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He W, Demas DM, Shajahan-Haq AN, Baumann WT. Modeling breast cancer proliferation, drug synergies, and alternating therapies. iScience 2023; 26:106714. [PMID: 37234088 PMCID: PMC10206440 DOI: 10.1016/j.isci.2023.106714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/12/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Estrogen receptor positive (ER+) breast cancer is responsive to a number of targeted therapies used clinically. Unfortunately, the continuous application of targeted therapy often results in resistance, driving the consideration of combination and alternating therapies. Toward this end, we developed a mathematical model that can simulate various mono, combination, and alternating therapies for ER + breast cancer cells at different doses over long time scales. The model is used to look for optimal drug combinations and predicts a significant synergism between Cdk4/6 inhibitors in combination with the anti-estrogen fulvestrant, which may help explain the clinical success of adding Cdk4/6 inhibitors to anti-estrogen therapy. Furthermore, the model is used to optimize an alternating treatment protocol so it works as well as monotherapy while using less total drug dose.
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Affiliation(s)
- Wei He
- Program in Genetics, Bioinformatics, and Computational Biology, VT BIOTRANS, Virginia Tech, Blacksburg, VA 24061, USA
| | - Diane M. Demas
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA
| | - Ayesha N. Shajahan-Haq
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20057, USA
| | - William T. Baumann
- Department of Electrical and Computer Engineering, Virginia Tech, Blacksburg, VA 24061, USA
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2
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Agarwal S, Sau S, Iyer AK, Dixit A, Kashaw SK. Multiple strategies for the treatment of invasive breast carcinoma: A comprehensive prospective. Drug Discov Today 2021; 27:585-611. [PMID: 34715356 DOI: 10.1016/j.drudis.2021.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 08/10/2021] [Accepted: 10/19/2021] [Indexed: 01/22/2023]
Abstract
In this review, we emphasize on evolving therapeutic strategies and advances in the treatment of breast cancer (BC). This includes small-molecule inhibitors under preclinical and clinical investigation, phytoconstituents with antiproliferative potential, targeted therapies as antibodies and antibody-drug conjugates (ADCs), vaccines as immunotherapeutic agents and peptides as a novel approach inhibiting the interaction of oncogenic proteins. We provide an update of molecules under different phases of clinical investigation which aid in the identification of loopholes or shortcomings that can be overcomed with future breast cancer research.
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Affiliation(s)
- Shivangi Agarwal
- Department of Pharmaceutical Sciences, Dr Harisingh Gour University, Sagar, MP, India
| | - Samaresh Sau
- Use-inspired Biomaterials & Integrated Nano Delivery (U-BiND) Systems Laboratory, Department of Pharmaceutical Sciences, Wayne State University, Detroit, MI, USA
| | - Arun K Iyer
- Use-inspired Biomaterials & Integrated Nano Delivery (U-BiND) Systems Laboratory, Department of Pharmaceutical Sciences, Wayne State University, Detroit, MI, USA; Molecular Imaging Program, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Sushil K Kashaw
- Department of Pharmaceutical Sciences, Dr Harisingh Gour University, Sagar, MP, India.
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Ratre P, Mishra K, Dubey A, Vyas A, Jain A, Thareja S. Aromatase Inhibitors for the Treatment of Breast Cancer: A Journey from the Scratch. Anticancer Agents Med Chem 2020; 20:1994-2004. [DOI: 10.2174/1871520620666200627204105] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 03/15/2020] [Indexed: 01/08/2023]
Abstract
Background:
Estrogens are essential for the growth of breast cancer in the case of premenopausal as
well as in postmenopausal women. However, most of the breast cancer incidences are reported in postmenopausal
women and the concurrent risk surges with an increase in age. Since the enzyme aromatase catalyses
essential steps in estrogen biosynthesis, Aromatase Inhibitors (AIs) are effective targeted therapy in patients
with Estrogen Receptor positive (ER+) breast cancer. AIs are more effective than Selective Estrogen Receptor
Modulators (SERMs) because they block both the genomic and nongenomic activities of ER. Till date, first,
second and third-generation AIs have been approved by the FDA. The third-generation AIs, viz. Letrozole,
Anastrozole, Exemestane, are currently used in the standard treatment for postmenopausal breast cancer.
Methods:
Data were collected from Medline, PubMed, Google Scholar, Science Direct through searching of
keywords: ‘aromatase’, ‘aromatase inhibitors’, ‘breast cancer’, ‘steroidal aromatase inhibitors’, ‘non-steroidal
inhibitors’ and ‘generations of aromatase inhibitors’.
Results:
In the current scenario of breast cancer chemotherapy, AIs are the most widely used agents which reveal
optimum efficacy along with the least side effects. Keeping in view the prominence of AIs in breast cancer
therapy, this review covered the detailed description of aromatase including its role in the biosynthesis of estrogen,
biochemistry, gene expression, 3D-structure, and information of reported AIs along with their role in breast
cancer treatment.
Conclusion:
AIs are the mainstream solution of the ER+ breast cancer treatment regimen with the continuous
improvement of human understanding of the importance of a healthy life of women suffering from breast cancer.
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Affiliation(s)
- Pooja Ratre
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Keerti Mishra
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Amit Dubey
- Chhattisgarh Council of Science and Technology, Raipur-492 014 (C.G.), India
| | - Amber Vyas
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur-492 010 (C.G.), India
| | - Akhlesh Jain
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
| | - Suresh Thareja
- School of Pharmaceutical Sciences, Guru Ghasidas Central University, Bilaspur-495 009 (C.G.), India
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Raptopoulos Z, Constantinou C. The Effect of Exercise on the Alleviation of Side Effects Induced by Aromatase Inhibitors in Postmenopausal Breast Cancer Patients. Curr Oncol Rep 2020; 22:110. [PMID: 32803384 DOI: 10.1007/s11912-020-00971-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Aromatase inhibitors (AIs) are effective in treating postmenopausal women suffering from estrogen receptor-positive breast cancer (BC). However, AIs are also commonly associated with a number of side effects which decrease the quality of life (QoL) of the patients. This review focuses on the effects of exercise interventions on reducing the side effects commonly experienced by BC patients on AI treatment. RECENT FINDINGS Recent studies in the literature support that exercise interventions are feasible and improve body composition, aromatase inhibitor-induced Arthralgia (AIIA), and the overall QoL of BC patients. Successful implementation of longitudinal exercise interventions is expected to improve the QoL of BC patients on AI treatment. Future studies should therefore be carried out with a larger number of postmenopausal BC patients on AI treatment to (a) investigate the effects of exercise interventions on depression, cognitive decline, and cardiotoxicity and (b) address the motivation that should be used to keep BC survivors engaged in exercise intervention programs.
