American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for women with hormone receptor-positive breast cancer: status report 2002

In silico ADMET analysis of the A-, B- and D-modified androstane derivatives with potential anticancer effects

The major challenge in the fight against cancer is to design new drugs that will be more selective for cancer cells, with fewer side effects. Synthetic steroids such as cyproterone, fulvestrant, exemestane and abiraterone are approved powerful drugs for the treatment of hormone-dependent diseases such as breast and prostate cancers. Therefore, androstane derivatives in 17-substituted, 17a-homo lactone and 16,17-seco series, with potent anticancer activity, were selected for pharmacokinetic and druglike predictions from the absorption, distribution, metabolism and excretion (ADME) models. In silico determination of physico-chemical and ADMET properties was performed using SwissADME and ProTox-II web tools. The possibility of gastrointestinal absorption and brain penetration was analyzed using the BOILED-Egg model, while the in silico evaluation of the similarities between selected steroid derivatives and FDA-approved drugs was carried out using the SwissSimilarity tool. Of all tested, two compounds that showed good in silico ADMET results, in addition to promising cytotoxicity and molecular docking results, could potentially be evaluated in in vivo tests.

The impact of letrozole on oocyte quality in assisted reproductive technology (ART); a randomized double-blind clinical trial

OBJECTIVE

To examine the effect of letrozole on oocyte quality and pregnancy outcome in assisted reproductive technology (ART).

METHODS

This double blind placebo controlled clinical trial was conducted in Vali-Asr Infertility Center. Infertile women candidate for IVF that underwent antagonist protocol were selected. Eligible women randomly allocated into treatment (letrozole/Let group) and control (placebo) group. Participants received letrozole 5 mg/day or placebo at the time of gonadotropin start until trigger day in the same manner. Number of oocyte retrieved, metaphase II oocyte number, high grade oocyte number (G1), high quality embryo, Chemical and clinical pregnancy rate and OHSS (ovarian hyperstimulation syndrome) rate was recorded. 216 infertile women (104 in letrozole and 112 in the control group) were evaluated.

RESULTS

In the Let group estradiol level was significantly lower (p_value < .001) and testosterone significantly higher than in the control group (p_value = .02). The number of retrieved oocytes, MII oocytes, G1 oocytes, and 2PN was significantly lower in the Let group (p < .05). No significant difference was found in the day of stimulation, total gonadotropin dose, OHSS rate, and clinical pregnancy rate between the two groups (p > 0.05).

CONCLUSIONS

According to the results, letrozole may reduce oocyte quality and cause poor IVF outcomes as well.

The Effect of Anastrozole on the Lipid Profile: Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

We aimed to investigate the impact of anastrozole administration on the traditional components of the lipid profile (ie, total cholesterol [TC], LDL-C, HDL-C, and triglycerides [TGs]) by means of a systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched the PubMed/Medline, Scopus, Embase, and Web of Science databases for relevant randomized controlled trials published in the English language until January 18, 2022. The weighted mean difference (WMD) and 95% CIs were calculated using a random-effects model (DerSimonian and Laird methods).

FINDINGS

Anastrozole administration significantly lowered TC concentrations when the treatment duration was ≤3 months (WMD = -2.73 mg/dL; 95% CI, -5.09 to -0.38 mg/dL; P = 0.02) and when the baseline TC concentration was ≥200 mg/dL (WMD = -3.64 mg/dL; 95% CI, -6.30 to -0.98 mg/dL; P = 0.007). HDL-C levels decreased after anastrozole administration when the treatment duration was >3 months (WMD = -1.67 mg/dL; 95% CI, -3.24 to -0.10 mg/dL; P = 0.03). Anastrozole administration had no impact on TG or LDL-C values.

IMPLICATIONS

Anastrozole administration in humans can decrease TC and HDL-C levels but has no effect on LDL-C or TG concentrations.

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Understanding resistance to immune checkpoint inhibitors in advanced breast cancer

INTRODUCTION

The addition of immune checkpoint inhibitors (ICIs) to frontline chemotherapy has improved survival for patients with advanced triple-negative breast cancer (TNBC) expressing programmed death-ligand 1 (PD-L1). Nonetheless, most patients develop resistance, with outcomes remaining poor for this population. Moreover, unsatisfactory activity has been observed with ICIs in PD-L1-negative TNBC and in other breast cancer (BC) subtypes, warranting a deeper understanding of resistance to ICIs in BC.

AREAS COVERED

We discuss the immune landscape of distinct BC subtypes, review the clinical activity of immunotherapy in BC, and highlight strategies under development to overcome resistance to ICIs.

EXPERT OPINION

Activity and resistance to ICIs in BC are strongly related to the intrinsic immunophenotype of the tumor tissue. Several promising biomarkers reflecting the immunological state of BC are emerging, with only PD-L1 expression currently adopted into clinical practice. However, limitations make of PD-L1 a sub-optimal biomarker for patient selection, which require efforts to integrate this marker with other immunological features. Concomitantly, a wide variety of drug combinations designed to overcome immune-resistance are being evaluated, with some encouraging signals observed in early-phase trials. Combination strategies tailored to patient and tumor immunophenotype may allow to overcome resistance and fully exploit the potential of ICIs.

The emerging role of immune checkpoint inhibitors for the treatment of breast cancer

INTRODUCTION

Breast cancer has traditionally been viewed as immunogenically 'cold,' but two immune checkpoint inhibitors have been approved in combination with chemotherapy for PD-L1 positive advanced triple-negative breast cancer (TNBC), and pembrolizumab was also recently approved for early stage TNBC. As the landscape is rapidly evolving, a comprehensive review of checkpoint inhibitors in breast cancer is needed to aid clinicians in selecting appropriate candidates for therapy, and to highlight ongoing promising studies in this area and topics in need of further investigation.

AREA COVERED

This review summarizes the latest evidence from completed and ongoing trials of immune checkpoint inhibitors. Ongoing studies were identified using a search of ClinicalTrials.gov with the term 'breast cancer' along with specific checkpoint inhibitor agents.

EXPERT OPINION

A number of novel combination strategies are under investigation to enhance response and overcome resistance to immunotherapy, with promising preliminary data from checkpoint inhibitors targeting TIGIT, combinations with small molecule inhibitors such as lenvatinib, and injectable agents directly influencing the immune microenvironment. As immunotherapy enters into the curative setting, biomarkers predictive of immunotherapy benefit are needed, as PD-L1 status has not been a helpful discriminator in completed trials in early-stage breast cancer.

Generic entry of aromatase inhibitors and pharmaceutical access: Initiation of hormonal therapy, timeliness of initiation, and drug choice

BACKGROUND

The trade-offs between innovation and pharmaceutical access are central to the policy debate on drug pricing. High prices may limit access, result in medication underuse, and negatively affect outcomes. Generic drugs make treatments more affordable. Prior research measured access as utilization without a defined population that should receive certain drugs, it is unknown whether generic entry reduces underuse and thus improves access.

OBJECTIVES

To measure changes in access (use, timeliness) with the introduction of three generic aromatase inhibitors (AIs, oral breast cancer drugs) between June 2010 and June 2011.

