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Slanař O, Hronová K, Bartošová O, Šíma M. Recent advances in the personalized treatment of estrogen receptor-positive breast cancer with tamoxifen: a focus on pharmacogenomics. Expert Opin Drug Metab Toxicol 2020; 17:307-321. [PMID: 33320718 DOI: 10.1080/17425255.2021.1865310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Tamoxifen is still an important drug in hormone-dependent breast cancer therapy. Personalization of its clinical use beyond hormone receptor positivity could improve the substantial variability of the treatment response.Areas covered: The overview of the current evidence for the treatment personalization using therapeutic drug monitoring, or using genetic biomarkers including CYP2D6 is provided. Although many studies focused on the PK aspects or the impact of CYP2D6 variability the translation into clinical routine is not clearly defined due to the inconsistent clinical outcome data.Expert opinion: We believe that at least the main candidate factors, i.e. CYP2D6 polymorphism, CYP2D6 inhibition, endoxifen serum levels may become important predictors of clinical relevance for tamoxifen treatment personalization in the future. To achieve this aim, however, further research should take into consideration more precise characterization of the disease, epigenetic factors and also utilize an appropriately powered multifactorial approach instead of a single gene evaluating studies.
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Affiliation(s)
- Ondřej Slanař
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolína Hronová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Olga Bartošová
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, Charles University and General University Hospital, Prague, Czech Republic
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Binkhorst L, Kloth JSL, de Wit AS, de Bruijn P, Lam MH, Chaves I, Burger H, van Alphen RJ, Hamberg P, van Schaik RHN, Jager A, Koch BCP, Wiemer EAC, van Gelder T, van der Horst GTJ, Mathijssen RHJ. Circadian variation in tamoxifen pharmacokinetics in mice and breast cancer patients. Breast Cancer Res Treat 2015; 152:119-128. [PMID: 26050156 PMCID: PMC4469299 DOI: 10.1007/s10549-015-3452-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/25/2015] [Indexed: 11/29/2022]
Abstract
The anti-estrogen tamoxifen is characterized by a large variability in response, partly due to pharmacokinetic differences. We examined circadian variation in tamoxifen pharmacokinetics in mice and breast cancer patients. Pharmacokinetic analysis was performed in mice, dosed at six different times (24-h period). Tissue samples were used for mRNA expression analysis of drug-metabolizing enzymes. In patients, a cross-over study was performed. During three 24-h periods, after tamoxifen dosing at 8 a.m., 1 p.m., and 8 p.m., for at least 4 weeks, blood samples were collected for pharmacokinetic measurements. Differences in tamoxifen pharmacokinetics between administration times were assessed. The mRNA expression of drug-metabolizing enzymes showed circadian variation in mouse tissues. Tamoxifen exposure seemed to be highest after administration at midnight. In humans, marginal differences were observed in pharmacokinetic parameters between morning and evening administration. Tamoxifen C(max )and area under the curve (AUC)0-8 h were 20 % higher (P < 0.001), and tamoxifen t(max) was shorter (2.1 vs. 8.1 h; P = 0.001), indicating variation in absorption. Systemic exposure (AUC0-24 h) to endoxifen was 15 % higher (P < 0.001) following morning administration. The results suggest that dosing time is of marginal influence on tamoxifen pharmacokinetics. Our study was not designed to detect potential changes in clinical outcome or toxicity, based on a difference in the time of administration. Circadian rhythm may be one of the many determinants of the interpatient and intrapatient pharmacokinetic variability of tamoxifen.