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Affiliation(s)
- Zacharias Raptopoulos
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, 21 Ilia Papakyriakou, 2414 Engomi, P.O. Box 24005, CY-1700, Nicosia, Cyprus
| | - Constantina Constantinou
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, 21 Ilia Papakyriakou, 2414 Engomi, P.O. Box 24005, CY-1700, Nicosia, Cyprus.
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5
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Aromatase inhibitors: Role in postmenopausal breast cancer. Arch Pharm (Weinheim) 2020; 353:e2000081. [DOI: 10.1002/ardp.202000081] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022]
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Bense RD, Qiu SQ, de Vries EGE, Schröder CP, Fehrmann RSN. Considering the biology of late recurrences in selecting patients for extended endocrine therapy in breast cancer. Cancer Treat Rev 2018; 70:118-126. [PMID: 30149225 DOI: 10.1016/j.ctrv.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 02/05/2023]
Abstract
Extended endocrine therapy can reduce recurrences occurring more than 5 years after diagnosis (late recurrences) in estrogen receptor (ER)-positive breast cancer. Given the side effects of endocrine therapy, optimal patient selection for extended treatment is crucial. Enhanced understanding of late recurrence biology could optimize patient selection in this setting. We therefore summarized the current knowledge of late recurrence biology, clinical trials on extended endocrine therapy, and tools for predicting late recurrence and benefit from treatment extension. Extending 5 years of tamoxifen therapy with 5 years of tamoxifen or an aromatase inhibitor (AI) reduces late recurrence risk by 2-5%, but results of extending AI-based therapy are inconsistent. Although several clinicopathological parameters and multigene assays are prognostic for late recurrence, selection tools predicting benefit from extended endocrine therapy are sparse. Therefore, we additionally performed a pooled analysis using 2231 mRNA profiles of patients with ER-positive/human epidermal growth factor receptor 2-negative breast cancer. Gene Set Enrichment Analysis was applied on genes ranked according to their association with early and late recurrence risk. Higher expression of estrogen-responsive genes was associated with a high recurrence risk beyond 5 years after diagnosis when patients had received no systemic therapy. Although 5 years of endocrine therapy reduced this risk, this effect disappeared after treatment cessation. This suggests that late recurrences of tumors with high expression of estrogen-responsive genes are likely ER-driven. Long-term intervention in this pathway by means of extended endocrine therapy might reduce late recurrences in patients with tumors showing high expression of estrogen-responsive genes.
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Affiliation(s)
- Rico D Bense
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Si-Qi Qiu
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; The Breast Center, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carolien P Schröder
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudolf S N Fehrmann
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Investigation of genotoxicity risk and DNA repair capacity in breast cancer patients using anastrozole. North Clin Istanb 2018; 5:6-13. [PMID: 29607425 PMCID: PMC5864710 DOI: 10.14744/nci.2017.55822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 08/21/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE: Breast cancer is the most common cancer in women worldwide and the incidence increases in postmenopausal women. Anastrozole is a non-steroidal (type II), third-generation aromatase inhibitor (AI) that is used in the treatment of postmenopausal estrogen-related breast cancer. Several studies have been conducted to assess the efficacy, safety, and superiority of AIs to tamoxifen; however, a literature search did not reveal a study that investigated the genotoxic potential of AIs. The aim of this study was to investigate the possible DNA damage risk profile and individual DNA repair capacity of patients using anastrozole with the modified alkaline comet assay in order to contribute to public health and health economics. METHODS: Women diagnosed with breast cancer after menopause comprised the study group. Six patients who had taken anastrozole for at least 6 months were retrospectively enrolled, and 12 patients who had not yet received treatment were prospectively enrolled as a control group. Peripheral blood lymphocytes were used to measure oxidized DNA damage using formamidopyrimidine DNA-glycosylase (FPG) and endonuclease III (endo III) in a modified comet assay. Individual DNA repair capacity was evaluated with the comet assay after a hydrogen peroxide (H2O2) challenge to examine the difference in DNA damage susceptibility. RESULTS: Analysis of DNA damage, oxidative base damage, susceptibility to DNA damage, and repair capacity revealed no significant difference between the control group and the patients taking anastrozole (p>0.05). Susceptibility to H2O2 damage was observed to increase with age (p<0.05). CONCLUSION: According to the results obtained in this study, anastrozole did not contribute to oxidative DNA damage. An H2O2 challenge with the comet assay is useful to evaluate circumstances of increased vulnerability to damage, such as aging and cancer.
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Goldvaser H, Barnes TA, Šeruga B, Cescon DW, Ocaña A, Ribnikar D, Amir E. Toxicity of Extended Adjuvant Therapy With Aromatase Inhibitors in Early Breast Cancer: A Systematic Review and Meta-analysis. J Natl Cancer Inst 2018; 110:4065461. [PMID: 28922781 DOI: 10.1093/jnci/djx141] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/13/2017] [Indexed: 09/19/2023] Open
Abstract
Background A number of randomized controlled trials (RCTs) have reported improvement in breast cancer outcomes from extending treatment with aromatase inhibitors (AIs) beyond the initial five years after diagnosis. However, the toxicity profile of extended AIs is uncertain. Methods We identified RCTs that compared extended AIs to placebo or no treatment using MEDLINE and a review of abstracts from key conferences between 2013 and 2016. Odds ratios (ORs), 95% confidence intervals (CIs), absolute risks, and the number needed to harm (NNH) were computed for prespecified safety and tolerability outcomes including cardiovascular events, bone fractures, second cancers (excluding new breast cancer), treatment discontinuation for adverse events, and death without recurrence. All statistical tests were two-sided. Results Seven trials comprising 16 349 patients met the inclusion criteria. Longer treatment with AIs was associated with increased odds of cardiovascular events (OR = 1.18, 95% CI = 1.00 to 1.40, P = .05, NNH = 122), bone fractures (OR = 1.34, 95% CI = 1.16 to 1.55, P < .001, NNH = 72), and treatment discontinuation for adverse events (OR = 1.45, 95% CI = 1.25 to 1.68, P < .001, NNH = 21). Longer treatment with AIs did not influence the odds of either second malignancy (OR = 0.93, 95% CI = 0.73 to 1.18, P = .56) or deaths without breast cancer recurrence (OR = 1.11, 95% CI = 0.90 to 1.36, P = .34). Conclusions Extended treatment with AIs is associated with an increased risk of cardiovascular events and bone fractures. There is no statistically significant increase in deaths without breast cancer recurrence among patients receiving longer treatment with AIs. These data should be taken into account when considering extended adjuvant AIs.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Tristan A Barnes
