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Bertelsen BE, Almås B, Fjermeros K, Viste K, Geisler SB, Sauer T, Selsås K, Geisler J. Superior suppression of serum estrogens during neoadjuvant breast cancer treatment with letrozole compared to exemestane. Breast Cancer Res Treat 2024; 206:347-358. [PMID: 38649619 PMCID: PMC11182829 DOI: 10.1007/s10549-024-07313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE The aromatase inhibitor letrozole and the aromatase inactivator exemestane are two of the most pivotal cancer drugs used for endocrine treatment of ER-positive breast cancer in all phases of the disease. Although both drugs inhibit CYP19 (aromatase) and have been used for decades, a direct head-to-head, intra-patient-cross-over comparison of their ability to decrease estrogen synthesis in vivo is still lacking. METHODS Postmenopausal breast cancer patients suitable for neoadjuvant endocrine therapy were randomized to receive either letrozole (2.5 mg o.d.) or exemestane (25 mg o.d.) for an initial treatment period, followed by a second treatment period on the alternative drug (intra-patient cross-over study design). Serum levels of estrone (E1), estradiol (E2), letrozole, exemestane, and 17-hydroxyexemestane were quantified simultaneously using a novel, ultrasensitive LC-MS/MS method established in our laboratory. RESULTS Complete sets of serum samples (baseline and during treatment with letrozole or exemestane) were available from 79 patients, including 40 patients starting with letrozole (cohort 1) and 39 with exemestane (cohort 2). Mean serum estrone and estradiol levels in cohort 1 were 174 pmol/L and 46.4 pmol/L at baseline, respectively. Treatment with letrozole suppressed serum E1 and E2 to a mean value of 0.2 pmol/L and 0.4 pmol/L (P < 0.001). After the cross-over to exemestane, mean serum levels of E1 and E2 increased to 1.4 pmol/L and 0.7 pmol/L, respectively. In cohort 2, baseline mean serum levels of E1 and E2 were 159 and 32.5 pmol/L, respectively. Treatment with exemestane decreased these values to 1.8 pmol/L for E1 and 0.6 pmol/L for E2 (P < 0.001). Following cross-over to letrozole, mean serum levels of E1 and E2 were significantly further reduced to 0.1 pmol/L and 0.4 pmol/L, respectively. Serum drug levels were monitored in all patients throughout the entire treatment and confirmed adherence to the protocol and drug concentrations within the therapeutic range for all patients. Additionally, Ki-67 values decreased significantly during treatment with both aromatase inhibitors, showing a trend toward a stronger suppression in obese women. CONCLUSION To the best of our knowledge, we present here for the first time a comprehensive and direct head-to-head, intra-patient-cross-over comparison of the aromatase inhibitor letrozole and the aromatase inactivator exemestane concerning their ability to suppress serum estrogen levels in vivo. All in all, our results clearly demonstrate that letrozole therapy results in a more profound suppression of serum E1 and E2 levels compared to exemestane.
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Affiliation(s)
- Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | - Bjørg Almås
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | - Kamilla Fjermeros
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Kristin Viste
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland, University Hospital, Bergen, Norway
| | | | - Torill Sauer
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Selsås
- Department of Breast- and Endocrine Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Untch M, Pérol D, Mayer EL, Cortes J, Nusch A, Cameron D, Barrios C, Delea T, Danyliv A, Mishra N, Gupta R, Pathak P, Fasching PA. Disease-free survival as a surrogate for overall survival in HR+/HER2- early breast cancer: A correlation analysis. Eur J Cancer 2024; 202:113977. [PMID: 38460476 DOI: 10.1016/j.ejca.2024.113977] [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: 11/10/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Overall survival (OS) is a universally accepted measure of clinical benefit; however, prolonged follow-up is needed to observe sufficient events. Disease-free survival (DFS) has been widely adopted as a primary endpoint for early breast cancer (EBC) trials, as follow-up is comparatively shorter. Here, we present an analysis evaluating DFS as a surrogate for OS for adjuvant treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) EBC. METHODS A systematic literature review which included randomized controlled trials (RCTs) with ≥80% of adult patients with HR+/HER2- EBC was conducted. The RCTs evaluated various systemic therapeutic categories; key inclusion criteria included reporting of DFS and OS hazard ratios (HRs) and mature OS data. Spearman rank correlation and weighted linear regression analyses evaluated DFS and OS HR correlation. A scenario analysis tested base-case analysis robustness, and a parallel analysis using patient-level data was conducted. RESULTS The base case (N = 14 RCTs) showed an unweighted Spearman coefficient of 0.81 between OS and DFS (weighted: 0.81), with 84% of the variability in OS explained by DFS differences (R2 from weighted regression). The surrogate threshold effect (Burzykowski T, Buyse M. Pharm Stat. 2006;5:173-186) was 0.82 for DFS/OS HR. Scenario analysis (n = 9 RCTs), which excluded chemotherapy trials, and patient-level analysis using FACE trial data were consistent with the base-case analysis. CONCLUSIONS These analyses support DFS as a reliable surrogate endpoint for OS in adjuvant HR+/HER2- EBC trials. Using DFS as a surrogate measure will permit timelier access to novel treatments for patients with HR+/HER2- EBC.
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Affiliation(s)
- Michael Untch
- Interdisciplinary Breast Cancer Center, Helios Klinikum Berlin-Buch, Berlin, Germany.
| | | | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Grupo Quiron, Madrid & Barcelona, Spain
| | - Arnd Nusch
- Practice for Hematology and Internal Oncology, Velbert, Germany
| | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Carlos Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | | | | | | | - Rhea Gupta
- Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Purnima Pathak
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Peter A Fasching
- University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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3
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Johansson H, Guerrieri-Gonzaga A, Gandini S, Bertelsen BE, Macis D, Serrano D, Mellgren G, Lazzeroni M, Thomas PS, Crew KD, Kumar NB, Briata IM, Galimberti V, Viale G, Vornik LA, Aristarco V, Buttiron Webber T, Spinaci S, Brown PH, Heckman-Stoddard BM, Szabo E, Bonanni B, DeCensi A. Alternative dosing regimen of exemestane in a randomized presurgical trial: the role of obesity in biomarker modulation. NPJ Breast Cancer 2024; 10:7. [PMID: 38238336 PMCID: PMC10796398 DOI: 10.1038/s41523-024-00616-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024] Open
Abstract
In a 3-arm presurgical trial, four-six weeks exemestane 25 mg three times/week (TIW) was non-inferior to 25 mg/day (QD) in suppressing circulating estradiol in postmenopausal women with ER-positive breast cancer. Since obesity may decrease exemestane efficacy, we analyzed changes in sex steroids, adipokines, Ki-67, and drug levels in relation to obesity. Postmenopausal women with early-stage ER-positive breast cancer were randomized to either exemestane 25 mg QD (n = 57), 25 mg TIW (n = 57), or 25 mg/week (QW, n = 62) for 4-6 weeks before breast surgery. Serum and tissue pre- and post-treatment biomarkers were stratified by body mass index (BMI)< or ≥30 kg/m2. Post-treatment median exemestane and 17-OH exemestane levels were 5-6 times higher in the QD arm compared to the TIW arm. For obese women, TIW maintained comparable reductions to QD in systemic estradiol levels, although the reduction in estrone was less with the TIW regimen. There was less suppression of SHBG with the TIW versus the QD dose schedule in obese women which should result in less systemic bioavailable estrogens. Metabolically, the effect of the TIW regimen was similar to the QD regimen for obese women in terms of leptin suppression and increase in the adiponectin-leptin ratio. Reduction in tissue Ki-67 was less for obese women on the TIW regimen than QD, although changes were similar for non-obese women. Our findings suggest that TIW exemestane should be explored further for primary cancer prevention in both normal weight and obese cohorts.