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Affiliation(s)
- Lisette Binkhorst
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
| | - Jacqueline S L Kloth
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Annelieke S de Wit
- Department of Genetics, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Mei H Lam
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Ines Chaves
- Department of Genetics, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Herman Burger
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robbert J van Alphen
- Department of Internal Medicine, TweeSteden Ziekenhuis, P.O. Box 90107, 5000 LA, Tilburg, Netherlands
| | - Paul Hamberg
- Department of Internal Medicine, Sint Franciscus Gasthuis, P.O. Box 10900, 3004 BA, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Erik A C Wiemer
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.,Department of Internal Medicine, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
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Binkhorst L, Mathijssen RH, Jager A, van Gelder T. Individualization of tamoxifen therapy: Much more than just CYP2D6 genotyping. Cancer Treat Rev 2015; 41:289-99. [DOI: 10.1016/j.ctrv.2015.01.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 12/30/2014] [Accepted: 01/07/2015] [Indexed: 12/12/2022]
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Carris N, Kutner S, Reilly-Rogers S. New Pharmacological Therapies for Vasomotor Symptom Management. Ann Pharmacother 2014; 48:1343-9. [DOI: 10.1177/1060028014543099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review 2 recently approved therapies for vasomotor symptoms (VMSs) of menopause. Data Sources: PubMed searches (June 2003 to May 2014) were conducted using the keywords paroxetine vasomotor and bazedoxifene vasomotor. References from relevant articles were reviewed for pertinent citations that were not identified in the PubMed search. Study Selection and Data Extraction: Phase 3 clinical trials of recently approved hormonal and nonhormonal therapies for the treatment of VMSs of menopause were selected. Studies that evaluated the use of paroxetine mesylate or bazedoxifene (BZA)/conjugated estrogens (CEs) for VMSs were included. Data Synthesis: Four studies for BZA/CEs were identified. One published report of low-dose paroxetine mesylate was identified that was a combined analysis of 2 phase 3 studies. Both agents significantly decrease the incidence of hot flushes compared with placebo and are approved for the treatment of moderate to severe VMSs associated with menopause. BZA/CEs is only approved for women with an intact uterus. In all circumstances, the use of BZA/CEs should be limited to the shortest duration possible. Paroxetine mesylate was not studied head-to-head against hormone therapy, but the magnitude of its effect on VMSs is less than expected with hormone therapy. Conclusions: BZA/CEs is an effective hormonal therapy for treating VMSs in women with an intact uterus. Paroxetine mesylate is the first nonhormonal therapy that the FDA has approved for VMSs, making both viable options for the treatment of VMSs of menopause.
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Affiliation(s)
| | - Sara Kutner
- Sarasota Memorial Hospital, Sarasota, FL, USA
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Yeh WL, Lin HY, Wu HM, Chen DR. Combination treatment of tamoxifen with risperidone in breast cancer. PLoS One 2014; 9:e98805. [PMID: 24886861 PMCID: PMC4041865 DOI: 10.1371/journal.pone.0098805] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 05/07/2014] [Indexed: 12/21/2022] Open
Abstract
Tamoxifen has long been used and still is the most commonly used endocrine therapy for treatment of both early and advanced estrogen receptor-positive breast cancer in pre- and post-menopause women. Tamoxifen exerts its cytotoxic effect primarily through cytostasis which is associated with the accumulation of cells in the G0/G1 phase of the cell cycle. Apoptotic activity can also be exerted by tamoxifen which involves cleavage of caspase 9, caspase 7, caspase 3, and poly-ADP-ribose polymerase (PARP). Down-regulation of anti-apoptotic proteins Bcl-2 and Bcl-xL and up-regulation of pro-apoptotic proteins Bax and Bak have also been observed. In addition, stress response protein of GRP 94 and GRP 78 have also been induced by tamoxifen in our study. However, side effects occur during tamoxifen treatment in breast cancer patients. Researching into combination regimen of tamoxifen and drug(s) that relieves tamoxifen-induced hot flushes is important, because drug interactions may decrease tamoxifen efficacy. Risperidone has been shown to be effective in reducing or eliminating hot flushes on women with hormonal variations. In this present study, we demonstrated that combination of tamoxifen with risperidone did not interfered tamoxifen-induced cytotoxic effects in both in vitro and in vivo models, while fluoxetine abrogated the effects of tamoxifen. This is the first paper suggesting the possibility of combination treatment of tamoxifen with risperidone in breast cancer patients, providing a conceivable resolution of tamoxifen-induced side effects without interfering the efficacy of tamoxifen against breast cancer.