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Boštjan Šeruga
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - David W Cescon
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Alberto Ocaña
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
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9
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Goldvaser H, AlGorashi I, Ribnikar D, Seruga B, Templeton AJ, Ocana A, Amir E. Efficacy of extended adjuvant therapy with aromatase inhibitors in early breast cancer among common clinicopathologically-defined subgroups: A systematic review and meta-analysis. Cancer Treat Rev 2017; 60:53-59. [DOI: 10.1016/j.ctrv.2017.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 01/05/2023]
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10
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Fu J, Wu L, Jiang M, Li D, Jiang T, Fu W, Wang L, Du J. Real-world impact of non-breast cancer-specific death on overall survival in resectable breast cancer. Cancer 2017; 123:2432-2443. [PMID: 28267199 DOI: 10.1002/cncr.30617] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/26/2016] [Accepted: 01/18/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Jianfei Fu
- Department of Oncology; Zhejiang University Jinhua Hospital; Jinhua China
| | - Lunpo Wu
- Department of Gastroenterology; Second Affiliated Hospital of Zhejiang University School of Medicine; Hangzhou China
- Institute of Gastroenterology; Zhejiang University; Hangzhou China
| | - Mengjie Jiang
- Department of Radiation Oncology; First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine; Hangzhou China
| | - Dan Li
- Department of Medical Oncology; Second Affiliated Hospital of Zhejiang University School of Medicine; Hangzhou China
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, Chinese National Ministry of Education; Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China); Second Affiliated Hospital of Zhejiang University School of Medicine; Hangzhou China
| | - Ting Jiang
- Department of Nuclear Medicine; Zhejiang University Jinhua Hospital; Jinhua China
| | - Wei Fu
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Liangjing Wang
- Department of Gastroenterology; Second Affiliated Hospital of Zhejiang University School of Medicine; Hangzhou China
- Institute of Gastroenterology; Zhejiang University; Hangzhou China
| | - Jinlin Du
- Department of Colorectal Surgery; Zhejiang University Jinhua Hospital; Jinhua China
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11
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Cherny NI, Sullivan R, Dafni U, Kerst JM, Sobrero A, Zielinski C, de Vries EGE, Piccart MJ. A standardised, generic, validated approach to stratify the magnitude of clinical benefit that can be anticipated from anti-cancer therapies: the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). Ann Oncol 2015; 26:1547-73. [PMID: 26026162 DOI: 10.1093/annonc/mdv249] [Citation(s) in RCA: 577] [Impact Index Per Article: 64.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 12/12/2022] Open
Abstract
The value of any new therapeutic strategy or treatment is determined by the magnitude of its clinical benefit balanced against its cost. Evidence for clinical benefit from new treatment options is derived from clinical research, in particular phase III randomised trials, which generate unbiased data regarding the efficacy, benefit and safety of new therapeutic approaches. To date, there is no standard tool for grading the magnitude of clinical benefit of cancer therapies, which may range from trivial (median progression-free survival advantage of only a few weeks) to substantial (improved long-term survival). Indeed, in the absence of a standardised approach for grading the magnitude of clinical benefit, conclusions and recommendations derived from studies are often hotly disputed and very modest incremental advances have often been presented, discussed and promoted as major advances or 'breakthroughs'. Recognising the importance of presenting clear and unbiased statements regarding the magnitude of the clinical benefit from new therapeutic approaches derived from high-quality clinical trials, the European Society for Medical Oncology (ESMO) has developed a validated and reproducible tool to assess the magnitude of clinical benefit for cancer medicines, the ESMO Magnitude of Clinical Benefit Scale (ESMO-MCBS). This tool uses a rational, structured and consistent approach to derive a relative ranking of the magnitude of clinically meaningful benefit that can be expected from a new anti-cancer treatment. The ESMO-MCBS is an important first step to the critical public policy issue of value in cancer care, helping to frame the appropriate use of limited public and personal resources to deliver cost-effective and affordable cancer care. The ESMO-MCBS will be a dynamic tool and its criteria will be revised on a regular basis.
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Affiliation(s)
- N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - R Sullivan
- Kings Health Partners Integrated Cancer Centre, King's College London, Institute of Cancer Policy, London, UK
| | - U Dafni
- University of Athens and Frontiers of Science Foundation-Hellas, Athens, Greece
| | - J M Kerst
- Department of Medical Oncology, Antoni van Leeuwenhoek Hospital
| | - A Sobrero
- Department of Medical Oncology, IRCCS San Martino IST, Genova, Italy
| | - C Zielinski
- Division of Oncology, Medical University Vienna, Vienna, Austria
| | - E G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M J Piccart
- Jules Bordet Institute, UniversitéLibre de Bruxelles, Brussels, Belgium Netherlands Cancer Institute, Amsterdam, The Netherlands
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12
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Chen TWW, Chen HM, Lin CH, Huang CS, Cheng AL, Lai MS, Lu YS. No increased venous thromboembolism risk in Asian breast cancer patients receiving adjuvant tamoxifen. Breast Cancer Res Treat 2014; 148:135-42. [PMID: 25240736 DOI: 10.1007/s10549-014-3140-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/16/2014] [Indexed: 11/25/2022]
Abstract
Tamoxifen is an effective endocrine treatment for early breast cancer (EBC) but increases the risk of venous thromboembolism. Whether Asian EBC patients (pts) bear the same risk when treated with adjuvant tamoxifen is uncertain. EBC pts diagnosed between 2004 and 2009 were selected from a population database in Taiwan. The pts were followed up from the index date to December 31, 2011 to collect events of deep vein thrombosis (DVT) and pulmonary embolism (PE). Cumulative incidence rates and hazard ratios (HRs) were used to compare the risk between pts treated with and without tamoxifen. In addition, comorbidities were included in an adjusted model of the risk of DVT and PE. A total of 28,029 EBC pts, including 17,843 (63.8 %) in the tamoxifen group and 10,155 (36.2 %) in the nontamoxifen group, were analyzed. The 7-year cumulative incidence rates for DVT and PE were 2.58 and 0.32 % in the tamoxifen group and 2.51 and 0.32 % in the nontamoxifen group (P = 0.92 for DVT, P = 0. 65 for PE), respectively. The HR for the nonadjusted and adjusted models showed no differences in DVT and PE risks between the tamoxifen and nontamoxifen groups. The uterine cancer risk was significantly increased in the pts receiving tamoxifen (adjusted HR = 2.79, P < 0.001), suggesting tamoxifen compliance. The risks of developing DVT and PE are not increased in Asian EBC pts receiving adjuvant tamoxifen. Ethnicity differences should be considered when discussing optimal endocrine treatments with EBC pts.