METHODS

This population-based study included 93,650 older (65+) women diagnosed with hormone receptor-positive breast cancer between 2007 and 2013 in the Surveillance, Epidemiology and End Results-Medicare linked database. We examined changes in access with generic entry for initiation of any adjuvant hormonal therapy drug (AIs or tamoxifen) within one year of diagnosis, time from diagnosis to initiation, and choice of initial therapy.

RESULTS

Among 93,650 newly diagnosed breast cancer cases, 67,372 initiated one of the four drugs. With generic entry, initiation rates increased from 69.5% to 74.3%, but non-initiation remained high (up to 25.7%). After controlling for demographics, clinical factors, and insurance coverage, the probability of initiation increased by 4.6 percentage points (P < 0.001, 95%CI: [4.1,5.2]) after generic entry. With generic entry, estimated time to initiation decreased by 0.3 months (P < 0.001, 95%CI: [0.2,0.3]) from 4.1 months, and the probability of choosing AIs over tamoxifen increased by 5.9 percentage points (P < 0.001, 95%CI: [5.3,6.5]). Patterns did not substantially differ by level of cost-sharing.

CONCLUSIONS

Generic entry of AIs was associated with increased probability of receiving recommended treatments, timeliness of treatment, and the probability of receiving clinically preferred treatments. Price changes with generic entry only partially explained these improvements. High non-initiation rates after generic entry suggest prices are not the sole determinant of access.

Aromatase Inhibitors for Ovarian Stimulation in Patients with Breast Cancer

BACKGROUND

Breast cancer is the most common malignancy diagnosed in women, and its treatment has a high probability of loss of fertility. Oocyte vitrification is the most commonly used technique to preserve fertility before starting oncological treatment. Aromatase inhibitors induce hypoestrogenemia while promoting the release of gonadotropins and constitute an alternative drug for ovarian stimulation in patients with breast cancer.

OBJECTIVE

In this mini-review, we update and describe the current status of aromatase inhibitor use in controlled ovarian stimulation for oocyte vitrification in patients with breast cancer.

RESULTS

Aromatase inhibitors are commonly used in combination with gonadotropins for ovarian stimulation in patients with breast cancer who preserve their fertility through oocyte vitrification. They achieve similar ovarian responses as conventional ovarian stimulation protocols in regards to the number of oocytes, and no additional complications after their use have been reported. Furthermore, aromatase inhibitors seem to be safe not only for offspring, as no more congenital defects occur in newborns from pregnancies achieved after their use, but also for the patients, as no more malignancy recurrence or increased mortality was found in cohort studies.

CONCLUSION

Aromatase inhibitors are elective drugs for ovarian stimulation in patients with breast cancer who decide to preserve their fertility through oocyte vitrification.

Letrozole as co-treatment agent in ovarian stimulation antagonist protocol in poor responders: A double-blind randomized clinical trial

Background

Ovarian stimulation (OS) for poor ovarian response (POR) patients is still a major challenge in assisted reproductive techniques. Aromatase inhibitors as co-treatment in antagonist protocol are suggested to these patients, but there are controversial reports.

Objective

To evaluate the effectiveness Letrozole (LZ) as adjuvant treatment in gonadotropin-releasing hormone (GnRH)-antagonist protocol in POR patients undergoing in vitro fertilization/ intracytoplasmic sperm injection cycles.

Materials and Methods

This double-blind randomized clinical trial was conducted in Arash women's hospital. One hundred sixty infertile women with POR based on Bologna criteria were allocated into two groups randomly: LZ + GnRH-antagonist (LA) and placebo + GnRH-antagonist (PA) groups. In the experimental group, the patients received 5 mg LZ on the first five days of OS with 150 IU of recombinant human follicle-stimulating hormone (rFSH) and 150 IUof human menopausal gonadotropin (HMG). The cycle outcomes were compared between groups.

Results

The total number of retrieved oocytes and the metaphase II oocytes in LA-treated group were significantly higher than those in the control group (p = 0.008, p = 0.002). The dosage of hMG used and the duration of OS and antagonist administration in LZ-treated group were significantly lower than those of the control group. The number of patients with no oocyte, in the control group, was higher than the LZ-treated group, and the clinical pregnancy rate in LA-treated group (25%) was higher than the control group (18%); however, the differences were not significant statistically.

Conclusion

Adding 5 mg of LZ to rFSH/hMG antagonist protocol may improve the in vitro fertilization/intracytoplasmic sperm injectioncycle outcome in POR patients.

Effect of Agaricus bisporus enriched diet on growth, hematology, and immune protection in Clarias gariepinus against Flavobacterium columnare

The purpose of the present study was to find out the effect of dietary enriched button mushroom, Agaricus bisporus at 1%, 5%, and 10% levels on growth performance, hematology, nonspecific immune responses, and disease resistance in catfish, Clarias gariepinus against Flavobacterium columnare for a period of four weeks. The percentage weight gain and specific growth rate (SGR) were higher in the infected fish fed with 5% A. bisporus enriched diet than with 1% and 10% diets. The red blood cell (RBC), white blood cell (WBC), hematocrit (PCV), and haemoglobin (Hb) values are similar (p > .05) among the experimental groups at the end of fourth week. The phagocytic activity, complement activity, and lysozyme activity were significantly enhanced in the infected fish fed with 5% A. bisporus diet during the experimental period; however, it was significantly enhanced with 10% A. bisporus enriched diet only on weeks 2 and 4. On the other hand, the respiratory burst (RB) activity increased significantly in the infected fish fed with 5% and 10% A. bisporus enriched diets. When fed with 5% A. bisporus diet the cumulative mortality was very low (10%), followed by a high survival rate (89%) in the infected fish; nevertheless, the cumulative mortality was 25% and 20% while it was 74% and 79% when fed with 1% and 10% enriched diets. The present study recommends a dietary supplement of A. bisporus at 5% or 10% level to achieve better growth without side effect, and enhance the nonspecific immune system that prevent mortalities from F. columnare infection in C. gariepinus.

Salinomycin overcomes acquired tamoxifen resistance through AIB1 and inhibits cancer cell invasion in endocrine resistant breast cancer

Salinomycin is a monocarboxylic polyether ionophore isolated from Streptomyces albus. It has been widely used as an antibiotic in veterinary medicine in poultry. A recent study demonstrated that salinomycin selectively inhibits human breast cancer stem cells; one possible mechanism of tamoxifen resistance. Our results show that salinomycin is effective in inhibiting MCF-7/LCC2 and MCF-7/LCC9 cell lines which are well-established endocrine resistant cells and has a synergistic effect in combination with tamoxifen using MTT proliferation assay. The inhibitory effect of salinomycin on the reduction of critical ER co-activator; amplified breast 1 (AIB1) mRNA and protein expression is overcoming tamoxifen resistance. Moreover, salinomycin significantly inhibits cell invasion in Matrigel invasion assay. The effect was mediated at least in part by the decrease of matrix metalopeptidase 9 (MMP-9) which is one critical enzyme facilitated in the cell invasion process. In conclusion, salinomycin should be developed as a novel agent used alone or in combination for endocrine-resistant breast cancer.