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Affiliation(s)
- Wei-Lan Yeh
- Department of Cell and Tissue Engineering, Changhua Christian Hospital, Changhua, Taiwan
- * E-mail: (DRC); (WLY)
| | - Hui-Yi Lin
- School of Pharmacy, China Medical University, Taichung, Taiwan
| | - Hung-Ming Wu
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
- * E-mail: (DRC); (WLY)
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Hoeft D. An overview of clinically significant drug interactions between medications used to treat psychiatric and medical conditions. Ment Health Clin 2014. [DOI: 10.9740/mhc.n197904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prescription rates and polypharmacy are increasing, resulting in a greater potential for drug interactions. Psychiatric patients frequently have co-morbid medical conditions, which further increases the risk of polypharmacy and drug interactions. Drug interactions that affect drugs with narrow therapeutic windowsare of particular concern. This review presents some of these drug interactions and provides strategies for identifying and resolving them.
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Affiliation(s)
- Dawn Hoeft
- Clinical Pharmacy Specialist, Psychiatry, The University of Minnesota Medical Center, Fairview West Bank Campus
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Pajares B, Torres E, Trigo JM, Sáez MI, Ribelles N, Jiménez B, Alba E. Tyrosine kinase inhibitors and drug interactions: a review with practical recommendations. Clin Transl Oncol 2012; 14:94-101. [DOI: 10.1007/s12094-012-0767-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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de Graan AJM, Teunissen SF, de Vos FY, Loos WJ, van Schaik RH, de Jongh FE, de Vos AI, van Alphen RJ, van der Holt B, Verweij J, Seynaeve C, Beijnen JH, Mathijssen RH. Dextromethorphan As a Phenotyping Test to Predict Endoxifen Exposure in Patients on Tamoxifen Treatment. J Clin Oncol 2011; 29:3240-6. [DOI: 10.1200/jco.2010.32.9839] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose Tamoxifen, a widely used agent for the prevention and treatment of breast cancer, is mainly metabolized by CYP2D6 and CYP3A to form its most abundant active metabolite, endoxifen. Interpatient variability in toxicity and efficacy of tamoxifen is substantial. Contradictory results on the value of CYP2D6 genotyping to reduce the variable efficacy have been reported. In this pharmacokinetic study, we investigated the value of dextromethorphan, a known probe drug for both CYP2D6 and CYP3A enzymatic activity, as a potential phenotyping probe for tamoxifen pharmacokinetics. Methods In this prospective study, 40 women using tamoxifen for invasive breast cancer received a single dose of dextromethorphan 2 hours after tamoxifen intake. Dextromethorphan, tamoxifen, and their respective metabolites were quantified. Exposure parameters of all compounds were estimated, log transformed, and subsequently correlated. Results A strong and highly significant correlation (r = −0.72; P < .001) was found between the exposures of dextromethorphan (0 to 6 hours) and endoxifen (0 to 24 hours). Also, the area under the plasma concentration–time curve of dextromethorphan (0 to 6 hours) and daily trough endoxifen concentration was strongly correlated (r = −0.70; P < .001). In a single patient using the potent CYP2D6 inhibitor paroxetine, the low endoxifen concentration was accurately predicted by dextromethorphan exposure. Conclusion Dextromethorphan exposure after a single administration adequately predicted endoxifen exposure in individual patients with breast cancer taking tamoxifen. This test could contribute to the personalization and optimization of tamoxifen treatment, but it needs additional validation and simplification before being applicable in future dosing strategies.
