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Pegram M, Jackisch C, Johnston SRD. Estrogen/HER2 receptor crosstalk in breast cancer: combination therapies to improve outcomes for patients with hormone receptor-positive/HER2-positive breast cancer. NPJ Breast Cancer 2023; 9:45. [PMID: 37258523 DOI: 10.1038/s41523-023-00533-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/04/2023] [Indexed: 06/02/2023] Open
Abstract
The human epidermal growth factor receptor 2 (HER2) is overexpressed in 13-22% of breast cancers (BC). Approximately 60-70% of HER2+ BC co-express hormone receptors (HRs). HR/HER2 co-expression modulates response to both anti-HER2-directed and endocrine therapy due to "crosstalk" between the estrogen receptor (ER) and HER2 pathways. Combined HER2/ER blockade may be an effective treatment strategy for patients with HR+/HER2+ BC in the appropriate clinical setting(s). In this review, we provide an overview of crosstalk between the ER and HER2 pathways, summarize data from recently published and ongoing clinical trials, and discuss clinical implications for targeted treatment of HR+/HER2+ BC.
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Affiliation(s)
- Mark Pegram
- Stanford Cancer Institute, Stanford, CA, USA.
| | - Christian Jackisch
- Obstetrics and Gynaecology and Breast Cancer Center, Klinikum Offenbach GmbH, Offenbach, Germany
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Rashad N, Abdelhamid T, Shouman SA, Nassar H, Omran MA, El Desouky ED, Khaled H. Capecitabine-Based Chemoendocrine Combination as First-Line Treatment for Metastatic Hormone-Positive Metastatic Breast Cancer: Phase 2 Study. Clin Breast Cancer 2020; 20:228-237. [PMID: 32005499 DOI: 10.1016/j.clbc.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/21/2019] [Accepted: 12/31/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Preclinical studies have suggested a synergistic effect of tamoxifen and capecitabine in estrogen receptor-positive cell lines. We evaluated the safety and efficacy of first-line chemoendocrine treatment in patients with metastatic breast cancer. Biochemical assessment was performed of serum levels of thymidine phosphorylase enzyme (TP), serum tamoxifen, hydroxytamoxifen, and 5-fluorouracil in relationship to efficacy. PATIENTS AND METHODS This prospective phase 2 interventional study studied patients with estrogen receptor-positive, HER2- metastatic breast cancer who received either tamoxifen/capecitabine or letrozole/capecitabine as first-line treatment. The dose of capecitabine provided at 2000 mg per day continuously as a fixed dose. RESULTS Forty women with a median age of 49.3 years were enrolled. For the whole study group, median progression-free survival (PFS) was 10 months and median overall survival (OS) was 23.3 months. The overall response rate was 60% and the clinical benefit rate 82.5%. Progesterone receptor positivity was associated with significantly longer PFS (12 vs. 7 months, P = .021). The most frequent adverse events were palmar-plantar erythrodysesthesia (62.5%), fatigue (62.5%), diarrhea (30%), abdominal pain (12.5%), and constipation (10%). Changes in serum level of TP were not correlated to response to treatment, PFS, or OS. Higher serum levels of tamoxifen and hydroxytamoxifen were correlated with higher response rates and longer PFS but not OS. CONCLUSION Chemoendocrine treatment is well tolerated, with no evidence of contradictory effects between the combination components. However, the efficacy data need more validation.
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MESH Headings
- Abdominal Pain/chemically induced
- Abdominal Pain/epidemiology
- Adult
- Antimetabolites, Antineoplastic/administration & dosage
- Antimetabolites, Antineoplastic/adverse effects
- Antineoplastic Agents, Hormonal/administration & dosage
- Antineoplastic Agents, Hormonal/adverse effects
- Antineoplastic Agents, Hormonal/pharmacokinetics
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/pharmacokinetics
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/blood
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Capecitabine/administration & dosage
- Capecitabine/adverse effects
- Capecitabine/pharmacokinetics
- Constipation/chemically induced
- Constipation/epidemiology
- Diarrhea/chemically induced
- Diarrhea/epidemiology
- Female
- Hand-Foot Syndrome/epidemiology
- Hand-Foot Syndrome/etiology
- Humans
- Letrozole/administration & dosage
- Letrozole/adverse effects
- Letrozole/pharmacokinetics
- Middle Aged
- Progression-Free Survival
- Prospective Studies
- Receptor, ErbB-2/analysis
- Receptors, Estrogen/analysis
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/analysis
- Receptors, Progesterone/metabolism
- Tamoxifen/administration & dosage
- Tamoxifen/adverse effects
- Tamoxifen/pharmacokinetics
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Affiliation(s)
- Noha Rashad
- Department of Medical Oncology, Maadi Armed Forces Hospital, Cairo, Egypt.
| | - Thoraya Abdelhamid
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Samia A Shouman
- Pharmacology Unit, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Hanan Nassar
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mervat A Omran
- Pharmacology Unit, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Eman D El Desouky
- Department of Biostatistics and Epidemiology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Hussein Khaled
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
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3
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Abrams MJ, Koffer PP, Wazer DE, Hepel JT. Postmastectomy Radiation Therapy Is Associated With Improved Survival in Node-Positive Male Breast Cancer: A Population Analysis. Int J Radiat Oncol Biol Phys 2017; 98:384-391. [DOI: 10.1016/j.ijrobp.2017.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/17/2016] [Accepted: 02/07/2017] [Indexed: 01/11/2023]
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Tanaka S, Hayek G, Jayapratap P, Yerrasetti S, Hilaire HS, Sadeghi A, Corsetti R, Fuhrman G. The Impact of Chemotherapy on Complications Associated with Mastectomy and Immediate Autologous Tissue Reconstruction. Am Surg 2016. [DOI: 10.1177/000313481608200830] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We performed this study to evaluate the impact of chemotherapy on the outcomes associated with immediate autologous tissue reconstruction (IATR) in the treatment of breast cancer. Patients were divided into two groups: Group 1 received chemotherapy before surgery and Group 2 did not receive chemotherapy. Records were reviewed to identify demographics, comorbidities, histology, and wound healing complications. Groups were compared using Kruskal-Wallis and Fisher exact tests as appropriate. A total of 128 patients were identified: 29 received chemotherapy before surgery (Group 1) and 99 did not receive chemotherapy (Group 2). Group 1 patients were more likely to have diabetes 27 per cent versus 6 per cent ( P = 0.005) despite both groups having a mean body mass index of 30. Group 2 patients had less advanced stage disease as expected because they did not receive chemotherapy; 37 per cent of Group 2 patients had stage 0 breast cancer ( P < 0.001). The incidence of wound complications was 17 per cent in Group 1 and 12 per cent in Group 2 ( P = NS). Preoperative chemotherapy for breast cancer followed by IATR was associated with no increased risk of healing complications. IATR can be offered to patients who require preoperative chemotherapy, and their healing will not be impaired as a result of the chemotherapy.
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Affiliation(s)
- Shoichiro Tanaka
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Genevieve Hayek
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Pravitha Jayapratap
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - Sita Yerrasetti
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - Hugo St. Hilaire
- Department of Surgery, Louisiana State University, New Orleans, Louisiana
| | - Ali Sadeghi
- Department of Surgery, Louisiana State University, New Orleans, Louisiana
| | - Ralph Corsetti
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - George Fuhrman
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Fan P, Maximov PY, Curpan RF, Abderrahman B, Jordan VC. The molecular, cellular and clinical consequences of targeting the estrogen receptor following estrogen deprivation therapy. Mol Cell Endocrinol 2015; 418 Pt 3:245-63. [PMID: 26052034 PMCID: PMC4760743 DOI: 10.1016/j.mce.2015.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/20/2015] [Accepted: 06/01/2015] [Indexed: 01/04/2023]
Abstract
During the past 20 years our understanding of the control of breast tumor development, growth and survival has changed dramatically. The once long forgotten application of high dose synthetic estrogen therapy as the first chemical therapy to treat any cancer has been resurrected, refined and reinvented as the new biology of estrogen-induced apoptosis. High dose estrogen therapy was cast aside once tamoxifen, from its origins as a failed "morning after pill", was reinvented as the first targeted therapy to treat any cancer. The current understanding of the mechanism of estrogen-induced apoptosis is described as a consequence of acquired resistance to long term antihormone therapy in estrogen receptor (ER) positive breast cancer. The ER signal transduction pathway remains a target for therapy in breast cancer despite "antiestrogen" resistance, but becomes a regulator of resistance. Multiple mechanisms of resistance come into play: Selective ER modulator (SERM) stimulated growth, growth factor/ER crosstalk, estrogen-induced apoptosis and mutations of ER. But it is with the science of estrogen-induced apoptosis that the next innovation in women's health will be developed. Recent evidence suggests that the glucocorticoid properties of medroxyprogesterone acetate blunt estrogen-induced apoptosis in estrogen deprived breast cancer cell populations. As a result breast cancer develops during long-term hormone replacement therapy (HRT). A new synthetic progestin with estrogen-like properties, such as the 19 nortestosterone derivatives used in oral contraceptives, will continue to protect the uterus from unopposed estrogen stimulation but at the same time, reinforce apoptosis in vulnerable populations of nascent breast cancer cells.
