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O'Brien SR, Edmonds CE, Ward RE, Taunk NK, Pantel AR, Mankoff DA. Update on 18F-Fluoroestradiol. Semin Nucl Med 2024:S0001-2998(24)00077-1. [PMID: 39368910 DOI: 10.1053/j.semnuclmed.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Accepted: 09/04/2024] [Indexed: 10/07/2024]
Abstract
18F-16α-Fluoroestradiol (18F-FES) is a radiolabeled estrogen analogue positron emission tomography (PET) imaging agent that binds to the estrogen receptor (ER) in the nucleus of ER-expressing cells. Proof-of-concept studies of 18F-FES demonstrated expected correlation between tumoral 18F-FES-positivity on PET-imaging and ER+ status assessed on biopsy samples by radioligand binding and immunohistochemistry. After decades of study, 18F-FES PET/CT gained clinical approval in 2016 in France and 2020 in the United States for use in patients with ER+ metastatic or recurrent breast cancer. ER+ as assessed by 18F-FES PET/CT has been shown to serve as a biomarker, identifying metastatic breast cancer patients who may respond to endocrine therapy and those who are unlikely to respond. In 2023, the Society of Nuclear Medicine and Molecular Imaging (SNMMI) published Appropriate Use Criteria for 18F-FES PET/CT, identifying four indications in which use of 18F-FES PET/CT was "appropriate": (1) To assess functional ER status in metastatic lesions unfavorable to biopsy or when biopsy is nondiagnostic, (2) To detect ER status when other imaging tests are equivocal or suspicious, and at (3) initial diagnosis of metastatic disease or (4) progression of metastatic disease, for considering endocrine therapy. This article reviews the foundations of 18F-FES imaging, including normal distribution, false positives, and false negatives, and describes the most up-to-date clinical uses as well as emerging research in breast cancer and other patient populations.
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Affiliation(s)
- Sophia R O'Brien
- Division of Nuclear Medicine Imaging and Therapy, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Radiology, Division of Breast Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Christine E Edmonds
- Department of Radiology, Division of Breast Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rebecca E Ward
- Division of Nuclear Medicine Imaging and Therapy, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Neil K Taunk
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Austin R Pantel
- Division of Nuclear Medicine Imaging and Therapy, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David A Mankoff
- Division of Nuclear Medicine Imaging and Therapy, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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Okwor V, Okwor CJ, Ukwuoma M, Nweke M. Effectiveness of combined targeted and hormonal therapies for post-menopausal women with hormone receptor-positive and HER2-negative advanced breast cancer: A systematic review and meta-analysis of RCTs. J Oncol Pharm Pract 2024:10781552241279019. [PMID: 39295518 DOI: 10.1177/10781552241279019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
OBJECTIVE we aim to synthesize available evidence on the effectiveness of hormonal plus targeted therapies for post-menopausal women with hormone receptor-positive and HER2-negative advanced breast cancer. DATA SOURCES AND METHODS We searched the following databases: Medline, PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, and African Journal. Only studies that investigated the effectiveness of hormonal therapy combined with targeted therapy for HR+/HER2- advanced breast cancer treatment were included. The outcomes were progression-free survival (PFS), overall survival (OS) and objective response rate (ORR). A random-effect meta-analysis model was employed. Statistical analysis was performed using Comprehensive Meta-analysis version 3. RESULTS 24 studies were included in the meta-analysis with an overall sample size of 7635. Median PFS, OS and ORR were found to be significantly increased in the combination group compared to hormonal monotherapy [SMD = 6.072 (95% CI = 3.785-8.360), p < 0.001], [SMD = 1.614 (95% CI = 0.139-3.089), p = 0.032] and [OR = 1.584 (CI 1.134-2.213), p = 0.007] respectively. Subgroup analysis showed a significant difference in PFS and ORR between patients who received "hormonal therapy + CDK4/6 inhibitors" vs hormonal therapy only [SMD = 6.015 (CI 3.069-8.960), p < 0.001], (OR = 1.828 (CI 1.030-3.243), p = 0.039] respectively. CONCLUSION Compared with hormonal monotherapy, targeted plus hormonal therapy significantly improves PFS, OS and ORR in postmenopausal women with HR+/HER2- advanced breast cancer.
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Affiliation(s)
- Vitalis Okwor
- Department of Radiation and Clinical Oncology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chika Juliet Okwor
- Department of Chemical Pathology, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria
| | - Maryjane Ukwuoma
- Department of Physiotherapy, University of Nigeria Teaching Hospital, Enugu, Enugu
| | - Martins Nweke
- Department of Physiotherapy, Evangel University Akaeze, Enugu, Nigeria
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Qureshi Z, Jamil A, Altaf F, Siddique R, Adilovic E, Fatima E, Shah S. Elacestrant in the treatment landscape of ER-positive, HER2-negative, ESR1-mutated advanced breast cancer: a contemporary narrative review. Ann Med Surg (Lond) 2024; 86:4624-4633. [PMID: 39118705 PMCID: PMC11305773 DOI: 10.1097/ms9.0000000000002293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/11/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative (HER2-) breast cancer with ESR1 mutations presents a significant therapeutic challenge due to its adaptive resistance mechanisms to chemotherapy, especially endocrine treatment. Elacestrant, a novel oral selective estrogen receptor degrader (SERD), has emerged as a promising agent in this treatment-resistant era. Method A comprehensive search was conducted on pivotal clinical trials, including the RAD1901-005 Trial, EMERALD TRIAL, ELIPSE, and ELEVATE, focusing on their methodologies, patient populations, treatment regimens, and outcomes. Discussion This narrative review describes the available preclinical and clinical evidence on elacestrant, focusing on its pharmacodynamics, pharmacokinetics, efficacy, and safety within the existing literature. Elacestrant has demonstrated excellent activity against ESR1 mutations associated with resistance to first-line endocrine therapies. Clinical trials have shown improved progression-free survival in patients with advanced ER+/HER2-, ESR1-mutated breast cancer. Safety profiles indicate a tolerable side effect spectrum consistent with other agents. Its oral bioavailability offers a convenient alternative to injectable SERDs, with potential implications for patient adherence and quality of life. The review also discusses the comparative efficacy of elacestrant relative to existing endocrine therapies and its possible use in combination regimens. Conclusion Ongoing clinical trials assessing elacestrant and other SERDs will yield data that might aid clinicians in determining the optimal selection and order of endocrine treatment drugs for ER+ breast cancer. The integration of targeted and immunotherapeutic agents with traditional chemotherapy represents a pivotal shift in Breast Cancer treatment, moving towards more personalized and effective regimens.
