1
|
Lin J, Zheng S, Liu Q. Incomplete ovarian function suppression in premenopausal breast cancer patients treated with gonadotropin-releasing hormone agonists. Cancer Treat Rev 2025; 133:102879. [PMID: 39793457 DOI: 10.1016/j.ctrv.2025.102879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 12/22/2024] [Accepted: 01/02/2025] [Indexed: 01/13/2025]
Abstract
BACKGROUND Ovarian function suppression (OFS) has emerged as a crucial adjuvant therapy for premenopausal breast cancer patients. Some patients fail to achieve complete OFS with commonly used OFS drugs. The definition of incomplete OFS remains unclear, and large-scale data on its incidence are lacking. This review provides a comprehensive overview of the definition, occurrence, impact on therapeutic efficacy and corresponding treatment measures for incomplete OFS. METHODS We searched PubMed, Embase and Cochrane Library databases in recent twenty years with keywords as "ovarian function escape", "incomplete OFS" and "estrogen breakthrough", and carried out a snowballing of references to important literature. Clinical literature of premenopausal breast cancer patients treated with OFS was screened. The patient characteristics, definition and incidence of incomplete OFS, prognosis, interventions and other information were extracted. RESULTS A total of 17 studies were included in the analysis, including RCTs, retrospective or prospective cohort studies and case reports. Literature indicates that the incidence of incomplete OFS is around 5-50 % when the estradiol (E2) threshold is set as 2.72 pg/mL, 10 pg/mL, 20 pg/mL, or 30 pg/mL. Young age, high body mass index (BMI), and no prior chemotherapy were the risk factors for incomplete OFS. The treatment of incomplete OFS included dose adjustments, alternative OFS drugs, or the adoption of other OFS measures. CONCLUSIONS The incomplete OFS rate decreased with the extension of treatment time. It is reasonable to monitor E2 levels to ensure successful OFS in the patients with high risk factors for incomplete OFS or with concurrent use of aromatase inhibitor (AI). Transient incomplete OFS seems to have no impact on prognosis, but sustained incomplete OFS needs personalized adjustment of treatment strategy to ensure complete OFS.
Collapse
Affiliation(s)
- Jinna Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China; Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China
| | - Shuqi Zheng
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China; Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China
| | - Qiang Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China; Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 510120 Guangzhou, China.
| |
Collapse
|
2
|
Dai S, Wu X, Huang X, Li J, Wang X, Wang S, Tang J, Shi Y, Xie X, Xu F, Liu P, Huang J, Xie X, An X, Chen M, Hong R, Xia W, Zheng Q, Jiang K, Zhong Y, Yuan Z, Huang Y, Bi X, Xue C. Clinical significance of serum estradiol monitoring in women receiving adjuvant aromatase inhibitor for hormone receptor-positive early breast cancer. Breast 2024; 78:103818. [PMID: 39357125 PMCID: PMC11480241 DOI: 10.1016/j.breast.2024.103818] [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: 06/22/2024] [Revised: 08/05/2024] [Accepted: 09/28/2024] [Indexed: 10/04/2024] Open
Abstract
PURPOSE The limited understanding of long-term estradiol (E2) suppression poses challenges to the effectiveness of adjuvant therapy with aromatase inhibitors (AI), necessitating comprehensive serum E2 monitoring to address this issue. Therefore, our objective was to investigate serum E2 levels in women undergoing adjuvant AI treatment and evaluate the significance of such monitoring. PATIENTS AND METHODS In this prospective cohort study, we recruited women who had received adjuvant AI treatment, including those who underwent ovarian function suppression (OFS). Serum E2 levels were measured using high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). The primary endpoint was the proportion of women with E2 levels exceeding 2.72 pg/mL, indicating inadequate suppression achieved with AI therapy. RESULTS A total of 706 patients were enrolled, including 482 women with OFS in combination with AI. Among them, 116 women (16.4 %) exhibited E2 levels exceeding 2.72 pg/mL. The majority of serum E2 elevations (77.6 %) occurred within the first two years of initiating endocrine therapy. Younger age, no prior chemotherapy, shorter duration of the current treatment regimen, and lower follicle stimulating hormone (FSH) levels were associated with inadequate E2 suppression. Serum E2 concentrations demonstrated dynamic variations and occasional rebound following adjuvant AI therapy. CONCLUSIONS Despite receiving adjuvant AI treatment for nearly two years, a certain proportion of patients failed to achieve the adequate threshold of E2 suppression. Our findings emphasize the significance of monitoring serum E2 levels during adjuvant AI therapy, particularly within the first two years. Further research is imperative to facilitate a more comprehensive comprehension of E2 monitoring.