Mathematical models of breast and ovarian cancers

Women constitute the majority of the aging United States (US) population, and this has substantial implications on cancer population patterns and management practices. Breast cancer is the most common women's malignancy, while ovarian cancer is the most fatal gynecological malignancy in the US. In this review, we focus on these subsets of women's cancers, seen more commonly in postmenopausal and elderly women. In order to systematically investigate the complexity of cancer progression and response to treatment in breast and ovarian malignancies, we assert that integrated mathematical modeling frameworks viewed from a systems biology perspective are needed. Such integrated frameworks could offer innovative contributions to the clinical women's cancers community, as answers to clinical questions cannot always be reached with contemporary clinical and experimental tools. Here, we recapitulate clinically known data regarding the progression and treatment of the breast and ovarian cancers. We compare and contrast the two malignancies whenever possible in order to emphasize areas where substantial contributions could be made by clinically inspired and validated mathematical modeling. We show how current paradigms in the mathematical oncology community focusing on the two malignancies do not make comprehensive use of, nor substantially reflect existing clinical data, and we highlight the modeling areas in most critical need of clinical data integration. We emphasize that the primary goal of any mathematical study of women's cancers should be to address clinically relevant questions. WIREs Syst Biol Med 2016, 8:337-362. doi: 10.1002/wsbm.1343 For further resources related to this article, please visit the WIREs website.

A randomized, single-blind, prospective trial comparing three different gonadotropin doses with or without addition of letrozole during ovulation stimulation in patients with poor ovarian response

OBJECTIVE

The aim of this randomized controlled trial (RCT) was to investigate whether IVF outcomes would differ between patients with POR who received three different gonadotropin doses with or without the addition of letrozole during ovulation stimulation.

STUDY DESIGN

Only those who fulfilled two of the three Bologna criteria were included to the study. 95 patients met the inclusion criteria and agreed to participate in the study. In the first group, 31 patients were treated with 450IU gonadotropins. In the second group, 31 patients were treated with 300IU gonadotropins. The third group comprised 33 patients and was treated with 150IU gonadotropins in combination with letrozole.

RESULTS

The results indicate that differences in doses of hMG and rFSH in patients with POR result in a similar number of retrieved MII and fertilized oocytes, similar fertilization rates, number of transferred embryos, implantation, cancelation, chemical, clinical, and ongoing pregnancy rates.

CONCLUSIONS

Increasing the dose of gonadotropins during ovulation stimulation is an intuitively appealing approach when the patient is a poor responder. However, increasing the dose does not necessarily improve the reproductive outcome. Using a mild stimulation with addition of letrozole was as effective as stimulation with higher doses of gonadotropins alone in this patient population.

Can steroidal ovarian suppression during the luteal phase after oocyte retrieval reduce the risk of severe OHSS?

Background

Ovarian stimulation in IVF cycle results in luteal supraphysiological steroid concentrations especially for high response patients. The aim of this study was to evaluate the efficacy of ovarian steroid hormone suppression in luteal phase after oocyte retrieval for preventing severe ovarian hyperstimulation syndrome (OHSS) in high-risk patients with embryo cryopreservation.

Methods

281 patients with high risk of OHSS were enrolled in this study among 4735 infertile women undergoing their first IVF treatment. The subjects were allocated into treatment and control group. The treatment group (n = 161) received letrozole (n = 43), mifepristone (n = 51), cetrotide (n = 39) and three-drug combinations (n = 28) during the luteal phase after oocyte retrieval, respectively. The control group (n = 120) received no medicine. Fertilization rate, good embryo rate, serum steroid concentration, clinical outcome, and incidence of severe OHSS were compared between the two groups.

Results

On days 2, 5 and 8 after oocyte retrieval, serum estradiol levels in the letrozole and three-drug combination therapy group were significantly lower than in the other three groups at the same time (P < 0.001, respectively). There were no significantly difference of serum luteinizing hormone concentration on days 2, 5 and 8 and progesterone concentration on day 8 after oocyte retreival among the five groups (P > 0.05, respectively). Compared with the control group, the incidence of severe OHSS, the paracentesis rate, the duration of hospitalization and the days of luteal phase in each subgroup of treatment groups was not significantly decreased (P > 0.05, respectively).

Conclusions

Our findings indicate that steroidal ovarian suppression in luteal phase after oocyte retrieval seems to be unable to prevent severe OHSS in high-risk patients with embryo cryopreservation.

Mammography Findings of Male Breast Diseases

Over the past 2 decades, the percentage of men presenting with breast complaints has increased from 0.8% to 2.4%, and men now account for 1% of all breast cancer cases. The most common male breast mass is gynecomastia, followed by lipoma and epidermal inclusion cysts. Because there is a paucity of parenchyma as compared with the female breast, the malignancy rapidly progresses to the next stage, with the appearance of secondary signs like nipple retraction, fixation to deeper tissues, skin ulceration or adenopathy. Diagnostic evaluation is needed only when the palpable mass is unilateral, hard, fixed, peripheral to the nipple, or associated with nipple discharge, skin changes, or lymphadenopathy. Male breast cancer usually occurs in a subareolar location or is positioned eccentric to the nipple; occasionally, it occurs in a peripheral position. Secondary signs like skin thickening, nipple retraction, and axillary lymphadenopathy may be seen. Microcalcifications can occur. Mammography can accurately distinguish between malignant and benign male breast disease. Radiologists are generally less familiar with breast disease in males compared with females. In this article, we discuss the clinical, and mammographic features of a variety of benign and malignant diseases that can occur in the male breast.

Validation of a rapid and sensitive LC-MS/MS method for determination of exemestane and its metabolites, 17β-hydroxyexemestane and 17β-hydroxyexemestane-17-O-β-D-glucuronide: application to human pharmacokinetics study

A novel, rapid and sensitive liquid chromatography-tandem mass spectrometric (LC-MS/MS) method was developed and validated for the evaluation of exemestane pharmacokinetics and its metabolites, 17β-dihydroexemestane (active metabolite) and 17β-dihydroexemestane-17-O-β-D-glucuronide (inactive metabolite) in human plasma. Their respective D3 isotopes were used as internal standards. Chromatographic separation of analytes was achieved using Thermo Fisher BDS Hypersil C18 analytic HPLC column (100 × 2.1 mm, 5 μm). The mobile phase was delivered at a rate of 0.5 mL/min by gradient elution with 0.1 % aqueous formic acid and acetonitrile. The column effluents were detected by API 4000 triple quadrupole mass spectrometer using electrospray ionisation (ESI) and monitored by multiple reaction monitoring (MRM) in positive mode. Mass transitions 297 > 121 m/z, 300 > 121 m/z, 299 > 135 m/z, 302 > 135 m/z, 475 > 281 m/z, and 478 > 284 m/z were monitored for exemestane, exemestane-d3, 17β-dihydroexemestane, 17β-dihydroexemestane-d3, 17β-dihydroexemestane-17-O-β-D-glucuronide, and 17β-dihydroexemestane-17-O-β-D-glucuronide-d3 respectively. The assay demonstrated linear ranges of 0.4 – 40.0 ng/mL, for exemestane; and 0.2 – 15.0 ng/mL, for 17β-dihydroexemestane and 17β-dihydroexemestane-17-O-β-D-glucuronide, with coefficient of determination (r²) of > 0.998. The precision (coefficient of variation) were ≤10.7%, 7.7% and 9.5% and the accuracies ranged from 88.8 to 103.1% for exemestane, 98.5 to 106.1% for 17β-dihydroexemestane and 92.0 to 103.2% for 17β-dihydroexemestane-17-O-β-D-glucuronide. The method was successfully applied to a pharmacokinetics/dynamics study in breast cancer patients receiving exemestane 25mg daily orally. For a representative patient, 20.7% of exemestane in plasma was converted into 17β-dihydroexemestane and 29.0% of 17β-dihydroexemestane was inactivated as 17β-dihydroexemestane-17-O-β-D-glucuronide 24 hours after ingestion of exemestane, suggesting that altered 17-dihydroexemestane glucuronidation may play an important role in determining effect of exemestane against breast cancer cells.