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Affiliation(s)
- Zaheer Qureshi
- The Frank H. Netter M.D. School of Medicine at Quinnipiac University
| | - Abdur Jamil
- Department of Medicine, Samaritan Medical Centre
| | - Faryal Altaf
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai/BronxCare Health System, New York, NY, USA
| | | | | | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Shivendra Shah
- Department of Medicine, Nepalgunj Medical College, Chisapani, Nepal
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Hageman E, Lussier ME. Elacestrant for ER-Positive HER2-Negative Advanced Breast Cancer. Ann Pharmacother 2024; 58:849-856. [PMID: 37888769 DOI: 10.1177/10600280231206131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE This article aims to discuss elacestrant, an oral selective estrogen receptor downregulator approved by the Food and Drug Administration (FDA) in January 2023 for the treatment of hormone receptor positive (HR+) human epidermal growth factor receptor 2 negative (HER2-) advanced breast cancer. DATA SOURCES PubMed, Embase, Medline, Clinicaltrials.gov, and the National Comprehensive Cancer Network (NCCN) were searched from inception to August 31, 2023. STUDY SELECTION AND DATA EXTRACTION Clinical trials published in English were included and relevant information regarding methodology and results were extracted. DATA SYNTHESIS Phase 1 and 3 trials showed elacestrant was safe and improved progression-free survival in patients with endocrine receptor 1 (ESR1) mutations who failed cyclin-dependent kinase 4/6 inhibitor (CDK 4/6i) plus 1 prior endocrine therapy compared with standard of care (SOC) (fulvestrant, anastrozole, letrozole, or exemestane monotherapy). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS Elacestrant maintains a comparable adverse event profile with other endocrine therapies and offers an alternative to typical sequential therapy which can delay the use of or be used after traditional chemotherapy. Elacestrant is currently being studied in CDK 4/6 inhibitor naïve patients and as a component of combination therapy for first-line use which could lead to future indications. CONCLUSIONS Elacestrant gained FDA approval in January 2023 and can be considered in patients with HR+ HER2- advanced breast cancer and ESR1 mutations who have progressed despite therapy with either CDK 4/6i plus aromatase inhibitors (AI) or fulvestrant or chemotherapy.
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Affiliation(s)
- Elizabeth Hageman
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Johnson City, NY, USA
| | - Mia E Lussier
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Johnson City, NY, USA
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Ferro A, Campora M, Caldara A, De Lisi D, Lorenzi M, Monteverdi S, Mihai R, Bisio A, Dipasquale M, Caffo O, Ciribilli Y. Novel Treatment Strategies for Hormone Receptor (HR)-Positive, HER2-Negative Metastatic Breast Cancer. J Clin Med 2024; 13:3611. [PMID: 38930141 PMCID: PMC11204965 DOI: 10.3390/jcm13123611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Estrogen receptor (ER)-positive breast cancer (BC) is the most common BC subtype. Endocrine therapy (ET) targeting ER signaling still remains the mainstay treatment option for hormone receptor (HR)-positive BC either in the early or in advanced setting, including different strategies, such as the suppression of estrogen production or directly blocking the ER pathway through SERMs-selective estrogen receptor modulators-or SERDs-selective estrogen receptor degraders. Nevertheless, the development of de novo or acquired endocrine resistance still remains challenging for oncologists. The use of novel ET combined with targeted drugs, such as cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, has significantly improved long-term outcome rates, thus changing the therapeutic algorithm for metastatic BC (MBC) and recently the therapeutic strategy in the adjuvant setting for early high-risk BC. Eluding the resistance to CDK4/6 inhibitors combined with ET is currently an unmet medical need, and there is disagreement concerning the best course of action for patients who continue to progress after this combination approach. Genetic changes in the tumor along its growth uncovered by genomic profiling of recurrent and/or metastatic lesions through tumor and/or liquid biopsies may predict the response or resistance to specific agents, suggesting the best therapeutic strategy for each patient by targeting the altered ER-dependent pathway (novel oral SERDs and a new generation of anti-estrogen agents) or alternative ER-independent signaling pathways such as PI3K/AKT/mTOR or tyrosine kinase receptors (HER2 mutations or HER2 low status) or by inhibiting pathways weakened through germline BRCA1/2 mutations. These agents are being investigated as single molecules and in combination with other target therapies, offering promising weapons to overcome or avoid treatment failure and propose increasingly more personalized treatment approaches. This review presents novel insights into ET and other targeted therapies for managing metastatic HR+/HER2- BC by exploring potential strategies based on clinical evidence and genomic profiling following the failure of the CDK4/6i and ET combination.
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Affiliation(s)
- Antonella Ferro
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Michela Campora
- Department of Pathology, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy;
| | - Alessia Caldara
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Delia De Lisi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Martina Lorenzi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Sara Monteverdi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Raluca Mihai
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK;
| | - Alessandra Bisio
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38123 Trento, Italy; (A.B.); (Y.C.)
| | - Mariachiara Dipasquale
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Orazio Caffo
- Medical Oncology, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy;
| | - Yari Ciribilli
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38123 Trento, Italy; (A.B.); (Y.C.)
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Gennari A, Brain E, De Censi A, Nanni O, Wuerstlein R, Frassoldati A, Cortes J, Rossi V, Palleschi M, Alberini JL, Matteucci F, Piccardo A, Sacchetti G, Ilhan H, D'Avanzo F, Ruffilli B, Nardin S, Monti M, Puntoni M, Fontana V, Boni L, Harbeck N. Early prediction of endocrine responsiveness in ER+/HER2-negative metastatic breast cancer (MBC): pilot study with 18F-fluoroestradiol ( 18F-FES) CT/PET. Ann Oncol 2024; 35:549-558. [PMID: 38423389 DOI: 10.1016/j.annonc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/15/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND 18F-fluoroestradiol (FES) positron emission tomography (PET)/computed tomography (CT) is considered an accurate diagnostic tool to determine whole-body endocrine responsiveness. In the endocrine therapy (ET)-FES trial, we evaluated 18F-FES PET/CT as a predictive tool in estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC). PATIENTS AND METHODS Eligible patients underwent an 18F-FES PET/CT at baseline. Patients with standardized uptake value (SUV) ≥ 2 received single-agent ET until progressive disease; patients with SUV < 2 were randomized to single-agent ET (arm A) or chemotherapy (ChT) (arm B). The primary objective was to compare the activity of first-line ET versus ChT in patients with 18F-FES SUV < 2. RESULTS Overall, 147 patients were enrolled; 117 presented with 18F-FES SUV ≥ 2 and received ET; 30 patients with SUV < 2 were randomized to ET or ChT. After a median follow-up of 62.4 months, 104 patients (73.2%) had disease progression and 53 died (37.3%). Median progression-free survival (PFS) was 12.4 months [95% confidence interval (CI) 3.1-59.6 months] in patients with SUV < 2 randomized to arm A versus 23.0 months (95% CI 7.7-30.0 months) in arm B, [hazard (HR) = 0.71, 95% CI 0.3-1.7 months]; median PFS was 18.0 months (95% CI 11.2-23.1 months) in patients with SUV ≥ 2 treated with ET. Median overall survival (OS) was 28.2 months (95% CI 14.2 months-not estimable) in patients with SUV < 2 randomized to ET (arm A) versus 52.8 months (95% CI 16.2 months-not estimable) in arm B (ChT). Median OS was not reached in patients with SUV ≥ 2. 60-month OS rate was 41.6% (95% CI 10.4% to 71.1%) in arm A, 42.0% (95% CI 14.0% to 68.2%) in arm B, and 59.6% (95% CI 48.6% to 69.0%) in patients with SUV ≥ 2. In patients with SUV ≥ 2, 60-month OS rate was 72.6% if treated with aromatase inhibitors (AIs) versus 40.6% in case of fulvestrant or tamoxifen (P < 0.005). CONCLUSIONS The ET-FES trial demonstrated that ER+/HER2- MBC patients are a heterogeneous population, with different levels of endocrine responsiveness based on 18F-FES CT/PET SUV.