Collapse
Affiliation(s)
- Shuqin Dai
- Department of Medicine Laboratory, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xingping Wu
- Department of Medicine Laboratory, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xuefang Huang
- Department of Clinic, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jibin Li
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xi Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Shusen Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jun Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yanxia Shi
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xiaoming Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Fei Xu
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Peng Liu
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Jiajia Huang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xinhua Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xin An
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Meiting Chen
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Rouxi Hong
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Wen Xia
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Qiufan Zheng
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Kuikui Jiang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yongyi Zhong
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Zhongyu Yuan
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Yuanyuan Huang
- Department of VIP Inpatient, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Xiwen Bi
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China
| | - Cong Xue
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, PR China.
| |
Collapse
|
3
|
McCann KE, Goldfarb SB, Traina TA, Regan MM, Vidula N, Kaklamani V. Selection of appropriate biomarkers to monitor effectiveness of ovarian function suppression in pre-menopausal patients with ER+ breast cancer. NPJ Breast Cancer 2024; 10:8. [PMID: 38242892 PMCID: PMC10798954 DOI: 10.1038/s41523-024-00614-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
Use of gonadotropin-releasing hormone (GnRH) agonists has been widely adopted to provide reversible ovarian function suppression for pre-menopausal breast cancer patients who are also receiving aromatase inhibitor or tamoxifen therapy based on results of 25 randomized trials representing almost 15,000 women demonstrating a survival benefit with this approach. Past clinical trials designed to establish the efficacy of GnRH agonists have monitored testosterone in the prostate cancer setting and estradiol in the breast cancer setting. We explore the merits of various biomarkers including estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) and their utility for informing GnRH agonist treatment decisions in breast cancer. Estradiol remains our biomarker of choice in ensuring adequate ovarian function suppression with GnRH agonist therapy among pre-menopausal women with breast cancer. We recommend future trials to continue to focus on estradiol levels as the primary endpoint, as they have in the past.
Collapse
Affiliation(s)
- Kelly E McCann
- University of California Los Angeles Medical Center, Los Angeles, CA, 90095, USA
| | - Shari B Goldfarb
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tiffany A Traina
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Meredith M Regan
- Dana Farber Cancer Institute / Harvard Medical School, Boston, MA, 02215, USA
| | | | - Virginia Kaklamani
- University of Texas Health Sciences Center San Antonio / MD Anderson Cancer Center, San Antonio, TX, 78229, USA.
| |
Collapse
|
4
|
Gupta A, Bandaru S, Manthri S. Goserelin Ovarian Ablation Failure in Premenopausal Women With Breast Cancer. Cureus 2021; 13:e19608. [PMID: 34956746 PMCID: PMC8674405 DOI: 10.7759/cureus.19608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
Breast cancer is the most prevalent cancer known worldwide in women. It is a heterogeneous, phenotypically diverse disease composed of several biologic subtypes that have distinct behavior and response to therapy. Hormone receptor-positive (i.e., estrogen [ER] and/or progesterone [PR] receptor-positive) breast cancers comprise the most common types of breast cancer, accounting for 75% of all cases. This makes endocrine therapy the standardized treatment for patients with ER+/PR+ breast cancer. Drugs that block estrogen receptors or that lower estrogen levels are the mainstay of treatment. High-risk patients benefit from the addition of ovarian function suppression (OFS)/ablation to either an aromatase inhibitor (AI) or tamoxifen. This case report discusses a 36-year-old premenopausal female who presented with an abnormal right breast lump in the upper outer quadrant of the right breast. Due to high suspicion of malignancy, a biopsy was performed which showed features of both lobular and ductal carcinoma with ER and PR positivity, HER 2 was negative. The patient underwent mastectomy with axillary lymph node removal due to concern for multifocal disease. No clinically relevant genetic mutations were present. Oncotype DX breast recurrence score was 16 and no chemotherapy was offered. Due to large tumor size, young age OFS with goserelin 3.6mg/28 days and letrozole 2.5 mg once daily was recommended. After 16 months of treatment, the patient developed a failure of goserelin-induced ovarian suppression. This case report highlights the possibility of the development of hormonal resistance after long-term use of goserelin.