Use of aromatase inhibitors in practice of gynecology

Purpose

The conversion of androgens into estrogens by aromatase is called aromatization and is inhibited by aromatase inhibitors (AIs). The aim of this article is to evaluate the use of aromatase inhibitors in gynecological diseases such as endometriosis, leiomyoma, estrogen- dependent gynecologic neoplasia and infertility.

Methods

This is a review of literature combined with experience and use of aromatase ınhıbıtors ın practıce of gynecology.

Conclusion

AIs are promising agents in treatment of estrogen dependent disease. However lack of experience, side effects and cost are limiting factors for using these agents in infertility treatment. However there is need for larger, well designed randomized trials to generate robust data in order to establish the true potential of aromatase inhibitors.

Comparison of estradiol and progesterone priming/antagonist/letrozole and microdose flare-up protocols for poor responders undergoing intracytoplasmic sperm injection

BACKGROUND

To compare the effect of the GnRH antagonist/letrozole/gonadotropin protocol with the microdose GnRH agonist flare-up protocol in poor ovarian responders for intracytoplasmic sperm injection.

MATERIALS AND METHODS

One hundred twenty-one consecutive patients suspected of having or with a history of poor ovarian response between January 2009 and June 2010, who were undergoing ICSI were enrolled. The microdose flareup (MF) protocol was used in 79 patients and the estradiol + progesterone/letrozole + gonadotropin and GnRH antagonist (EP/ALG) protocol was used in 42 patients.

RESULTS

Age of the patients, duration of infertility, basal FSH, the total gonadotropin consumption, duration of stimulation, E2 level on the day of hCG administration, the number of embryo transferred, the fertilization rate, implantation rate, clinical pregnancy rate and the live birth rate were not statistically different (p > 0.05). Only the number of oocytes retrieved was significantly higher in the EP/LGA group (1.7 ± 0.7 versus 2.6 ± 0.6).

CONCLUSION

The EP/LGA protocol has no significant improvement against the microdose flare-up protocol in poor responder patients.

Acute but not sustained aromatase inhibition displays antidepressant properties

Aromatase inhibitors block the conversion of androgens to oestrogens and are used for the treatment of hormone-responsive breast cancer in menopause and recently also in premenopausal women. We investigate whether decreased oestrogen synthesis following aromatase inhibition leads to a depressive-like behavioural response in cycling female rats. Using the forced swim test (FST) we estimate the response of acute (three injections in 24 h) and sustained (7 d) letrozole and fluoxetine administration. Acute aromatase inhibition decreases immobility duration in the FST, indicating its antidepressant potential. Instead, sustained aromatase inhibition did not show such antidepressant potential. Testosterone elevation associates with the decreased depressive behaviour in the FST following acute letrozole treatment, but interestingly progesterone explains the increased swimming behaviour. Present findings may have potential implications for women treated with aromatase inhibitors, especially before menopause, as well as for the role of gonadal hormones in the expression of depressive symptoms and antidepressant response.

Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: american society of clinical oncology clinical practice guideline focused update

PURPOSE

To update the ASCO clinical practice guideline on adjuvant endocrine therapy on the basis of emerging data on the optimal duration of treatment, particularly adjuvant tamoxifen.

METHODS

ASCO convened the Update Committee and conducted a systematic review of randomized clinical trials from January 2009 to June 2013 and analyzed three historical trials. Guideline recommendations were based on the Update Committee's review of the evidence. Outcomes of interest included survival, disease recurrence, and adverse events.

RESULTS

This guideline update reflects emerging data on duration of tamoxifen treatment. There have been five studies of tamoxifen treatment beyond 5 years of therapy. The two largest studies with longest reported follow-up show a breast cancer survival advantage with 10-year durations of tamoxifen use. In addition to modest gains in survival, extended therapy with tamoxifen for 10 years compared with 5 years was associated with lower risks of breast cancer recurrence and contralateral breast cancer.

RECOMMENDATIONS

Previous ASCO guidelines recommended treatment of women who have hormone receptor-positive breast cancer and are premenopausal with 5 years of tamoxifen, and those who are postmenopausal a minimum of 5 years of adjuvant therapy with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor (in sequence). If women are pre- or perimenopausal and have received 5 years of adjuvant tamoxifen, they should be offered 10 years total duration of tamoxifen. If women are postmenopausal and have received 5 years of adjuvant tamoxifen, they should be offered the choice of continuing tamoxifen or switching to an aromatase inhibitor for 10 years total adjuvant endocrine therapy.

Effectiveness of the antagonist/letrozole protocol for treating poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection: a systematic review and meta-analysis

In view of the conflicting data regarding the efficacy of the gonadotropin-releasing hormone (GnRH) antagonist/letrozole (A/L) protocol for treating poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), this systematic review and meta-analysis aimed to compare the effectiveness of the A/L protocol and the microdose GnRH agonist flare up (MF) protocol for such treatment. MEDLINE, EMBASE, Web of Science, and the China National Knowledge Infrastructure were searched for studies comparing the A/L and MF protocols for treating poor responders undergoing IVF/ICSI. We retrieved reports of three trials with data for 688 cycles in women. The clinical pregnancy rate was significantly decreased with the A/L compared with MF protocol (RR 0.70; 95% CI: 0.57-0.86; p = 0.001), the duration of gonadotrophin stimulation was lower with the A/L than MF protocol (MD -1.25; 95% CI: -2.37 to -0.12; p = 0.03). Moreover, there was no significant difference in cycle cancellation rate, number of oocytes retrieved, and the total dose of gonadotrophin between the two protocols. In conclusions, the clinical pregnancy rate may be lower with the A/L than MF protocol for treating poor responsers undergoing IVF/ICSI, but large-scale randomised controlled trials are needed to assess the A/L protocol.

Ethnobotany, phytochemistry, and bioactivity of the genus Turnera (Passifloraceae) with a focus on damiana--Turnera diffusa

ETHNOPHARMACOLOGICAL RELEVANCE

Half a dozen of the currently accepted 135 Turnera species are used in traditional medicine, most notably Turnera diffusa Willd. ex Schult. which is one of the most highly appreciated plant aphrodisiacs. Other traditional uses of Turnera L. species include the treatment of anaemia, bronchitis, cough, diabetes, fever, fungal disease, gastrointestinal complaints, pain, pulmonary and respiratory diseases, skin disorders, and women׳s health problems. Additionally, Turnera species are used as abortives, expectorants, and laxatives.

PHYTOCHEMISTRY

Flavonoids (22 different compounds), maltol glucoside, phenolics, cyanogenic glycosides (7 different compounds), monoterpenoids, sesquiterpenoids, triterpenoids, the polyterpene ficaprenol-11, fatty acids, and caffeine have been found in the genus Turnera.