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Affiliation(s)
| | | | - Sara Gandini
- IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Debora Macis
- IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | | | | | - Nagi B Kumar
- Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | | | | | | | - Lana A Vornik
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - Powel H Brown
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eva Szabo
- Division of Cancer Prevention, NCI Bethesda, MD, USA
| | | | - Andrea DeCensi
- E.O. Galliera Hospital, Genoa, Italy
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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4
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Ke CH, Lin CN, Lin CS. Hormone, Targeted, and Combinational Therapies for Breast Cancers: From Humans to Dogs. Int J Mol Sci 2024; 25:732. [PMID: 38255807 PMCID: PMC10815110 DOI: 10.3390/ijms25020732] [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: 11/18/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Breast cancer (BC) is the most frequent cancer in women. In female dogs, canine mammary gland tumor (CMT) is also the leading neoplasm. Comparative oncology indicates similar tumor behaviors between human BCs (HBCs) and CMTs. Therefore, this review summarizes the current research in hormone and targeted therapies and describes the future prospects for HBCs and CMTs. For hormone receptor-expressing BCs, the first medical intervention is hormone therapy. Monoclonal antibodies against Her2 are proposed for the treatment of Her2+ BCs. However, the major obstacle in hormone therapy or monoclonal antibodies is drug resistance. Therefore, increasing alternatives have been developed to overcome these difficulties. We systemically reviewed publications that reported inhibitors targeting certain molecules in BC cells. The various treatment choices for humans decrease mortality in females with BC. However, the development of hormone or targeted therapies in veterinary medicine is still limited. Even though some clinical trials have been proposed, severe side effects and insufficient case numbers might restrict further explorations. This difficulty highlights the urgent need to develop updated hormone/targeted therapy or novel immunotherapies. Therefore, exploring new therapies to provide more precise use in dogs with CMTs will be the focus of future research. Furthermore, due to the similarities shared by humans and dogs, well-planned prospective clinical trials on the use of combinational or novel immunotherapies in dogs with CMTs to obtain solid results for both humans and dogs can be reasonably anticipated in the future.
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Affiliation(s)
- Chiao-Hsu Ke
- Sustainable Swine Research Center, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan; (C.-H.K.); (C.-N.L.)
- Animal Disease Diagnostic Center, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
| | - Chao-Nan Lin
- Sustainable Swine Research Center, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan; (C.-H.K.); (C.-N.L.)
- Animal Disease Diagnostic Center, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
- Department of Veterinary Medicine, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
| | - Chen-Si Lin
- Department of Veterinary Medicine, School of Veterinary Medicine, National Taiwan University, Taipei 10617, Taiwan
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Domínguez-Cejudo MA, Gil-Torralvo A, Cejuela M, Molina-Pinelo S, Salvador Bofill J. Targeting the Tumor Microenvironment in Breast Cancer: Prognostic and Predictive Significance and Therapeutic Opportunities. Int J Mol Sci 2023; 24:16771. [PMID: 38069096 PMCID: PMC10706312 DOI: 10.3390/ijms242316771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
Breast cancer is one of the most prevalent tumors among women. Its prognosis and treatment outcomes depend on factors related to tumor cell biology. However, recent studies have revealed the critical role of the tumor microenvironment (TME) in the development, progression, and treatment response of breast cancer. In this review, we explore the different components of the TME and their relevance as prognostic and predictive biomarkers in breast cancer. In addition, techniques for assessing the tumor microenvironment, such as immunohistochemistry or gene expression profiling, and their clinical utility in therapeutic decision-making are examined. Finally, therapeutic strategies targeting the TME are reviewed, highlighting their potential clinical benefits. Overall, this review emphasizes the importance of the TME in breast cancer and its potential as a clinical tool for better patient stratification and the design of personalized therapies.
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Affiliation(s)
- María A. Domínguez-Cejudo
- Institute of Biomedicine of Seville (IBiS), HUVR, CSIC, Universidad de Sevilla, 41013 Seville, Spain (S.M.-P.)
- Andalusian—Roche Network Mixed Alliance in Precision Medical Oncology, 41092 Sevilla, Spain
| | - Ana Gil-Torralvo
- Institute of Biomedicine of Seville (IBiS), HUVR, CSIC, Universidad de Sevilla, 41013 Seville, Spain (S.M.-P.)
- Andalusian—Roche Network Mixed Alliance in Precision Medical Oncology, 41092 Sevilla, Spain
- Medical Oncology Department, Virgen del Rocio Hospital, 41013 Seville, Spain
| | - Mónica Cejuela
- Medical Oncology Department, Virgen del Rocio Hospital, 41013 Seville, Spain
| | - Sonia Molina-Pinelo
- Institute of Biomedicine of Seville (IBiS), HUVR, CSIC, Universidad de Sevilla, 41013 Seville, Spain (S.M.-P.)
- Andalusian—Roche Network Mixed Alliance in Precision Medical Oncology, 41092 Sevilla, Spain
| | - Javier Salvador Bofill
- Institute of Biomedicine of Seville (IBiS), HUVR, CSIC, Universidad de Sevilla, 41013 Seville, Spain (S.M.-P.)
- Andalusian—Roche Network Mixed Alliance in Precision Medical Oncology, 41092 Sevilla, Spain
- Medical Oncology Department, Virgen del Rocio Hospital, 41013 Seville, Spain
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6
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Campone M, Bidard FC, Neven P, Wang L, Ling B, Dong Y, Paux G, Herold C, De Giorgi U. AMEERA-4: a randomized, preoperative window-of-opportunity study of amcenestrant versus letrozole in early breast cancer. Breast Cancer Res 2023; 25:141. [PMID: 37950338 PMCID: PMC10638815 DOI: 10.1186/s13058-023-01740-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Window-of-opportunity (WOO) studies provide insights into the clinical activity of new drugs in breast cancer. METHODS AMEERA-4 (NCT04191382) was a WOO study undertaken to compare the pharmacodynamic effects of amcenestrant, a selective estrogen receptor degrader, with those of letrozole in postmenopausal women with newly diagnosed, operable estrogen receptor-positive, human epidermal growth factor receptor 2-negative (ER+/HER2-) breast cancer. Women were randomized (1:1:1) to receive amcenestrant 400 mg, amcenestrant 200 mg, or letrozole 2.5 mg once daily for 14 days before breast surgery. The primary endpoint was change in Ki67 between baseline and Day 15 (i.e., day of surgery). RESULTS Enrollment was stopped early because of slow recruitment, in the context of the COVID-19 pandemic. The modified intent-to-treat population consisted of 95 study participants with baseline and post-treatment Ki67 values, whereas the safety population included 104 participants who had received at least one dose of study medication. Relative change from baseline in Ki67 was - 75.9% (95% confidence interval [CI] - 81.9 to - 67.9) for amcenestrant 400 mg, - 68.2% (- 75.7 to - 58.4) for amcenestrant 200 mg, and - 77.7% (- 83.4 to - 70.0) for letrozole (geometric least-squares mean [LSM] estimates). Absolute change in ER H-score from baseline (LSM estimate) was - 176.7 in the amcenestrant 400 mg arm, - 202.9 in the amcenestrant 200 mg arm, and - 32.5 in the letrozole arm. There were no Grade ≥ 3 treatment-related adverse events. CONCLUSIONS Both amcenestrant and letrozole demonstrated antiproliferative activity in postmenopausal women with previously untreated, operable ER+/HER2- breast cancer and had good overall tolerability. TRIAL REGISTRATION ClinicalTrials.gov, NCT04191382 https://clinicaltrials.gov/ct2/show/NCT04191382 . Registered 9 December 2019.