Collapse
Affiliation(s)
- Aanchal Gupta
- Internal Medicine, Faculty of Medicine, St. Martinus University, Willemstad, CUW
| | - Sindhura Bandaru
- Internal Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | | |
Collapse
|
5
|
Affiliation(s)
- Harold J Burstein
- From the Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Harvard Medical School - all in Boston
| |
Collapse
|
6
|
Coyne K, Silverman P, Liu JH. Oral GnRH Antagonist Ovarian Suppression After Escape From GnRH Agonist in Breast Cancer Patients. Clin Breast Cancer 2020; 20:e551-e554. [PMID: 32616435 DOI: 10.1016/j.clbc.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/01/2020] [Accepted: 05/18/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Kathryn Coyne
- Department of Obstetrics and Gynecology, University Hospital MacDonald Women's Hospital, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Paula Silverman
- Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, OH
| | - James H Liu
- Department of Obstetrics and Gynecology, University Hospital MacDonald Women's Hospital, University Hospital Cleveland Medical Center, Cleveland, OH.
| |
Collapse
|
7
|
Bertelsen BE, Kellmann R, Viste K, Bjørnevik AT, Eikesdal HP, Lønning PE, Sagen JV, Almås B. An Ultrasensitive Routine LC-MS/MS Method for Estradiol and Estrone in the Clinically Relevant Sub-Picomolar Range. J Endocr Soc 2020; 4:bvaa047. [PMID: 32500111 PMCID: PMC7252770 DOI: 10.1210/jendso/bvaa047] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/20/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Current analytical routine methods lack the sensitivity to monitor plasma estrogen levels in breast cancer patients treated with aromatase inhibitors. Such monitoring is warranted for premenopausal patients treated with an aromatase inhibitor and an LH-releasing hormone analogue in particular. Therefore, we aimed to develop a routine tandem mass spectroscopy combined with liquid chromatography (LC-MS/MS) method for estradiol (E2) and estrone (E1) for use in the sub-picomolar range. METHOD Calibrators, quality controls (QC), or serum samples were spiked with isotope-labeled internal standard and purified by liquid-liquid extraction. The reconstituted extracts were analyzed by LC-MS/MS in negative electrospray ionization mode. QCs at 6 levels made from pooled patient sera were used to validate the accuracy, sensitivity, and precision of the method. RESULTS We achieved limits of quantification of 0.6 pmol/L (0.16 pg/mL) for E2 and 0.3 pmol/L (0.07 pg/mL) for E1. The coefficient of variation was below 9.0% at all QC levels for E2 (range, 1.7-153 pmol/L), and below 7.8% for E1 (range, 1.7-143 pmol/L). The method is traceable to the E2 reference standard BCR576. Reference ranges for E2 and E1 in healthy, postmenopausal women were obtained, for E2: 3.8 to 36 pmol/L, for E1: 22 to 122 pmol/L. We measured and confirmed ultra-low E2 and E1 concentrations in sera from patients on the aromatase inhibitors letrozole or exemestane. CONCLUSION This ultrasensitive LC-MS/MS method is suitable for routine assessment of serum E1 and E2 levels in breast cancer patients during estrogen suppression therapy. The method satisfies all requirements for measurement of E2 in the clinical setting as stated by the Endocrine Society in 2013. PRECIS We report an ultrasensitive LCMS/MS routine assay that measures pretreatment and suppressed levels of estradiol/estrone during aromatase inhibitor treatment of postmenopausal breast cancer patients.