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Affiliation(s)
- Ping Fan
- Department of Breast Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Philipp Y Maximov
- Department of Breast Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Ramona F Curpan
- Institute of Chemistry, Romanian Academy, Timisoara, Romania
| | | | - V Craig Jordan
- Department of Breast Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA.
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Jatoi I, Bandos H, Jeong JH, Anderson WF, Romond EH, Mamounas EP, Wolmark N. Time-Varying Effects of Breast Cancer Adjuvant Systemic Therapy. J Natl Cancer Inst 2015; 108:djv304. [PMID: 26518884 DOI: 10.1093/jnci/djv304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The benefits of breast cancer adjuvant systemic treatments are generally assumed to be proportional (or constant) over time, but limited data suggest that some treatment effects may vary with time. We therefore systematically assessed the proportional hazards assumption across all 19 breast cancer adjuvant systemic therapy trials in the National Surgical Adjuvant Breast and Bowel Project (NSABP) database. METHODS The NSABP breast cancer trials were tested for the proportionality of hazard rates between randomized treatment groups for five endpoints: overall survival, disease-free survival and recurrence, local-regional recurrence, or distant recurrence as first events. When the proportional hazards assumption did not hold, a "change point for the relative risk" technique was used to identify the temporal breakdown of the treatment effect. RESULTS Time-varying treatment effects were observed in nearly half of the trials (nine of 19). In six (B-05, B-11, B-12, B-14, B-16, and B-20), novel treatment benefits diminished statistically significantly at specific time points following surgery. In B-09 and B-31, novel treatment benefits were delayed and emerged more than one year after surgery (1.57 and 1.32 years correspondingly), but the benefit in B-09 reversed after the third year of follow-up. In one trial (B-23), the initial advantage and subsequent disadvantage of one of the regimens was evident. CONCLUSIONS Breast cancer adjuvant systemic therapy can have statistically significant time-varying effects, which should be considered in the design, analysis, reporting, and translation of clinical trials. These time-dependent effects will have greater relevance as the number of long-term breast cancer survivors increases.
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Affiliation(s)
- Ismail Jatoi
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW).
| | - Hanna Bandos
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Jong-Hyeon Jeong
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - William F Anderson
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Edward H Romond
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Eleftherios P Mamounas
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Norman Wolmark
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
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7
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Minasian LM, Tangen CM, Wickerham DL. Ongoing Use of Data and Specimens From National Cancer Institute-Sponsored Cancer Prevention Clinical Trials in the Community Clinical Oncology Program. Semin Oncol 2015; 42:748-63. [PMID: 26433556 DOI: 10.1053/j.seminoncol.2015.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Large cancer prevention trials provide opportunities to collect a wide array of data and biospecimens at study entry and longitudinally, for a healthy, aging population without cancer. This provides an opportunity to use pre-diagnostic data and specimens to evaluate hypotheses about the initial development of cancer. We report on strides made by, and future possibilities for, the use of accessible biorepositories developed from precisely annotated samples obtained through large-scale National Cancer Institute (NCI)-sponsored cancer prevention clinical trials conducted by the NCI Cooperative Groups. These large cancer prevention studies, which have enrolled more than 80,000 volunteers, continue to contribute to our understanding of cancer development more than 10 years after they were closed.
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Affiliation(s)
- Lori M Minasian
- Division of Cancer Prevention, U.S. National Cancer Institute, Rockville, MD.
| | - Catherine M Tangen
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - D Lawrence Wickerham
- Department of Human Oncology, Pittsburgh Campus of Temple University School of Medicine, Pittsburgh, PA
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Valdivieso M, Corn BW, Dancey JE, Wickerham DL, Horvath LE, Perez EA, Urton A, Cronin WM, Field E, Lackey E, Blanke CD. The Globalization of Cooperative Groups. Semin Oncol 2015; 42:693-712. [PMID: 26433551 DOI: 10.1053/j.seminoncol.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The National Cancer Institute (NCI)-supported adult cooperative oncology research groups (now officially Network groups) have a longstanding history of participating in international collaborations throughout the world. Most frequently, the US-based cooperative groups work reciprocally with the Canadian national adult cancer clinical trial group, NCIC CTG (previously the National Cancer Institute of Canada Clinical Trials Group). Thus, Canada is the largest contributor to cooperative groups based in the United States, and vice versa. Although international collaborations have many benefits, they are most frequently utilized to enhance patient accrual to large phase III trials originating in the United States or Canada. Within the cooperative group setting, adequate attention has not been given to the study of cancers that are unique to countries outside the United States and Canada, such as those frequently associated with infections in Latin America, Asia, and Africa. Global collaborations are limited by a number of barriers, some of which are unique to the countries involved, while others are related to financial support and to US policies that restrict drug distribution outside the United States. This article serves to detail the cooperative group experience in international research and describe how international collaboration in cancer clinical trials is a promising and important area that requires greater consideration in the future.
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Affiliation(s)
- Manuel Valdivieso
- Division of Hematology/Oncology, University of Michigan; and SWOG, Executive Officer, Quality Assurance and International Initiatives, Ann Arbor, MI.
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv, Israel; and Department of Radiation Oncology, Jefferson Medical College, Philadelphia, PA
| | - Janet E Dancey
- Director, NCIC Clinical Trials Group; Scientific Director Canadian Cancer Clinical Trials Network; Program Leader, High Impact Clinical Trials, Ontario Institute for Cancer Research; Professor of Oncology, Queen's University, Kingston, Ontario, Canada
| | - D Lawrence Wickerham
- Deputy Chairman, NRG Oncology, Pittsburgh, PA; Department of Human Oncology, Pittsburgh Campus, Drexel University School of Medicine; Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA
| | - L Elise Horvath
- Executive Officer, Alliance for Clinical Trials in Oncology, Chicago, IL
| | - Edith A Perez
- Deputy Director at Large, Mayo Clinic Cancer Center; Group Vice Chair, Alliance for Clinical Trials in Oncology; Hematology/Oncology and Cancer Biology Mayo Clinic, Jacksonville, FL
| | - Alison Urton
- Group Administrator, NCIC Clinical Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Walter M Cronin
- Associate Director, NRG Oncology Statistics and Data Management Center (SDMC); Associate Director, Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Erica Field
- Project Specialist III, RTOG, Philadelphia, PA
| | - Evonne Lackey
- Coordinating Center Manager, SWOG Statistical Center, Seattle, WA
| | - Charles D Blanke
- Chair, SWOG; Department of Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University and Knight Cancer Institute, Portland, OR
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Piasecka-Srader J, Blanco FF, Delman DH, Dixon DA, Geiser JL, Ciereszko RE, Petroff BK. Tamoxifen prevents apoptosis and follicle loss from cyclophosphamide in cultured rat ovaries. Biol Reprod 2015; 92:132. [PMID: 25833159 DOI: 10.1095/biolreprod.114.126136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 03/25/2015] [Indexed: 12/23/2022] Open
Abstract
Recent studies documented that the selective estrogen receptor modulator tamoxifen prevents follicle loss and promotes fertility following in vivo exposure of rodents to irradiation or ovotoxic cancer drugs, cyclophosphamide and doxorubicin. In an effort to characterize the ovarian-sparing mechanisms of tamoxifen in preantral follicle classes, cultured neonatal rat ovaries (Day 4, Sprague Dawley) were treated for 1-7 days with active metabolites of cyclophosphamide (i.e., 4-hydroxycyclophosphamide; CTX) (0, 1, and 10 μM) and tamoxifen (i.e., 4-hydroxytamoxifen; TAM) (0 and 10 μM) in vitro, and both apoptosis and follicle numbers were measured. CTX caused marked follicular apoptosis and follicular loss. TAM treatment decreased follicular loss and apoptosis from CTX in vitro. TAM alone had no effect on these parameters. IGF-1 and IGF-1 receptor were assessed in ovarian tissue showing no impact of TAM or CTX on these endpoints. Targeted mRNA analysis during follicular rescue by TAM revealed decreased expression of multiple genes related to inflammation, including mediators of lipoxygenase and prostaglandin production and signaling (Alox5, Pla2g1b, Ptgfr), cytokine binding (Il1r1, Il2rg ), apoptosis (Tnfrsf1a), second messenger signaling (Mapk1, Mapk14, Plcg1), as well as tissue remodeling and vasodilation (Bdkrb2, Klk15). The results suggest that TAM protects the ovary from CTX-mediated toxicity through direct ovarian actions that oppose follicular loss.
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Affiliation(s)
- Joanna Piasecka-Srader
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Fernando F Blanco
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, Kansas
| | - Devora H Delman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Dan A Dixon
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, Kansas
| | - James L Geiser
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Renata E Ciereszko
- Department of Animal Physiology, University of Warmia and Mazury, Olsztyn, Poland
| | - Brian K Petroff
- Diagnostic Companion Animal and Population Health Laboratory, Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
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10
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Ting AY, Petroff BK. Challenges and Potential for Ovarian Preservation with SERMs. Biol Reprod 2015; 92:133. [PMID: 25810474 DOI: 10.1095/biolreprod.115.128207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/12/2015] [Indexed: 01/08/2023] Open
Abstract
Tamoxifen (TAM) is a selective estrogen receptor modulator with tissue-specific effects on estrogen signaling used predominantly for treatment and chemoprevention of breast cancers. Recent studies have shown that TAM prevents infertility and decreases follicular loss from common cancer chemotherapy and radiation therapy in preclinical models. Here we review current and novel uses of selective estrogen receptor modulator s and advantages and challenges for translation of TAM for human fertility preservation.