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Affiliation(s)
- Mario Campone
- Institut de Cancérologie de l'Ouest, René Gauducheau, Boulevard Jacques Monod, 44805, Saint-Herblain, France.
| | - François-Clément Bidard
- Institut Curie, Paris and Saint-Cloud, France
- Versailles Saint Quentin, Saint-Cloud, France
- Paris-Saclay University, Saint-Cloud, France
| | - Patrick Neven
- Department of Gynaecological Oncology, Multidisciplinary Breast Center, University Hospitals Louvain, Campus Gasthuisberg, Leuven, Belgium
| | | | | | | | | | | | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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7
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Orozco Leal G, Armstrong N, Kernohan A, Ahmadu C, Coughlan D, McDermott K, Duffy S, O'Meara S, Robinson T, Vale L, Kleijnen J. Abemaciclib in Combination with Endocrine Therapy for Adjuvant Treatment of Hormone Receptor-Positive, HER2-Negative, Node-Positive Early Breast Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2023; 41:741-750. [PMID: 36952138 PMCID: PMC10034868 DOI: 10.1007/s40273-023-01259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 06/01/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) invited the manufacturer (Eli Lilly) of abemaciclib (Verzenios) to submit evidence for the clinical and cost effectiveness of this drug in combination with endocrine therapy (ET) for the treatment of adult patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, node-positive early breast cancer at high risk of recurrence, as part of the Institute's Single Technology Appraisal (STA) process. Kleijnen Systematic Reviews Ltd, in combination with Newcastle University, was commissioned to act as the independent Evidence Review Group (ERG). This paper summarised the Company Submission (CS), presents the ERG's critical review of the clinical and cost-effectiveness evidence in the CS, highlights the key methodological considerations, and describes the development of the NICE guidance by the Appraisal Committee. The ERG produced a critical review of the evidence for the clinical and cost-effectiveness evidence in the CS and also independently searched for relevant evidence and modified the manufacturer decision analytic model to examine the impact of altering some of the key assumptions. A systematic literature review identified the MonarchE trial, an ongoing, open-label, randomised, double blind trial involving 5637 people comparing abemaciclib in combination with ET versus ET alone. The trial included two cohorts that used different inclusion criteria to define high risk of recurrence. The ERG considered Cohort 1 as an adequate representation of this population and the AC concluded that Cohort 1 was generalisable to National Health Service clinical practice. Trial results showed improvements in invasive disease-free survival for the abemaciclib arm, which was considered an appropriate surrogate outcome. The ERG believed that the modelling structure presented in the de novo economic model by the company was appropriate but highlighted several areas of uncertainty that had the potential to have a significant impact on the resulting incremental cost-effectiveness ratio (ICER). Areas of uncertainty included the extrapolation of long-term survival curves, the duration of treatment effect and treatment waning, and the proportion of patients who receive other CDK4/6 treatments for metastatic disease after receiving abemaciclib. ICER estimates were £9164 per quality-adjusted life-year gained for the company's base-case and £17,810 for the ERG's base-case. NICE recommended abemaciclib with ET as an option for the adjuvant treatment of HR-positive, HER2-negative, node-positive early breast cancer at high risk of recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tomos Robinson
- Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Luke Vale
- Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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8
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Skafida E, Andrikopoulou A, Terpos E, Markellos C, Moustafa S, Pectasides D, Dimopoulos MA, Zagouri F, Vassilopoulos D. Impact of CDK4/6 Inhibitors on Aromatase Inhibitor-Associated Musculoskeletal Syndrome (AIMSS) in the Adjuvant Setting. Breast J 2023; 2023:3614296. [PMID: 37293258 PMCID: PMC10247331 DOI: 10.1155/2023/3614296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 09/20/2022] [Accepted: 03/28/2023] [Indexed: 06/10/2023]
Abstract
Background Third-generation aromatase inhibitors (AIs) are the mainstay of treatment in hormone receptor (HR)-positive breast cancer. Even though it is considered to be a well-tolerated therapy, AI-induced musculoskeletal symptoms are common and may be accused for treatment discontinuation. Recently, selective cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors changed the therapeutic setting, and currently, ribociclib, palbociclib, and abemaciclib are all approved in combination with nonsteroidal AIs in patients with ER-positive, HER2-negative advanced or metastatic breast cancer. This systematic review aims to identify the frequency of aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) in the adjuvant setting in patients under AI monotherapy compared to patients under combination therapy with AIs and CDK4/6 inhibitors and demonstrate the underlying mechanism of action. Methods This study was performed in accordance with PRISMA guidelines. The literature search and data extraction from all randomized clinical trials (RCTs) were done by two independent investigators. Eligible articles were identified by a search of MEDLINE and ClinicalTrial.gov database concerning the period 2000/01/01-2021/05/01. Results Arthralgia was reported in 13.2 to 68.7% of patients receiving AIs for early-stage breast cancer, while arthralgia induced by CDK4/6 inhibitors occurred in a much lower rate [20.5-41.2%]. Bone pain (5-28.7% vs. 2.2-17.2%), back pain (2-13.4% vs. 8-11.2%), and arthritis (3.6-33.6% vs. 0.32%) were reported less frequently in patients receiving the combination of CDK4/6 inhibitors with ET. Conclusions CDK4/6 inhibitors might have a protective effect against joint inflammation and arthralgia occurrence. Further studies are warranted to investigate arthralgia incidence in this population.
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Affiliation(s)
- Efthymia Skafida
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | | | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Christos Markellos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Savvina Moustafa
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Pectasides
- Oncology Section, Second Department of Internal Medicine, Hippokration Hospital, Athens, Greece
| | | | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
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9
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Fabian CJ, Mudaranthakam DP. Reduced-Frequency Endocrine Therapy and Challenges of Noninferiority Study Designs. JAMA Oncol 2023; 9:672-674. [PMID: 36951870 PMCID: PMC11008220 DOI: 10.1001/jamaoncol.2023.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Affiliation(s)
- Carol J Fabian
- Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City
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10
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Bliss JM, Tovey H, Evans A, Holcombe C, Horgan K, Mallon E, Vidya R, Skene A, Dodson A, Hills M, Detre S, Zabaglo L, Banerji J, Kilburn L, Morden JP, Robertson JFR, Smith I, Dowsett M. Clinico-pathologic relationships with Ki67 and its change with short-term aromatase inhibitor treatment in primary ER + breast cancer: further results from the POETIC trial (CRUK/07/015). Breast Cancer Res 2023; 25:39. [PMID: 37046348 PMCID: PMC10099675 DOI: 10.1186/s13058-023-01626-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/27/2023] [Indexed: 04/14/2023] Open
Abstract
PURPOSE Ki67 assessed at diagnosis (Ki67baseline) is an important prognostic factor in primary oestrogen receptor-positive (ER +) breast cancer. Proportional change in Ki67 after 2 weeks (∆Ki672week) is associated with clinical benefit from endocrine therapies and residual Ki67 (Ki672week) with recurrence-free survival. The aim was to define the association between Ki67baseline and after aromatase inhibitor (AI) exposure ∆Ki672week and Ki672week with key prognostic and biologic factors utilising data from the POETIC study. PATIENTS AND METHODS In POETIC 4480 postmenopausal patients with primary ER and/or PgR + breast cancer were randomised 2:1 to 2 weeks' presurgical AI (anastrozole or letrozole) or no presurgical treatment (control). Ki67 was measured centrally in core-cut biopsies taken prior to AI and in core-cuts or the excision biopsy at surgery. Relationships between the Ki67 and biologic factors were explored using linear regression. RESULTS Established associations of Ki67baseline with biologic factors including PgR status, tumour grade, tumour size, histological subtype, nodal status, and vascular invasion were confirmed in the HER2- subpopulation. In the HER2 + subpopulation only grade and tumour size were significantly associated with Ki67baseline. In control group Ki672week was 18% lower than Ki67baseline (p < 0.001) when Ki672week was measured in excision biopsies but not when measured in core-cuts. Median suppression by AIs (∆Ki672week) was 79.3% (IQR: -89.9 to -54.6) and 53.7% (IQR: -78.9 to -21.1) for HER2-negative and HER2-positive cases, respectively. Significantly less suppression occurred in PgR- vs PgR + and HER2 + vs HER2- tumours which remained apparent after adjustment for 2-week sample type. CONCLUSIONS The magnitude of this study allowed characterisation of relationships between Ki67baseline, ∆Ki672week and Ki672week with high degrees of confidence providing a reference source for other studies. Lower values of Ki67 occur when measured on excision biopsies and could lead to apparent but artefactual decreases in Ki67: this should be considered when either ∆Ki672week or Ki672week is used in routine clinical practice to aid treatment decisions or in clinical trials assessing new drug therapies.