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Affiliation(s)
- A Gennari
- Department of Translational Medicine, University of Piemonte Orientale, Novara; Division of Medical Oncology, Maggiore University Hospital, Novara, Italy.
| | - E Brain
- Department of Medical Oncology, Institut Curie-Hôpital René Huguenin, Saint-Cloud, France
| | - A De Censi
- Medical Oncology, E.O. Ospedali Galliera, Genova
| | - O Nanni
- Biostatistics and Clinical Trials Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - R Wuerstlein
- Department of Obstetrics and Gynecology and CCC Munich, LMU University Hospital, Munich, Germany
| | - A Frassoldati
- Clinical Oncology, S. Anna University Hospital, Ferrara, Italy
| | - J Cortes
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quironsalud Group, Barcelona; Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - V Rossi
- Division of Medical Oncology, Maggiore University Hospital, Novara, Italy
| | - M Palleschi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - J L Alberini
- Nuclear Medicine Department Centre Georges-Francois Leclerc, Dijon Cedex, France
| | - F Matteucci
- Nuclear Medicine Unit, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) -"Dino Amadori", Meldola
| | - A Piccardo
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa
| | - G Sacchetti
- Division of Nuclear Medicine Unit, Maggiore University Hospital, Novara, Italy
| | - H Ilhan
- Department of Nuclear Medicine, LMU University Hospital, Munich, Germany
| | - F D'Avanzo
- Division of Medical Oncology, Maggiore University Hospital, Novara, Italy
| | - B Ruffilli
- Department of Translational Medicine, University of Piemonte Orientale, Novara
| | - S Nardin
- Medical Oncology Unit 1, IRCCS-Ospedale Policlinico San Martino, Genoa
| | - M Monti
- Biostatistics and Clinical Trials Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - M Puntoni
- Clinical and Epidemiological Research Unit, University Hospital of Parma, Parma
| | - V Fontana
- Department of Clinical Epidemiology, IRCSS Ospedale Policlinico San Martino, Genoa, Italy
| | - L Boni
- Department of Clinical Epidemiology, IRCSS Ospedale Policlinico San Martino, Genoa, Italy
| | - N Harbeck
- Department of Obstetrics and Gynecology and CCC Munich, LMU University Hospital, Munich, Germany
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Ferreira Almeida C, Correia-da-Silva G, Teixeira N, Amaral C. Influence of tumor microenvironment on the different breast cancer subtypes and applied therapies. Biochem Pharmacol 2024; 223:116178. [PMID: 38561089 DOI: 10.1016/j.bcp.2024.116178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
Despite the significant improvements made in breast cancer therapy during the last decades, this disease still has increasing incidence and mortality rates. Different targets involved in general processes, like cell proliferation and survival, have become alternative therapeutic options for this disease, with some of them already used in clinic, like the CDK4/6 inhibitors for luminal A tumors treatment. Nevertheless, there is a demand for novel therapeutic strategies focused not only on tumor cells, but also on their microenvironment. Tumor microenvironment (TME) is a very complex and dynamic system that, more than surrounding and supporting tumor cells, actively participates in tumor development and progression. During the last decades, it has become clear that the cellular and acellular components of TME differ between the various breast cancer subtypes and shape the differences regarding their severity and prognosis. The pivotal role of the TME in controlling tumor growth and influencing responses to therapy represents a potential source for novel targets and therapeutic strategies. In this review, we present a description of the multiple therapeutic options used for different breast cancer subtypes, as well as the influence that the TME may exert on the development of the disease and on the response to the distinct therapies, which in some cases may explain their failure by the occurrence of relapses and resistance. Furthermore, the ongoing studies focused on the use of TME components for developing potential cancer treatments are described.
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Affiliation(s)
- Cristina Ferreira Almeida
- UCIBIO, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal
| | - Georgina Correia-da-Silva
- UCIBIO, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal.
| | - Natércia Teixeira
- UCIBIO, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal
| | - Cristina Amaral
- UCIBIO, Laboratory of Biochemistry, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal.
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Keigley QJ, Fowler AM, O'Brien SR, Dehdashti F. Molecular Imaging of Steroid Receptors in Breast Cancer. Cancer J 2024; 30:142-152. [PMID: 38753748 PMCID: PMC11101139 DOI: 10.1097/ppo.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
ABSTRACT Steroid receptors regulate gene expression for many important physiologic functions and pathologic processes. Receptors for estrogen, progesterone, and androgen have been extensively studied in breast cancer, and their expression provides prognostic information as well as targets for therapy. Noninvasive imaging utilizing positron emission tomography and radiolabeled ligands targeting these receptors can provide valuable insight into predicting treatment efficacy, staging whole-body disease burden, and identifying heterogeneity in receptor expression across different metastatic sites. This review provides an overview of steroid receptor imaging with a focus on breast cancer and radioligands for estrogen, progesterone, and androgen receptors.
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Affiliation(s)
- Quinton J Keigley
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Sophia R O'Brien
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Farrokh Dehdashti
- Division of Nuclear Medicine, Edward Mallinckrodt Institute of Radiology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
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Ulaner GA, Vaz SC, Groheux D. Quarter-Century Transformation of Oncology: Positron Emission Tomography for Patients with Breast Cancer. PET Clin 2024; 19:147-162. [PMID: 38177052 DOI: 10.1016/j.cpet.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
PET radiotracers have become indispensable in the care of patients with breast cancer. 18F-fluorodeoxyglucose has become the preferred method of many oncologists for systemic staging of breast cancer at initial diagnosis, detecting recurrent disease, and for measuring treatment response after therapy. 18F-Sodium Fluoride is valuable for detection of osseous metastases. 18F-fluoroestradiol is now FDA-approved with multiple appropriate clinical uses. There are multiple PET radiotracers in clinical trials, which may add utility of PET imaging for patients with breast cancer in the future. This article will describe the advances during the last quarter century in PET for patients with breast cancer.