BIOACTIVITY

Bioactivities experimentally proven for members of the genus Turnera encompass antianxiety, antiaromatase, antibacterial including antimycobacterial, antidiabetic, antioxidant, adapatogenic, antiobesity, antispasmodic, cytotoxic, gastroprotective, hepatoprotective, and aphrodisiac activities. Most of these activities have so far been investigated only in chemical, cell based, or animal assays. In contrast, the antiobesity activity was also investigated in a study on healthy human subjects and with a herbal preparation containing among other ingredients Turnera diffusa leaves. Moreover, the enhancement of female sexual function was assessed in humans; again the product contained besides Turnera diffusa other potentially bioactive ingredients. However, with only few exceptions, most of the traditional uses and the experimentally verified bioactivities can currently not be related to a particular compound or compound class. A notable exception is the flavonoid apigenin, which was identified animal experiments as the antinociceptive principle of Turnera diffusa.

CONCLUSION

In this review, the current knowledge on ethnobotanical uses of members of the genus Turnera, the secondary metabolites reported from Turnera, and experimentally documented bioactivities from Turnera extracts and pure compounds derived from Turnera extracts are compiled. Moreover, some of the most interesting avenues for future research projects are being discussed briefly. These include in particular the aphrodisiac activity of Turnera diffusa and the antibiotic activity potentiating effect of Turnera ulmifolia L. against aminoglycoside resistant bacteria.

Ovarian stimulation in cancer patients

The patients referred for fertility preservation owing to a malignant disease do not represent the typical population of subfertile patients treated in IVF units. Cancer may affect multiple tissues throughout the body and can result in a variety of complications during controlled ovarian stimulation. Determination of the controlled ovarian stimulation protocol and gonadotropin dose for oocyte/embryo cryopreservation requires an individualized assessment. This review highlights the new protocols that are emerging to reduce time constraints and emphasizes management considerations to decrease complications.

Exemestane: one part of the chemopreventive spectrum for ER-positive breast cancer

Development of drugs to prevent breast cancer has focused largely on anti-estrogenic agents, leading to approval by the US FDA of two such agents for this purpose: tamoxifen and raloxifene. However, the uptake of these drugs by high-risk women and their primary care physicians has been limited, due in large part to a perceived unfavorable risk:benefit balance. The current focus is on aromatase inhibitors, which appear to have more acceptable side effects in addition to being more efficacious in reducing breast cancer risk in high-risk women. The placebo-controlled phase III MAP.3 trial tested the AI exemestane in high-risk women and documented a 65% relative reduction in total and a 73% reduction in ER-positive breast cancers in the intervention compared to the placebo group. Toxicities centered around musculoskeletal side effects, but in the relatively short 35-month median follow-up period, these did not impair quality-of-life. A bone study nested within MAP.3 demonstrated significant decreases in bone mineral density (BMD) and in structural parameters of bone quality. The strengths and weaknesses of preventive exemestane as evaluated in the MAP.3 trial are discussed as are relevant areas for future consideration: influence of obesity, alternative dosing, and biomarker use in phase III prevention trials of aromatase inhibitors.

Effectiveness of aromatase inhibitors and tamoxifen in reducing subsequent breast cancer

Tamoxifen (TAM) has been prescribed for decades and aromatase inhibitors (AIs) have been used since the early 2000s in preventing subsequent breast cancer. However, outside of clinical trials, the effectiveness of AIs is not established. We examined the long-term risk of subsequent breast cancer among survivors treated with TAM and AIs in a large health plan. The study included 22,850 survivors, diagnosed with initial breast cancer (stages 0-IV) from 1996 to 2006, and followed 13 years maximum. We compared the risk of subsequent breast cancer in those who used TAM and/or AIs versus nonusers (the reference group). Hazard ratios (HR) adjusted for patient, tumor, treatment, and health-care characteristics were estimated using Cox models with time-dependent drug use status. Women who used TAM/AIs had a large reduction in risk of subsequent breast cancer compared with nonusers. While confidence intervals (CI) for all hormone treatment groups overlapped, women with high adherence (medication possession ratio ≥80%) who used AIs exclusively and had positive ER or PR receptor status had the greatest risk reduction (HR = 0.34, 95% CI: 0.28-0.41), followed by those who switched from TAM to AIs (HR = 0.39, 95% CI: 0.30-0.49), and those who used TAM exclusively (HR = 0.42, 95% CI: 0.36-0.47). Women with high adherence had the greatest risk reduction in subsequent breast cancer, but the results were not substantially different from women who took the drugs less regularly. Compared with nonusers, the reduction in subsequent breast cancer risk ranged from 58% to 66% across the hormone treatment groups and degree of adherence.

MGMT inhibition restores ERα functional sensitivity to antiestrogen therapy

Antiestrogen therapy resistance remains a huge stumbling block in the treatment of breast cancer. We have found significant elevation of O(6) methylguanine DNA methyl transferase (MGMT) expression in a small sample of consecutive patients who have failed tamoxifen treatment. Here, we show that tamoxifen resistance is accompanied by upregulation of MGMT. Further we show that administration of the MGMT inhibitor, O(6)-benzylguanine (BG), at nontoxic doses, leads to restoration of a favorable estrogen receptor alpha (ERα) phosphorylation phenotype (high p-ERα Ser167/low p-ERα Ser118), which has been reported to correlate with sensitivity to endocrine therapy and improved survival. We also show BG to be a dual inhibitor of MGMT and ERα. In tamoxifen-resistant breast cancer cells, BG alone or in combination with antiestrogen (tamoxifen [TAM]/ICI 182,780 [fulvestrant, Faslodex]) therapy enhances p53 upregulated modulator of apoptosis (PUMA) expression, cytochrome C release and poly (ADP-ribose) polymerase (PARP) cleavage, all indicative of apoptosis. In addition, BG increases the expression of p21(cip1/waf1). We also show that BG, alone or in combination therapy, curtails the growth of tamoxifen-resistant breast cancer in vitro and in vivo. In tamoxifen-resistant MCF7 breast cancer xenografts, BG alone or in combination treatment causes significant delay in tumor growth. Immunohistochemistry confirms that BG increases p21(cip1/waf1) and p-ERα Ser167 expression and inhibits MGMT, ERα, p-ERα Ser118 and ki-67 expression. Collectively, our results suggest that MGMT inhibition leads to growth inhibition of tamoxifen-resistant breast cancer in vitro and in vivo and resensitizes tamoxifen-resistant breast cancer cells to antiestrogen therapy. These findings suggest that MGMT inhibition may provide a novel therapeutic strategy for overcoming antiestrogen resistance.