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Affiliation(s)
- Tom Wei-Wu Chen
- Department of Oncology, National Taiwan University Hospital, 7, Chung-Shan South Rd., Taipei, 10002, Taiwan
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Soyder A, Ozbaş S, Koçak S. Locoregional Recurrence and Survival Rates after Breast-Conserving Surgery and Hormonal Therapy in 70-Year-Old or Older Patients with Stage I or IIA Breast Carcinoma. ACTA ACUST UNITED AC 2014; 8:134-7. [PMID: 24419104 DOI: 10.1159/000350776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Data for treatment of elderly women (≥ 70 years) with estrogen receptor-positive early stage breast cancer are available. We have compared different treatment options to determine whether lumpectomy (LU) plus adjuvant hormonal therapy (HT) is as effective as combined LU, HT, and radiotherapy (RT). METHOD Medical records of elderly patients over 69 years of age who had been treated for T1N0M0 (stage I) and T2N0M0 (stage IIA) at 2 different medical centers between March 2004 and January 2011 were assessed, and 35 patients were included in this study. 21 of these patients underwent only breast-conserving surgery (BCS) and HT (Group 1: T1N0M0-Group 1a, n = 16; T2N0M0-Group 1b, n = 5) and the others either BCS, HT and RT (Group 2, n = 4) or BCS, chemotherapy (CT), HT and RT (Group 3, n = 10). Adjuvant HT for all the patients comprised aromatase inhibitors. RESULTS The mean follow-up period for Groups 1, 2 and 3 were 32.2, 31.3 and 20.4 months, respectively. No locoregional recurrence or cancer-specific mortality occurred in any of these patients; 1 patient from Group 1 died of a different cause. DISCUSSION The BCS+HT regimen seems to be an efficient treatment option for early stage breast cancer in selected 70-year-old and older patient groups.
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Affiliation(s)
- Aykut Soyder
- Department of Surgery, Adnan Menderes University School of Medicine, Aydin, Turkey
| | - Serdar Ozbaş
- Department of Surgery, Adnan Menderes University School of Medicine, Aydin, Turkey
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14
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Marrero-Alonso J, Morales A, García Marrero B, Boto A, Marín R, Cury D, Gómez T, Fernández-Pérez L, Lahoz F, Díaz M. Unique SERM-like properties of the novel fluorescent tamoxifen derivative FLTX1. Eur J Pharm Biopharm 2013; 85:898-910. [PMID: 23727370 DOI: 10.1016/j.ejpb.2013.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 04/09/2013] [Accepted: 04/30/2013] [Indexed: 11/17/2022]
Abstract
Tamoxifen is a selective estrogen receptor modulator extensively used on estrogen receptor-positive breast cancer treatment. However, clinical evidences demonstrate the increased incidence of undesirable side effects during chronic therapies, the most life threatening being uterine cancers. Some of these effects are related to tissue-dependent estrogenic actions of tamoxifen, but the exact mechanisms remain poorly understood. We have designed and synthesized a novel fluorescent tamoxifen derivative, FLTX1, and characterized its biological and pharmacological activities. Using confocal microscopy, we demonstrate that FLTX1 colocalizes with estrogen receptor α (ERα). Competition studies showed that FLTX1 binding was totally displaced by unlabeled tamoxifen and partially by estradiol, indicating the existence of non-ER-related triphenylethylene-binding sites. Ligand binding assays showed that FLTX1 exhibits similar affinity for ER than tamoxifen. FLTX1 exhibited antiestrogenic activity comparable to tamoxifen in MCF7 and T47D cells transfected with 3xERE-luciferase reporter. Interestingly, FLTX1 lacked the strong agonistic effect of tamoxifen on ERα-dependent transcriptional activity. Additionally, in vivo assays in mice revealed that unlike tamoxifen, FLTX1 was devoid of estrogenic uterotrophic effects, lacked of hyperplasic and hypertrophic effects, and failed to alter basal proliferating cell nuclear antigen immunoreactivity. In the rat uterine model of estrogenicity/antiestrogenicity, FLTX1 displayed antagonistic activity comparable to tamoxifen at lower doses, and only estrogenic uterotrophy at the highest dose. We conclude that the fluorescent derivative FLTX1 is not only a suitable probe for studies on the molecular pharmacology of tamoxifen, but also a potential therapeutic substitute to tamoxifen, endowed with potent antiestrogenic properties but devoid of uterine estrogenicity.
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Affiliation(s)
- Jorge Marrero-Alonso
- Departamento de Biología Animal, Universidad de La Laguna, Tenerife, Spain; Instituto Canario de Investigación del Cáncer (ICIC), Spain
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John-Baptiste AA, Wu W, Rochon P, Anderson GM, Bell CM. A systematic review and methodological evaluation of published cost-effectiveness analyses of aromatase inhibitors versus tamoxifen in early stage breast cancer. PLoS One 2013; 8:e62614. [PMID: 23671612 PMCID: PMC3646035 DOI: 10.1371/journal.pone.0062614] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/22/2013] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND A key priority in developing policies for providing affordable cancer care is measuring the value for money of new therapies using cost-effectiveness analyses (CEAs). For CEA to be useful it should focus on relevant outcomes and include thorough investigation of uncertainty. Randomized controlled trials (RCTs) of five years of aromatase inhibitors (AI) versus five years of tamoxifen in the treatment of post-menopausal women with early stage breast cancer, show benefit of AI in terms of disease free survival (DFS) but not overall survival (OS) and indicate higher risk of fracture with AI. Policy-relevant CEA of AI versus tamoxifen should focus on OS and include analysis of uncertainty over key assumptions. METHODS We conducted a systematic review of published CEAs comparing an AI to tamoxifen. We searched Ovid MEDLINE, EMBASE, PsychINFO, and the Cochrane Database of Systematic Reviews without language restrictions. We selected CEAs with outcomes expressed as cost per life year or cost per quality adjusted life year (QALY). We assessed quality using the Neumann checklist. Using structured forms two abstractors collected descriptive information, sources of data, baseline assumptions on effectiveness and adverse events, and recorded approaches to assessing parameter uncertainty, methodological uncertainty, and structural uncertainty. RESULTS We identified 1,622 citations and 18 studies met inclusion criteria. All CE estimates assumed a survival benefit for aromatase inhibitors. Twelve studies performed sensitivity analysis on the risk of adverse events and 7 assumed no additional mortality risk with any adverse event. Sub-group analysis was limited; 6 studies examined older women, 2 examined women with low recurrence risk, and 1 examined women with multiple comorbidities. CONCLUSION Published CEAs comparing AIs to tamoxifen assumed an OS benefit though none has been shown in RCTs, leading to an overestimate of the cost-effectiveness of AIs. Results of these CEA analyses may be suboptimal for guiding policy.
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Affiliation(s)
- Ava A John-Baptiste
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.