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Affiliation(s)
- Anne-Joy M. de Graan
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Sebastiaan F. Teunissen
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Filip Y.F.L. de Vos
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Walter J. Loos
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Ron H.N. van Schaik
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Felix E. de Jongh
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Aad I. de Vos
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Robbert J. van Alphen
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Bronno van der Holt
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Jaap Verweij
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Caroline Seynaeve
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Jos H. Beijnen
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
| | - Ron H.J. Mathijssen
- Anne-Joy M. de Graan, Filip Y.F.L. de Vos, Walter J. Loos, Bronno van der Holt, Jaap Verweij, Caroline Seynaeve, Ron H.J. Mathijssen, Erasmus Medical Center–Daniel den Hood Cancer Center, University Medical Center; Ron H.N. van Schaik, Erasmus Medical Center; Felix E. de Jongh, Ikazia Hospital, Rotterdam; Sebastiaan F. Teunissen, Jos H. Beijnen, Slotervaart Hospital, Amsterdam; Aad I. de Vos, Admiraal De Ruyter Hospital, Goes; and Robbert J. van Alphen, Medical Spectrum Twente, Enschede, the Netherlands
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Irvin WJ, Walko CM, Weck KE, Ibrahim JG, Chiu WK, Dees EC, Moore SG, Olajide OA, Graham ML, Canale ST, Raab RE, Corso SW, Peppercorn JM, Anderson SM, Friedman KJ, Ogburn ET, Desta Z, Flockhart DA, McLeod HL, Evans JP, Carey LA. Genotype-guided tamoxifen dosing increases active metabolite exposure in women with reduced CYP2D6 metabolism: a multicenter study. J Clin Oncol 2011; 29:3232-9. [PMID: 21768473 DOI: 10.1200/jco.2010.31.4427] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE We examined the feasibility of using CYP2D6 genotyping to determine optimal tamoxifen dose and investigated whether the key active tamoxifen metabolite, endoxifen, could be increased by genotype-guided tamoxifen dosing in patients with intermediate CYP2D6 metabolism. PATIENTS AND METHODS One hundred nineteen patients on tamoxifen 20 mg daily ≥ 4 months and not on any strong CYP2D6 inhibiting medications were assayed for CYP2D6 genotype and plasma tamoxifen metabolite concentrations. Patients found to be CYP2D6 extensive metabolizers (EM) remained on 20 mg and those found to be intermediate (IM) or poor (PM) metabolizers were increased to 40 mg daily. Eighty-nine evaluable patients had tamoxifen metabolite measurements repeated 4 months later. RESULTS As expected, the median baseline endoxifen concentration was higher in EM (34.3 ng/mL) compared with either IM (18.5 ng/mL; P = .0045) or PM (4.2 ng/mL; P < .001). When the dose was increased from 20 mg to 40 mg in IM and PM patients, the endoxifen concentration rose significantly; in IM there was a median intrapatient change from baseline of +7.6 ng/mL (-0.6 to 23.9; P < .001), and in PM there was a change of +6.1 ng/mL (2.6 to 12.5; P = .020). After the dose increase, there was no longer a significant difference in endoxifen concentrations between EM and IM patients (P = .84); however, the PM endoxifen concentration was still significantly lower. CONCLUSION This study demonstrates the feasibility of genotype-driven tamoxifen dosing and demonstrates that doubling the tamoxifen dose can increase endoxifen concentrations in IM and PM patients.
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Affiliation(s)
- William J Irvin
- University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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de Souza JA, Olopade OI. CYP2D6 genotyping and tamoxifen: an unfinished story in the quest for personalized medicine. Semin Oncol 2011; 38:263-73. [PMID: 21421116 DOI: 10.1053/j.seminoncol.2011.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The philosophy behind personalized medicine is that each patient has a unique biologic profile that should guide the choice of therapy, resulting in an improved treatment outcome, ideally with reduced toxicity. Thus, there has been increasing interest in identifying genetic variations that are predictive of a drug's efficacy or toxicity. Although it is one of the most effective drugs for treating breast cancer, tamoxifen is not effective in all estrogen receptor (ER)-positive breast cancer patients, and it is frequently associated with side effects, such as hot flashes. Relative resistance to tamoxifen treatment may be a result, in part, from impaired drug activation by cytochrome P450 2D6 (CYP2D6). Indeed, recent studies have identified allelic variations in CYP2D6 to be an important determinant of tamoxifen's activity (and toxicity). This article will summarize the current information regarding the influence of the major genotypes and CYP2D6 inhibitors on tamoxifen metabolism, with a focus on its clinical utility and the current level of evidence for CYP2D6 genotyping of patients who are candidates for tamoxifen treatment.
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Affiliation(s)
- Jonas A de Souza
- Department of Medicine, The University of Chicago Comprehensive Cancer Center, Chicago, IL 60637, USA
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Abstract
The selective estrogen receptor modulator tamoxifen has been used for more than three decades for the treatment, and more recently prevention, of breast cancer in women of all ages. The conversion of tamoxifen to active metabolites involves several cytochrome P450 (CYP) enzymes. CYP2D6 is the key enzyme responsible for the conversion of N-desmethyl tamoxifen to endoxifen. Single nucleotide polymorphisms in the CYP2D6 gene are not uncommon, and some alleles code for enzymes with reduced, null, or increased activity. Multiple studies suggest that women who carry one or two variant CYP2D6 alleles that encode enzymes with null or reduced activity may have an inferior breast cancer outcome when treated with tamoxifen in the adjuvant setting compared to women carrying two alleles encoding an enzyme with normal activity. Unfortunately, the data are not uniformly concordant, and definitive evidence that would change routine clinical practice is not yet available. CYP2D6 activity can also be reduced by concomitant use of drugs that inhibit the enzyme, including antidepressants used for psychiatric conditions or to relieve hot flashes, and these should be avoided in tamoxifen users whenever possible. Emerging data suggest that host factors may also predict interpatient variability in response to aromatase inhibitors.