Use of the aromatase inhibitor letrozole for ovulation induction in women with polycystic ovarian syndrome

Clomiphene citrate (CC) is the most commonly used oral agent for the induction of ovulation. It is a nonsteroidal selective estrogen receptor modulator that has predominant antiestrogenic action resulting in long-lasting estrogen receptor depletion. Side effects include antiestrogenic effects systemically and on the endometrium and cervical mucous. Letrozole is a potent, nonsteroidal, aromatase inhibitor, originally used for postmenopausal breast cancer therapy, at present its only registered indication. We hypothesized that letrozole could mimic the action of CC without depletion of estrogen receptors. As there is no estrogen receptor antagonism, antiestrogenic effects such as poor cervical mucus and thin endometrium are not expected with aromatase inhibitor treatment. In addition, because estrogen receptors in the brain are not depleted, normal negative feedback occurs with letrozole and generally results in monoovulation. We and others have demonstrated the success of aromatase inhibition in inducing ovulation in women with polycystic ovarian syndrome. Letrozole may be very effective for ovulation induction and pregnancy in cases of CC resistance. When used together with follicle-stimulating hormone (FSH) injections, letrozole resulted in a significant reduction in the FSH dose needed for controlled ovarian hyperstimulation. Aromatase inhibitors likely increase ovarian sensitivity to FSH, and may be useful in poor responders and in women undergoing ovarian stimulation for in vitro fertilization. The safety of letrozole in pregnancy outcome studies has been demonstrated by examination of spontaneous pregnancy loss, multiple pregnancy rates, and congenital anomalies compared with a control group of infertility patients treated with CC. In addition, new data suggest that CC may result in cardiac anomalies and other birth defects and in low birth weight babies. We believe aromatase inhibitors are acceptable alternatives to CC as first line oral agents for ovulation induction or controlled ovarian stimulation.

Toremifene is an effective and safe alternative to tamoxifen in adjuvant endocrine therapy for breast cancer: results of four randomized trials

Compared to tamoxifen, the efficacy and side effects of toremifene in adjuvant endocrine therapy for breast cancer were not very clear. This meta-analysis was conducted to give a more precise estimation of the efficacy and severe side effects of toremifene given in the adjuvant setting in comparison to tamoxifen. The electronic database PubMed was searched for randomized trials comparing toremifene with tamoxifen as adjuvant therapies. Four randomized trials published in three articles were eligible, including 1,890 pooled cases treated with toremifene and 1,857 cases treated with tamoxifen. Compared to patients in tamoxifen group, patients in toremifene group did not have a significantly different overall survival rate (risk ratio (RR): 1.07, 95% confidence interval (CI): 0.97-1.19, P = 0.994 for heterogeneity) or a disease-free survival (DFS) rate (RR: 1.05, 95% CI: 0.95-1.17, P = 0.431 for heterogeneity) at the end of the follow-up time. The rates of thromboembolic events in toremifene group, including deep vein thrombosis (odds ratio (OR): 0.68, 95% CI: 0.40-1.17, P = 0.926 for heterogeneity), cerebrovascular accident (OR: 0.59, 95% CI: 0.32-1.09, P = 0.438 for heterogeneity), and pulmonary embolism (OR: 0.91, 95% CI: 0.42-2.01, P = 0.618 for heterogeneity), were not significantly different from those in tamoxifen group. The rates of endometrial polyps and endometrial cancer between the two groups were almost the same. This meta-analysis suggested that toremifene was as effective as tamoxifen in the adjuvant setting for both perimenopausal and postmenopausal breast cancer patients with similar severe adverse effects to tamoxifen. Toremifene was a convincing and safe change for tamoxifen in adjuvant endocrine therapy.

Comparing guidelines for adjuvant endocrine therapy in postmenopausal women with breast cancer: a coming of age

Following surgery for early breast cancer, the standard of care for postmenopausal women is adjuvant therapy with any combination of radiation therapy, endocrine therapy, chemotherapy and/or targeted therapy. Clinicians rely on many tools, including guidelines, to make these treatment decisions. Such guidelines include the St Gallen consensus statement, the American Society of Clinical Oncology guidelines and the National Comprehensive Cancer Network guidelines, as well as various regional and national guidelines. Recommendations may vary, because different methods and criteria were used to assess the strength of supporting data. This article provides an overview of global guidelines for the adjuvant treatment of breast cancer and points out the major differences. Ongoing changes are highlighted, particularly those regarding the adjuvant endocrine treatment of postmenopausal women with breast cancer. While previous guidelines recommended tamoxifen alone, all major guidelines now recommend using third-generation aromatase inhibitors either in sequence with tamoxifen or as upfront treatment.

Cancer therapy associated bone loss: implications for hip fractures in mid-life women with breast cancer

PURPOSE

Aromatase inhibitors (AIs) have been recently associated with hip fractures. We present a case series of breast cancer survivors and a systematic review of bone health care in breast cancer.

EXPERIMENTAL DESIGN

We completed clinical assessments and bone density testing (BMD) of hip fractures from January 2005 to December 2008. Prefracture and 12-month functional status was obtained. Systematic review included case reports and review of MEDLINE, PubMed, EMBASE, and Food and Drug Administration Adverse Event Reporting System (FDA AERS) from January 1998 to December 2008 (search terms: breast cancer, bone loss, osteopenia, osteoporosis, malignancy, cancer treatment, menopause, adriamycin, cytoxan, tamoxifen, and AIs).

RESULTS

Median age was 53.5 years; five women had osteopenia, one osteoporosis. Five cases were ER (+), and received surgery, XRT chemotherapy, and anastrozole. Functional decline was noted at 12 months, with difficulty in performing heavy housekeeping, climbing stairs, and shopping. The FDA AERS database included 228 cases of fractures associated with breast cancer therapy; 77/228 (29.4%) were hip or femur fractures. Among mid-life women under the age of 64 years there were 78 fractures; 15/228 (19%) were hip and femur fractures. AIs were the most common drug class associated with fractures (n = 149, 65%).

CONCLUSIONS

Cancer treatment induced bone loss results in hip fractures among mid-life women with breast cancer. Hip fractures occur at younger ages and higher BMD than expected for patients in this age group without breast cancer. Hip fractures result in considerable functional decline. Greater awareness of this adverse drug effect is needed.

Upregulation of ventricular potassium channels by chronic tamoxifen treatment

AIMS

Tamoxifen is a selective oestrogen receptor modulator widely used in the prevention and treatment of breast cancer. Women receiving long-term tamoxifen therapy do not experience cardiac arrhythmias although acute perfusion of tamoxifen has been shown to inhibit cardiac K(+) currents. This observation suggests that chronic tamoxifen treatment does not negatively modulate cardiac K(+) currents. Therefore, we investigated the chronic effects of tamoxifen on K(+) currents and channels in mouse and guinea pig ventricles.

METHODS AND RESULTS

Female mice and guinea pigs were treated with placebo or tamoxifen pellets for 60 days. Voltage-clamp experiments showed that the density of the Ca²(+)-independent transient outward (I(to)), the ultrarapid delayed rectifier (I(Kur)), the steady-state (I(ss)), and the inward rectifier (I(K1)) K(+) currents were increased in tamoxifen-treated mice ventricle. Western blot analysis revealed that protein expression of the underlying K(+) channels Kv4.3 (I(to)), Kv1.5 (I(Kur)), Kv2.1 (I(ss)), and Kir2.1 (I(K1)) were significantly higher in the ventricle of tamoxifen-treated mice. Protein expression of the K(+) channel subunits encoding I(Kr) and I(Ks) (ERG1, KCNQ1, and KCNE1) was also increased in tamoxifen-treated guinea pig ventricle.

CONCLUSION

Conditions with high oestrogen levels are associated with reduced K(+) currents. Thus, conceivably, tamoxifen might prevent the inhibitory effects of oestrogen on K(+) channels by blocking the oestrogen receptors, which would explain the reported increase in K(+) currents. These findings could contribute to explain the absence of cardiac arrhythmia with long-term tamoxifen therapy.