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Affiliation(s)
- Judith M Bliss
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK.
| | - Holly Tovey
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | | | | | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | | | | | | | - Andrew Dodson
- UK NEQAS for Immunocytochemistry and In-Situ Hybridisation, London, UK
| | - Margaret Hills
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, and Breast Cancer Now Centre, The Institute of Cancer Research, London, UK
| | - Simone Detre
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, and Breast Cancer Now Centre, The Institute of Cancer Research, London, UK
| | - Lila Zabaglo
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, and Breast Cancer Now Centre, The Institute of Cancer Research, London, UK
| | - Jane Banerji
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Lucy Kilburn
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - James P Morden
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | | | - Ian Smith
- Breast Unit, Royal Marsden Hospital, London, UK
| | - Mitch Dowsett
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, and Breast Cancer Now Centre, The Institute of Cancer Research, London, UK
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11
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Park C, Heo JH, Mehta S, Han S, Spencer JC. Adherence to Adjuvant Endocrine Therapy and Survival Among Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer. Clin Drug Investig 2023; 43:167-176. [PMID: 36740664 DOI: 10.1007/s40261-023-01247-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Although improving adherence to adjuvant endocrine therapies (AETs) is critical to ensure better patient outcomes, the evidence is still lacking on differences in 5-year AET adherence trajectories. This study aimed to estimate the time trend of adherence by the type of individual AET and the association of adherence to AETs with overall survival among older women with hormone receptor-positive breast cancer. METHODS This study used the Surveillance, Epidemiology, and End Results-Medicare database 2006-2016. We included women aged ≥ 65 years with newly diagnosed hormone receptor-positive breast cancer and who had initiated AET (anastrozole, letrozole, exemestane, or tamoxifen). Adherence to AETs was defined as the proportion of days covered that was calculated for the follow-up period (5 years). The overall survival time was defined as the time from the date of AET initiation to death. The linear mixed models with repeated measures were used to estimate the changes in adherence to AETs. The Cox proportional hazard model was used to assess the relationships (hazard ratio [HR] and 95% confidence interval [CI]) between adherence to AETs and death. RESULTS A total of 11,617 patients were included. Anastrozole was the most commonly used (n = 6,908), followed by letrozole (n = 2,586), tamoxifen (n = 1,750), and exemestane (n = 373). The mean (standard deviation) of proportion of days covered for 5 years was 57.4 (34.6), indicating the highest proportion of days covered in the anastrozole group [61.1 (34.1)] and the lowest proportion of days covered in the exemestane group [44.0 (35.1)]. Overall, adherence to AET decreased over the 5-year follow-up period in all AET groups, but the decrease in the tamoxifen group was steeper (42.3% decreased) compared with other AETs. Anastrozole, letrozole, and exemestane groups were associated with a lower risk of death compared with the tamoxifen group (HR = 0.80, 95% CI 0.71-0.89 for anastrozole; HR = 0.82, 95% CI 0.72-0.93 for letrozole; HR = 0.82, 95% CI 0.63-1.07 for exemestane). CONCLUSIONS Patients who initiated with tamoxifen had a steeper decrease in adherence over the 5 years compared with anastrozole, letrozole, and exemestane groups. Furthermore, higher adherence was associated with a decreased risk of mortality. Physicians should be cognizant of decreasing adherence over time and choose effective treatment options with minimal side-effect profiles to better support adherence by patients with breast cancer.
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Affiliation(s)
- Chanhyun Park
- College of Pharmacy, The University of Texas at Austin, 2400 Inner Campus Drive, Austin, TX, 78705, USA.
| | - Ji-Haeng Heo
- College of Pharmacy, The University of Texas at Austin, 2400 Inner Campus Drive, Austin, TX, 78705, USA
| | - Sanica Mehta
- College of Natural Sciences, The University of Texas at Austin, Austin, TX, USA
| | - Sola Han
- College of Pharmacy, The University of Texas at Austin, 2400 Inner Campus Drive, Austin, TX, 78705, USA
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12
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Malagrinò M, Zavatta G. Review of bone health in women with estrogen receptor-positive breast cancer receiving endocrine therapy. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221149493. [PMID: 36644991 PMCID: PMC9846301 DOI: 10.1177/17455057221149493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In estrogen-receptor-positive tumors, adjuvant endocrine therapy has been shown to be highly beneficial for both overall and disease-free survival. Estradiol is key in regulating bone and mineral physiology, and several studies found a strong correlation between these therapies and the risk of fractures. Since these therapies are often given for 5 through 10 years, the timing for bisphosphonates or denosumab initiation seems essential to managing bone metabolism. However, gray zones and discrepancies between guidelines remain as to the best threshold when to start antiresorptive treatment, or whether antiresorptive treatment should be administered to every woman undergoing adjuvant endocrine therapy, independent of their risk factors for fractures. Treatment options and strategies should be discussed at the start of hormone adjuvant therapy to come to a shared decision with the patient, with the final aim of reducing the risk of future fractures as much as possible. This review will cover present guidelines and literature on antiresorptive treatment in this setting, to provide clinicians with useful clues for managing these patients.
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Affiliation(s)
- Matteo Malagrinò
- Division of Endocrinology and Diabetes
Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy,Department of Medical and Surgical
Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Guido Zavatta
- Division of Endocrinology and Diabetes
Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy,Department of Medical and Surgical
Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy,Guido Zavatta, Department of Medical and
Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via
Massarenti 9, 40138 Bologna, Italy.
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13
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Wang K, Shen L, Tian W, Zhang S. Comparison of changes in lipid profiles of premenopausal women with early-stage breast cancer treated with different endocrine therapies. Sci Rep 2022; 12:22650. [PMID: 36587111 PMCID: PMC9805421 DOI: 10.1038/s41598-022-27008-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Adjuvant endocrine therapy improves the prognosis of early breast cancer with hormone receptor positivity. However, there is no systematic report on the effect of endocrine therapy (particularly ovarian function suppression, OFS) on serum lipids in premenopausal women. This retrospective cohort study aimed to determine whether various endocrine treatments had different effects on blood lipids. This study enrolled 160 premenopausal patients with stage I-III breast cancer in eastern China. The initial diagnostic information was retrieved from patient's medical records, including age at the time of diagnosis, tumor characteristics, anticancer treatment and past medical history. The changes in blood lipids in patients receiving different types of endocrine therapy were compared at the 3rd, 6th, 12th, and 24th months after initiating endocrine therapy. Generalized linear mixed model was used in our analyses. Our data revealed that low-density lipoprotein cholesterol (LDL-C) levels in patients with tamoxifen (TAM) were significantly lower in the 6th, 12th, and 24th months than that in the 3rd month, while high-density lipoprotein cholesterol (HDL-C) levels in the 6th, 12th, and 24th months were significantly higher than that in the 3rd month, indicating that blood lipid levels generally improved with time. While in TAM plus OFS group, HDL-C levels were significantly higher in the 24th month than in the 3rd month, total cholesterol (TC) levels were significantly higher in the 24th month than in the 6th month. The lipid profiles of OFS plus aromatase inhibitor (AI) group did not show significant differences at any time point but were significantly higher than those of the other two groups especially in LDL and TC. TAM group tended to have lower serum lipid levels. With longer follow-up, no statistically significant difference in values was observed between TAM and TAM plus OFS groups at various time points. Compared with the other two groups, OFS plus AI group presented an increasing trend toward LDL-C and TC. The risk of dyslipidemia requires further investigation using a large sample size.