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Affiliation(s)
- Gary A Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute, Irvine, CA, USA; Departments of Radiology and Translational Genomics, University of Southern California, Los Angeles, CA, USA.
| | - Sofia Carrilho Vaz
- Nuclear Medicine-Radiopharmacology, Champalimaud Clinical Center, Champalimaud Foundation, Lisbon, Portugal; Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - David Groheux
- Nuclear Department of Nuclear Medicine, Saint-Louis Hospital, Paris, France; Centre d'Imagerie Radio-Isotopique (CIRI), La Rochelle, France; University Paris-Diderot, INSERM U976, HIPI, Paris, France
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10
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Ulaner GA, Vaz SC. Women's Health Update: Growing Role of PET for Patients with Breast Cancer. Semin Nucl Med 2024; 54:247-255. [PMID: 38365547 DOI: 10.1053/j.semnuclmed.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
Positron Emission Tomography (PET) has been growing in usage for patients with breast cancer, due to an increased number of FDA-approved PET radiotracers pertinent to patients with breast cancer as well as increased prospective evidence for the value of these agents. The leading PET radiotracer for patients with breast cancer is 18F-fluorodeoxyglucose (18F-FDG), which measures glucose metabolism. There is prospective evidence for the use of 18F-FDG PET in systemic staging of newly diagnosed locally advanced breast cancer (stages IIB-IIIC), monitoring breast cancer treatment response, and detecting breast cancer recurrence, particularly in no special type (NST) breast cancer. 16α-18F-fluoro-17β-Fluoroestradiol (18F-FES) is a radiolabeled estrogen which evaluates estrogen receptor (ER) accessible for estrogen binding. There is prospective evidence supporting 18F-FES PET as a predictive biomarker for selecting patients with metastatic breast cancer for endocrine therapies. 18F-FES PET has also been shown to be valuable in the evaluation of ER status of lesions which are difficult to biopsy, for evaluation of ER status in lesions that are equivocal on other imaging modalities, and for selecting optimal dosage of novel ER-targeted systemic therapies in early clinical trials. Multiple investigators have suggested 18F-FES PET will have an increasing role for patients with invasive lobular breast cancer (ILC), which is less optimally evaluated by 18F-FDG PET. Sodium 18F-Fluoride (18F-NaF) evaluates bone turnover and has been effective in evaluation of malignancies which commonly metastasize to bone. In patients with metastatic breast cancer, 18F-NaF PET/CT has demonstrated superior sensitivity for osseous metastases than 99mTc-MDP or CT. In addition to these three FDA-approved PET radiotracers, there are multiple novel radiotracers currently in clinical trials with potential to further increase PET usage for patients with breast cancer.
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Affiliation(s)
- Gary A Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute, Newport Beach, CA; Radiology, University of Southern California, Los Angeles, CA.
| | - Sofia Carrilho Vaz
- Nuclear Medicine-Radiopharmacology, Champalimaud Clinical Center, Champalimaud Foundation, Lisbon, Portugal; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Neupane N, Bawek S, Gurusinghe S, Ghaffary EM, Mirmosayyeb O, Thapa S, Falkson C, O’Regan R, Dhakal A. Oral SERD, a Novel Endocrine Therapy for Estrogen Receptor-Positive Breast Cancer. Cancers (Basel) 2024; 16:619. [PMID: 38339371 PMCID: PMC10854647 DOI: 10.3390/cancers16030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/05/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Breast cancer is the most common cancer among women worldwide, and estrogen receptor-positive (ER+) breast cancer accounts for a significant proportion of cases. While various treatments are available, endocrine therapies are often the first-line treatment for this type of breast cancer. However, the development of drug resistance poses a significant challenge in managing this disease. ESR1 mutations have been identified as a common mechanism of endocrine therapy resistance in ER+ breast cancer. The first-generation selective estrogen receptor degrader (SERD) fulvestrant has shown some activity against ESR1 mutant tumors. However, due to its poor bioavailability and need for intramuscular injection, it may not be the optimal therapy for patients. Second-generation SERDs were developed to overcome these limitations. These newer drugs have improved oral bioavailability and pharmacokinetics, making them more convenient and effective for patients. Several oral SERDs are now in phase III trials for early and advanced ER+ breast cancer. This review summarizes the background of oral SERD development, the current status, and future perspectives.
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Affiliation(s)
- Niraj Neupane
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY 14621, USA;
| | - Sawyer Bawek
- Department of Internal Medicine, University at Buffalo, Buffalo, NY 14203, USA; (S.B.); (S.G.)
| | - Sayuri Gurusinghe
- Department of Internal Medicine, University at Buffalo, Buffalo, NY 14203, USA; (S.B.); (S.G.)
| | - Elham Moases Ghaffary
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran; (E.M.G.); (O.M.)
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran; (E.M.G.); (O.M.)
| | - Sangharsha Thapa
- Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA;
| | - Carla Falkson
- Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.F.); (R.O.)
| | - Ruth O’Regan
- Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.F.); (R.O.)
| | - Ajay Dhakal
- Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.F.); (R.O.)
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12
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Rej RK, Roy J, Allu SR. Therapies for the Treatment of Advanced/Metastatic Estrogen Receptor-Positive Breast Cancer: Current Situation and Future Directions. Cancers (Basel) 2024; 16:552. [PMID: 38339303 PMCID: PMC10854569 DOI: 10.3390/cancers16030552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
The hormone receptor-positive (HR+) type is the most frequently identified subtype of breast cancer. HR+ breast cancer has a more positive prognosis when compared to other subtypes, such as human epidermal growth factor protein 2-positive disorder and triple-negative disease. The advancement in treatment outcomes for advanced HR+ breast cancer has been considerably elevated due to the discovery of cyclin-dependent kinase 4/6 inhibitors and their combination effects with endocrine therapy. However, despite the considerable effectiveness of tamoxifen, a selective estrogen receptor modulator (SERMs), and aromatase inhibitors (AI), the issue of treatment resistance still presents a significant challenge for HR+ breast cancer. As a result, there is a focus on exploring new therapeutic strategies such as targeted protein degradation and covalent inhibition for targeting ERα. This article discusses the latest progress in treatments like oral selective ER degraders (SERDs), complete estrogen receptor antagonists (CERANs), selective estrogen receptor covalent antagonists (SERCAs), proteolysis targeting chimera (PROTAC) degraders, and combinations of CDK4/6 inhibitors with endocrine therapy. The focus is specifically on those compounds that have transitioned into phases of clinical development.