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17
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Lux MP, Reichelt C, Karnon J, Tänzer TD, Radosavac D, Fasching PA, Beckmann MW, Thiel FC. Cost-Benefit Analysis of Endocrine Therapy in the Adjuvant Setting for Postmenopausal Patients with Hormone Receptor-Positive Breast Cancer, Based on Survival Data and Future Prices for Generic Drugs in the Context of the German Health Care System. Breast Care (Basel) 2011; 6:381-389. [PMID: 22619649 PMCID: PMC3357170 DOI: 10.1159/000333118] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Cost-effectiveness analyses have focused on aromatase inhibitors (AIs), but the results are inconsistent and disease-free survival has often been extrapolated to overall survival. The present study calculates the cost-effectiveness of 5 years of letrozole versus tamoxifen versus anastrozole in the context of the German health care system, using survival data from the Breast International Group (BIG) 1-98 study and the Arimidex, Tamoxifen, Alone or in Combination (ATAC) study and generic prices. MATERIALS AND METHODS: A hybrid model was developed that incorporates recurrence rates, overall survival, treatment costs and treatment-associated adverse events and the resulting costs. The basic assumption was that generic anastrozole would lead to a price reduction to 75% of the original price. Further analyses were carried out with 50% and 25% of the original prices for anastrozole and letrozole. RESULTS: The cost-benefit model showed a gain of 0.3124 or 0.0659 quality-adjusted life years (QALYs) for letrozole or anastrozole. Incremental costs of € 29,375.15/QALY for letrozole (100% of original price) were calculated and € 94,648.03/QALY for anastrozole (75% of original price). Marked increases in cost-effectiveness are observed with further decreases in price (anastrozole: 50% price € 54,715.17/QALY, 25% price € 14,779.57/QALY; letrozole 75% price € 20,988.59/QALY, 50% price € 12,602.03/QALY, 25% price € 4,215.46/QALY). CONCLUSION: The present model including the inverse probability of censoring weighted analysis (IPCW) for letrozole and generic prices for both AIs shows that letrozole is cost effective.
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Affiliation(s)
- Michael P. Lux
- University Breast Center for Franconia, Frauenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen
| | | | - Jon Karnon
- Discipline of Public Health, School of Population Health and Clinical Practice, University of Adelaide, Australia
| | - Thorsten D. Tänzer
- Medicornea Ltd., Neuss, Stiftung Krankenhaus Bethanien für die Grafschaft Moers, Germany
| | - Dragan Radosavac
- Dept. of Internal Medicine II/Cardiology, Stiftung Krankenhaus Bethanien für die Grafschaft Moers, Germany
| | - Peter A. Fasching
- University Breast Center for Franconia, Frauenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen
| | - Matthias W. Beckmann
- University Breast Center for Franconia, Frauenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen
| | - Falk C. Thiel
- University Breast Center for Franconia, Frauenklinik des Universitätsklinikums Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen
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Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst 2011; 103:1299-309. [PMID: 21743022 DOI: 10.1093/jnci/djr242] [Citation(s) in RCA: 409] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Aromatase inhibitors are associated with consistent improvements in disease-free survival but not in overall survival. We conducted a literature-based meta-analysis of randomized trials to examine whether the relative toxicity of aromatase inhibitors compared with tamoxifen may explain this finding. METHODS We conducted a systematic review to identify randomized controlled trials that compared aromatase inhibitors and tamoxifen as primary adjuvant endocrine therapy in postmenopausal women by searching MEDLINE, EMBASE, and databases of the American Society of Clinical Oncology and San Antonio Breast Cancer Symposium. Odds ratios (ORs), 95% confidence intervals (CIs), absolute risks, and the number needed to harm associated with one adverse event were computed for prespecified serious adverse events including cardiovascular disease, cerebrovascular disease, bone fractures, thromboembolic events, endometrial carcinoma and other second cancers not including new breast cancer. All statistical tests were two-sided. RESULTS Seven trials enrolling 30,023 patients met the inclusion criteria. Longer duration of aromatase inhibitor use was associated with increased odds of developing cardiovascular disease (OR = 1.26, 95% CI = 1.10 to 1.43, P < .001; number needed to harm = 132) and bone fractures (OR = 1.47, 95% CI = 1.34 to 1.61, P < .001; number needed to harm = 46), but a decreased odds of venous thrombosis (OR = 0.55, 95% CI = 0.46 to 0.64, P < .001; number needed to harm = 79) and endometrial carcinoma (OR = 0.34, 95% CI = 0.22 to 0.53, P < .001; number needed to harm = 258). Five years of aromatase inhibitors was associated with a non-statistically significant increased odds of death without recurrence compared with 5 years of tamoxifen alone or tamoxifen for 2-3 years followed by an aromatase inhibitor for 2-3 years (OR = 1.11, 95% CI = 0.98 to 1.26, P = .09). CONCLUSIONS The cumulative toxicity of aromatase inhibitors when used as up-front treatment may explain the lack of overall survival benefit despite improvements in disease-free survival. Switching from tamoxifen to aromatase inhibitors reduces this toxicity and is likely the best balance between efficacy and toxicity.
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Affiliation(s)
- Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, 610 University Ave, Toronto, ON M5G 2M9, Canada.
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Assessing clinical efficacy of drugs in cancer patients: are we on the right track? ACTA ACUST UNITED AC 2011. [DOI: 10.4155/cli.11.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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21
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Vitry AI, Thai LP, Lu CY. Time and geographical variations in utilization of endocrine therapy for breast cancer in Australia. Intern Med J 2011; 41:162-6. [DOI: 10.1111/j.1445-5994.2010.02304.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Yu KD, Huang AJ, Shao ZM. Tailoring adjuvant endocrine therapy for postmenopausal breast cancer: a CYP2D6 multiple-genotype-based modeling analysis and validation. PLoS One 2010; 5:e15649. [PMID: 21187922 PMCID: PMC3004945 DOI: 10.1371/journal.pone.0015649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 11/18/2010] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Previous studies have suggested that postmenopausal women with breast cancer who present with wild-type CYP2D6 may actually have similar or superior recurrence-free survival outcomes when given tamoxifen in place of aromatase inhibitors (AIs). The present study established a CYP2D6 multiple-genotype-based model to determine the optimal endocrine therapy for patients harboring wild-type CYP2D6. METHODS We created a Markov model to determine whether tamoxifen or AIs maximized 5-year disease-free survival (DFS) for extensive metabolizer (EM) patients using annual hazard ratio (HR) data from the BIG 1-98 trial. We then replicated the model by evaluating 9-year event-free survival (EFS) using HR data from the ATAC trial. In addition, we employed two-way sensitivity analyses to explore the impact of HR of decreased-metabolizer (DM) and its frequency on survival by studying a range of estimates. RESULTS The 5-year DFS of tamoxifen-treated EM patients was 83.3%, which is similar to that of genotypically unselected patients who received an AI (83.7%). In the validation study, we further demonstrated that the 9-year EFS of tamoxifen-treated EM patients was 81.4%, which is higher than that of genotypically unselected patients receiving tamoxifen (78.4%) and similar to that of patients receiving an AI (83.2%). Two-way sensitivity analyses demonstrated the robustness of the results. CONCLUSIONS Our modeling analyses indicate that, among EM patients, the DFS/EFS outcome of patients receiving tamoxifen is similar to that of patients receiving an AI. Further prospective clinical trials are needed to evaluate the value of the CYP2D6 genotype in the selection of endocrine therapy.