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Affiliation(s)
- Kaiyue Wang
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Lu Shen
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Wei Tian
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Suzhan Zhang
- grid.13402.340000 0004 1759 700XCancer Institute (The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), Department of Surgical Oncology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
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14
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Buono G, Arpino G, Del Mastro L, Fabi A, Generali D, Puglisi F, Zambelli A, Cinieri S, Nuzzo F, Di Lauro V, Vigneri P, Bianchini G, Montemurro F, Gennari A, De Laurentiis M. Extended adjuvant endocrine treatment for premenopausal women: A Delphi approach to guide clinical practice. Front Oncol 2022; 12:1032166. [PMID: 36387212 PMCID: PMC9645191 DOI: 10.3389/fonc.2022.1032166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/22/2022] [Indexed: 10/02/2023] Open
Abstract
The use of an aromatase inhibitor (AI) in combination with ovarian function suppression (OFS) has become the mainstay of adjuvant endocrine therapy in high-risk premenopausal patients with hormone receptor-positive breast cancer. Although five years of such therapy effectively reduces recurrence rates, a substantial risk of late recurrence remains in this setting. Multiple trials have shown that extending AI treatment beyond five years could offer further protection. However, as these studies comprised only postmenopausal patients, no direct evidence currently exists to inform about the potential benefits and/or side effects of extended AI + OFS therapies in premenopausal women. Given these grey areas, we conducted a Delphi survey to report on the opinion of experts in breast cancer treatment and summarize a consensus on the discussed topics. A total of 44 items were identified, all centred around two main themes: 1) defining reliable prognostic factors to pinpoint premenopausal patients eligible for endocrine therapy extension; 2) designing how such therapy should optimally be administered in terms of treatment combinations and duration based on patients' menopausal status. Each item was separately discussed and anonymously voted by 12 experts representing oncological institutes spread across Italy. The consensus threshold was reached in 36 out of 44 items (82%). Herein, we discuss the levels of agreement/disagreement achieved by each item in relation to the current body of literature. In the absence of randomized trials to guide the tailoring of extended AI treatment in premenopausal women, conclusions from our study provide a framework to assist routine clinical practice.
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Affiliation(s)
- Giuseppe Buono
- Department of Breast and Thoracic Oncology, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione “G. Pascale”, Naples, Italy
| | - Grazia Arpino
- Department of Clinical Medicine and Surgery, Oncology Division, University of Naples “Federico II”, Naples, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) “San Martino” General Hospital, Genoa, Italy
| | - Alessandra Fabi
- Precision Medicine in Breast Cancer, Scientific Directorate, Department of Women Child and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Daniele Generali
- Breast Cancer Unit, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Fabio Puglisi
- Department of Medicine, University of Udine, Udine, Italy
- Department of Medical Oncology, Centro di Riferimento Oncologico (CRO) Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Alberto Zambelli
- Medical Oncology, “Papa Giovanni XXIII” Hospital, Bergamo, Italy
| | - Saverio Cinieri
- Medical Oncology Division and Breast Unit, “Senatore Antonio Perrino” Hospital, Brindisi, Italy
| | - Francesco Nuzzo
- Department of Breast and Thoracic Oncology, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione “G. Pascale”, Naples, Italy
| | - Vincenzo Di Lauro
- Department of Breast and Thoracic Oncology, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione “G. Pascale”, Naples, Italy
| | - Paolo Vigneri
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giampaolo Bianchini
- Department of Medical Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) “San Raffaele” Hospital, Milan, Italy
| | - Filippo Montemurro
- Breast Unit, Candiolo Cancer Institute, Fondazione del Piemonte per l’Oncologia - Istituto di Ricovero e Cura a Carattere Scientifico (FPO-IRCCS), Candiolo, Italy
| | - Alessandra Gennari
- Medical Oncology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Michelino De Laurentiis
- Department of Breast and Thoracic Oncology, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione “G. Pascale”, Naples, Italy
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15
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Appraising Adjuvant Endocrine Therapy in Hormone Receptor Positive HER2-Negative Breast Cancer—A Literature Review. Curr Oncol 2022; 29:4956-4969. [PMID: 35877254 PMCID: PMC9320044 DOI: 10.3390/curroncol29070394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/25/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Approximately 75% of breast cancer (BC) is associated with luminal differentiation expressing endocrine receptors (ER). For ER+ HER2− tumors, adjuvant endocrine therapy (ET) is the cornerstone treatment. Although relapse events steadily continue, the ET benefits translate to dramatically lengthen life expectancy with bearable side-effects. This review of ER+ HER2− female BC outlines suitable adjuvant treatment strategies to help guide clinical decision making around appropriate therapy. Methods: A literature search was conducted in Embase, Medline, and the Cochrane Libraries, using ER+ HER−, ET BC keywords. Results: In low-risk patients: five years of ET is the standard option. While Tamoxifen remains the preferred selection for premenopausal women, AI is the choice for postmenopausal patients. In the high-risk category: ET plus/minus OFS with two years of Abemaciclib is recommended. Although extended ET for a total of ten years is an alternative, the optimal AI duration is undetermined; nevertheless an additional two to three years beyond the initial five years may be sufficient. In this postmenopausal group, bisphosphonate is endorsed. Conclusions: Classifying the risk category assists in deciding the treatment route and its optimal duration. Tailoring the breadth of ET hinges on a wide array of factors to be appraised for each individualized case, including weighing its benefits and harms.
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Ma Y, Jia R, Xia B, Tang B, Xu Z. Adult height in pubertal boys with short stature treated with GH/letrozole: a hospital record-based retrospective study. BMC Pediatr 2022; 22:371. [PMID: 35764954 PMCID: PMC9238122 DOI: 10.1186/s12887-022-03438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The growth potential in pubertal boys with short stature is limited by the effect of estrogen on epiphyseal fusion. This study aims to identify the efficacy and safety of the combination of growth hormone (GH) and letrozole on adult height (AH) in pubertal boys with short stature.
Methods
This is a retrospective record based study. Pubertal boys with short stature who were treated with GH and letrozole were followed up at outpatient clinics in our hospital. Twenty subjects who reached AH are reported here.
Results
Baseline chronological age was 12.12 ± 1.14 yr and bone age was 13.00 ± 0.93 yr. The period of GH/letrozole treatment was 1.94 ± 0.67 yr. Height standard deviation score for bone age was increased from -1.46 ± 0.51 before treatment to -0.12 ± 0.57 after treatment (P < 0.001). The predicted AH before treatment, predicted AH after treatment, AH, and genetic target height were 161.02 ± 4.12 cm, 172.11 ± 4.20 cm, 172.67 ± 2.72 cm, and 167.67 ± 3.56 cm, respectively. There was a significant predicted AH difference before and after treatment (P < 0.001). There was a significant difference between predicted AH before treatment and genetic target height (P < 0.001). Predicted AH after therapy was higher than that of gene target height (P < 0.001), as well as AH and genetic target height (P < 0.001). There was no significant side effect.
Conclusions
GH and letrozole combination can enhance AH in pubertal boys with short stature.