Biological reprogramming in acquired resistance to endocrine therapy of breast cancer

Endocrine therapies targeting the proliferative effect of 17β-estradiol through estrogen receptor α (ERα) are the most effective systemic treatment of ERα-positive breast cancer. However, most breast tumors initially responsive to these therapies develop resistance through molecular mechanisms that are not yet fully understood. The long-term estrogen-deprived (LTED) MCF7 cell model has been proposed to recapitulate acquired resistance to aromatase inhibitors in postmenopausal women. To elucidate this resistance, genomic, transcriptomic and molecular data were integrated into the time course of MCF7-LTED adaptation. Dynamic and widespread genomic changes were observed, including amplification of the ESR1 locus consequently linked to an increase in ERα. Dynamic transcriptomic profiles were also observed that correlated significantly with genomic changes and were predicted to be influenced by transcription factors known to be involved in acquired resistance or cell proliferation (for example, interferon regulatory transcription factor 1 and E2F1, respectively) but, notably, not by canonical ERα transcriptional function. Consistently, at the molecular level, activation of growth factor signaling pathways by EGFR/ERBB/AKT and a switch from phospho-Ser118 (pS118)- to pS167-ERα were observed during MCF7-LTED adaptation. Evaluation of relevant clinical settings identified significant associations between MCF7-LTED and breast tumor transcriptome profiles that characterize ERα-negative status, early response to letrozole and tamoxifen, and recurrence after tamoxifen treatment. In accordance with these profiles, MCF7-LTED cells showed increased sensitivity to inhibition of FGFR-mediated signaling with PD173074. This study provides mechanistic insight into acquired resistance to endocrine therapies of breast cancer and highlights a potential therapeutic strategy.

American Society of Clinical Oncology clinical practice guideline: update on adjuvant endocrine therapy for women with hormone receptor-positive breast cancer

PURPOSE

To develop evidence-based guidelines, based on a systematic review, for endocrine therapy for postmenopausal women with hormone receptor-positive breast cancer.

METHODS

A literature search identified relevant randomized trials. Databases searched included MEDLINE, PREMEDLINE, the Cochrane Collaboration Library, and those for the Annual Meetings of the American Society of Clinical Oncology (ASCO) and the San Antonio Breast Cancer Symposium (SABCS). The primary outcomes of interest were disease-free survival, overall survival, and time to contralateral breast cancer. Secondary outcomes included adverse events and quality of life. An expert panel reviewed the literature, especially 12 major trials, and developed updated recommendations.

RESULTS

An adjuvant treatment strategy incorporating an aromatase inhibitor (AI) as primary (initial endocrine therapy), sequential (using both tamoxifen and an AI in either order), or extended (AI after 5 years of tamoxifen) therapy reduces the risk of breast cancer recurrence compared with 5 years of tamoxifen alone. Data suggest that including an AI as primary monotherapy or as sequential treatment after 2 to 3 years of tamoxifen yields similar outcomes. Tamoxifen and AIs differ in their adverse effect profiles, and these differences may inform treatment preferences.

CONCLUSION

The Update Committee recommends that postmenopausal women with hormone receptor-positive breast cancer consider incorporating AI therapy at some point during adjuvant treatment, either as up-front therapy or as sequential treatment after tamoxifen. The optimal timing and duration of endocrine treatment remain unresolved. The Update Committee supports careful consideration of adverse effect profiles and patient preferences in deciding whether and when to incorporate AI therapy.

Breast cancer in men in the United States: a population-based study of diagnosis, treatment, and survival

BACKGROUND

Breast cancer in men is rare, so clinical trials are not practical. Recommendations suggest treating men who are diagnosed with breast cancer using the guidelines for postmenopausal women; however, to date, no population-based studies have evaluated patterns of care.

METHODS

To examine characteristics, treatment, and survival among men with newly diagnosed breast cancer, in 2003 and 2004, 512 men were identified from the Surveillance, Epidemiology and End Results Program. Data were reabstracted and therapy was verified through the patients' treating physicians.

RESULTS

The majority of men (79%) were diagnosed through discovery of a breast lump or other signs/symptoms. Among men who had invasive disease, 86% underwent mastectomy, 37% received chemotherapy, and 58% received hormone therapy. In multivariate analysis, tumor size (P=.01) and positive lymph node status (P<.0001) were associated positively with the use of chemotherapy, whereas age group (P<.0001) and current unmarried status (P=.01) had negative associations. Among men who had invasive, estrogen receptor (ER)-positive/borderline tumors, the use of tamoxifen or aromatase inhibitors (AIs) was associated with age group (P=.05). Among men who had invasive disease, cancer mortality was associated with tumor size (P<.0001). Among men with ER-positive/borderline disease, increased cancer mortality was associated with tumor size (P<.0001), current unmarried status (P=.04), and decreased mortality with tamoxifen (P=.04).

CONCLUSIONS

Tumor characteristics and marital status were the primary predictors of therapy and cancer mortality among men with breast cancer. Although AIs are not currently recommended, they are commonly prescribed. However, their use did not result in a decrease in cancer mortality. Research must examine the efficacy of AIs with and without gonadotropin-releasing hormone analogues.

4-Hydroxytamoxifen inhibits K(+) currents in mouse ventricular myocytes

Tamoxifen is a widely used chemotherapeutic agent, which has been associated with prolongation of the QT interval. Other studies have reported that acute exposure to tamoxifen can reduce cardiac K(+) currents. However, in vivo tamoxifen is largely metabolized and most of its activity is attributable to its major metabolite, 4-hydroxytamoxifen (4OH-tamoxifen). Accordingly, in the present study, we performed voltage-clamp experiments to directly investigate the effects of 4OH-tamoxifen on the repolarizing K(+) currents in adult mouse ventricular myocytes in order to determine whether the effects of tamoxifen on repolarization could be ascribed to 4OH-tamoxifen. K(+) currents were recorded before and after acute exposure to 4OH-tamoxifen (0.5, 1 and 10microM). 4OH-tamoxifen reduced the density of the Ca(2+)-independent transient outward (I(to)), the ultrarapid delayed rectifier (I(Kur)) and the inward rectifier (I(K1)) K(+) currents (by up to 43%, 41% and 26%, respectively) but had no significant effect on the steady-state outward K(+) current (I(ss)). Voltage dependence of steady-state inactivation and reactivation time of I(to) and I(Kur) were not affected by 4OH-tamoxifen. Experiments using the pure estrogen receptor antagonist, ICI 182,780 and the inhibitor of gene transcription, actinomycin D, were undertaken to assess the involvement of estrogen receptor. Administered alone these compounds did not affect the density of K(+) currents. Moreover, pretreatment of the cells with ICI 182,780 or actinomycin D did not prevent the inhibitory response to 4OH-tamoxifen. Overall, 4OH-tamoxifen reduced K(+) currents in mouse ventricle and this effect is unrelated to gene transcription and does not involve interaction of the drug with estrogen receptor.

