Each case was matched to up to four eligible controls on age, sex, practice site, and duration of follow-up before index date using incidence density sampling. Exposure of interest was digoxin therapy before index date. The odds ratios (ORs) and 95% confidence intervals (CIs) for CRC associated with digoxin use were estimated using conditional logistic regression analysis, adjusted for BMI, alcoholism, smoking history, diabetes mellitus, heart disease, chronic NSAIDs use and previous screening colonoscopies. RESULTS The case-control analysis included 20 990 CRC patients and 82 054 controls whose mean follow-up time before index date was 6.5 years (SD 4.0). The adjusted OR for CRC among current digoxin users was increased compared with non-users with an adjusted ORs of 1.41 (95%CI 1.25-1.59, p < 0.0001), 1.45 (95%CI 1.22-1.72, p < 0.0001) and 1.41 (95%CI 1.00-1.99, p = 0.049) for first prescriptions 1-5 years, 5-10 years and more than 10 years before index date respectively. Similar results were observed when cumulative duration and number of digoxin prescriptions were analyzed. The risk was not elevated for past digoxin users. CONCLUSIONS Current digoxin use is associated with increased CRC risk.
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Affiliation(s)
- Ben Boursi
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; The Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Tel Aviv University, Tel Aviv, Israel
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15
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Couraud S, Dell'Aniello S, Bouganim N, Azoulay L. Cardiac glycosides and the risk of breast cancer in women with chronic heart failure and supraventricular arrhythmia. Breast Cancer Res Treat 2014; 146:619-26. [PMID: 25038879 DOI: 10.1007/s10549-014-3058-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/09/2014] [Indexed: 01/01/2023]
Abstract
The aim of this study is to determine whether the use of cardiac glycosides (CGs), drugs used in the treatment of congestive heart failure (CHF) and supra-ventricular arrhythmia, is associated with an increased risk of breast cancer. A cohort of 53,454 women newly diagnosed with CHF or supra-ventricular arrhythmia between January 1, 1988 and December 31, 2010, followed until December 31, 2012, was identified using the United Kingdom Clinical Practice Research Datalink. A nested case-control analysis was performed, where all incident cases of breast cancer occurring during follow-up were identified and matched with up to 10 controls on age, cohort entry date, and duration of follow-up. Conditional logistic regression models were used to estimate adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) of incident breast cancer associated with the use of CGs, along with measures of cumulative duration of use and dose. All analyses considered a one year lag period prior to the event, necessary for latency considerations and to minimize detection bias. The 898 breast cancer cases diagnosed beyond one year of follow-up were matched to 8,940 controls. Overall, use of CGs was not associated with an increased risk of breast cancer when compared to non-use (OR 1.07, 95 % CI 0.90-1.26). Furthermore, the risk did not vary with cumulative duration of use or cumulative dose. The findings of this large population-based study indicate that the use of CGs is not associated with an increased risk of breast cancer. This should provide reassurance to physicians and patients using these drugs.
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Affiliation(s)
- Sébastien Couraud
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Côte Sainte-Catherine, H-425.1, Montreal, QC, H3T 1E2, Canada
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Hashemi SHB, Karimi S, Mahboobi H. Lifestyle changes for prevention of breast cancer. Electron Physician 2014; 6:894-905. [PMID: 25763165 PMCID: PMC4324293 DOI: 10.14661/2014.894-905] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 05/17/2014] [Accepted: 06/10/2014] [Indexed: 12/29/2022] Open
Abstract
Breast cancer is the second most common cause of death from cancer among women. Lifestyle changes are shown to be important in the prevention of breast cancer. Diet, physical activity, smoking, alcohol use, and vitamin and mineral use are key factors influencing the risk of breast cancer among women. Because these factors are related to each other, it is difficult to assess their individual roles in breast cancer. Some of these factors are alterable, meaning that women can decrease their risk for breast cancer by changing their behavior. Breast cancer is associated with a high rate of mortality and morbidity among women. Therefore, it is logical to try to find ways to decrease the risk of developing breast cancer. Lifestyle changes seem to be an easy, effective, and economical way to help prevention breast cancer. In women with a confirmed breast cancer diagnosis who are under radiotherapy treatment after undergoing a mastectomy, lifestyle changes are still very important. Some factors, such as smoking cessation and prevention of weight gain, may improve the long-term survival chances of these patients. Therefore, ways to increase women’s knowledge about the role of lifestyle changes in the prevention of breast cancer and in the survival of patients with diagnosed breast cancer should be considered and studied.
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Affiliation(s)
| | - Samieh Karimi
- Hormozgan fertility and infertility research center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Hamidreza Mahboobi
- Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran ; B.A of psychology, Payam Noor University (PNU), Tehran, Iran
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Cragg GM, Grothaus PG, Newman DJ. New horizons for old drugs and drug leads. JOURNAL OF NATURAL PRODUCTS 2014; 77:703-23. [PMID: 24499205 DOI: 10.1021/np5000796] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
There is mounting urgency to find new drugs for the treatment of serious infectious diseases and cancer that are rapidly developing resistance to previously effective drugs. One approach to addressing this need is through drug repurposing, which refers to the discovery of new useful activities for "old" clinically used drugs through screening them against relevant disease targets. A large number of potential drug that, for various reasons, have failed to advance to clinical and commercial use can be added to the candidates available for such purposes. The application of new techniques and methodology developed through the impressive progress made in multidisciplinary, natural product-related research in recent years should aid substantially in expediting the discovery and development process. This review briefly outlines some of these developments as applied to a number of selected natural product examples, which may also include advances in chemical synthesis of derivatives with extended biological activities.
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Affiliation(s)
- Gordon M Cragg
- Natural Products Branch, Developmental Therapeutics Program, Division of Cancer Treatment and Diagnosis, Frederick National Laboratory , P.O. Box B, Frederick, Maryland 21702, United States
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