Collapse
Affiliation(s)
| | - Ralf Kellmann
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | - Kristin Viste
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | | | - Hans Petter Eikesdal
- Department of Oncology Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Per Eystein Lønning
- Department of Oncology Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Jørn V Sagen
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Bjørg Almås
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
8
|
Impact of ovarian function suppression in premenopausal women with estrogen receptor-positive early breast cancer. Curr Opin Oncol 2020; 31:43-51. [PMID: 30299291 DOI: 10.1097/cco.0000000000000491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This manuscript aims at providing an updated overview on the role of adding ovarian function suppression to tamoxifen or an aromatase inhibitor as adjuvant endocrine therapy in premenopausal women with estrogen receptor-positive early breast cancer. RECENT FINDINGS Until recently, tamoxifen alone was the only recommended adjuvant treatment option for premenopausal women with estrogen receptor-positive disease. However, recent important evidence has contributed to significantly modify the endocrine treatment landscape in this setting. SUMMARY With the only exception of patients with low-risk clinical-pathological features characterized by excellent survival outcomes with tamoxifen alone, the use of ovarian function suppression is to be considered standard of care for most of premenopausal women with estrogen receptor-positive disease. Regarding the choice of its best partner as endocrine agent, the available data suggest that the higher the risk of disease recurrence the larger benefit can be observed with a more profound estrogen deprivation that can be obtained with ovarian function suppression and an aromatase inhibitor as compared to ovarian function suppression and tamoxifen. Despite the significant improvement in our understanding on the role of ovarian function suppression in this setting, several unanswered questions remain and further research efforts are needed in the field.
Collapse
|
9
|
Abbas W, Rao RR. Revisiting adjuvant ovarian suppression in premenopausal breast cancer patients. Indian J Cancer 2019; 56:293-296. [PMID: 31607695 DOI: 10.4103/ijc.ijc_697_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Adjuvant ovarian suppression, on addition to chemotherapy, reduces the risk of breast cancer in pre-menopausal women after surgery and adjuvant hormonal therapy. Suppression of Ovarian Function Trial (SOFT) and Tamoxifen and Exemestane Trial (TEXT) showed greater benefit with exemestane in high risk females in comparison to Tamoxifen. Ovarian Function Suppression (OFS) and exemestane became the standard of care, with 30% patients experiencing grade 3 and more side effects. Much higher benefit was seen in high risk group. But there are concerns about incomplete OFS (estrogen escape) with exemestane plus OFS. Updated analysis of TEXT AND SOFT showed better survival benefit with OFS plus Tamoxifen as compared to OFS plus exemestane. Overall survival is a better end point. Should preference be given to Tamoxifen over exemestane? Further research is required to get the final answer.
Collapse
Affiliation(s)
- Waseem Abbas
- Department of Medical Oncology, Max Institute of Cancer Care, Shalimar Bagh, New Delhi, India
| | - Ranga Raju Rao
- Department of Medical Oncology, Max Institute of Cancer Care, Shalimar Bagh, New Delhi, India
| |
Collapse
|
10
|
Pan K, Bosserman LD, Chlebowski RT. Ovarian Suppression in Adjuvant Endocrine Therapy for Premenopausal Breast Cancer. J Clin Oncol 2019; 37:858-861. [PMID: 30742565 DOI: 10.1200/jco.18.01360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathy Pan
- 1 Los Angeles Biomedical Research Institute, Torrance, CA
| | | | | |
Collapse
|
11
|
Bardia A, Hurvitz S. Targeted Therapy for Premenopausal Women with HR +, HER2 - Advanced Breast Cancer: Focus on Special Considerations and Latest Advances. Clin Cancer Res 2018; 24:5206-5218. [PMID: 29884743 DOI: 10.1158/1078-0432.ccr-18-0162] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/12/2018] [Accepted: 06/06/2018] [Indexed: 11/16/2022]
Abstract
The incidence of advanced breast cancer in premenopausal women is increasing, and breast cancer in younger women is often more aggressive and has a worse prognosis compared with breast cancer in older women. Premenopausal women with hormone receptor-positive (HR+) breast cancer are frequently under-represented in clinical trials, and treatment strategies in the premenopausal setting are usually extrapolated from data from postmenopausal patients, with the addition of ovarian function suppression to endocrine therapy in HR+ disease. However, the underlying biology of breast cancer in premenopausal women can be different from postmenopausal women, and treatment strategies should ideally be specifically tested in premenopausal patients. Recent phase III trials have now investigated cyclin-dependent kinase 4/6 (CDK4/6) inhibitors in premenopausal patients with HR+, HER2- advanced breast cancer: Palbociclib and abemaciclib have been tested in a subset of premenopausal patients in the PALOMA-3 and MONARCH-2 studies, and ribociclib has been tested in the phase III MONALEESA-7 trial, which was entirely dedicated to premenopausal women. This comprehensive review summarizes the differences in the biology of HR+, HER2- breast cancer in the premenopausal population compared with the postmenopausal population; discusses special considerations for treatment of premenopausal women; and reviews the evidence from clinical trials investigating endocrine therapy, other targeted treatments, and ovarian function suppression in the HR+, HER2- advanced breast cancer setting. Clin Cancer Res; 24(21); 5206-18. ©2018 AACR.