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Affiliation(s)
- Rohan Kalyan Rej
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Joyeeta Roy
- Departments of Medicinal Chemistry, College of Pharmacy, Rogel Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Srinivasa Rao Allu
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
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13
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Castorina L, Comis AD, Prestifilippo A, Quartuccio N, Panareo S, Filippi L, Castorina S, Giuffrida D. Innovations in Positron Emission Tomography and State of the Art in the Evaluation of Breast Cancer Treatment Response. J Clin Med 2023; 13:154. [PMID: 38202160 PMCID: PMC10779934 DOI: 10.3390/jcm13010154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/14/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
The advent of hybrid Positron Emission Tomography/Computed Tomography (PET/CT) and PET/Magnetic Resonance Imaging (MRI) scanners resulted in an increased clinical relevance of nuclear medicine in oncology. The use of [18F]-Fluorodeoxyglucose ([18F]FDG) has also made it possible to study tumors (including breast cancer) from not only a dimensional perspective but also from a metabolic point of view. In particular, the use of [18F]FDG PET allowed early confirmation of the efficacy or failure of therapy. The purpose of this review was to assess the literature concerning the response to various therapies for different subtypes of breast cancer through PET. We start by summarizing studies that investigate the validation of PET/CT for the assessment of the response to therapy in breast cancer; then, we present studies that compare PET imaging (including PET devices dedicated to the breast) with CT and MRI, focusing on the identification of the most useful parameters obtainable from PET/CT. We also focus on novel non-FDG radiotracers, as they allow for the acquisition of information on specific aspects of the new therapies.
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Affiliation(s)
- Luigi Castorina
- Nuclear Medicine Outpatient Unit, REM Radiotherapy Srl, Via Penninanzzo 11, 95029 Viagrande, Italy;
| | - Alessio Danilo Comis
- Nuclear Medicine Outpatient Unit, REM Radiotherapy Srl, Via Penninanzzo 11, 95029 Viagrande, Italy;
| | - Angela Prestifilippo
- Department of Oncology, IOM Mediterranean Oncology Institute, Via Penninanzzo 7, 95029 Viagrande, Italy; (A.P.); (D.G.)
| | - Natale Quartuccio
- Nuclear Medicine Unit, Ospedali Riuniti Villa Sofia-Cervello, 90146 Palermo, Italy;
| | - Stefano Panareo
- Nuclear Medicine Unit, Oncology and Haematology Department, University Hospital of Modena, 41124 Modena, Italy;
| | - Luca Filippi
- Nuclear Medicine Unit, Department of Oncohaematology, Fondazione PTV Policlinico Tor Vergata University Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Serena Castorina
- Nuclear Medicine Unit, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy
| | - Dario Giuffrida
- Department of Oncology, IOM Mediterranean Oncology Institute, Via Penninanzzo 7, 95029 Viagrande, Italy; (A.P.); (D.G.)
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14
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Betz M, Massard V, Gilson P, Witz A, Dardare J, Harlé A, Merlin JL. ESR1 Gene Mutations and Liquid Biopsy in ER-Positive Breast Cancers: A Small Step Forward, a Giant Leap for Personalization of Endocrine Therapy? Cancers (Basel) 2023; 15:5169. [PMID: 37958343 PMCID: PMC10649433 DOI: 10.3390/cancers15215169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The predominant forms of breast cancer (BC) are hormone receptor-positive (HR+) tumors characterized by the expression of estrogen receptors (ERs) and/or progesterone receptors (PRs). Patients with HR+ tumors can benefit from endocrine therapy (ET). Three types of ET are approved for the treatment of HR+ BCs and include selective ER modulators, aromatase inhibitors, and selective ER downregulators. ET is the mainstay of adjuvant treatment in the early setting and the backbone of the first-line treatment in an advanced setting; however, the emergence of acquired resistance can lead to cancer recurrence or progression. The mechanisms of ET resistance are often related to the occurrence of mutations in the ESR1 gene, which encodes the ER-alpha protein. As ESR1 mutations are hardly detectable at diagnosis but are present in 30% to 40% of advanced BC (ABC) after treatment, the timeline of testing is crucial. To manage this resistance, ESR1 testing has recently been recommended; in ER+ HER2- ABC and circulating cell-free DNA, so-called liquid biopsy appears to be the most convenient way to detect the emergence of ESR1 mutations. Technically, several options exist, including Next Generation Sequencing and ultra-sensitive PCR-based techniques. In this context, personalization of ET through the surveillance of ESR1 mutations in the plasma of HR+ BC patients throughout the disease course represents an innovative way to improve the standard of care.
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Affiliation(s)
- Margaux Betz
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - Vincent Massard
- Département d’Oncologie Médicale, Institut de Cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France;
| | - Pauline Gilson
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - Andréa Witz
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - Julie Dardare
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - Alexandre Harlé
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - Jean-Louis Merlin
- Département de Biopathologie, Institut de Cancérologie de Lorraine, CNRS UMR 7039 CRAN, Université de Lorraine, 54519 Vandœuvre-lès-Nancy, France
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15
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Ulaner GA, Fowler AM, Clark AS, Linden H. Estrogen Receptor-Targeted and Progesterone Receptor-Targeted PET for Patients with Breast Cancer. PET Clin 2023; 18:531-542. [PMID: 37270377 DOI: 10.1016/j.cpet.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Estrogen receptor (ER)-targeted imaging with 16α-18F-fluoro-17β-fluoroestradiol (18F-FES) has multiple proven clinical applications for patients with ER-positive breast cancer, including helping to select optimal patients for endocrine therapies, assessing ER status in lesions that are difficult to biopsy, and evaluating lesions with inconclusive results on other imaging tests. This has led to US Food and Drug Administration approval of 18F-FES PET for patients with ER-positive breast cancer. Newer progesterone receptor-targeted imaging agents are in clinical trials.
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Affiliation(s)
- Gary A Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute, Newport Beach, CA, USA; Radiology and Translational Genomics, University of Southern California, Los Angeles, CA, USA.
| | - Amy M Fowler
- Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy S Clark
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah Linden
- Medical Oncology, University of Washington, Seattle, WA, USA
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16
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Beumer JH, Foldi J. Pharmacology and pharmacokinetics of elacestrant. Cancer Chemother Pharmacol 2023; 92:157-163. [PMID: 37314500 PMCID: PMC10713198 DOI: 10.1007/s00280-023-04550-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023]
Abstract
Elacestrant, a novel oral selective estrogen receptor (ER) degrader (SERD), was approved by the Food and Drug Administration (FDA) on January 27, 2023, for use in patients with ER and/or progesterone receptor (PR)-positive and HER2-negative metastatic breast cancer whose tumors harbor an ESR1 missense mutation (ESR1-mut), after at least one line of endocrine therapy (ET). The FDA made its decision based on the randomized phase 3 EMERALD trial, which met its primary endpoint of improved median progression-free survival (mPFS) with elacestrant monotherapy versus standard-of-care endocrine monotherapy in the overall intention to treat population; however, this benefit was largely driven by the ESR1-mut cohort. Elacestrant is a dose-dependent mixed ER agonist/antagonist, which at high doses acts as a direct ER antagonist as well as selective downregulator of ER. It is 11% bioavailable, primarily metabolized by CYP3A4 in the liver and excreted in feces. This leads to drug-drug interactions with strong CYP3A4 inhibitors and inducers, such as itraconazole and rifampin, respectively. In accordance with its clearance route, dose reduction is recommended in patients with moderate hepatic dysfunction but not in renal dysfunction. Studies evaluating elacestrant in severe hepatic dysfunction as well as in patients from racial and ethnic minority groups are ongoing. Overall, elacestrant is the first orally bioavailable SERD approved by the FDA for use in patients with metastatic breast cancer. Current clinical trials are ongoing evaluating it in the adjuvant setting in patients with early stage ER-positive breast cancers.