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Affiliation(s)
- Alison Y Ting
- Division of Reproduction and Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon
| | - Brian K Petroff
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
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11
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Cortazar P, Geyer CE. Pathological complete response in neoadjuvant treatment of breast cancer. Ann Surg Oncol 2015; 22:1441-6. [PMID: 25727556 DOI: 10.1245/s10434-015-4404-8] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND There has been recent interest in using pathological complete response (pCR) as a potential surrogate endpoint for long-term outcomes in the neoadjuvant treatment of high-risk, early-stage breast cancer. METHODS We review the clinical trials that have contributed to our understanding of the association between pCR and long-term outcomes, describe the various definitions of pCR, describe patient populations in which pCR may predict long-term benefit, and discuss the implications of pCR on drug development and accelerated approval for neoadjuvant treatment of breast cancer. RESULTS Varying definitions of pCR across clinical trials conducted in heterogeneous patient populations make understanding the association of pCR with long-term outcomes challenging. The US Food and Drug Administration established the Collaborative Trials in Neoadjuvant Breast Cancer group to evaluate the potential use of pCR as a regulatory endpoint. The group demonstrated that pCR defined as no residual invasive cancer in the breast and axillary nodes with presence or absence of in situ cancer (ypT0/is ypN0 or ypT0 ypN0) provided a better association with improved outcomes compared to eradication of invasive tumor from the breast alone (ypT0/is). CONCLUSION Even though pCR was not validated as a surrogate endpoint for long-term outcomes, the promising data regarding the strong association of pCR with substantially improved outcomes in individual patients with more aggressive subtypes of breast cancer supported the opening of an accelerated approval pathway for patients with high-risk, early-stage breast cancer.
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Affiliation(s)
- Patricia Cortazar
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA,
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12
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Estrogen receptor-alpha 36 mediates the anti-apoptotic effect of estradiol in triple negative breast cancer cells via a membrane-associated mechanism. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2014; 1843:2796-806. [PMID: 25108195 DOI: 10.1016/j.bbamcr.2014.07.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 11/20/2022]
Abstract
17β-Estradiol can promote the growth and development of several estrogen receptor (ER)-negative breast cancers. The effects are rapid and non-genomic, suggesting that a membrane-associated ER is involved. ERα36 has been shown to mediate rapid, non-genomic, membrane-associated effects of 17β-estradiol in several cancer cell lines, including triple negative HCC38 breast cancer cells. Moreover, the effect is anti-apoptotic. The aim of this study was to determine if ERα36 mediates this anti-apoptotic effect, and to elucidate the mechanism involved. Taxol was used to induce apoptosis in HCC38 cells, and the effect of 17β-estradiol pre-treatment was determined. Antibodies to ERα36, signal pathway inhibitors, ERα36 deletion mutants, and ERα36-silencing were used prior to these treatments to determine the role of ERα36 in these effects and to determine which signaling molecules were involved. We found that the anti-apoptotic effect of 17β-estradiol in HCC38 breast cancer cells is in fact mediated by membrane-associated ERα36. We also showed that this signaling occurs through a pathway that requires PLD, LPA, and PI3K; Gαs and calcium signaling may also be involved. In addition, dynamic palmitoylation is required for the membrane-associated effect of 17β-estradiol. Exon 9 of ERα36, a unique exon to ERα36 not found in other identified splice variants of ERα with previously unknown function, is necessary for these effects. This study provides a working model for a mechanism by which estradiol promotes anti-apoptosis through membrane-associated ERα36, suggesting that ERα36 may be a potential membrane target for drug design against breast cancer, particularly triple negative breast cancer.
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Kim J, Kim M, Lee JH, Lee H, Lee SK, Bae SY, Jun SY, Kil WH, Lee JE, Kim SW, Nam SJ. Ovarian function preservation with GnRH agonist in young breast cancer patients: does it impede the effect of adjuvant chemotherapy? Breast 2014; 23:670-5. [PMID: 25088482 DOI: 10.1016/j.breast.2014.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 07/08/2014] [Accepted: 07/13/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Concurrent endocrine therapy with chemotherapy had a concern of potential antagonism. However, gonadotropin-releasing hormone (GnRH) agonist has been used concurrently with chemotherapy to prevent premature ovarian failure for young breast cancer patients. The aim of this study was to determine the impact of concurrent use of GnRH agonists on relapse-free and overall survival, and to establish the oncologic safety of ovarian protection with GnRH agonists. METHODS Premenopausal women aged between 20 and 40 years who received adjuvant chemotherapy for breast cancer from January 2002 to April 2012 were classified into two groups; One treated with GnRH agonists for ovarian protection during chemotherapy, and the other without ovarian protection. A propensity score matching strategy was used to create matched sets of two groups with age, pathologic stage, hormone receptor, and Her2 status. RESULTS A total of 101 patients treated with concurrent GnRH agonist during chemotherapy were compared with 335 propensity score matched patients. Among them, 81.2% were younger than 35 years and 58.4% were hormone responsive. Survival analysis using stratified Cox regression showed that women treated with concurrent GnRH agonists had better recurrence-free survival (adjusted Hazard ratio 0.21, p = 0.009; unadjusted Hazard ratio 0.33, p = 0.034). CONCLUSIONS Ovarian protection using GnRH agonists can be safely considered for young women with breast cancer in terms of oncologic outcomes. Further studies are needed to assess the long-term outcomes of concurrent GnRH agonist use with chemotherapy.
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Affiliation(s)
- Jiyoung Kim
- Department of Surgery, Jeju National University School of Medicine, Jeju National University Hospital, Ara 1-dong, 1753-3, Jeju-si, Jeju Special Self-governing Province, Republic of Korea
| | - Minkook Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Jun Ho Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Hyunchul Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Se Kyung Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Soo Youn Bae
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Si-Youl Jun
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon-Si, Republic of Korea
| | - Won Ho Kil
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea.
| | - Seok Won Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
| | - Seok Jin Nam
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, Republic of Korea
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Abstract
Chemoprevention is proposed as a clinical analogue of population prevention, aimed at reducing likelihood of disease progression, not across the population, but in identified high-risk individuals and not by behavioral or lifestyle modification, but by the use of pharmaceutical agents. Cardiovascular chemoprevention is successful via control of hyperlipidemias and hypertension. However, chemoprevention of cancer is an almost universal failure: not only are some results null; even more frequently, there is an excess of disease, including disease that the agents were chosen specifically to reduce. A brief introduction is followed by the evidence for a wide variety of agents and their largely deleterious, sometimes null, and in one case, largely beneficial, consequences as possible chemopreventives. The agents include (i) those that are food derived and their synthetic analogues: β-carotene, folic acid, retinol and retinoids, vitamin E, multivitamin supplements, vitamin C, calcium and selenium and (ii) agents targeted at metabolic and hormonal pathways: statins, estrogen and antagonists, 5α-reductase inhibitors. There are two agents for which there is good evidence of benefit when the strategy is focused on those at defined high risk but where wider application is much more problematic: aspirin and tamoxifen. The major problems with cancer chemoprevention are presented. This is followed by a hypothesis to explain the failure of cancer chemoprevention as an enterprise, arguing that the central tenets that underpin it are flawed and showing why, far from doing good, cancer chemoprevention causes harm.
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Affiliation(s)
- John D Potter
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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Joerger M, Thürlimann B. Chemotherapy regimens in early breast cancer: major controversies and future outlook. Expert Rev Anticancer Ther 2013; 13:165-78. [PMID: 23406558 DOI: 10.1586/era.12.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The addition of adjuvant chemotherapy in early breast cancer improves overall survival by approximately 10%. Recommendations favor the use of anthracyclines and taxanes in patients with luminal B disease, while the use of an anthracycline, taxane and alkylating agent is recommended in triple-negative disease. In luminal B disease, the addition of chemotherapy to endocrine treatment depends on estrogen receptor expression and overall risk. Chemotherapy is not recommended in most patients with luminal A (highly hormone-sensitive and low proliferation) breast cancer. A major controversy is the addition of adjuvant chemotherapy to endocrine treatment in patients with estrogen receptor-positive breast cancer. In some of these patients, multigene signatures such as the 21-gene recurrence score may be a useful addition to histopathology. The introduction of molecular subtypes and gene signatures improves the complexity of early breast cancer treatment, and individual institutes have to find their policy based on their histopathological information and the availability of gene signatures.
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Affiliation(s)
- Markus Joerger
- Department of Oncology & Hematology, Cantonal Hospital, Rorschacherstrasse 95, 9007 St Gallen, Switzerland.