Collapse
Affiliation(s)
- Aditya Bardia
- Massachusetts General Hospital Cancer Center/Harvard Medical School, Boston, Massachusetts.
| | - Sara Hurvitz
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, California
| |
Collapse
|
12
|
Haynes BP, Ginsburg O, Gao Q, Folkerd E, Afentakis M, Quang LH, Han PT, Khoa PH, Dinh NV, To TV, Clemons M, Smith IE, Dowsett M. Molecular changes in premenopausal oestrogen receptor-positive primary breast cancer in Vietnamese women after oophorectomy. NPJ Breast Cancer 2017; 3:47. [PMID: 29214214 PMCID: PMC5703856 DOI: 10.1038/s41523-017-0049-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/20/2017] [Accepted: 11/01/2017] [Indexed: 12/16/2022] Open
Abstract
For premenopausal women with primary ER + breast cancer, oophorectomy (OvX) is an evidence-based cost-effective option and is standard treatment in many countries. However, there is virtually no data describing the effects of OvX on breast tumour biology. We therefore, characterised the endocrine and genome-wide transcriptional impact of OvX in 56 premenopausal women with ER + breast cancer for 2 weeks prior to mastectomy. Plasma estradiol concentrations decreased from 406 ± 41 to 20.7 ± 2.6 pmol/l (mean ± sem) 24 h after OvX, and to 8.1 ± 0.8 pmol/l 2 weeks later at mastectomy. Ki67 decreased in 33/36 (91.7%) tumours. The expression of 655 genes changed significantly (FDR < 1%) with an absolute mean fold-change (FC) ≥ 1.25 (257 up, 398 down). Archetypal oestrogen-regulated genes (TFF1, GREB1, PGR and PDZK1) showed large decreases in expression (FC = 0.20–0.69; p < 1e-6-1e-7). Proliferation-associated genes (e.g. TOP2A, AURKA and UBE2C) were also strongly downregulated (FC = 0.38–0.56; p < 1e-7) along with putative progesterone-regulated genes (e.g. FKBP4, MYB; FC = 0.64–0.68; p < 1e-4-1e-7). The gene expression changes did not differ according to HER2 status and correlated strongly with the changes reported previously after aromatase inhibitor (AI) treatment in postmenopausal women (rho = 0.55, p < 1e-04). However, after OvX the mean FC was significantly higher compared to AI (p < 1e-04). In conclusion, changes in tumoural gene expression after OvX were largely similar, but of a greater magnitude to those observed after AI in postmenopausal patients; however, OvX appeared to have a greater effect on progesterone-regulated genes than AI. Surgical removal of the ovaries alters the expression of hundreds of genes in the tumour cells of premenopausal women with breast cancer. Ben Haynes from Royal Marsden Hospital in London, UK and colleagues characterised molecular changes in 56 premenopausal women from Vietnam with oestrogen receptor-positive breast cancer who underwent oophorectomies, a standard treatment for this patient population. They showed that blood levels of the hormone estradiol dropped precipitously following ovary-removal surgery. Levels of a protein that was indicative of tumour growth also went down, as did genes involved in regulating hormone signalling and cell proliferation. The results are consistent with those seen in postmenopausal women following treatment with an oestrogen-blocking drug, but oophorectomy had a more dramatic effect. The data could aid the search for predictive biomarkers of who stands to benefit most from ovary removal.