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Affiliation(s)
- Jan H Beumer
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15261, USA.
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Hillman Research Pavilion, Room G27E, 5117 Centre Avenue, Pittsburgh, PA, 15213-1863, USA.
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Julia Foldi
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Hillman Research Pavilion, Room G27E, 5117 Centre Avenue, Pittsburgh, PA, 15213-1863, USA
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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17
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Chandarlapaty S, Dickler MN, Perez Fidalgo JA, Villanueva-Vázquez R, Giltnane J, Gates M, Chang CW, Cheeti S, Fredrickson J, Wang X, Collier A, Moore HM, Metcalfe C, Lauchle J, Humke EW, Bardia A. An Open-label Phase I Study of GDC-0927 in Postmenopausal Women with Locally Advanced or Metastatic Estrogen Receptor-Positive Breast Cancer. Clin Cancer Res 2023; 29:2781-2790. [PMID: 37261814 PMCID: PMC10390885 DOI: 10.1158/1078-0432.ccr-23-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/01/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE GDC-0927 is a novel, potent, nonsteroidal, orally bioavailable, selective estrogen receptor (ER) degrader that induces tumor regression in ER+ breast cancer xenograft models. PATIENTS AND METHODS This phase I dose-escalation multicenter study enrolled postmenopausal women with ER+/HER2- metastatic breast cancer to determine the safety, pharmacokinetics, and recommended phase II dose of GDC-0927. Pharmacodynamics was assessed with [18F]-fluoroestradiol (FES) PET scans. RESULTS Forty-two patients received GDC-0927 once daily. The MTD was not reached. The most common adverse events (AE) regardless of causality were nausea, constipation, diarrhea, arthralgia, fatigue, hot flush, back pain, and vomiting. There were no deaths, grade 4/5 AEs, or treatment-related serious AEs. Two patients experienced grade 2 AEs of special interest of deep vein thrombosis and jugular vein thrombosis, both considered unrelated to GDC-0927. Following dosing, approximately 1.6-fold accumulation was observed, consistent with the observed half-life and dosing frequency. There were no complete or partial responses. Pharmacodynamics was supported by >90% reduction in FES uptake and an approximately 40% reduction in ER expression, suggesting ER degradation is not the mechanistic driver of ER antagonism. Twelve patients (29%) achieved clinical benefit; 17 patients (41%) showed a confirmed best overall response of stable disease. Baseline levels of ER and progesterone receptor protein and mutant ESR1 circulating tumor DNA did not correlate with clinical benefit. CONCLUSIONS GDC-0927 appeared to be well tolerated with pharmacokinetics supporting once-daily dosing. There was evidence of target engagement and preliminary evidence of antitumor activity in heavily pretreated patients with advanced/metastatic ER+/HER2- breast cancer with and without ESR1 mutations.
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Affiliation(s)
| | | | | | | | | | - Mary Gates
- Genentech, Inc., South San Francisco, California
| | | | | | | | | | - Ann Collier
- Genentech, Inc., South San Francisco, California
| | | | | | | | | | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
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18
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Bhatia N, Thareja S. Elacestrant: a new FDA-approved SERD for the treatment of breast cancer. Med Oncol 2023; 40:180. [PMID: 37191763 DOI: 10.1007/s12032-023-02045-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/03/2023] [Indexed: 05/17/2023]
Abstract
Elacestrant (RAD-1901), a selective estrogen receptor degrader, was approved by USFDA on January 27, 2023, for the treatment of breast cancer. It has been developed by Menarini Group under the brand name Orserdu®. Elacestrant showed anticancer activity both in vitro and in vivo in ER+ HER2-positive breast cancer models. The present review delebrates the development stages of Elacestrant, with its medicinal chemistry, synthesis, mechanism of action, and pharmacokinetic studies. Clinical data and safety profile has also been discussed, including data from randomized trials.
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Affiliation(s)
- Neha Bhatia
- Department of Pharmaceutical Sciences and Natural Products, School of Pharmaceutical Sciences, Central University of Punjab, Bathinda, Punjab, 151401, India
| | - Suresh Thareja
- Department of Pharmaceutical Sciences and Natural Products, School of Pharmaceutical Sciences, Central University of Punjab, Bathinda, Punjab, 151401, India.
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19
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Varella L, Cristofanilli M. Evaluating Elacestrant in the Management of ER-Positive, HER2-Negative Advanced Breast Cancer: Evidence to Date. Onco Targets Ther 2023; 16:189-196. [PMID: 36993871 PMCID: PMC10041978 DOI: 10.2147/ott.s400563] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
Breast cancer remains the second leading cause of cancer mortality in women. Endocrine therapy is the backbone treatment for hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer, the most common subtype. Although several endocrine therapy agents are available, essentially all HR-positive metastatic breast cancers will become resistant to these drugs. ESR1 mutations represent an important mechanism of resistance to aromatase inhibitors. Elacestrant is a novel oral selective estrogen receptor degrader (SERD) that selectively binds to the estrogen receptor in breast cancer cells, inhibiting tumor growth. Preclinical data suggested greater efficacy of elacestrant in combination with cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) or everolimus. In a Phase III clinical trial, elacestrant demonstrated a significant although modest improvement in median progression-free survival (PFS) compared to standard of care endocrine therapy in patients with HR-positive, HER2-negative advanced breast cancer. Importantly, there was also a significant benefit in patients with ESR1 mutations, which led to the FDA approval of elacestrant in this patient group. Elacestrant was generally well tolerated, with main side effects being upper gastrointestinal symptoms. There are several ongoing clinical trials evaluating the efficacy of elacestrant in the early setting as well as in combination with other targeted agents in the treatment of metastatic breast cancer. Other novel oral SERDs are also currently being evaluated in the treatment of HR-positive breast cancer. Results of ongoing clinical trials with these drugs will help clinicians decide the best sequence and combination of endocrine therapy agents.