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Shah-Khan M, Boughey JC. Evolution of axillary nodal staging in breast cancer: clinical implications of the ACOSOG Z0011 trial. Cancer Control 2013; 19:267-76. [PMID: 23037494 DOI: 10.1177/107327481201900403] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Management of the axilla in breast cancer patients has evolved from routine axillary lymph node dissection (ALND) for all patients to a highly selective approach based on the assessment of the sentinel lymph nodes (SLNs) as well as tumor and patient characteristics. Although ALND continues to have an important role in staging and regional control for many breast cancer patients, recent trial results question the need for routine ALND in patients who have positive SLNs. METHODS Not all axillary disease becomes clinically detectable or relevant with respect to recurrence and survival. Therefore, recent trends indicate that many surgeons have omitted ALND in subgroups of patients, particularly those with clinically node-negative, SLN-positive, early-stage breast cancer undergoing breast-conserving therapy with postoperative irradiation. This review explores trends in axillary management, focusing primarily on the clinical implications of the results from the American College of Surgeons Oncology Group (ACOSOG) Z0011 randomized controlled trial. RESULTS According to the results of the ACOSOG Z0011 trial, the use of SLN dissection alone did not result in inferior survival compared with ALND in patients with limited SLN disease treated with breast-conserving therapy. This subgroup of women was spared the morbidity associated with ALND. However, several points of debate, including the smaller than anticipated sample size, the older study population, and the length of follow-up, suggest caution when applying these findings to all women with breast cancer. CONCLUSIONS Although the findings of ACOSOG Z0011 are impressive, in clinical practice they are applicable to a limited number of women with breast cancer: those with T1-2 primary tumors with clinically negative axilla and 1 to 2 positive SLNs undergoing breast-conserving surgery and adjuvant whole-breast irradiation. The next generation of clinical trials may answer some of the remaining questions regarding how best to manage the axilla in additional subsets of patients undergoing treatment of breast cancer.
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Affiliation(s)
- Miraj Shah-Khan
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Younus M, Kissner M, Reich L, Wallis N. Putting the cardiovascular safety of aromatase inhibitors in patients with early breast cancer into perspective: a systematic review of the literature. Drug Saf 2012; 34:1125-49. [PMID: 22077502 DOI: 10.2165/11594170-000000000-00000] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In the adjuvant setting, the third-generation aromatase inhibitors (AIs) anastrozole, letrozole and exemestane are recommended at some point during treatment, either in the upfront, switch after tamoxifen or extended treatment setting after tamoxifen in postmenopausal patients with hormone receptor-positive early breast cancer. AIs have demonstrated superior disease-free survival and overall benefit-to-risk profiles compared with tamoxifen. Potential adverse events, including cardiovascular (CV) side effects, should be considered in the long-term management of patients undergoing treatment with AIs. AIs reduce estrogen levels by inhibiting the aromatase enzyme, thus reducing the levels of circulating estrogen. This further reduction in estrogen levels may potentially increase the risk of developing CV disease. This systematic review evaluated published clinical data for changes in plasma lipoproteins and ischaemic CV events during adjuvant therapy with AIs in patients with hormone receptor-positive early breast cancer. The electronic databases MEDLINE, EMBASE, Derwent Drug File and BIOSIS were searched to identify English-language articles published from January 1998 to 15 April 2011 that reported data on AIs and plasma lipoproteins and/or ischaemic CV events. Overall, available data did not show any definitive patterns or suggest an unfavourable effect of AIs on plasma lipoproteins from baseline to follow-up assessment in patients with hormone receptor-positive early breast cancer. Changes that occurred in plasma lipoproteins were observed soon after initiation of AI therapy and generally remained stable throughout the studies. Available data do not support a substantial risk of ischaemic CV events associated with adjuvant AI therapy; however, studies with longer follow-up are required to better characterize the CV profile of AIs.
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Affiliation(s)
- Muhammad Younus
- Epidemiology, Worldwide Safety Strategy, Pfizer Inc., New York, NY, USA
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Del Re M, Michelucci A, Simi P, Danesi R. Pharmacogenetics of anti-estrogen treatment of breast cancer. Cancer Treat Rev 2011; 38:442-50. [PMID: 21917382 DOI: 10.1016/j.ctrv.2011.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 08/08/2011] [Accepted: 08/12/2011] [Indexed: 10/17/2022]
Abstract
A major effort is underway to select genetic polymorphisms potentially relevant to the clinical efficacy and safety of endocrine treatment of breast cancer. Genetic factors of the host that affect the metabolism of tamoxifen, a widely used drug for the adjuvant treatment of breast cancer, have received particular attention. Cytochrome P450 isoform 2D6 (CYP2D6) is a key step in the metabolism of tamoxifen to its active moiety endoxifen. Women with functionally deficient genetic variants of CYP2D6 who are given drugs that inhibit CYP2D6 are exposed to low endoxifen plasma levels and may enjoy reduced benefits from tamoxifen treatment. Therefore, CYP2D6 status may be an important predictor of the benefits of tamoxifen to an individual; unfortunately, the data are not uniformly concordant, and definitive evidence that would suggest the routine analysis of CYP2D6 before commencing tamoxifen treatment is not yet available. Recent research has focused on the role UDP-glucuronosyltransferases, a family of metabolizing enzymes that play an important role in the metabolic clearance of tamoxifen and of the aromatase inhibitors as well, and how interindividual differences in these enzymes may play a role in the clinical outcome upon administration of anti-estrogen treatment. In conclusion, whether a pharmacogenetic profile should be obtained prior to initiating tamoxifen therapy is currently a matter of debate, although summing up all the scientific evidence available on this issue it appears that the genetic screening would be an useful support for clinical decision making in selected patients.
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Affiliation(s)
- Marzia Del Re
- Division of Pharmacology, Department of Internal Medicine, University of Pisa, Italy
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Bessonova L, Taylor TH, Mehta RS, Zell JA, Anton-Culver H. Risk of a second breast cancer associated with hormone-receptor and HER2/neu status of the first breast cancer. Cancer Epidemiol Biomarkers Prev 2011; 20:389-96. [PMID: 21217087 DOI: 10.1158/1055-9965.epi-10-1016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Hormone-receptor (HR) and HER2/neu-receptor (HER2) status of breast tumors are important indicators for targeted therapies. We examine the association of receptor status and risk for a second breast cancer. METHODS We analyzed data on 106,331 women in the California Cancer Registry whose first cancer is locoregional invasive breast disease, diagnosed from 1999 through 2005, yielding 1,613 second primary breast cancers. Standardized incidence ratios (SIR) with 95% confidence intervals (CIs) were used to evaluate risk of second tumors, accounting for age at first diagnosis, duration at risk, and race/ethnicity. RESULTS Among non-Hispanic whites, HR-positive first tumors signal a reduction in risk for second breast cancers (SIR = 0.83, 95% CI: 0.77-0.89) whereas HR-negative status signals elevated risk (SIR = 1.48, 95% CI: 1.29-1.70). Asian/Pacific Islanders, African Americans, and Hispanics are at elevated risk of second breast cancers regardless of HR status of the first tumor. Hispanics with HR-negative first tumors are at greater risk than those with HR-positive disease (HR(-): SIR = 3.76, 95% CI: 2.97-4.71; HR(+): SIR = 1.86, 95% CI: 1.56-2.20). HER2 status does not differentiate risk for second tumors in any group examined. CONCLUSIONS HR status of a first breast cancer is a marker for risk of a second breast cancer. HER2 status does not seem to be a marker of risk for a second breast cancer. Risk differences across race/ethnic groups by HR status suggest heterogeneity of breast cancers across race/ethnicity. IMPACT These data suggest that HR status may be helpful in shaping strategies to reduce risk of a second breast cancer, while HER2 status seems uninformative for this purpose.
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Affiliation(s)
- Leona Bessonova
- Department of Epidemiology, University of California Irvine, Irvine, CA 92697, USA
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20
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Jacobs MA, Stearns V, Wolff AC, Macura K, Argani P, Khouri N, Tsangaris T, Barker PB, Davidson NE, Bhujwalla ZM, Bluemke DA, Ouwerkerk R. Multiparametric magnetic resonance imaging, spectroscopy and multinuclear (²³Na) imaging monitoring of preoperative chemotherapy for locally advanced breast cancer. Acad Radiol 2010; 17:1477-85. [PMID: 20863721 DOI: 10.1016/j.acra.2010.07.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 07/09/2010] [Accepted: 07/10/2010] [Indexed: 12/12/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this prospective study was to investigate using multiparametric and multinuclear magnetic resonance imaging during preoperative systemic therapy for locally advanced breast cancer. MATERIALS AND METHODS Women with operable stage 2 or 3 breast cancer who received preoperative systemic therapy were studied using dynamic contrast-enhanced magnetic resonance imaging, magnetic resonance spectroscopy, and ²³Na magnetic resonance. Quantitative metrics of choline peak signal-to-noise ratio, total tissue sodium concentration, tumor volumes, and Response Evaluation Criteria in Solid Tumors were determined and compared to final pathologic results using receiver-operating characteristic analysis. Hormonal markers were investigated. Statistical significance was set at P < .05. RESULTS Eighteen eligible women were studied. Fifteen responded to therapy, four (22%) with pathologic complete response and 11 (61%) with pathologic partial response. Three patients (17%) had no response. Among estrogen receptor-positive, HER2-positive, and triple-negative phenotypes, observed frequencies of pathologic complete response, pathologic partial response, and no response were 2, 5, and 0; 1, 4, and 0; and 1, 1, and 3, respectively. Responders (pathologic complete response and pathologic partial response) had the largest reductions in choline signal-to-noise ratio (35%, from 7.2 ± 2.3 to 4.6 ± 2; P < .01) compared to nonresponders (11%, from 8.4 ± 2.7 to 7.5 ± 3.6; P = .13) after the first cycle. Total tissue sodium concentration significantly decreased in responders (27%, from 66 ± 18 to 48.4 ± 8 mmol/L; P = .01), while there was little change in nonresponders (51.7 ± 7.6 to 56.5 ± 1.6 mmol/L; P = .50). Lesion volume decreased in responders (40%, from 78 ± 78 to 46 ± 51 mm³; P = .01) and nonresponders (21%, from 100 ± 104 to 79.2 ± 87 mm³; P = .23) after the first cycle. The largest reduction in Response Evaluation Criteria in Solid Tumors occurred after the first treatment in responders (18%, from 24.5 ± 20 to 20.2 ± 18 mm; P = .01), with a slight decrease in tumor diameter noted in nonresponders (17%, from 23 ± 19 to 19.2 ± 19.1 mm; P = .80). CONCLUSIONS Multiparametric and multinuclear imaging parameters were significantly reduced after the first cycle of preoperative systemic therapy in responders, specifically, choline signal-to-noise ratio and sodium. These new surrogate radiologic biomarkers maybe able to predict and provide a platform for potential adaptive therapy in patients.