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Affiliation(s)
- Michaela J Higgins
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02114, USA.
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Bai JPF, Pacanowski M, Rahman A, Lesko LL. The Impact of Pharmacogenetics on the Clinical Outcomes of Prodrugs. PRODRUGS AND TARGETED DELIVERY 2011. [DOI: 10.1002/9783527633166.ch16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Dezentjé VO, van Blijderveen NJ, Gelderblom H, Putter H, van Herk-Sukel MP, Casparie MK, Egberts AC, Nortier JW, Guchelaar HJ. Reply to R. Ferraldeschi et al. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.30.3057] [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)
| | | | | | - Hein Putter
- Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Antoine C.G. Egberts
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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Cronin-Fenton D, Lash TL, Sørensen HT. Selective serotonin reuptake inhibitors and adjuvant tamoxifen therapy: risk of breast cancer recurrence and mortality. Future Oncol 2010; 6:877-80. [PMID: 20528223 DOI: 10.2217/fon.10.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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15
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Ferraldeschi R, Howell SJ, Thompson AM, Newman WG. Avoidance of CYP2D6 inhibitors in patients receiving tamoxifen. J Clin Oncol 2010; 28:e584-5; author reply e586. [PMID: 20823421 DOI: 10.1200/jco.2010.30.1887] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Lammers LA, Mathijssen RHJ, van Gelder T, Bijl MJ, de Graan AJM, Seynaeve C, van Fessem MA, Berns EM, Vulto AG, van Schaik RHN. The impact of CYP2D6-predicted phenotype on tamoxifen treatment outcome in patients with metastatic breast cancer. Br J Cancer 2010; 103:765-71. [PMID: 20700120 PMCID: PMC2966615 DOI: 10.1038/sj.bjc.6605800] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Cytochrome P450 2D6 (CYP2D6) has a crucial role in the metabolic conversion of tamoxifen into the active metabolite endoxifen. In this cohort study, the effect of CYP2D6-predicted phenotype, defined as the combined effect of CYP2D6 genetic variation and concomitant use of CYP2D6-inhibiting medication, on time to breast cancer progression (TTP) and overall survival (OS) in women who use tamoxifen for metastatic breast cancer (MBC) was examined. Methods: We selected patients treated with tamoxifen (40 mg per day) for hormone receptor-positive MBC from whom a blood sample for pharmacogenetic analysis (CYP2D6*3, *4, *5, *6, *10 and *41) was available. Patient charts (n=102) were reviewed to assess TTP and OS, and to determine whether CYP2D6 inhibitors were prescribed during tamoxifen treatment. Results: OS was significantly shorter in patients with a poor CYP2D6 metaboliser phenotype, compared with extensive metabolisers (HR=2.09; P=0.034; 95% CI: 1.06–4.12). Co-administration of CYP2D6 inhibitors alone was also associated with a worse OS (HR=3.55; P=0.002; 95% CI: 1.59–7.96) and TTP (HR=2.97; P=0.008; 95% CI: 1.33–6.67) compared with patients without CYP2D6 inhibitors. Conclusion: CYP2D6 phenotype is an important predictor of treatment outcome in women who are receiving tamoxifen for MBC. Co-administration of CYP2D6 inhibitors worsens treatment outcome of tamoxifen and should therefore be handled with care.