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17
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Boszkiewicz K, Piwowar A, Petryszyn P. Aromatase Inhibitors and Risk of Metabolic and Cardiovascular Adverse Effects in Breast Cancer Patients-A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11113133. [PMID: 35683517 PMCID: PMC9181297 DOI: 10.3390/jcm11113133] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/14/2022] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
Aromatase inhibitors (AIs) have been considered first-line therapy for patients with hormone-dependent breast cancer due to their high efficacy and good tolerability. However, AIs are not free of adverse events, and studies show that therapy with AIs is associated with an increased risk of cardiovascular events and the development of insulin resistance and diabetes. We searched the Cochrane Central Register of Controlled Trials, PubMed and EMBASE up to 27 October 2020 for the prevalence of cardiovascular and/or metabolic adverse effects during treatment with AIs in postmenopausal women with breast cancer. A meta-analysis was performed using a random effects model. Odds ratios and 95% confidence intervals were calculated and illustrated using forest plot charts. We performed separate analyses depending on trial design. Twenty two studies met the inclusion criteria. AIs were associated with a higher risk of cardiovascular events, especially when we compared study arms in which AIs were used (alone or in sequence with TAM) with the arms in which TAM was used alone (OR = 1.16; 95%CI 1.04-1.30) or when comparing patients taking AIs alone to patients taking TAM alone or in sequence with AIs (OR = 1.24; 95%CI 1.11-1.38). A pooled analysis of five trials comparing adjuvant AIs to TAM showed the odds for arterial hypertension being 1.31 times higher for patients taking AIs; however, this did not reach statistical significance (OR = 1.31; 95%CI 0.47-3.65). We have not shown an increased risk of dyslipidemia or weight gain with the use of AIs. Our results suggest that postmenopausal women with breast cancer treated with AIs have an increased risk of cardiovascular events in comparison with TAM, potentially due more to a cardioprotective effect of the latter than the cardiotoxicity of AIs. We were unable to prove a similar association for hypertension, dyslipidemia, hyperglycemia or weight gain. Further high-quality RCTs and post-marketing safety observational studies are needed to definitively evaluate the impact of AIs on metabolic disorders in breast cancer patients.
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Affiliation(s)
- Kamila Boszkiewicz
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
- Correspondence:
| | - Agnieszka Piwowar
- Department of Toxicology, Wroclaw Medical University, Borowska Street 211, 50-556 Wroclaw, Poland;
| | - Paweł Petryszyn
- Department of Clinical Pharmacology, Wroclaw Medical University, Borowska Street 211a, 50-556 Wroclaw, Poland;
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Liao H, Pei W, Zhong J, Shao B, Liu X, Liu Y, Zhang J, Rugo HS, Li H. Efficacy and Safety of Initial 5 Years of Adjuvant Endocrine Therapy in Postmenopausal Hormone Receptor-Positive Breast Cancer: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 13:886954. [PMID: 35721183 PMCID: PMC9198062 DOI: 10.3389/fphar.2022.886954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/13/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose: To identify the optimal initial 5 years of adjuvant endocrine therapy for hormone receptor-positive postmenopausal early breast cancer (EBC) patients. Methods: We conducted a systematic search of the PubMed, Web of Science, and EMBASE to obtain relevant studies published between January 2000 and January 2022. Randomized clinical trials assessing the efficacy and safety of initial 5 years of adjuvant endocrine therapy were included. The primary outcomes were disease-free survival and overall survival and the secondary outcome was severe adverse effects (SAEs). A Bayesian network meta-analysis was carried out to indirectly compare all regimens and the value of surface under the cumulative ranking curve (SUCRA) was used to obtain rankings. Results: Eleven studies with 49,987 subjects were included. For DFS, exemestane (EXE) [hazard ratio (HR) 0.91, 95% confidence interval (95%CI) 0.87–0.96], anastrozole (ANA) (0.94, 0.90–0.97), letrozole (LET) (0.93, 0.89–0.97), tamoxifen (TAM) followed by EXE (0.91, 0.87–0.96), and TAM followed by ANA (0.92, 0.87–0.98) were more favorable than TAM, with TAM followed by EXE ranking as the first of SUCRA. For OS, only TAM followed by ANA showed significant superiority than TAM (HR 0.91, 95%CI 0.86–0.97) and ranked as the first of SUCRA. For SAEs, EXE (HR 1.72, 95%CI 1.04–2.98), ANA (1.58, 1.03–2.43), and LET (1.63, 1.02–2.57) showed greater associations with bone fracture than TAM. However, no significant difference in the incidences of cardiac events, thromboembolic events, and cerebrovascular events was found among all comparisons. Conclusion: The sequential use of aromatase inhibitors, which has the best curative effects and relatively mild side effects, may be the optimal treatment mode for hormone receptor-positive postmenopausal EBC patients. In addition, the three kinds of aromatase inhibitors achieved roughly equal efficacy, but caused different types of SAEs. Systematic Review Registration: [website], identifier [registration number].
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Affiliation(s)
- Hao Liao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Wendi Pei
- Center for Reproductive Medicine, Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology and Key Laboratory of Assisted Reproduction, Department of Obstetrics and Gynecology, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Jianxin Zhong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Bin Shao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Xiaoran Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yaxin Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jiayang Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Hope S. Rugo
- University of California, San Francisco Comprehensive Cancer Center, San Francisco, CA, United States
| | - Huiping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital and Institute, Beijing, China
- *Correspondence: Huiping Li,
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Park C, Park SK, Woo A, Ng BP. Health-related quality of life among elderly breast cancer patients treated with adjuvant endocrine therapy: a U.S Medicare population-based study. Qual Life Res 2022; 31:1345-1357. [PMID: 35064415 DOI: 10.1007/s11136-021-03059-x] [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] [Accepted: 12/02/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The evidence regarding the impact of individual adjuvant endocrine therapies (AET) on health-related quality of life (HRQoL) is limited. We aimed to assess the association between the type of AET and HRQoL and to examine the relationship between HRQoL and one-year mortality among women with breast cancer in the USA. METHODS This retrospective cross-sectional study used the 2006-2017 Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey database to identify older women with early-stage hormone receptor-positive breast cancer. Multivariate linear regressions were used to assess the association between types of AET (anastrozole, letrozole, exemestane, and tamoxifen) and HRQoL scores (physical component summary (PCS) and mental component summary (MCS)). Multivariate logistic regressions were used to predict the impact of PCS and MCS on one-year mortality. RESULTS Out of 3537 older women with breast cancer, anastrozole was the most commonly prescribed (n = 1945, 55.0%). Regarding PCS, there was no significant difference between the four AET agents. Higher MCS scores, which indicate better HRQoL, were reported in patients treated with anastrozole (vs. letrozole [β = 1.26, p = 0.007] and exemestane [β = 2.62, p = 0.005) and tamoxifen (vs. letrozole [β = 1.49, p = 0.010] and exemestane [β = 2.85, p = 0.004]). Lower PCS and MCS scores were associated with higher one-year mortality, regardless of type of AET initiated, except for tamoxifen in MCS. CONCLUSION Although there was no significant difference in physical HRQoL scores between AET agents, anastrozole and tamoxifen were associated with better mental HRQoL scores.
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Affiliation(s)
- Chanhyun Park
- Health Outcome Division, The University of Texas at Austin College of Pharmacy, 2409 University Avenue MC A1930, Austin, TX, 78712-1120, USA.
| | - Sun-Kyeong Park
- School of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Ahye Woo
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Boon Peng Ng
- College of Nursing, University of Central Florida, Orlando, FL, USA
- Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, FL, USA
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20
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Bertelsen BE, Viste K, Helland T, Hagland M, Søiland H, Geisler J, Lende TH, Lønning PE, Sagen JV, Mellgren G, Almås B. Simultaneous Quantification of Aromatase Inhibitors and Estrogens in Postmenopausal Breast Cancer Patients. J Clin Endocrinol Metab 2022; 107:1368-1374. [PMID: 34958096 PMCID: PMC9016448 DOI: 10.1210/clinem/dgab923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT Currently there are no assays that can simultaneously quantify serum levels of the third-generation aromatase inhibitors (AIs): letrozole, anastrozole, and exemestane, and the ultra-low levels of estrogens in postmenopausal breast cancer patients on AI treatment. Such measurements may be pivotal for the determination of optimal and individualized treatment regimens. We aimed at developing a liquid chromatography-tandem mass spectrometry (MS/MS) method for simultaneous assessment of letrozole, anastrozole, exemestane, and 17-hydroxyexemestane as well as subpicomolar levels of estradiol and estrone. METHODS Internal standards, calibrators, serum samples, and quality controls were in fully automated steps transferred to a deep-well plate for a 2-step liquid-liquid extraction. The extracts were reconstituted and analytes were separated chromatographically using 2 serially coupled columns, then subject to MS/MS in electrospray ionization mode. The method was thoroughly validated and is traceable to 2 accredited estrogen methods. RESULTS The measurement range for estrone and estradiol was 0.2 to 12 000 pmol/L and 0.8 to 13 000 pmol/L, and covered the expected therapeutic range for the AIs. All analytes had a precision of less than or equal to 13%, and accuracies within 100 ± 8%. As proof of concept, AI and estrogen levels were determined in serum samples from postmenopausal breast cancer patients under treatment. CONCLUSION We present here an assay suitable for the simultaneous measurement of serum levels of all third-generation AIs and ultra-low levels of estrogens, providing a powerful new tool to study drug efficacy and compliance. The method is highly valuable for postmenopausal patients whose pretreatment estradiol levels are below the threshold of detection for most routine assays, but still require suppression.