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Affiliation(s)
- Michael A Jacobs
- The Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Tsoutsou PG, Belkacemi Y, Gligorov J, Kuten A, Boussen H, Bese N, Koukourakis MI. Optimal sequence of implied modalities in the adjuvant setting of breast cancer treatment: an update on issues to consider. Oncologist 2010; 15:1169-78. [PMID: 21041378 DOI: 10.1634/theoncologist.2010-0187] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The adjuvant setting of early breast cancer treatment is an evolving field where different modalities must be combined to improve outcomes; moreover, quality of life of breast cancer survivors emerges as a new important parameter to consider, thus implying a better understanding of toxicities of these modalities. We have conducted a review focusing on the latest literature of the past 3 years, trying to evaluate the existing data on the maximum acceptable delay of radiotherapy when given as sole adjuvant treatment after surgery and the optimal sequence of all these modalities with respect to each other. It becomes evident radiotherapy should be given as soon as possible and within a time frame of 6-20 weeks. Chemotherapy is given before radiotherapy and hormone therapy. However, radiotherapy should be started within 7 months after surgery in these cases. Hormone therapy with tamoxifen might be given safely concomitantly or sequentially with radiotherapy although solid data are still lacking. The concurrent administration of letrozole and radiotherapy seems to be safe, whereas data on trastuzumab can imply only that it is safe to use concurrently with radiotherapy. Randomized comparisons of hormone therapy and trastuzumab administration with radiotherapy need to be performed.
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Affiliation(s)
- Pelagia G Tsoutsou
- Radiation Oncology Department, University Hospital of Alexandroupolis, Dragana 68 100, Alexandroupolis, Greece.
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Abstract
AIMS Endocrine therapy is a pivotal treatment for women with hormone-receptor positive breast cancer. In premenopausal women, endocrine therapy primarily consists of tamoxifen and ovarian suppressive strategies. Younger women experience improvements in the risks of relapse or death from breast cancer with the use of chemotherapy as well, with part of this benefit explained by resultant premature amenorrhea. Unfortunately despite a centuries worth of clinical trials, the most efficacious combination of hormonal therapies and chemotherapy has yet to be determined. This paper serves as a comprehensive review of the substantial data in the adjuvant treatment of premenopausal, hormone receptor-positive women with breast cancer. METHODS AND RESULTS PubMed and American Society of Clinical Oncology (ASCO) Proceedings searches from 1896 to present were performed. All of the trials examining the role of ovarian suppression and tamoxifen with and without chemotherapy in premenopausal women were included. The current data suggests that endocrine therapy can be an important alternative to chemotherapy in select patient populations, and improvements in outcome are also seen with the combination of hormonal and chemotherapy strategies in other populations. A majority of the trials examined did not use what is considered to be current standards of care regarding chemotherapy regimens and durations of adjuvant hormonal therapy. Many unanswered questions remain particularly regarding the combined use of ovarian suppression and tamoxifen in women who are also receiving chemotherapy. CONCLUSION There is a persistent need to define optimal endocrine therapy in premenopasusal women with hormone-receptor positive breast cancer. Contemporaneous trials, such as the SOFT trial will provide direction, and additional biomarker and pharmacogenomic data will further supplement individualized patient decision making.
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Pritchard KI. Tailored targeted therapy for all: a realistic and worthwhile objective against. Breast Cancer Res 2009; 11 Suppl 3:S8. [PMID: 20030883 PMCID: PMC2797688 DOI: 10.1186/bcr2427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kathleen I Pritchard
- Sunnybrook Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5.
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Nath A, Sitruk-Ware R. Pharmacology and clinical applications of selective estrogen receptor modulators. Climacteric 2009; 12:188-205. [PMID: 19387883 DOI: 10.1080/13697130802657896] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Compounds that can be described as selective estrogen receptor modulators (SERMs) have expanded dramatically over the past two decades. The ability of SERMs to act as estrogens in certain tissues while remaining inert or acting as an anti-estrogen in other tissues has opened up opportunities for treating specific estrogen-modulated diseases without accepting the risk of systemic estrogen activity. SERM development has resulted in significant therapeutic advances for breast cancer, osteoporosis and potentially other diseases associated with the menopause. After the publication of the Women's Health Initiative, interest in compound selectivity that reduces menopausal symptoms while protecting bone, breast, uterus and the heart has increased. Future SERMs may also have a therapeutic profile that can be tailored to specific patient populations, including men. This review paper summarizes the characteristics of different SERMs from various pharmacological categories and the feasibility and scope of their use for a large range of disease/health conditions.
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Affiliation(s)
- A Nath
- Population Council, New York, NY 10065, USA
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Staal S, O'Connell MJ, Allegra CJ. The Marriage of Growth Factor Inhibitors and Chemotherapy: Bliss or Bust? J Clin Oncol 2009; 27:1545-8. [DOI: 10.1200/jco.2008.20.3224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Stephen Staal
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | | | - Carmen J. Allegra
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL
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A phase II study of fulvestrant in the treatment of multiply-recurrent epithelial ovarian cancer. Gynecol Oncol 2009; 113:205-9. [PMID: 19239974 DOI: 10.1016/j.ygyno.2009.01.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 01/07/2009] [Accepted: 01/09/2009] [Indexed: 12/14/2022]
Abstract
Objective. The goal of treating recurrent ovarian cancer is disease control while minimizing toxicity. Fulvestrant, a novel estrogen receptor (ER) antagonist, has proven clinically beneficial and well-tolerated in treating recurrent breast cancer. Ovarian cancer often expresses ER and may respond to anti-estrogen therapy. We evaluated fulvestrant in women with recurrent ovarian or primary peritoneal cancer. Methods. Patients with ER-positive, multiply recurrent ovarian or primary peritoneal carcinoma and either measurable disease according to RECIST criteria or an abnormal and rising CA-125 were eligible for enrollment. Treatment consisted of single agent fulvestrant, 500 mg IM on Day 1, 250 mg IM on Day 15, and 250 mg IM on Day 29 and every 28 days thereafter until either intolerance or disease progression. Disease response was assessed by monthly physical exams and CA-125 levels as well as CT scans bimonthly. The primary endpoint was clinical benefit (CB=complete response (CR)+partial response (PR)+stable disease (SD)) at 90 days. Results. Thirty-one women were enrolled and 26 women (median age of 61) met inclusion criteria and received at least one dose. Patients had received a median of 5 prior chemotherapeutic regimens (range: 2-13). We observed one CR (4%), one PR (4%), and 9 patients with SD (35%) using modified-Rustin criteria (CA-125 level). Using modified-RECIST criteria 13 patients (50%) achieved SD. The median time to disease progression was 62 days (mean 86 days). Grade 1 toxicity included headache (1 patient) and bromidrosis (2 patients). Conclusions. Fulvestrant is well-tolerated and efficacious. Objective response rates are low, but disease stabilization was common.