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Affiliation(s)
- Ke-Da Yu
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
| | - A-Ji Huang
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
| | - Zhi-Ming Shao
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
- * E-mail:
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Forero-Torres A, Saleh MN, Galleshaw JA, Jones CF, Shah JJ, Percent IJ, Nabell LM, Carpenter JT, Falkson CI, Krontiras H, Urist MM, Bland KI, De Los Santos JF, Meredith RF, Caterinicchia V, Bernreuter WK, O'Malley JP, Li Y, LoBuglio AF. Pilot trial of preoperative (neoadjuvant) letrozole in combination with bevacizumab in postmenopausal women with newly diagnosed estrogen receptor- or progesterone receptor-positive breast cancer. Clin Breast Cancer 2010; 10:275-80. [PMID: 20705559 DOI: 10.3816/cbc.2010.n.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Tumor content or expression of vascular endothelial growth factor (VEGF) is associated with impaired efficacy of antiestrogen adjuvant therapy. We designed a pilot study to assess the feasibility and short-term efficacy of neoadjuvant letrozole and bevacizumab (anti-VEGF) in postmenopausal women with stage II and III estrogen receptor/progesterone receptor-positive breast cancer. PATIENTS AND METHODS Patients were treated with a neoadjuvant regimen of letrozole orally 2.5 mg/day and bevacizumab intravenously 15 mg/kg every 3 weeks for a total of 24 weeks before the surgical treatment of their breast cancer. Patients were followed for toxicity at 3-week intervals, and tumor assessment (a physical examination and ultrasound) was performed at 6-week intervals. Positron emission tomography (PET) scans were performed before therapy and 6 weeks after the initiation of therapy. RESULTS Twenty-five evaluable patients were treated. The regimen was well-tolerated, except in 2 patients who were taken off the study for difficulties controlling their hypertension. An objective clinical response occurred in 17 of 25 patients (68%), including 16% complete responses (CRs) and 52% partial responses. The 4 patients with clinical CRs manifested pathologic CRs in their breasts (16%), although 1 patient had residual tumor cells in her axillary nodes. Eight of 25 patients (32%) attained stage 0 or 1 status. The PET scan response at 6 weeks correlated with clinical CRs and breast pathologic CRs at 24 weeks (P < .0036). CONCLUSION Combination neoadjuvant therapy with letrozole and bevacizumab was well-tolerated and resulted in impressive clinical and pathologic responses. The Translational Breast Cancer Research Consortium has an ongoing randomized phase II trial of this regimen in this patient population.
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Affiliation(s)
- Andres Forero-Torres
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294-3300, USA.
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24
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van Londen GJ, Perera S, Vujevich K, Rastogi P, Lembersky B, Brufsky A, Vogel V, Greenspan SL. The impact of an aromatase inhibitor on body composition and gonadal hormone levels in women with breast cancer. Breast Cancer Res Treat 2010; 125:441-6. [PMID: 21046232 DOI: 10.1007/s10549-010-1223-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 10/09/2010] [Indexed: 11/29/2022]
Abstract
Aromatase inhibitors (AIs) have become the standard adjuvant therapy of postmenopausal breast cancer survivors. AIs induce a reduction of bioavailable estrogens by inhibiting aromatase, which would be expected to induce alterations in body composition, more extensive than induced by menopause. The objectives are to examine the impact of AIs on (1) DXA-scan derived body composition and (2) gonadal hormone levels. This is a sub-analysis of a 2-year double-blind, placebo-controlled, randomized trial of 82 women with nonmetastatic breast cancer, newly menopausal following chemotherapy, who were randomized to risedronate (35 mg once weekly) versus placebo, and stratified for their usage of AI versus no AI. Outcomes included DXA-scan derived body composition and gonadal hormone levels. As a group, total body mass increased in women over 24 months. Women on AIs gained a significant amount of lean body mass compared to baseline as well as to no-AI users (P < 0.05). Women not on an AI gained total body fat compared to baseline and AI users (P < 0.05). Free testosterone significantly increased and sex hormone binding globulin (SHBG) significantly decreased in women on AIs compared to no AIs at 24 months (P < 0.01) while total estradiol and testosterone levels remained stable. Independent of AI usage, chemotherapy-induced postmenopausal breast cancer patients demonstrated an increase of total body mass. AI users demonstrated maintenance of total body fat, an increase in lean body mass and free testosterone levels, and a decrease in SHBG levels compared to no-AI users. The mechanisms and implications of these changes need to be studied further.
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Affiliation(s)
- G J van Londen
- Medicine, University of Pittsburgh, Kaufmann Medical Bldg, Pittsburgh, PA, 15213, USA.
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25
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Seruga B, Ocana A, Niraula S, Amir E. Absolute Benefits of Aromatase Inhibitors in Adjuvant Treatment of Breast Cancer: Should We Know More? J Clin Oncol 2010; 28:e346-7; author reply e348. [DOI: 10.1200/jco.2010.28.3564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bostjan Seruga
- Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Alberto Ocana
- Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Saroj Niraula
- Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
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26
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Bartlett JMS, Thomas J, Ross DT, Seitz RS, Ring BZ, Beck RA, Pedersen HC, Munro A, Kunkler IH, Campbell FM, Jack W, Kerr GR, Johnstone L, Cameron DA, Chetty U. Mammostrat as a tool to stratify breast cancer patients at risk of recurrence during endocrine therapy. Breast Cancer Res 2010; 12:R47. [PMID: 20615243 PMCID: PMC2949634 DOI: 10.1186/bcr2604] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 03/28/2010] [Accepted: 07/08/2010] [Indexed: 12/21/2022] Open
Abstract
Introduction Patients with early-stage breast cancer, treated with endocrine therapy, have approximately 90% 5-year disease-free survival. However, for patients at higher risk of relapse despite endocrine therapy, additional adjuvant therapy, such as chemotherapy, may be indicated. The challenge is to prospectively identify such patients. The Mammostrat® test uses five immunohistochemical markers to stratify patients on tamoxifen therapy into risk groups to inform treatment decisions. We tested the efficacy of this panel in a mixed population of cases treated in a single center with breast-conserving surgery and long-term follow-up. Methods Tissue microarrays from a consecutive series (1981 to 1998) of 1,812 women managed by wide local excision and postoperative radiotherapy were collected following appropriate ethical review. Of 1,390 cases stained, 197 received no adjuvant hormonal or chemotherapy, 1,044 received tamoxifen only, and 149 received a combination of hormonal therapy and chemotherapy. Median age at diagnosis was 57, 71% were postmenopausal, 23.9% were node-positive and median tumor size was 1.5 cm. Samples were stained using triplicate 0.6 mm2 tissue microarray cores, and positivity for p53, HTF9C, CEACAM5, NDRG1 and SLC7A5 was assessed. Each case was assigned a Mammostrat® risk score, and distant recurrence-free survival (DRFS), relapse-free survival (RFS) and overall survival (OS) were analyzed by marker positivity and risk score. Results Increased Mammostrat® scores were significantly associated with reduced DRFS, RFS and OS in estrogen receptor (ER)-positive breast cancer (P < 0.00001). In multivariate analyses the risk score was independent of conventional risk factors for DRFS, RFS and OS (P < 0.05). In node-negative, tamoxifen-treated patients, 10-year recurrence rates were 7.6 ± 1.5% in the low-risk group versus 20.0 ± 4.4% in the high-risk group. Further, exploratory analyses revealed associations with outcome in both ER-negative and untreated patients. Conclusions This is the fifth independent study providing evidence that Mammostrat® can act as an independent prognostic tool for ER-positive, tamoxifen-treated breast cancer. In addition, this study revealed for the first time a possible association with outcome regardless of node status and ER-negative tumors. When viewed in the context of previous results, these data provide further support for this antibody panel as an aid to patient management in early-stage breast cancer.