Collapse
Affiliation(s)
- Ben P Haynes
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Ophira Ginsburg
- Department of Medicine, University of Toronto, Toronto, Canada.,Department of Population Health, NYU School of Medicine/Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Qiong Gao
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
| | - Elizabeth Folkerd
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Maria Afentakis
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Le Hong Quang
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Thi Han
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Hong Khoa
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Nguyen Van Dinh
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Ta Van To
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Ian E Smith
- The Breast Unit, Department of Medicine, Royal Marsden Hospital, Fulham Road, London, UK
| | - Mitch Dowsett
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK.,The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
| |
Collapse
|
13
|
Chlebowski RT, Pan K. Complexity of intermittent letrozole adjuvant therapy. Lancet Oncol 2017; 19:13-15. [PMID: 29158010 DOI: 10.1016/s1470-2045(17)30854-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Rowan T Chlebowski
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA 91010, USA.
| | - Kathy Pan
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| |
Collapse
|
14
|
Adjuvant ovarian suppression for resected breast cancer: 2017 critical assessment. Breast Cancer Res Treat 2017; 166:1-13. [DOI: 10.1007/s10549-017-4379-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
|
15
|
Current advances in endocrine therapy options for premenopausal women with hormone receptor positive breast cancer. Gynecol Oncol 2017; 147:153-157. [PMID: 28662774 DOI: 10.1016/j.ygyno.2017.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/15/2017] [Accepted: 06/17/2017] [Indexed: 01/13/2023]
|
16
|
Loibl S, Turner NC, Ro J, Cristofanilli M, Iwata H, Im SA, Masuda N, Loi S, André F, Harbeck N, Verma S, Folkerd E, Puyana Theall K, Hoffman J, Zhang K, Bartlett CH, Dowsett M. Palbociclib Combined with Fulvestrant in Premenopausal Women with Advanced Breast Cancer and Prior Progression on Endocrine Therapy: PALOMA-3 Results. Oncologist 2017; 22:1028-1038. [PMID: 28652278 DOI: 10.1634/theoncologist.2017-0072] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/23/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The efficacy and safety of palbociclib, a cyclin-dependent kinase 4/6 inhibitor, combined with fulvestrant and goserelin was assessed in premenopausal women with advanced breast cancer (ABC) who had progressed on prior endocrine therapy (ET). PATIENTS AND METHODS One hundred eight premenopausal endocrine-refractory women ≥18 years with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) ABC were among 521 women randomized 2:1 (347:174) to fulvestrant (500 mg) ± goserelin with either palbociclib (125 mg/day orally, 3 weeks on, 1 week off) or placebo. This analysis assessed whether the overall tolerable safety profile and significant progression-free survival (PFS) improvement extended to premenopausal women. Potential drug-drug interactions (DDIs) and ovarian suppression with goserelin were assessed via plasma pharmacokinetics and biochemical analyses, respectively. (ClinicalTrials.gov identifier: NCT01942135) RESULTS: Median PFS for premenopausal women in the palbociclib (n = 72) versus placebo arm (n = 36) was 9.5 versus 5.6 months, respectively (hazard ratio, 0.50, 95% confidence interval: 0.29-0.87), and consistent with the significant PFS improvement in the same arms for postmenopausal women. Any-grade and grade ≤3 neutropenia, leukopenia, and infections were among the most frequent adverse events reported in the palbociclib arm with concurrent goserelin administration. Hormone concentrations were similar between treatment arms and confirmed sustained ovarian suppression. Clinically relevant DDIs were not observed. CONCLUSION Palbociclib combined with fulvestrant and goserelin was an effective and well-tolerated treatment for premenopausal women with prior endocrine-resistant HR+/HER2- ABC. Inclusion of both premenopausal and postmenopausal women in pivotal combination ET trials facilitates access to novel drugs for young women and should be considered as a new standard for clinical trial design. IMPLICATIONS FOR PRACTICE PALOMA-3, the first registrational study to include premenopausal women in a trial investigating a CDK4/6 inhibitor combined with endocrine therapy, has the largest premenopausal cohort reported in an endocrine-resistant setting. In pretreated premenopausal women with hormone receptor-positive advanced breast cancer, palbociclib plus fulvestrant and goserelin (luteinizing hormone-releasing hormone [LHRH] agonist) treatment almost doubled median progression-free survival (PFS) and significantly increased the objective response rate versus endocrine monotherapy, achieving results comparable to those reported for chemotherapy without apparently interfering with LHRH agonist-induced ovarian suppression. The significant PFS gain and tolerable safety profile strongly support use of this regimen in premenopausal women with endocrine-resistant disease who could possibly delay chemotherapy.