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Affiliation(s)
- Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
| | - Kristin Viste
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
| | - Thomas Helland
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
| | - Magnus Hagland
- Department of Clinical Science, University of Bergen, Bergen, 5021, Norway
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, 5021, Norway
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger 4011, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog 1478, Norway
- Institute of Clinical Medicine, University of Oslo, Campus AHUS 0318, Norway
| | - Tone Hoel Lende
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger 4011, Norway
| | - Per Eystein Lønning
- Department of Clinical Science, University of Bergen, Bergen, 5021, Norway
- Department of Oncology, Haukeland University Hospital, Bergen 5021, Norway
| | - Jørn V Sagen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
- Department of Clinical Science, University of Bergen, Bergen, 5021, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
- Department of Clinical Science, University of Bergen, Bergen, 5021, Norway
| | - Bjørg Almås
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Vestland, 5009, Norway
- Correspondence: Bjørg Almås, PhD, Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Haukelandsbakken, Bergen, Vestland, 5009 Norway.
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21
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Bradley R, Braybrooke J, Gray R, Hills RK, Liu Z, Pan H, Peto R, Dodwell D, McGale P, Taylor C, Francis PA, Gnant M, Perrone F, Regan MM, Berry R, Boddington C, Clarke M, Davies C, Davies L, Duane F, Evans V, Gay J, Gettins L, Godwin J, James S, Liu H, MacKinnon E, Mannu G, McHugh T, Morris P, Read S, Straiton E, Jakesz R, Fesl C, Pagani O, Gelber R, De Laurentiis M, De Placido S, Gallo C, Albain K, Anderson S, Arriagada R, Bartlett J, Bergsten-Nordström E, Bliss J, Brain E, Carey L, Coleman R, Cuzick J, Davidson N, Del Mastro L, Di Leo A, Dignam J, Dowsett M, Ejlertsen B, Goetz M, Goodwin P, Halpin-Murphy P, Hayes D, Hill C, Jagsi R, Janni W, Loibl S, Mamounas EP, Martín M, Mukai H, Nekljudova V, Norton L, Ohashi Y, Pierce L, Poortmans P, Pritchard KI, Raina V, Rea D, Robertson J, Rutgers E, Spanic T, Sparano J, Steger G, Tang G, Toi M, Tutt A, Viale G, Wang X, Whelan T, Wilcken N, Wolmark N, Cameron D, Bergh J, Swain SM. Aromatase inhibitors versus tamoxifen in premenopausal women with oestrogen receptor-positive early-stage breast cancer treated with ovarian suppression: a patient-level meta-analysis of 7030 women from four randomised trials. Lancet Oncol 2022; 23:382-392. [PMID: 35123662 PMCID: PMC8885431 DOI: 10.1016/s1470-2045(21)00758-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND For women with early-stage oestrogen receptor (ER)-positive breast cancer, adjuvant tamoxifen reduces 15-year breast cancer mortality by a third. Aromatase inhibitors are more effective than tamoxifen in postmenopausal women but are ineffective in premenopausal women when used without ovarian suppression. We aimed to investigate whether premenopausal women treated with ovarian suppression benefit from aromatase inhibitors. METHODS We did a meta-analysis of individual patient data from randomised trials comparing aromatase inhibitors (anastrozole, exemestane, or letrozole) versus tamoxifen for 3 or 5 years in premenopausal women with ER-positive breast cancer receiving ovarian suppression (goserelin or triptorelin) or ablation. We collected data on baseline characteristics, dates and sites of any breast cancer recurrence or second primary cancer, and dates and causes of death. Primary outcomes were breast cancer recurrence (distant, locoregional, or contralateral), breast cancer mortality, death without recurrence, and all-cause mortality. As distant recurrence invariably results in death from breast cancer several years after the occurrence, whereas locoregional recurrence and new contralateral breast cancer are not usually fatal, the distant recurrence analysis is shown separately. Standard intention-to-treat log-rank analyses estimated first-event rate ratios (RR) and their confidence intervals (CIs). FINDINGS We obtained data from all four identified trials (ABCSG XII, SOFT, TEXT, and HOBOE trials), which included 7030 women with ER-positive tumours enrolled between June 17, 1999, and Aug 4, 2015. Median follow-up was 8·0 years (IQR 6·1-9·3). The rate of breast cancer recurrence was lower for women allocated to an aromatase inhibitor than for women assigned to tamoxifen (RR 0·79, 95% CI 0·69-0·90, p=0·0005). The main benefit was seen in years 0-4 (RR 0·68, 99% CI 0·55-0·85; p<0·0001), the period when treatments differed, with a 3·2% (95% CI 1·8-4·5) absolute reduction in 5-year recurrence risk (6·9% vs 10·1%). There was no further benefit, or loss of benefit, in years 5-9 (RR 0·98, 99% CI 0·73-1·33, p=0·89) or beyond year 10. Distant recurrence was reduced with aromatase inhibitor (RR 0·83, 95% CI 0·71-0·97; p=0·018). No significant differences were observed between treatments for breast cancer mortality (RR 1·01, 95% CI 0·82-1·24; p=0·94), death without recurrence (1·30, 0·75-2·25; p=0·34), or all-cause mortality (1·04, 0·86-1·27; p=0·68). There were more bone fractures with aromatase inhibitor than with tamoxifen (227 [6·4%] of 3528 women allocated to an aromatase inhibitor vs 180 [5·1%] of 3502 women allocated to tamoxifen; RR 1·27 [95% CI 1·04-1·54]; p=0·017). Non-breast cancer deaths (30 [0·9%] vs 24 [0·7%]; 1·30 [0·75-2·25]; p=0·36) and endometrial cancer (seven [0·2%] vs 15 [0·3%]; 0·52 [0·22-1·23]; p=0·14) were rare. INTERPRETATION Using an aromatase inhibitor rather than tamoxifen in premenopausal women receiving ovarian suppression reduces the risk of breast cancer recurrence. Longer follow-up is needed to assess any impact on breast cancer mortality. FUNDING Cancer Research UK, UK Medical Research Council.
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22
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Bassatne A, Bou Khalil A, Chakhtoura M, Arabi A, Van Poznak C, El-Hajj Fuleihan G. Effect of antiresorptive therapy on aromatase inhibitor induced bone loss in postmenopausal women with early-stage breast cancer: A systematic review and meta-analysis of randomized controlled trials. Metabolism 2022; 128:154962. [PMID: 34958816 DOI: 10.1016/j.metabol.2021.154962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/30/2021] [Accepted: 12/14/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Aromatase inhibitors (AIs) are routinely used to treat postmenopausal women with early-stage breast cancer. Although AIs improve breast cancer outcomes, they increase the risk of osteoporosis and fractures. This systematic review and meta-analysis assesses the effect of antiresorptive drugs on AI induced bone loss in postmenopausal women with non-metastatic breast cancer. METHODS We searched four databases until November 4th 2020. We included Randomized controlled trials (RCTs) of antiresorptive drugs in postmenopausal women with breast cancer treated with AI. Two authors screened studies, extracted data and assessed the risk of bias independently and in duplicate. RESULTS We identified 14 RCTs: 7 on zoledronic acid, 6 on oral bisphosphonates and 1 on denosumab. The mean difference in bone mineral density (BMD) was 5% at the lumbar spine and 4% at the total hip, at 12 months, favoring zoledronic acid compared to control. The certainty of the evidence was low for lumbar spine and moderate for total hip BMD. Similarly, the mean difference was 3% at the lumbar spine and 2% at the total hip, favoring oral bisphosphonates with moderate certainty. The mean difference was 6% at the lumbar spine, and 4% at the total hip BMD favoring denosumab compared to placebo. In addition, zoledronic acid resulted in a mean difference in bone turnover marker levels of -35-41%, and the relarive risk for morphometric vertebral fractures was 0.7 [0.3-1.4], compared to control. Denosumab reduced fracture incidence by 50% compared to placebo. CONCLUSION Evidence suggests a protective effect of antiresorptive drugs on BMD and bone turnover markers in postmenopausal women with non-metastatic breast cancer on AI. However, data on fracture risk reduction remains unclear.