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Zell JA, Honda J, Ziogas A, Anton-Culver H. Survival after colorectal cancer diagnosis is associated with colorectal cancer family history. Cancer Epidemiol Biomarkers Prev 2009; 17:3134-40. [PMID: 18990755 DOI: 10.1158/1055-9965.epi-08-0587] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) family history is a known risk factor for CRC development; however, effects of CRC family history on survival after CRC diagnosis are less well-defined. Our population-based analysis investigates whether familial CRC cases exhibit improved survival compared with sporadic CRC cases. METHODS Cases enrolled in the University of California Irvine Gene-Environment Study of Familial Colorectal Cancer from 1994 to 1996 were analyzed, with follow-up through December 2006. Cases were categorized as familial or sporadic based on self-reported CRC family history in a first-degree relative. Univariate and multivariate survival analyses with Cox proportional hazards ratios were done for overall survival (OS) and CRC-SS (CRC-SS). RESULTS One thousand one hundred fifty-four CRC cases were analyzed, including 781 colon cancer and 373 rectal cancer cases. Nineteen percent of colon cases had family history of CRC in a first-degree relative, compared with 16% of rectal cancer cases. No statistically significant differences between familial and sporadic colon or rectal cancer cases were detected for age, gender, ethnicity, stage, tumor location, histology, tumor grade, or stage-specific treatment rendered. Among colon cancer cases, family history of CRC (versus no family history as a reference group) was associated with improved OS (adjusted hazard ratio, 0.760; 95% confidence interval, 0.580-0.997), but not with CRC-SS (hazard ratio, 0.880; 95% confidence interval, 0.621-1.246). No OS or CRC-SS differences were detected for rectal cancer cases. CONCLUSIONS CRC cases with family history of the disease have improved overall survival compared with sporadic CRC cases, a finding that is independent of other relevant clinical factors.
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Affiliation(s)
- Jason A Zell
- Chao Family Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA 92697, USA.
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Pagani O. Timing of adjuvant therapy. Cancer Treat Res 2009; 151:255-279. [PMID: 19593517 DOI: 10.1007/978-0-387-75115-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- O Pagani
- Institute of Oncology of Southern Switzerland, Ospedale Italiano, Viganello, Lugano, Switzerland.
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Fossland VS, Stroop JB, Schwartz RC, Kurtzman SH. Genetic Issues in Patients with Breast Cancer. Surg Oncol Clin N Am 2009; 18:53-71, viii. [DOI: 10.1016/j.soc.2008.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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31
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Fisher B. Biological Research in the Evolution of Cancer Surgery: A Personal Perspective. Cancer Res 2008; 68:10007-20. [DOI: 10.1158/0008-5472.can-08-0186] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
Breast cancer remains the second leading cause of malignancy-related death in women in the USA, regardless of advances in novel therapeutic agents. High priority should be given to research aimed at the study of pharmacological and natural compounds that could potentially prevent the development of breast cancer in susceptible patients. Tamoxifen has been shown to reduce the incidence of estrogen receptor-positive invasive breast cancer in women with a high risk of developing this condition by nearly 50%, and studies in osteoporosis have revealed a similar protective effect of raloxifene in postmenopausal women. The aromatase inhibitors are superior to tamoxifen in reducing the recurrence of breast cancer in postmenopausal women; large clinical trials are currently evaluating the chemopreventive effect of these agents. The list of agents with the potential for chemoprevention in breast cancer is extensive and continues to expand. There is an immense need to develop drugs that will decrease the incidence of estrogen receptor-negative breast cancer in women at high risk of developing the disease. Herein, we review the most important chemopreventive agents in breast cancer and clinical trials that have evaluated their efficacy.
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Affiliation(s)
- Aurelio B Castrellon
- University of Miami Miller's School Of Medicine, Division of Hematology/Medical Oncology, Sylvester Comprehensive Cancer Center, 1475 NW 12th Avenue Miami, FL 33136, USA.
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Pritchard KI. Combining endocrine agents with chemotherapy: Which patients and what sequence? Cancer 2008; 112:718-722. [DOI: 10.1002/cncr.23189] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Benign and Malignant Diseases of the Breast. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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35
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Linn SC, Jonkers J. Treating the genetic make-up of breast cancer: a new fashion? Expert Rev Anticancer Ther 2007; 7:1065-7. [PMID: 17725409 DOI: 10.1586/14737140.7.8.1065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Maucort-Boulch D, Roy P. Modeling the effect of tamoxifen chemoprevention on long-term mortality in white women at high risk of breast cancer. Eur J Cancer Prev 2007; 15:347-52. [PMID: 16835505 DOI: 10.1097/00008469-200608000-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tamoxifen has long been studied as a drug to treat breast cancer and now for its preventive effect. Intermediate results from studies on the preventive effect of tamoxifen vs. placebo endorsed tamoxifen's efficacy after a short follow-up. Effect of tamoxifen on long-term survival was simulated in women at a high risk of breast cancer. The model allows for tamoxifen effect on breast cancer according to estrogen receptor status, endometrial cancer, and pulmonary embolism. A virtual cohort of 200,000 white women was split into two treatment arms (placebo vs. tamoxifen), two age groups (35-49 and 50-74), and followed-up for 20 years. Incidence rates stemmed from the National Surgical Adjuvant Breast and bowel Project-P1, or the chemoprevention trials overview by Cuzick et al., and relative survival probabilities from surveillance, epidemiology, and end results. Six hypotheses of tamoxifen effects and their variations along time were considered. In the National Surgical Adjuvant Breast and Bowel Project-based results, women aged 35-49 took advantage of tamoxifen whatever the follow-up duration and hypothesis, except the one of only side effects remaining 15 years after treatment withdrawal. In the overview-based results, the advantage existed only when effect on pulmonary embolism stopped. Women aged 50-74 experienced underwent tamoxifen side effects that outweighed advantages whatever the follow-up duration and hypothesis, except the one of only beneficial remaining effect 15 years after treatment withdrawal. Overall, the slight positive effect of tamoxifen on long-term mortality should be cautiously interpreted for young women. In women aged over 50 years, however, tamoxifen chemoprevention could not be recommended.
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Conte P, Frassoldati A. Aromatase Inhibitors in the Adjuvant Treatment of Postmenopausal Women with Early Breast Cancer: Putting Safety Issues into Perspective. Breast J 2007; 13:28-35. [PMID: 17214790 DOI: 10.1111/j.1524-4741.2006.00359.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Tamoxifen has been the gold standard adjuvant therapy for the treatment of postmenopausal women with hormone-receptor-positive (HR+) early breast cancer for many years. Tamoxifen treatment is limited to 5 years because of the development of de novo and acquired resistance, and an ongoing risk of adverse events, including endometrial cancer, thromboembolic events, and gynecological symptoms with long-term use. The third-generation aromatase inhibitors (AIs), letrozole, anastrozole, and exemestane, are displacing tamoxifen as the first-choice therapy for HR+ early breast cancer, and are now recommended as the preferred therapy by national and international guidelines. Recent randomized trials have demonstrated that the AIs are more effective than tamoxifen in preventing disease recurrence when used in substitution and sequential strategies in the early adjuvant setting, and letrozole has been shown to be more effective than placebo in the extended adjuvant setting (after 5 years of tamoxifen therapy). Trial safety data show that the overall tolerability of AIs is similar to that of tamoxifen, with adverse events being predictably characteristic of estrogen deprivation; however, some important differences in adverse event profiles between tamoxifen and the AIs have been demonstrated. In addition to antiestrogenic effects, tamoxifen acts as an estrogen agonist in some tissues, which can lead to serious side effects not associated with the AIs, which prevent estrogen biosynthesis. A lower incidence of gynecological and thromboembolic events is observed in patients taking AIs, and fewer cases of endometrial cancer are seen compared with tamoxifen. Adverse events that are more frequent with adjuvant AI therapy compared with tamoxifen include arthralgia and myalgia, bone loss, and effects on the cardiovascular system and blood lipids. The effects of AIs on bone are predictable and may be easily managed, where necessary, with bisphosphonates. Studies examining the effects of AIs on the cardiovascular system and lipid profiles, including in the extended adjuvant setting, suggest that these adverse events may be due to the absence of a protective effect of tamoxifen rather than true AI toxicity. Further studies are required to determine the long-term safety of AI therapy in postmenopausal women with HR+ early breast cancer.
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Affiliation(s)
- PierFranco Conte
- Department of Oncology and Hematology, The University of Modena and Reggio Emilia, Modena, Italy. conte.
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Morales L, Canney P, Dyczka J, Rutgers E, Coleman R, Cufer T, Welnicka-Jaskiewicz M, Nortier J, Bogaerts J, Therasse P, Paridaens R. Postoperative adjuvant chemotherapy followed by adjuvant tamoxifen versus nil for patients with operable breast cancer: a randomised phase III trial of the European Organisation for Research and Treatment of Cancer Breast Group. Eur J Cancer 2006; 43:331-40. [PMID: 17134892 DOI: 10.1016/j.ejca.2006.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 10/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The contribution of adjuvant tamoxifen in breast cancer patients after receiving adjuvant chemotherapy is not fully established. We investigated the impact of tamoxifen, given sequentially after completion of adjuvant chemotherapy in patients with operable breast cancer. PATIENTS AND METHODS Between March 1991 and June 1999, 1863 women with stages I-IIIA operable breast cancer who had undergone surgery and completed six cycles of adjuvant combination chemotherapy with either CMF, CAF, CEF, FAC or FEC were randomised to receive either tamoxifen 20 mg daily for 3 years or no further treatment. Irrespective of menstrual status and hormone receptor content of the primary tumour, patients were stratified by institute, chemotherapy scheme and age (above 50 years or younger). The main end-point was to detect a 5% increase in the 5 year survival (from 80% to 85%) in favour of antioestrogen therapy. Secondary end-points were relapse free survival (RFS), local control, incidence of second primary breast cancer and correlation of results with hormone receptor content. RESULTS After exclusion of all patients from three sites because of inadequate documentation, a total of 1724 patients (93%) were analysed (Tam 861 and Control 863). At a median follow-up of 6.5 years, 5-year RFS on tamoxifen was 73% versus 67% in controls (p=0.035). No difference was seen in overall survival. The benefit of tamoxifen therapy was mainly seen in the subgroup of patients with histologically documented positive axillary nodes (5-year RFS on tamoxifen 71% versus 64% in the control group, p=0.044) and in patients with tumours expressing the ER and PR positive phenotype (5-year RFS on tamoxifen 77% versus 70% in the control group, p=0.014). CONCLUSIONS Tamoxifen administered for 3 years after completion of adjuvant chemotherapy in this otherwise unselected group of patients for endocrine sensitivity had a limited impact on relapse and had no detectable effect on overall survival. The beneficial effect of tamoxifen is mainly confined to the subgroup of patients with node-positive disease and to patients with tumours expressing the ER and PR positive phenotype.