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Affiliation(s)
- John M S Bartlett
- Endocrine Cancer Group, Edinburgh Cancer Research Centre, Edinburgh University, Carrington Crescent, Edinburgh EH4 2XU, UK.
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Ferraldeschi R, Newman WG. The Impact of CYP2D6 Genotyping on Tamoxifen Treatment. Pharmaceuticals (Basel) 2010; 3:1122-1138. [PMID: 27713292 PMCID: PMC4034025 DOI: 10.3390/ph3041122] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 03/12/2010] [Accepted: 04/09/2010] [Indexed: 12/11/2022] Open
Abstract
Tamoxifen remains a cornerstone of treatment for patients with oestrogen-receptor-positive breast cancer. Tamoxifen efficacy depends on the biotransformation, predominantly via the cytochrome P450 2D6 (CYP2D6) isoform, to the active metabolite endoxifen. Both genetic and environmental (drug-induced) factors may alter CYP2D6 enzyme activity directly affecting the concentrations of active tamoxifen metabolites. Several studies suggest that germline genetic variants in CYP2D6 influence the clinical outcomes of patients treated with adjuvant tamoxifen. Here, we review the existing data relating CYP2D6 genotypes to tamoxifen efficacy.
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Affiliation(s)
- Roberta Ferraldeschi
- Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK.
- Genetic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Oxford Road, Manchester, M13 9WL, UK.
| | - William G Newman
- Genetic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Oxford Road, Manchester, M13 9WL, UK.
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28
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Wishart GC, Chetty U. Introduction to sessions on guidelines and endocrine therapy, the influence of breast screening on number of mastectomies and the challenge between molecular science and traditional dogma in the treatment of breast cancer. Introduction to Session 6. Breast Cancer Res 2010; 11 Suppl 3:S17. [PMID: 20030868 PMCID: PMC2797697 DOI: 10.1186/bcr2436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Gordon C Wishart
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
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29
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Nabholtz JM, Mouret-Reynier MA, Durando X, Van Praag I, Nayl B, Ferriere JP, Chollet P. Role of aromatase inhibitors in the upfront adjuvant hormonal therapy of postmenopausal patients with breast cancer. Indian J Surg Oncol 2010; 1:19-26. [PMID: 22930614 PMCID: PMC3420988 DOI: 10.1007/s13193-010-0007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 12/03/2009] [Indexed: 10/19/2022] Open
Abstract
Tamoxifen has been considered for several decades as the standard upfront hormonal therapy for patients with endocrine-sensitive early breast cancer. The efficacy and favorable toxicity profiles of third-generation aromatase inhibitors (AIs), anastrozole, letrozole and exemestane, in advanced disease led to their development in early breast cancer. Recent trial results consistently showed the superiority of AIs over tamoxifen in using the two following therapeutic approaches: either the upfront strategy (randomization of newly diagnosed patients: tamoxifen for 5 years vu AI for 5 years) or the sequencial strategy (randomization of newly diagnosed patients: tamoxifen (2-3 years) followed by AI or the inverse for a total of 5 years vs upfront AI for 5 years).Despite some common characteristics, a body of evidence on AIs suggests some specific differences between the three agents in terms of efficacy as well as toxicity profiles. Thus, these hormonal agents may not be considered interchangeable in clinical practice. This review will explore available results from AIs trials and will try to define their present role in the upfront adjuvant management of postmenopausal patients with breast cancer.
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Affiliation(s)
- Jean-Marc Nabholtz
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Marie-Ange Mouret-Reynier
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Xavier Durando
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Isabelle Van Praag
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Béatrice Nayl
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Jean-Pierre Ferriere
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
| | - Philippe Chollet
- Department of Medicine, Jean Perrin Comprehensive Cancer Centre of Auvergne, Clermont-Ferrand, France
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31
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Montemurro F, Del Mastro L, Aglietta M. Reply to A. Sánchez-Muñoz et al. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.25.4326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Filippo Montemurro
- University Division of Medical Oncology and Hematology, Institute for Cancer Research and Treatment, Candiolo, Italy
| | - Lucia Del Mastro
- Department Medical Oncology, National Cancer Research Institute, Genoa, Italy
| | - Massimo Aglietta
- University Division of Medical Oncology and Hematology, Institute for Cancer Research and Treatment, Candiolo, Torino, Italy
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Sánchez-Muñoz A, Ribelles N, Márquez A, Pérez-Ruiz E, Alba E. Aromatase Inhibitors As Adjuvant Therapy for Breast Cancer: Overall Survival Versus Disease-Free Survival As a Primary End Point in Clinical Practice. J Clin Oncol 2009; 27:e255-6; author reply e257-8. [DOI: 10.1200/jco.2009.25.3914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alfonso Sánchez-Muñoz
- Medical Oncology Department, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - Nuria Ribelles
- Medical Oncology Department, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - Antonia Márquez
- Medical Oncology Department, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - Elisabeth Pérez-Ruiz
- Medical Oncology Department, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - Emilio Alba
- Medical Oncology Department, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
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Progress in tailoring adjuvant endocrine therapy for postmenopausal women with early breast cancer. Curr Opin Oncol 2009; 21:491-8. [DOI: 10.1097/cco.0b013e32832fc8b0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bosco JLF, Lash TL, Prout MN, Buist DSM, Geiger AM, Haque R, Wei F, Silliman RA. Breast cancer recurrence in older women five to ten years after diagnosis. Cancer Epidemiol Biomarkers Prev 2009; 18:2979-83. [PMID: 19843686 DOI: 10.1158/1055-9965.epi-09-0607] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the risk of recurrence >5 years after diagnosis among older breast cancer survivors. A community-based population of women >or=65 years diagnosed with early-stage breast cancer who survived disease free for 5 years was followed for 5 additional years or until a diagnosis of breast cancer recurrence, second primary, death, or loss to follow-up. These 5-year disease-free survivors (N = 1,277) had primary breast cancers that were node negative (77%) and estrogen receptor positive or unknown (86%). Five percent (n = 61) developed a recurrence between 5 and 10 years after diagnosis: 25% local, 9.8% regional, and 66% distant. Women who were node positive [hazard ratio (HR), 3.9; 95% confidence interval (95% CI), 1.5-10], had poorly differentiated tumors (HR, 2.5; 95% CI, 0.9-6.6), or who received breast conserving surgery without radiation therapy (HR, 2.4; 95% CI, 1.0-5.8) had higher recurrence rates compared with node negative, well differentiated, and receipt of mastectomy, respectively. Not receiving adjuvant tamoxifen, compared with receiving adjuvant tamoxifen, was also positively associated with late recurrence among women with estrogen receptor-positive/unknown tumors. Although relatively few women experience a late recurrence, most recurrences present as advanced disease, which is difficult to treat in older women. This study of late recurrence emphasizes that the risk, although small, is not negligible even in this group at high risk of death due to competing causes.