Prevention Strategies with Aromatase Inhibitors

Aromatase (estrogen synthetase) inhibitors are superior to tamoxifen in terms of both efficacy and toxicity in the treatment of advanced breast cancer and also in the neoadjuvant setting. Recent results from the Arimidex, Tamoxifen, Alone or in Combination adjuvant trial showed a marked reduction in contralateral primary breast cancer with anastrozole, an apparent prevention effect. A similar effect was seen in the MA.17 adjuvant trial comparing letrozole with placebo after 5 years of adjuvant tamoxifen. This has accelerated interest in aromatase inhibitors as primary preventive therapy. Two studies being conducted by the National Cancer Institute of Canada's Clinical Trials Group select women by virtue of mammographic breast density. The International Breast Cancer Intervention Study 2 trial randomizes women at elevated risk to anastrozole or placebo. Because of its steroidal structure, exemestane may be more effective than the nonsteroidal aromatase inhibitors and may protect bone and lipid metabolism from the effects of estrogen ablation. Elevated prostaglandin E2 levels from cyclooxygenase-2 induction by preinvasive and invasive breast lesions increase a number of tumor-promoting pathways, including aromatase, as well as angiogenetic, antiapoptotic, and others. Additive or synergistic effects between celecoxib, a cyclooxygenase-2 inhibitor, and exemestane have been demonstrated and have led to the National Cancer Institute of Canada's Clinical Trials Group MAP.3 trial, which will randomize women at elevated risk to placebo or to exemestane with or without celecoxib. The efficacy and long-term toxicity data from the aromatase inhibitor prevention trials, and the identification of risk profiles from trial results, are awaited with interest.

Data from the Arimidex, Tamoxifen, Alone or in Combination (ATAC) Trial

The third-generation aromatase inhibitors (AIs) have improved efficacy and safety versus tamoxifen for treatment of advanced breast cancer. Currently, anastrozole is the only third-generation AI with adjuvant therapy data in postmenopausal women. Initial and updated results from the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial (median follow-up, 47 months) confirm it to be more effective than tamoxifen for disease-free survival with several important tolerability benefits. As a result, there has been much debate about whether or not anastrozole should be used routinely to treat postmenopausal women with early breast cancer. In its review, the American Society of Clinical Oncology Health Services Research Committee agreed that the updated ATAC analyses provided a greater level of assurance, in terms of both toxicity and efficacy, for use of anastrozole in the adjuvant setting. However, pending 5-year data from ATAC and other trials of adjuvant AI use, adjuvant anastrozole was recommended by American Society of Clinical Oncology Health Research Committee for use only under certain circumstances, with 5 years of tamoxifen remaining the standard. Anastrozole should be the preferred AI in this setting; data from the ATAC trial should not be extrapolated to other members of the class. Despite this conservative recommendation, the overall risk:benefit profile from the ATAC trial favors anastrozole, and it is expected that a more favorable efficacy and adverse effect profile will be maintained. Anastrozole should, therefore, now be considered a valid alternative option to tamoxifen for adjuvant hormonal treatment in all postmenopausal women with hormone receptor-positive early breast cancer.

Sequencing of Endocrine Therapy in Postmenopausal Women with Advanced Breast Cancer

The introduction of the nonsteroidal aromatase inhibitor (NS-AI) anastrozole as an alternative to tamoxifen for adjuvant therapy of women with resected hormone receptor-positive breast cancer has added a management category into which patients presenting with metastatic disease can be placed. There are now essentially three such categories: (a) tamoxifen sensitive (no prior AI); (b) tamoxifen resistant (no prior AI); and (c) NS-AI resistant (no prior tamoxifen). Well-conducted Phase III trials provide evidence for choosing first-line therapy for advanced disease in categories a and b. In tamoxifen-sensitive patients, one can choose either NS-AI, anastrozole, or letrozole. In tamoxifen-resistant patients, one can choose either of the NS-AIs, the steroidal AI exemestane, or the estrogen receptor down-regulator fulvestrant. The situation is quite different for patients in category c. There are no Phase III trials of agents in patients who have experienced disease progression on a NS-AI. Phase II data are available for exemestane and high-dose estrogens, and retrospective data are available for tamoxifen and fulvestrant. Additional clinical trials are needed to determine an optimal sequencing strategy.

Aromatase inhibitor for treatment of a recurrent abdominal wall endometrioma in a postmenopausal woman

OBJECTIVE

Treat an abdominal wall endometrioma in a post-menopausal patient.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT(S)

A post-menopausal women with a large recurrent abdominal wall endometrioma.

INTERVENTION(S)

The patient was managed with the combination of an aromatase inhibitor, a progestin, and serial cyst aspiration.

MAIN OUTCOME MEASURE(S)

Serum and cyst estradiol levels as well as sonographic demonstration of resolution.

RESULT(S)

Serum and cyst estradiol levels were significantly diminished and the cyst diminished in size.

CONCLUSION(S)

Taken together, this case demonstrates a novel approach for managing and monitoring medical therapy for unusual clinical presentations of endometriosis. Furthermore, it illustrates that endometriotic implants can be a source of circulating estrogen in postmenopausal women, and that this source of estrogen is generated by increased aromatase activity.

Endocrine therapy for the treatment of postmenopausal women with breast cancer

The treatment of women with estrogen receptor-positive breast cancer has advanced significantly in the past decade. Tamoxifen was the gold standard hormonal therapy for breast cancer until the introduction of aromatase inhibitors and fulvestrant. Many of these new treatments are useful only for patients who are postmenopausal. There are data to support the use of these new agents both in the metastatic and adjuvant settings. Here, we briefly review the recent clinical trials supporting the use of these agents in both the adjuvant and metastatic settings. We will discuss possible mechanisms of resistance to endocrine agents that could be exploited therapeutically to improve the outcome for patients with hormone receptor-positive breast cancers.

Mild ovarian stimulation for IVF

BACKGROUND

Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment.

METHODS

Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible.

RESULTS

Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed.

CONCLUSIONS

Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.

Male breast cancer: thirteen years experience of a single center

Background

This retrospective study analysed the epidemiological, clinical, and therapeutic profiles of breast cancer in males.

Methods

We report our experience at the Hospital of the University of Baskent, where 20 cases of male breast cancer were observed and treated between 1995–2008.

Results

Median age at presentation was 66,7 ± 10,9 years. Average follow-up was 63 ± 18,5 months. The main presenting symptom was a mass in 65% of cases (13 patients). Ýnvasive ductal carcinoma was the most frequent pathologic type (70% of cases).

Conclusion

Male breast cancer patients have an incidence of prostate cancer higher than would be predicted in the general population. Cause of men have a higher rate of ER positivity the responses with hormonal agents are good.

Histone deacetylase inhibitor induced modulation of anti-estrogen therapy

Histone deacetylase (HDAC) inhibitors are a novel class of anti-tumor agents with a potential role in the treatment of breast cancer. In ER-positive cells, treatment with selective and non-selective HDAC inhibitors has been associated with a transcriptional down-regulation (and possibly protein modification via the HSP90 chaperone function) of ER and its response genes. In ER-negative cell lines, HDAC inhibitors have been shown to re-establish ER expression. In addition, HDAC inhibitors have been reported to modulate the progesterone receptor. Despite the opposing effects in ER-positive and ER-negative breast cancer cells, the addition of an HDAC inhibitor potentiated and restored the efficacy of anti-estrogen therapy in preclinical models. This has led to the initiation of several clinical trials combining HDAC inhibitors with anti-estrogen therapy. In this review, we will summarize the relationship between estrogen signaling and HDACs, examine how HDAC inhibitors impact this relationship and synergize with anti-estrogens to inhibit tumor growth, and discuss the clinical possibilities and potential of this new approach.