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Affiliation(s)
- Leticia Varella
- Division of Medical Oncology, Internal Medicine Department, Weill Cornell Medicine, New York, NY, USA
- Correspondence: Leticia Varella, Tel +1 646 962 9888, Fax +1 646 962 0193, Email
| | - Massimo Cristofanilli
- Division of Medical Oncology, Internal Medicine Department, Weill Cornell Medicine, New York, NY, USA
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20
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Pagliuca M, Donato M, D’Amato AL, Rosanova M, Russo AOM, Scafetta R, De Angelis C, Trivedi MV, André F, Arpino G, Del Mastro L, De Laurentiis M, Puglisi F, Giuliano M. New steps on an old path: Novel estrogen receptor inhibitors in breast cancer. Crit Rev Oncol Hematol 2022; 180:103861. [DOI: 10.1016/j.critrevonc.2022.103861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
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21
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Ferraro E, Walsh EM, Tao JJ, Chandarlapaty S, Jhaveri K. Accelerating drug development in breast cancer: New frontiers for ER inhibition. Cancer Treat Rev 2022; 109:102432. [PMID: 35839531 DOI: 10.1016/j.ctrv.2022.102432] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/13/2022]
Abstract
The estrogen receptor (ER) is an important driver in the proliferation, tumorigenesis, and progression of breast cancers, and targeting ER signaling at different levels is a successful strategy in the control of hormone receptor positive (HR+) breast cancer. Endocrine therapy has been the treatment of choice for HR+ breast cancer in the early and advanced stages with multiple agents, including selective estrogen receptor modulators (SERMS), selective estrogen receptor degraders (SERDs), and aromatase inhibitors (AIs), which vary in their mechanisms of action and pharmacokinetics. Combination strategies also employ cyclin dependent kinase 4 and 6 and phosphatidylinositol 3-kinase to maximize the benefits of endocrine therapy. This paper reviews the clinical development of SERDs and other novel ER inhibitors, as well as combination strategies to overcome mechanisms of ER pathway escape. It also assesses the advantages of newer oral ER inhibitors with increased bioavailability, improved therapeutic index, better administration, and increased efficacy, as well as discussing future directions in the field.
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Affiliation(s)
- Emanuela Ferraro
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elaine M Walsh
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Jacqueline J Tao
- Graduate Medical Education, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sarat Chandarlapaty
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Komal Jhaveri
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA; Early Drug Development Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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22
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Downton T, Zhou F, Segara D, Jeselsohn R, Lim E. Oral Selective Estrogen Receptor Degraders (SERDs) in Breast Cancer: Advances, Challenges, and Current Status. Drug Des Devel Ther 2022; 16:2933-2948. [PMID: 36081610 PMCID: PMC9447452 DOI: 10.2147/dddt.s380925] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
Abstract
Several endocrine therapies are currently available for the treatment of estrogen receptor (ER) positive breast cancer, but the clinical benefit of these agents is limited by endocrine therapy drug resistance. A common mechanism of endocrine therapy resistance is ESR1 mutations. The first-generation selective estrogen receptor degrader (SERD) fulvestrant has activity against ESR1 mutant tumors but requires intramuscular injection and has poor bioavailability that precludes optimal drug dosing. This led to the development of second-generation SERDs which are potent and have improved oral bioavailability and pharmacokinetics. Several of these oral SERDs are now in phase III trials in both the early and advanced ER positive breast cancer settings. This review summarizes the background of oral SERD development, the current status and future perspectives.
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Affiliation(s)
- Teesha Downton
- Garvan Institute of Medical Research, Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent’s Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Fiona Zhou
- Garvan Institute of Medical Research, Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent’s Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Davendra Segara
- Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | - Elgene Lim
- Garvan Institute of Medical Research, Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent’s Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Correspondence: Elgene Lim, Tel +61 2 9355 5600, Fax +61 2 9355 5602, Email
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23
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Zuo Q, Park NH, Lee JK, Madak Erdogan Z. Liver Metastatic Breast Cancer: Epidemiology, Dietary Interventions, and Related Metabolism. Nutrients 2022; 14:2376. [PMID: 35745105 PMCID: PMC9228756 DOI: 10.3390/nu14122376] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/22/2022] [Accepted: 05/28/2022] [Indexed: 02/06/2023] Open
Abstract
The median overall survival of patients with metastatic breast cancer is only 2-3 years, and for patients with untreated liver metastasis, it is as short as 4-8 months. Improving the survival of women with breast cancer requires more effective anti-cancer strategies, especially for metastatic disease. Nutrients can influence tumor microenvironments, and cancer metabolism can be manipulated via a dietary modification to enhance anti-cancer strategies. Yet, there are no standard evidence-based recommendations for diet therapies before or during cancer treatment, and few studies provide definitive data that certain diets can mediate tumor progression or therapeutic effectiveness in human cancer. This review focuses on metastatic breast cancer, in particular liver metastatic forms, and recent studies on the impact of diets on disease progression and treatment.
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Affiliation(s)
- Qianying Zuo
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (Q.Z.); (N.H.P.)
| | - Nicole Hwajin Park
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (Q.Z.); (N.H.P.)
| | - Jenna Kathryn Lee
- Department of Neuroscience, Northwestern University, Evanston, IL 60208, USA;
| | - Zeynep Madak Erdogan
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (Q.Z.); (N.H.P.)
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Carl R. Woese Institute of Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
- Department of Biomedical and Translational Sciences, Carle-Illinois College of Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Ulaner GA. 16α-18F-fluoro-17β-Fluoroestradiol (FES): Clinical Applications for Patients With Breast Cancer. Semin Nucl Med 2022; 52:574-583. [DOI: 10.1053/j.semnuclmed.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 12/25/2022]
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Chen YC, Yu J, Metcalfe C, De Bruyn T, Gelzleichter T, Malhi V, Perez-Moreno PD, Wang X. Latest generation estrogen receptor degraders for the treatment of hormone receptor-positive breast cancer. Expert Opin Investig Drugs 2021; 31:515-529. [PMID: 34694932 DOI: 10.1080/13543784.2021.1983542] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The selective estrogen receptor degrader (SERD) and full receptor antagonist provides an important therapeutic option for hormone receptor (HR)-positive breast cancer. Endocrine therapies include tamoxifen, a selective estrogen receptor modulator (SERM), that exhibits receptor agonist and antagonist activity, and aromatase inhibitors that block estrogen biosynthesis but which demonstrate acquired resistance. Fulvestrant, the only currently approved SERD, is limited by poor drug-like properties. A key focus for improving disease management has been development of oral SERDs with optimized target occupancy and potency and superior clinical efficacy. AREAS COVERED Using PubMed, clinicaltrials.gov, and congress websites, this review explored the preclinical development and clinical pharmacokinetics from early phase clinical studies (2015 or later) of novel oral SERDs, including giredestrant, amcenestrant, camizestrant, elacestrant, and rintodestrant. EXPERT OPINION Numerous oral SERDs are in clinical development, aiming to form the core endocrine therapy for HR-positive breast cancer. Through property- and structure-based drug design of estrogen receptor-binding, antagonism, degradation, anti-proliferation, and pharmacokinetic properties, these SERDs have distinct profiles which impact clinical dosing, efficacy, and safety. Assuming preliminary safety and activity data are confirmed in phase 3 trials, these promising agents could further improve the management, outcomes, and quality of life in HR-positive breast cancer.