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Affiliation(s)
- Jaclyn L F Bosco
- Department of Medicine, Section of Geriatrics, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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35
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Lefebvre-Lacoeuille C, Catala L, Descamps P. [Is our current knowledge sufficient for the up-front use of aromatase inhibitors as adjuvant therapy for breast cancer?]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2009; 38:453-455. [PMID: 19640658 DOI: 10.1016/j.jgyn.2009.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 06/16/2009] [Indexed: 05/28/2023]
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36
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Hietanen P. Does the expert panel at the St Gallen meeting provide an unbiased opinion about the management of women with early breast cancer? Ann Oncol 2009; 20:1749-51; author reply 1751-2. [DOI: 10.1093/annonc/mdp399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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37
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Abstract
Despite the perception of many oncologists that tamoxifen is an inferior drug, and should be substituted by an aromatase inhibitor in post-menopausal women, the current evidence strongly supports the view that AIs should be used 2-3 years after tamoxifen to achieve the maximal overall survival (OS) advantage.
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Affiliation(s)
- L Hughes-Davies
- Cambridge Breast Unit, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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38
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Goldhirsch A, Ingle JN, Gelber RD, Coates AS, Thürlimann B, Senn HJ. Thresholds for therapies: highlights of the St Gallen International Expert Consensus on the primary therapy of early breast cancer 2009. Ann Oncol 2009; 20:1319-29. [PMID: 19535820 PMCID: PMC2720818 DOI: 10.1093/annonc/mdp322] [Citation(s) in RCA: 992] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 05/12/2009] [Indexed: 12/18/2022] Open
Abstract
The 11(th) St Gallen (Switzerland) expert consensus meeting on the primary treatment of early breast cancer in March 2009 maintained an emphasis on targeting adjuvant systemic therapies according to subgroups defined by predictive markers. Any positive level of estrogen receptor (ER) expression is considered sufficient to justify the use of endocrine adjuvant therapy in almost all patients. Overexpression or amplification of HER2 by standard criteria is an indication for anti-HER2 therapy for all but the very lowest risk invasive tumours. The corollary is that ER and HER2 must be reliably and accurately measured. Indications for cytotoxic adjuvant therapy were refined, acknowledging the role of risk factors with the caveat that risk per se is not a target. Proliferation markers, including those identified in multigene array analyses, were recognised as important in this regard. The threshold for indication of each systemic treatment modality thus depends on different criteria which have been separately listed to clarify the therapeutic decision-making algorithm.
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MESH Headings
- Algorithms
- Antineoplastic Agents, Hormonal/therapeutic use
- Breast Neoplasms/metabolism
- Breast Neoplasms/therapy
- Breast Neoplasms, Male/metabolism
- Breast Neoplasms, Male/therapy
- Chemotherapy, Adjuvant
- Decision Support Techniques
- Female
- Humans
- Male
- Neoplasms, Hormone-Dependent/metabolism
- Neoplasms, Hormone-Dependent/therapy
- Radiotherapy, Adjuvant
- Receptor, ErbB-2/antagonists & inhibitors
- Receptor, ErbB-2/biosynthesis
- Receptors, Estrogen/biosynthesis
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Affiliation(s)
- A Goldhirsch
- International Breast Cancer Study Group, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
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Nabholtz JM, Mouret-Reynier MA, Durando X, Van Praagh I, Al-Sukhun S, Ferriere JP, Chollet P. Comparative review of anastrozole, letrozole and exemestane in the management of early breast cancer. Expert Opin Pharmacother 2009; 10:1435-47. [DOI: 10.1517/14656560902953738] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Montemurro F, Aglietta M, Del Mastro L. Aromatase inhibitors as adjuvant therapy for breast cancer. J Clin Oncol 2009; 27:2566-7. [PMID: 19332706 DOI: 10.1200/jco.2009.22.2695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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41
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Kesisis G, Makris A, Miles D. Update on the use of aromatase inhibitors in early-stage breast cancer. Breast Cancer Res 2009; 11:211. [PMID: 19889200 PMCID: PMC2790854 DOI: 10.1186/bcr2410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aromatase inhibitors are currently included in the 'optimal' management of early-stage breast cancer. Uncertainty remains, however, as to the most appropriate treatment strategy, particularly for newly diagnosed women as they seek to trade off the cost, toxicities and efficacy of the treatment options. Recent publications provide conflicting advice on the role of aromatase inhibitors in the treatment of postmenopausal patients with early-stage hormone receptor-positive breast cancer. This review provides updates on the clinical trials of aromatase inhibitors in early breast cancer and tries to provide practical clinical guidance on their optimal use.
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Affiliation(s)
- Georgios Kesisis
- Mount Vernon Cancer Centre, Rickmansworth, Northwood, Middlesex, HA6 2RN, UK
| | - Andreas Makris
- Mount Vernon Cancer Centre, Rickmansworth, Northwood, Middlesex, HA6 2RN, UK
| | - David Miles
- Mount Vernon Cancer Centre, Rickmansworth, Northwood, Middlesex, HA6 2RN, UK
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