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Affiliation(s)
- L A Lammers
- Department of Hospital Pharmacy, Erasmus MC, University Hospital, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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17
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Barton DL, LaVasseur BI, Sloan JA, Stawis AN, Flynn KA, Dyar M, Johnson DB, Atherton PJ, Diekmann B, Loprinzi CL. Phase III, placebo-controlled trial of three doses of citalopram for the treatment of hot flashes: NCCTG trial N05C9. J Clin Oncol 2010; 28:3278-83. [PMID: 20498389 PMCID: PMC2903326 DOI: 10.1200/jco.2009.26.6379] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 03/15/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Up to 75% of women experience hot flashes, which can negatively impact quality of life. As hot flash physiology is not definitively understood, it cannot be assumed that effective agents represent class effects. Therefore, there is a continued need for rigorous evaluation to identify effective nonhormonal options for hot flash relief. METHODS A randomized, double-blind trial evaluated citalopram at target doses of 10, 20, or 30 mg/d versus placebo for 6 weeks. Postmenopausal women with at least 14 bothersome hot flashes per week recorded hot flashes for 7 days before starting treatment and were then titrated to their target doses. The primary end point was the change from baseline to 6 weeks in hot flash score. RESULTS Two hundred fifty-four women were randomly assigned onto this study. Data for hot flash scores and frequencies showed significant improvement in hot flashes with citalopram over placebo, with no significant differences among doses. Reductions in mean hot flash scores were 2.0 (23%), 7.0 (49%), 7.7 (50%), and 10.7 (55%) for placebo and 10, 20, and 30 mg of citalopram, respectively (P CONCLUSION Citalopram is an effective, well-tolerated agent in managing hot flashes. There does not appear to be a significant dose response above 10 mg/d, but broader helpful effects of the agent appear to be more evident at 20 mg/d.
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18
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Sideras K, Ingle JN, Ames MM, Loprinzi CL, Mrazek DP, Black JL, Weinshilboum RM, Hawse JR, Spelsberg TC, Goetz MP. Coprescription of tamoxifen and medications that inhibit CYP2D6. J Clin Oncol 2010; 28:2768-76. [PMID: 20439629 PMCID: PMC2881853 DOI: 10.1200/jco.2009.23.8931] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 11/18/2009] [Indexed: 12/14/2022] Open
Abstract
Evidence has emerged that the clinical benefit of tamoxifen is related to the functional status of the hepatic metabolizing enzyme cytochrome P450 2D6 (CYP2D6). CYP2D6 is the key enzyme responsible for the generation of the potent tamoxifen metabolite, endoxifen. Multiple studies have examined the relationship of CYP2D6 status to breast cancer outcomes in tamoxifen-treated women; the majority of studies demonstrated that women with impaired CYP2D6 metabolism have lower endoxifen concentrations and a greater risk of breast cancer recurrence. As a result, practitioners must be aware that some of the most commonly prescribed medications coadministered with tamoxifen interfere with CYP2D6 function, thereby reducing endoxifen concentrations and potentially increasing the risk of breast cancer recurrence. After reviewing the published data regarding tamoxifen metabolism and the evidence relating CYP2D6 status to breast cancer outcomes in tamoxifen-treated patients, we are providing a guide for the use of medications that inhibit CYP2D6 in patients administered tamoxifen.
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Affiliation(s)
- Kostandinos Sideras
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - James N. Ingle
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Matthew M. Ames
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Charles L. Loprinzi
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - David P. Mrazek
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - John L. Black
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Richard M. Weinshilboum
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - John R. Hawse
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Thomas C. Spelsberg
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Matthew P. Goetz
- From the Departments of Oncology, Molecular Pharmacology and Experimental Therapeutics, Psychiatry, and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
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Seruga B, Amir E. Cytochrome P450 2D6 and outcomes of adjuvant tamoxifen therapy: results of a meta-analysis. Breast Cancer Res Treat 2010; 122:609-17. [PMID: 20454926 DOI: 10.1007/s10549-010-0902-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 04/16/2010] [Indexed: 10/19/2022]
Abstract
Pharmacological evidence shows that cytochrome P450 2D6 (CYP2D6) function is important in the conversion of tamoxifen to its active metabolites. Many retrospective analyses have assessed the role of both CYP2D6 genotype and concurrent administration of drug inhibitors of CYP2D6 on outcome of tamoxifen therapy. These studies have frequently been of small size and their data highly variable. A published data meta-analysis of trials evaluating outcomes of tamoxifen therapy in early breast cancer was undertaken. Hazard ratios (HRs) were extracted for disease-free survival (DFS) and overall survival (OS). Pooled estimates were computed using inverse-variance and random-effect modeling. Data from 10 studies assessing CYP2D6 genotype were included in a meta-analysis. There was significant heterogeneity in the definition of comparison groups between studies. When compared to reduced CYP2D6 function, normal function was associated with a trend toward improved DFS (HR 2.07, 95% CI 0.96-4.49, P = 0.06) but not OS (HR 1.36, 95% CI 0.73-2.52, P = 0.34). Pooling of data from two studies evaluating CYP2D6 drug inhibitors showed that concomitant administration of these with tamoxifen was associated with a non-significant association with DFS (HR 1.37, 95% CI 0.69-2.73, P = 0.37). Analysis of the effect of CYP2D6 drug inhibitors on OS was not possible. The effect of CYP2D6 genotype on breast cancer seems to be relatively small and may not warrant testing of CYP2D6 genotype in all women with hormone receptor positive breast cancer. The effect of CYP2D6 genotype on outcome in low-risk patients may not be clinically relevant, while the upfront use of aromatase inhibitors is a reasonable alternative to tamoxifen in high-risk post-menopausal women, irrespective of CYP2D6 genotype. There are limited data supporting the association of potent inhibitors of CYP2D6 and detrimental outcome, but avoidance of such drugs seems reasonable.