Collapse
Affiliation(s)
- Sibylle Loibl
- German Breast Group GBG Forschungs GmbH, Neu-Isenburg, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Jungsil Ro
- National Cancer Center, Goyang-si, South Korea
| | - Massimo Cristofanilli
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Seock-Ah Im
- Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Norikazu Masuda
- Breast Oncology, NHO Osaka National Hospital, Osaka-city, Japan
| | - Sherene Loi
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Nadia Harbeck
- Brustzentrum der Universität München (LMU), Munich, Germany
| | - Sunil Verma
- University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | | | | | - Ke Zhang
- Pfizer Inc., San Diego, California, USA
| | | | - Mitchell Dowsett
- Royal Marsden Hospital and Institute of Cancer Research, London, UK
| |
Collapse
|
17
|
Ovarian ablation for premenopausal breast cancer: A review of treatment considerations and the impact of premature menopause. Cancer Treat Rev 2017; 55:26-35. [DOI: 10.1016/j.ctrv.2017.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 01/14/2023]
|
18
|
Chlebowski RT, Pan K, Nananda F. Response. Breast Cancer Res Treat 2017; 163:633-634. [PMID: 28353060 DOI: 10.1007/s10549-017-4197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/07/2017] [Indexed: 12/01/2022]
Affiliation(s)
| | - Kathy Pan
- Los Angeles BioMedical Research Institute, Harbor-UCLA Medical Center, 1500 E. Duarte Road, Duarte, CA, 91019-3000, USA
| | - F Nananda
- University of New England, Biddeford, ME, USA
| |
Collapse
|
19
|
Bhattacharya P, Abderrahman B, Jordan VC. Opportunities and challenges of long term anti-estrogenic adjuvant therapy: treatment forever or intermittently? Expert Rev Anticancer Ther 2017; 17:297-310. [PMID: 28281842 DOI: 10.1080/14737140.2017.1297233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Extended adjuvant (5-10 years) therapy targeted to the estrogen receptor (ER) has significantly decreased mortality from breast cancer (BC). Areas covered: Translational research advanced clinical testing of extended adjuvant therapy with tamoxifen or aromatase inhibitors (AIs). Short term therapy or non-compliance increase recurrence, but surprisingly recurrence and death does not increase dramatically after 5 years of adjuvant therapy stops. Expert commentary: Compliance ensures optimal benefit from extended antihormone adjuvant therapy.Retarding acquired resistance using CDK4/6 or mTOR inhibitors is discussed. Preventing acquired resistance from mutations of ER could be achieved with Selective ER Downregulators (SERDs), eg fulvestrant. Fulvestrant is a depot injectable so oral SERDs are sought for extended use. In reality, a 'super SERD' which destroys ER but improves women's health like a Selective ER Modulator (SERM), would aid compliance to prevent recurrence and death. Estrogen-induced apoptosis occurs in 30% of BC with antihormone resistance. The 'one in three' rule that dictates that one in three unselected patients respond to either hormonal or antihormonal therapy in BC occurs with estrogen or antiestrogen therapy and must be improved. The goal is to maintain patients for their natural lives by blocking cancer cell survival through precision medicine using short cycles of estrogen apoptotic salvage therapy, and further extended antihormone maintenance.