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Ejlertsen B, Mouridsen HT, Jensen MB, Bengtsson NO, Bergh J, Cold S, Edlund P, Ewertz M, de Graaf PW, Kamby C, Nielsen DL. Similar efficacy for ovarian ablation compared with cyclophosphamide, methotrexate, and fluorouracil: from a randomized comparison of premenopausal patients with node-positive, hormone receptor-positive breast cancer. J Clin Oncol 2006; 24:4956-62. [PMID: 17075113 DOI: 10.1200/jco.2005.05.1235] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the efficacy of ovarian ablation versus chemotherapy in early breast cancer patients with hormone receptor-positive disease. PATIENTS AND METHODS We conducted an open, randomized, multicenter trial including premenopausal breast cancer patients with hormone receptor-positive tumors and either axillary lymph node metastases or tumors with a size of 5 cm or more. Patients were randomly assigned to ovarian ablation by irradiation or to nine courses of chemotherapy with intravenous cyclophosphamide, methotrexate, and fluorouracil (CMF) administered every 3 weeks. RESULTS Between 1990 and May 1998, 762 patients were randomly assigned, and the present analysis is based on 358 first events. After a median follow-up time of 8.5 years, the unadjusted hazard ratio for disease-free survival in the ovarian ablation group compared with the CMF group was 0.99 (95% CI, 0.81 to 1.22). After a median follow-up time of 10.5 years, overall survival (OS) was similar in the two groups, with a hazard ratio of 1.11 (95% CI, 0.88 to 1.42) for the ovarian ablation group compared with the CMF group. CONCLUSION In this study, ablation of ovarian function in premenopausal women with hormone receptor-positive breast cancer had a similar effect to CMF on disease-free and OS. No significant interactions were demonstrated between treatment modality and hormone receptor content, age, or any of the well-known prognostic factors.
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Affiliation(s)
- Bent Ejlertsen
- Department of Oncology, Bldg 5012 Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark.
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40
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Dehdashti AR, Hegi ME, Regli L, Pica A, Stupp R. New trends in the medical management of glioblastoma multiforme: the role of temozolomide chemotherapy. Neurosurg Focus 2006; 20:E6. [PMID: 16709037 DOI: 10.3171/foc.2006.20.4.3] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Standard care for newly diagnosed glioblastoma multiforme (GBM) previously consisted of resection to the greatest extent feasible, followed by radiotherapy. The role of chemotherapy was controversial and its efficacy was marginal at best. Five years ago temozolomide (TMZ) was approved specifically for the treatment of recurrent malignant glioma. The role of TMZ chemotherapy administered alone or as an adjuvant therapy for newly diagnosed GBM has been evaluated in a large randomized trial whose results suggested a significant prolongation of survival following treatment. Findings of correlative molecular studies have indicated that methylguanine methyltransferase promoter methylation may be used as a predictive factor in selecting patients most likely to benefit from such treatment. In this short review the authors summarize the current role of TMZ chemotherapy in the management of GBM, with an emphasis on approved indications and practical aspects.
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Affiliation(s)
- Amir R Dehdashti
- Department of Neurosurgery, Multidisciplinary Oncology Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Hutchins LF, Green SJ, Ravdin PM, Lew D, Martino S, Abeloff M, Lyss AP, Allred C, Rivkin SE, Osborne CK. Randomized, controlled trial of cyclophosphamide, methotrexate, and fluorouracil versus cyclophosphamide, doxorubicin, and fluorouracil with and without tamoxifen for high-risk, node-negative breast cancer: treatment results of Intergroup Protocol INT-0102. J Clin Oncol 2005; 23:8313-21. [PMID: 16293862 DOI: 10.1200/jco.2005.08.071] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE We evaluated the efficacy of cyclophosphamide, methotrexate, and fluorouracil (CMF) versus cyclophosphamide, doxorubicin, and fluorouracil (CAF) in node-negative breast cancer patients with and without tamoxifen (TAM), overall and by hormone receptor (HR) status. PATIENTS AND METHODS Node-negative patients identified by tumor size (> 2 cm), negative HR, or high S-phase fraction (n = 2,690) were randomly assigned to CMF, CAF, CMF + TAM (CMFT), or CAF + TAM (CAFT). Cox regression evaluated overall survival (OS) and disease-free survival (DFS) for CAF versus CMF and TAM versus no TAM separately. Two-sided CIs and one-sided P values for planned comparisons were calculated. RESULTS Ten-year estimates indicated that CAF was not significantly better than CMF (P = .13) for the primary outcome of DFS (77% v 75%; HR = 1.09; 95% CI, 0.94 to 1.27). CAF had slightly better OS than CMF (85% v 82%, HR = 1.19 for CMF v CAF; 95% CI, 0.99 to 1.43); values were statistically significant in the planned one-sided test (P = .03). Toxicity was greater with CAF and did not increase with TAM. Overall, TAM had no benefit (DFS, P = .16; OS, P = .37), but the TAM effect differed by HR groups. For HR-positive patients, TAM was beneficial (DFS, HR = 1.32 for no TAM v TAM; 95% CI, 1.09 to 1.61; P = .003; OS, HR = 1.26; 95% CI, 0.99 to 1.61; P = .03), but not for HR-negative patients (DFS, HR = 0.81 for no TAM v TAM; 95% CI, 0.64 to 1.03; OS, HR = 0.79; 95% CI, 0.60 to 1.05). CONCLUSION CAF did not improve DFS compared with CMF; there was a slight effect on OS. Given greater toxicity, we cannot conclude CAF to be superior to CMF. TAM is effective in HR-positive disease, but not in HR-negative disease.
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Affiliation(s)
- Laura F Hutchins
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Osipo C, Meeke K, Liu H, Cheng D, Lim S, Weichel A, Jordan VC. Trastuzumab therapy for tamoxifen-stimulated endometrial cancer. Cancer Res 2005; 65:8504-13. [PMID: 16166331 DOI: 10.1158/0008-5472.can-04-4107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A novel in vivo model of tamoxifen-stimulated endometrial cancer was developed and the role of HER-2/neu investigated by using trastuzumab. Tamoxifen-stimulated tumors (ECC-1TAM) were growth stimulated by 17beta-estradiol (E2), tamoxifen, or raloxifene. Trastuzumab inhibited growth of E2-stimulated ECC-1E2 tumors by 50% and tamoxifen-stimulated ECC-1TAM tumors by 100%. ECC-1 tumors expressed functional estrogen receptor alpha (ER alpha) as measured by induction of pS2 and c-myc mRNAs. E2 induced pS2 and c-myc mRNAs up to 40-fold in ECC-1E2 and ECC-1TAM. Tamoxifen induced pS2 and c-myc mRNAs up to 5-fold in ECC-1E2 tumors and up to 10-fold in ECC-TAM tumors. Trastuzumab blocked E2-induced pS2 mRNA (P < 0.01) in ECC-1E2 by 50% and tamoxifen-induced c-myc mRNA (P < 0.1) in ECC-1TAM tumors by 70%. Trastuzumab decreased phosphorylated and total HER-2/neu protein in ECC-1E2 and ECC-1TAM tumors. However, only phospho-ERK-1/2 and not phospho-Akt protein was decreased by trastuzumab in tamoxifen-treated ECC-1TAM tumors. The insulin-like growth factor (IGF-I) signaling pathway also activates extracellular signal-related kinase (ERK)-1/2 and could block the efficacy of trastuzumab in ECC-1E2 tumors. The results showed that IGF-I, IGF-IR mRNAs, and phospho-insulin receptor substrate-1 (IRS-1) protein were decreased in ECC-1TAM compared with ECC-1E2 tumors. The results show that trastuzumab is an effective therapy for both E2-stimulated and tamoxifen-stimulated endometrial cancer. The data suggest estrogenic activities of E2 and tamoxifen at ER alpha-regulated pS2 and c-myc genes are in part mediated by HER-2/neu. However, trastuzumab is a better growth inhibitor of ECC-1TAM tumors where there is diminished IGF-I signaling allowing for complete blockade of the downstream phospho-ERK-1/2 signal.