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Affiliation(s)
- Ya-Chi Chen
- Clinical Pharmacology, Genentech, Inc., South San Francisco, CA, USA
| | - Jiajie Yu
- Clinical Pharmacology, Genentech, Inc., South San Francisco, CA, USA
| | - Ciara Metcalfe
- Discovery Oncology, Genentech, Inc., South San Francisco, CA, USA
| | - Tom De Bruyn
- Drug Metabolism and Pharmacokinetics, Genentech, Inc., South San Francisco, CA, USA
| | - Thomas Gelzleichter
- Genentech Research and Early Development, Genentech, Inc., South San Francisco, CA, USA
| | - Vikram Malhi
- Clinical Pharmacology, Genentech, Inc., South San Francisco, CA, USA
| | | | - Xiaojing Wang
- Discovery Chemistry, Genentech, Inc., South San Francisco, CA, USA
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McAndrew NP, Finn RS. Clinical Review on the Management of Hormone Receptor-Positive Metastatic Breast Cancer. JCO Oncol Pract 2021; 18:319-327. [PMID: 34637323 DOI: 10.1200/op.21.00384] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The natural history of hormone receptor-positive breast cancer tends to be more favorable than other subtypes such as human epidermal growth factor receptor 2-amplified and triple-negative. In addition, the natural dependence on steroid hormone signaling has allowed for therapeutic targeting of this pathway and significant improvements in survival while maintaining quality of life: the two main goals in management of the disease. The sequential use of endocrine agents including the selective estrogen receptor modulators (tamoxifen), aromatase inhibitors (letrozole, anastrozole, and exemestane) and the selective estrogen receptor degrader fulvestrant has been the backbone of management for years. In the past decade, the introduction of molecularly targeted agents against intracellular targets such as mammalian target of rapamycin (everolimus), cyclin-dependent kinases 4 and 6 (palbociclib, ribociclib, and abemaciclib), and phosphatidylinositol 3-kinase (alpelisib) has offered patients effective nonchemotherapy-based options, which are improving outcomes. Although knowledge gaps still exist in regard to the optimal sequencing of these new regimens, they have expanded our repertoire of options for patients and have shifted the need for cytotoxic chemotherapy and its associated complications to later lines. Still, formatting a plan for these patients includes taking into account traditional prognostic factors such as menopausal status, previous treatments, disease-free interval for those patients with early breast cancer that has recurred, and tumor burden. To assist in developing this treatment plan, we will review the current data with systemic agents in the management of these patients.
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Affiliation(s)
- Nicholas P McAndrew
- Division of Hematology Oncology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard S Finn
- Division of Hematology Oncology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
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Bardia A, Kaklamani V, Wilks S, Weise A, Richards D, Harb W, Osborne C, Wesolowski R, Karuturi M, Conkling P, Bagley RG, Wang Y, Conlan MG, Kabos P. Phase I Study of Elacestrant (RAD1901), a Novel Selective Estrogen Receptor Degrader, in ER-Positive, HER2-Negative Advanced Breast Cancer. J Clin Oncol 2021; 39:1360-1370. [PMID: 33513026 PMCID: PMC8078341 DOI: 10.1200/jco.20.02272] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 01/10/2023] Open
Abstract
PURPOSE This phase I study (RAD1901-005; NCT02338349) evaluated elacestrant, an investigational oral selective estrogen receptor degrader (SERD), in heavily pretreated women with estrogen receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer, including those with estrogen receptor gene alpha (ESR1) mutation. The primary objective was to determine the maximum tolerated dose and/or recommended phase II dose (RP2D). METHODS The study consisted of a 3 + 3 design (elacestrant capsules) followed by expansion at RP2D (400-mg capsules, then 400-mg tablets) for the evaluation of safety and antitumor activity. Elacestrant was taken once daily until progression or intolerability. RESULTS Of 57 postmenopausal women enrolled, 50 received RP2D (400 mg once daily): median age, 63 years; median three prior anticancer therapies, including cyclin-dependent kinase 4,6 inhibitors (CDK4/6i; 52%), SERD (52%), and ESR1 mutation (circulating tumor DNA; 50%). No dose-limiting toxicities occurred; the most common adverse events at RP2D (400-mg tablet; n = 24) were nausea (33.3%) and increased blood triglycerides and decreased blood phosphorus (25.0% each). Most adverse events were grade 1-2 in severity. The objective response rate was 19.4% (n = 31 evaluable patients receiving RP2D), 15.0% in patients with prior SERD, 16.7% in patients with prior CDK4/6i, and 33.3% in patients with ESR1 mutation (n = 5/15). The clinical benefit rate (24-week) was 42.6% overall (n = 47 patients receiving RP2D), 56.5% (n = 23, ESR1 mutation), and 30.4% (n = 23, prior CDK4/6i). Elacestrant clinical benefit was associated with decline in ESR1 mutant allele fraction. CONCLUSION Elacestrant 400 mg orally once daily has an acceptable safety profile and demonstrated single-agent activity with confirmed partial responses in heavily pretreated patients with estrogen receptor-positive metastatic breast cancer. Notably, responses were observed in patients with ESR1 mutation as well as those with prior CDK4/6i and prior SERD. A phase III trial investigating elacestrant versus standard endocrine therapy is ongoing.
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Affiliation(s)
- Aditya Bardia
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | - Amy Weise
- Barbara Ann Karmanos Cancer Center, Detroit, MI
| | | | - Wael Harb
- Horizon Oncology Center, Lafayette, IN
| | - Cynthia Osborne
- Texas Oncology-Baylor Charles A. Sammons Cancer Center; Dallas, TX
| | | | | | - Paul Conkling
- US Oncology Research, Virginia Oncology Associates, Norfolk, VA
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Molecular Biomarkers for Contemporary Therapies in Hormone Receptor-Positive Breast Cancer. Genes (Basel) 2021; 12:genes12020285. [PMID: 33671468 PMCID: PMC7922594 DOI: 10.3390/genes12020285] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Systemic treatment of hormone receptor-positive (HR+) breast cancer is undergoing a renaissance, with a number of targeted therapies including CDK4/6, mTOR, and PI3K inhibitors now approved for use in combination with endocrine therapies. The increased use of targeted therapies has changed the natural history of HR+ breast cancers, with the emergence of new escape mechanisms leading to the inevitable progression of disease in patients with advanced cancers. The identification of new predictive and pharmacodynamic biomarkers to current standard-of-care therapies and discovery of new therapies is an evolving and urgent clinical challenge in this setting. While traditional, routinely measured biomarkers such as estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal growth factor receptor 2 (HER2) still represent the best prognostic and predictive biomarkers for HR+ breast cancer, a significant proportion of patients either do not respond to endocrine therapy or develop endocrine resistant disease. Genomic tests have emerged as a useful adjunct prognostication tool and guide the addition of chemotherapy to endocrine therapy. In the treatment-resistant setting, mutational profiling has been used to identify ESR1, PIK3CA, and AKT mutations as predictive molecular biomarkers to newer therapies. Additionally, pharmacodynamic biomarkers are being increasingly used and considered in the metastatic setting. In this review, we summarise the current state-of-the-art therapies; prognostic, predictive, and pharmacodynamic molecular biomarkers; and how these are impacted by emerging therapies for HR+ breast cancer.
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