Collapse
Affiliation(s)
- Poulomi Bhattacharya
- a Department of Breast Medical Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Balkees Abderrahman
- a Department of Breast Medical Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - V Craig Jordan
- a Department of Breast Medical Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| |
Collapse
|
20
|
Lambertini M, Del Mastro L, Viglietti G, Pondé NF, Solinas C, de Azambuja E. Ovarian Function Suppression in Premenopausal Women with Early-Stage Breast Cancer. Curr Treat Options Oncol 2017; 18:4. [DOI: 10.1007/s11864-017-0442-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
21
|
Chlebowski RT, Pan K, Col NF. Ovarian suppression in combination endocrine adjuvant therapy in premenopausal women with early breast cancer. Breast Cancer Res Treat 2016; 161:185-190. [PMID: 27785653 DOI: 10.1007/s10549-016-4024-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 10/15/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE The benefits of adding ovarian suppression to either tamoxifen or aromatase inhibitors as adjuvant breast cancer therapy in premenopausal women are controversial. Therefore, we performed a systematic literature review and meta-analysis of relevant randomized trials. METHODS We identified and combined four qualifying trials reporting disease-free survival (DFS) and overall survival (OS) using meta-analysis. RESULTS Combining ABCSG-12, SOFT, and TEXT studies, there were 65 fewer DFS events (HR 0.89, 95% CI 0.57-1.39) but 30 more deaths for ovarian suppression plus aromatase inhibitor compared to ovarian suppression plus tamoxifen (HR 1.31, 95% CI 0.93-1.84, P = 0.12, τ = 0.03, heterogeneity, P = 0.18). DFS and OS were more concordant for combined SOFT and E-3193 findings; for ovarian suppression plus tamoxifen compared to tamoxifen alone, there were 24 fewer DFS events (HR 0.83, 95% CI 0.67-1.07, P = 0.09, τ 2 = 0) and 14 fewer deaths (HR 0.76, 95% CI 0.53-1.07). The SOFT Estrogen Substudy demonstrated inconsistent estrogen suppression with combined ovarian suppression and aromatase inhibitor. CONCLUSION Given the discordance between DFS and OS and inconsistent estrogen suppression with ovarian suppression plus aromatase inhibitor, adding aromatase inhibitor to ovarian suppression as adjuvant therapy in premenopausal women is premature.
Collapse
Affiliation(s)
- Rowan T Chlebowski
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 W. Carson Street, Torrance, CA, 90502, USA.
| | - Kathy Pan
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 W. Carson Street, Torrance, CA, 90502, USA
| | | |
Collapse
|
22
|
Hsieh AHC, Kichenadasse G, Vatandoust S, Roy A, Sukumaran S, Karapetis CS, Martin H, Chong LC, Koczwara B. Goserelin toxicities and preferences for ovarian suppression method in pre-menopausal women with breast cancer. Intern Med J 2016; 46:1153-1159. [PMID: 27389059 DOI: 10.1111/imj.13169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Affiliation(s)
- A. H.-C. Hsieh
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
| | - G. Kichenadasse
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
- Flinders Centre for Innovation in Cancer; Flinders University; Adelaide South Australia Australia
| | - S. Vatandoust
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
- Flinders Centre for Innovation in Cancer; Flinders University; Adelaide South Australia Australia
| | - A. Roy
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
- Flinders Centre for Innovation in Cancer; Flinders University; Adelaide South Australia Australia
| | - S. Sukumaran
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
| | - C. S. Karapetis
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
- Flinders Centre for Innovation in Cancer; Flinders University; Adelaide South Australia Australia
| | - H. Martin
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
| | - L. C. Chong
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
| | - B. Koczwara
- Department of Medical Oncology; Flinders Medical Centre; Adelaide South Australia Australia
- Flinders Centre for Innovation in Cancer; Flinders University; Adelaide South Australia Australia
| |
Collapse
|
23
|
Lambertini M, Poggio F, Vaglica M, Blondeaux E, Del Mastro L. News on the medical treatment of young women with early-stage HER2-negative breast cancer. Expert Opin Pharmacother 2016; 17:1643-55. [DOI: 10.1080/14656566.2016.1199685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Matteo Lambertini
- Department of Medical Oncology, U.O. Oncologia Medica 2, IRCCS AOU San Martino, IST, Genova, Italy
- BrEAST Data Centre, Department of Medicine, Institut Jules Bordet, and l’Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Francesca Poggio
- Department of Medical Oncology, U.O. Oncologia Medica 2, IRCCS AOU San Martino, IST, Genova, Italy
| | - Marina Vaglica
- Department of Medical Oncology, U.O. Sviluppo Terapie Innovative, IRCCS AOU San Martino, IST, Genova, Italy
| | - Eva Blondeaux
- Department of Medical Oncology, U.O. Oncologia Medica 2, IRCCS AOU San Martino, IST, Genova, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, U.O. Sviluppo Terapie Innovative, IRCCS AOU San Martino, IST, Genova, Italy
| |
Collapse
|