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Affiliation(s)
- Bostjan Seruga
- Division of Medical Oncology and Hematology, Princess Margaret Hospital and University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9, Canada
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20
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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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Dezentjé VO, van Blijderveen NJC, Gelderblom H, Putter H, van Herk-Sukel MPP, Casparie MK, Egberts ACG, Nortier JWR, Guchelaar HJ. Effect of concomitant CYP2D6 inhibitor use and tamoxifen adherence on breast cancer recurrence in early-stage breast cancer. J Clin Oncol 2010; 28:2423-9. [PMID: 20385997 DOI: 10.1200/jco.2009.25.0894] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The use of cytochrome P450 2D6-inhibiting drugs (CYP2D6 inhibitors) during tamoxifen treatment leads to a decrease in plasma concentration of endoxifen, the major active tamoxifen metabolite. Concomitant use of CYP2D6 inhibitors, such as selective serotonin reuptake inhibitors, as well as low tamoxifen adherence may negatively impact tamoxifen efficacy in patients with breast cancer. The objectives of this study were to relate concomitant CYP2D6 inhibitor use and tamoxifen adherence to breast cancer event-free time (EFT). PATIENTS AND METHODS Data were from PHARMO and included a community pharmacy dispensing database; PALGA, a nationwide pathology database; and the Dutch Medical Register in the Netherlands. Patients with breast cancer treated with adjuvant tamoxifen between 1994 and 2006 were included. A Cox proportional hazards model with a time-dependent definition for concomitant CYP2D6 inhibitor exposure was used. Adherence calculated over the first year after tamoxifen initiation was related to breast cancer events in the following period. RESULTS In total, 1,962 patients with breast cancer using tamoxifen were included, among whom 150 (7.6%) frequently used a CYP2D6 inhibitor during tamoxifen treatment. No association between concomitant CYP2D6 inhibitor use and breast cancer recurrence was observed (adjusted hazard ratio [HR], 0.87; 95% CI, 0.42 to 1.79; P = .69). Poor tamoxifen adherence was associated with lower EFT (adjusted HR, 0.987; 95% CI, 0.975 to 0.999; P = .029). CONCLUSION This observational study did not show an association between concomitant CYP2D6 inhibitor use and breast cancer recurrence among patients treated with adjuvant tamoxifen despite the strong biologic rationale. This study shows, to the best of our knowledge for the first time, that poor tamoxifen adherence is associated with an increased risk of breast cancer events.
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Affiliation(s)
- Vincent O Dezentjé
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
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Lash TL, Rosenberg CL. Evidence and practice regarding the role for CYP2D6 inhibition in decisions about tamoxifen therapy. J Clin Oncol 2010; 28:1273-5. [PMID: 20124162 DOI: 10.1200/jco.2009.26.7906] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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23
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Higgins MJ, Stearns V. CYP2D6 Polymorphisms and Tamoxifen Metabolism: Clinical Relevance. Curr Oncol Rep 2010; 12:7-15. [DOI: 10.1007/s11912-009-0076-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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