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MESH Headings
- Animals
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/pharmacology
- Cell Growth Processes/drug effects
- Cell Line, Tumor
- Endometrial Neoplasms/drug therapy
- Endometrial Neoplasms/metabolism
- Endometrial Neoplasms/pathology
- Estradiol/pharmacology
- Estrogen Receptor alpha/biosynthesis
- Female
- Humans
- Membrane Proteins/biosynthesis
- Membrane Proteins/genetics
- Mice
- Mice, Inbred BALB C
- Mice, Nude
- Presenilin-2
- Proto-Oncogene Proteins c-myc/biosynthesis
- Proto-Oncogene Proteins c-myc/genetics
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Receptor, ErbB-2/genetics
- Receptor, ErbB-2/immunology
- Receptor, ErbB-2/physiology
- Stimulation, Chemical
- Tamoxifen/pharmacology
- Trastuzumab
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Clodia Osipo
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Pritchard KI. Aromatase Inhibitors in Adjuvant Therapy of Breast Cancer: Before, Instead of, or Beyond Tamoxifen. J Clin Oncol 2005; 23:4850-2. [PMID: 16009956 DOI: 10.1200/jco.2005.03.904] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Quinn McGlothin TD. Breast surgery as a specialized practice. Am J Surg 2005; 190:264-8. [PMID: 16023443 DOI: 10.1016/j.amjsurg.2005.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 04/15/2005] [Indexed: 10/25/2022]
Abstract
The interest in breast surgery as a specialized practice has expanded over the last decade as technology advances and medicine became more complex and specialized overall. There is evidence that breast cancers treated in high-volume centers and by specialists result in improved survival and that the demand for breast surgical oncologists will increase with the aging population. Breast specialists of the future are more likely to be trained in oncoplastic techniques, thereby providing more comprehensive care.
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Colleoni M, Li S, Gelber RD, Coates AS, Castiglione-Gertsch M, Price KN, Lindtner J, Rudenstam CM, Crivellari D, Collins J, Pagani O, Simoncini E, Thürlimann B, Murray E, Forbes J, Erzen D, Holmberg S, Veronesi A, Goldhirsch A. Timing of CMF chemotherapy in combination with tamoxifen in postmenopausal women with breast cancer: role of endocrine responsiveness of the tumor. Ann Oncol 2005; 16:716-25. [PMID: 15817593 DOI: 10.1093/annonc/mdi163] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Controversy persists about whether chemotherapy benefits all breast cancer patients. PATIENTS AND METHODS In the International Breast Cancer Study Group (IBCSG) trial VII, 1212 postmenopausal patients with node-positive disease were randomized to receive tamoxifen for 5 years or tamoxifen plus three concurrent courses of cyclophosphamide, methotrexate and 5-fluorouracil ('classical' CMF) chemotherapy, either early, delayed or both. In IBCSG trial IX, 1669 postmenopausal patients with node-negative disease were randomized to receive either tamoxifen alone or three courses of adjuvant classical CMF prior to tamoxifen. Results were assessed according to estrogen receptor (ER) content of the primary tumor. RESULTS For patients with node-positive, ER-positive disease, adding CMF either early, delayed or both reduced the risk of relapse by 21% (P=0.06), 26% (P=0.02) and 25% (P=0.02), respectively, compared with tamoxifen alone. There was no difference in disease-free survival when CMF was given prior to tamoxifen in patients with node-negative, ER-positive tumors. CONCLUSIONS CMF given concurrently (early, delayed or both) with tamoxifen was more effective than tamoxifen alone for patients with node-positive, endocrine-responsive breast cancer, supporting late administration of chemotherapy even after commencement of tamoxifen. In contrast, sequential CMF and tamoxifen for patients with node-negative, endocrine-responsive disease was ineffective.
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Affiliation(s)
- M Colleoni
- European Institute of Oncology, Milan, Italy.
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Bradbury BD, Lash TL, Kaye JA, Jick SS. Tamoxifen-treated breast carcinoma patients and the risk of acute myocardial infarction and newly-diagnosed angina. Cancer 2005; 103:1114-21. [PMID: 15712362 DOI: 10.1002/cncr.20900] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND It is known that tamoxifen therapy favorably affects blood cholesterol levels and other cardiovascular disease risk factors; however, to our knowledge, few studies to date have reported a lower risk of heart disease for breast carcinoma patients who are treated with tamoxifen. METHODS A nested, matched, case-control study design was used with data from the General Practice Research Database to examine whether patients with breast carcinoma who had been treated with tamoxifen were at reduced risk of having a first acute myocardial infarction (MI) or of developing angina compared with unexposed women. All women between age 30 years and age 85 years who had been diagnosed with breast carcinoma and treated with tamoxifen, or who had been diagnosed with carcinoma of the bladder or colorectum, or nonmelanoma skin cancer between January 1991 and December 1999 were identified. From this population, all women were identified who had newly diagnosed acute MI or angina that occurred at least 1 year after their cancer diagnosis. Four female control participants were matched to each case based on age (+/- 1 year), date of MI or angina diagnosis (corresponding date for matched controls), and date of cancer diagnosis (+/- 6 months). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were generated using conditional logistic regression, controlling for the matching factors, and adjusting for important risk factors, including body mass index, use of hormone replacement therapy, smoking status, and treated hypertension. RESULTS Current users of tamoxifen had a reduced rate ratio of acute MI or angina (adjusted OR, 0.4; 95% CI, 0.2-0.7) compared with nonusers. The effect persisted with increasing cumulative dose and length of use. CONCLUSIONS The treatment of breast carcinoma with tamoxifen was found to reduce a woman's risk of acute MI or angina during the 5 years of recommended therapy.
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Affiliation(s)
- Brian D Bradbury
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Dellapasqua S, Colleoni M, Gelber RD, Goldhirsch A. Adjuvant Endocrine Therapy for Premenopausal Women With Early Breast Cancer. J Clin Oncol 2005; 23:1736-50. [PMID: 15755982 DOI: 10.1200/jco.2005.11.050] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Silvia Dellapasqua
- Division of Medical Oncology, Department of Medicine, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
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Abstract
BACKGROUND Previous studies have reported an increased risk of cataract for breast cancer patients treated with tamoxifen. We assessed whether breast cancer patients treated with tamoxifen were at increased risk of developing cataracts compared to women not prescribed tamoxifen. METHODS We used a nested, matched case-control study design and data collected in the General Practice Research Database. We identified all women 30-79 years old who were diagnosed with breast cancer and treated with tamoxifen within 6 months, or with bladder cancer, colorectal cancer or non-melanoma skin cancer between January 1991 and December 1999. From this population, we identified all newly diagnosed cases of cataract. We matched four female controls to each case on age (+/- 1 year), index date and study entry date (+/- 6 months). We assessed the risk of cataracts for current, past and ever users of tamoxifen and according to cumulative use of tamoxifen. We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) controlling the matching factors and adjusting for important cataract risk factors. FINDINGS Current tamoxifen users were at no increased risk of cataract (AOR = 1.0, 95% CI: 0.7, 1.4). There was no evidence of an increased risk with increasing cumulative dose. INTERPRETATION We detected no increased risk of cataract among breast cancer patients who were treated with tamoxifen compared to women with other cancers who were not prescribed tamoxifen.
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Affiliation(s)
- Brian D Bradbury
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
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49
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Pico C, Martin M, Jara C, Barnadas A, Pelegri A, Balil A, Camps C, Frau A, Rodriguez-Lescure A, Lopez-Vega JM, De La Haba J, Tres A, Alvarez I, Alba E, Arcusa A, Oltra A, Batista N, Checa T, Perez-Carrion R, Curto J. Epirubicin-cyclophosphamide adjuvant chemotherapy plus tamoxifen administered concurrently versus sequentially: randomized phase III trial in postmenopausal node-positive breast cancer patients. A GEICAM 9401 study. Ann Oncol 2004; 15:79-87. [PMID: 14679124 DOI: 10.1093/annonc/mdh016] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A prospective randomized clinical trial was implemented to assess whether the concomitant or the sequential addition of tamoxifen to chemotherapy provides improved clinical benefit in the adjuvant treatment of breast cancer in postmenopausal patients. PATIENTS AND METHODS Four-hundred and eighty-five patients with node-positive operable disease were randomized to receive tamoxifen (20 mg/day) concomitantly (CON) or sequentially (SEQ) to EC chemotherapy (epirubicin 75 mg/m(2) + cyclophosphamide 600 mg/m(2) on day 1, every 21 days for four cycles). RESULTS In the 474 fully evaluable patients there were 96 events; eight being second neoplasms and 88 being related to the breast cancer. Of these, 48 of 88 occurred in the CON arm and 40 of 88 in the SEQ arm. The Kaplan-Meier estimation of disease-free survival (DFS) at 5 years was 70% in the CON and 75% in the SEQ group (log-rank test, P = 0.43). Adjusted hazard ratio for treatment was 1.11 (95% confidence interval 0.71-1.73; P = 0.64). CONCLUSION This study fails to show an advantage of one treatment arm over the other, but a trend, albeit non-significant, appears to favor the sequential addition of tamoxifen to epirubicin + cyclophosphamide and, as such, warrants further investigation.
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Affiliation(s)
- C Pico
- Servicio de Oncología Médica, Hospital General Universitario de Alicante, Alicante, Spain
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50
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Affiliation(s)
- A Goldhirsch
- Department of Medicine, European Institute of Oncology, Milan, Italy
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