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Affiliation(s)
- Aya Bassatne
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abir Bou Khalil
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Asma Arabi
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Cairns J, Ingle JN, Kalari KR, Goetz MP, Weinshilboum RM, Gao H, Li H, Bari MG, Wang L. Anastrozole Regulates Fatty Acid Synthase in Breast Cancer. Mol Cancer Ther 2022; 21:206-216. [PMID: 34667110 PMCID: PMC8742770 DOI: 10.1158/1535-7163.mct-21-0509] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/27/2021] [Accepted: 10/13/2021] [Indexed: 12/14/2022]
Abstract
Our previous matched case-control study of postmenopausal women with resected early-stage breast cancer revealed that only anastrozole, but not exemestane or letrozole, showed a significant association between the 6-month estrogen concentrations and risk of breast cancer. Anastrozole, but not exemestane or letrozole, is a ligand for estrogen receptor α. The mechanisms of endocrine resistance are heterogenous and with the new mechanism of anastrozole, we have found that treatment of anastrozole maintains fatty acid synthase (FASN) protein level by limiting the ubiquitin-mediated FASN degradation, leading to increased breast cancer cell growth. Mechanistically, anastrozole decreases the guided entry of tail-anchored proteins factor 4 (GET4) expression, resulting in decreased BCL2-associated athanogene cochaperone 6 (BAG6) complex activity, which in turn, prevents RNF126-mediated degradation of FASN. Increased FASN protein level can induce a negative feedback loop mediated by the MAPK pathway. High levels of FASN are associated with poor outcome only in patients with anastrozole-treated breast cancer, but not in patients treated with exemestane or letrozole. Repressing FASN causes regression of breast cancer cell growth. The anastrozole-FASN signaling pathway is eminently targetable in endocrine-resistant breast cancer.
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Affiliation(s)
- Junmei Cairns
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - James N. Ingle
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Krishna R. Kalari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Matthew P. Goetz
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Richard M. Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Huanyao Gao
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hu Li
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Mehrab Ghanat Bari
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA,Corresponding author: Liewei Wang, Gonda 19-460, 200 1 Street SW, Rochester MN USA 55905. Phone: +1 507 284-5264; Fax: +1 507-284-4455;
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24
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Wang J, Yin J, Qiu J, Jiang J, Hu Y, Zhu K, Zheng H, Luo T, Zhong X. Comparison of dyslipidemia incidence in Chinese early-stage breast cancer patients following different endocrine therapies: A population-based cohort study. Front Endocrinol (Lausanne) 2022; 13:815960. [PMID: 36147563 PMCID: PMC9486544 DOI: 10.3389/fendo.2022.815960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is lack of large-scale real-world research evidence showing the impact of endocrine therapy on blood lipids in Chinese breast cancer patients, especially those with premenopausal breast cancer. Based on a large breast cancer cohort at West China Hospital, we aimed to compare the risk of dyslipidemia between premenopausal and postmenopausal women based on the endocrine therapy used. METHODS A total of 1,883 early-stage breast cancer (EBC) patients who received endocrine monotherapy [selective estrogen receptor modulator (SERM) and aromatase inhibitor (AI), with or without ovarian function suppression] with normal blood lipid levels at baseline were retrospectively included between October 2008 and April 2017. Dyslipidemia was defined as an abnormality in cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein, and total cholesterol (TC) levels. The risk accumulation function was used to calculate the incidence of dyslipidemia in order to assess the absolute risk, while the multivariate Cox regression model was used to calculate the relative risk of dyslipidemia between the groups. RESULTS Patients with EBC were followed up for 60 months to monitor their blood lipid levels. The accumulated 5-year incidence of dyslipidemia in postmenopausal patients was higher than that in premenopausal patients (adjusted HR [95% confidence interval], 1.25 [1.01-1.56], 41.7% vs. 31.2%, p = 0.045). In premenopausal patients, the risk of abnormal TC was significantly higher in the OFS+AI group compared with that in the SERM group (adjusted HR [95% CI], 6.24 [3.19-12.20], p < 0.001, 5-year abnormal rates: 21.5% vs. 2.4%), and that of abnormal LDL-C level also increased (adjusted HR [95% CI], 10.54 [3.86-28.77], p < 0.001, 5-year abnormal rates: 11.1% vs. 0.9%). In postmenopausal patients, the risk of abnormal TC or LDL-C levels showed a similar trend in the AI and SERM groups. CONCLUSIONS In addition to postmenopausal patients, dyslipidemia is also common in premenopausal Chinese patients with EBC who received endocrine therapy. Irrespective of menopausal status, AI treatment increases the risk of TC/LDL-C dyslipidemia than SERM treatment.
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Affiliation(s)
- Junren Wang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Jin Yin
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
- School of Computer Science and Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiajun Qiu
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Jingwen Jiang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yao Hu
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Kunrui Zhu
- Cancer Center, Breast Disease Center, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Zheng
- Cancer Center, Breast Disease Center, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Luo
- Cancer Center, Breast Disease Center, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaorong Zhong
- Cancer Center, Breast Disease Center, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xiaorong Zhong,
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Nabieva N, Fasching PA. Endocrine Treatment for Breast Cancer Patients Revisited-History, Standard of Care, and Possibilities of Improvement. Cancers (Basel) 2021; 13:5643. [PMID: 34830800 PMCID: PMC8616153 DOI: 10.3390/cancers13225643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/07/2021] [Accepted: 11/09/2021] [Indexed: 01/16/2023] Open
Abstract
PURPOSE OF REVIEW Due to the findings of current studies and the approval of novel substances for the therapy of hormone-receptor-positive breast cancer patients, the established standards of endocrine treatment are changing. The purpose of this review is to give an overview of the history of endocrine treatment, to clarify its role in the present standard of care, and to discuss the possibilities of improvement. RECENT FINDINGS Tamoxifen, aromatase inhibitors, and fulvestrant are the main drugs that have been used for decades in the therapy of hormone-receptor-positive breast cancer patients. However, since a relevant number of women suffer at some point from disease recurrence or progression, several novel substances are being investigated to overcome resistance mechanisms by interfering with certain signaling pathways, such as the PI3K/AKT/mTOR or the CDK4/6 pathways. mTOR and CDK4/6 inhibitors were the first drugs approved for this purpose and many more are in development. SUMMARY Endocrine treatment is one of the best tolerable cancer therapies available. Continuous investigation serves to improve patients' outcomes and modernize the current standard of care. Considering the resistance mechanisms and substances analyzed against these, endocrine treatment of hormone-receptor-positive breast cancer is on the brink of a new era.
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Affiliation(s)
- Naiba Nabieva
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany;
- Novartis Oncology, Novartis Pharma GmbH, 90429 Nuremberg, Germany
| | - Peter A. Fasching
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany;
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Nunes FAP, de Farias MLF, Oliveira FP, Vieira L, Lima LFC, de Paula Paranhos F, de Mendonça LMC, Madeira M. Use of aromatase inhibitors in patients with breast cancer is associated with deterioration of bone microarchitecture and density. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:505-511. [PMID: 34283901 PMCID: PMC10522186 DOI: 10.20945/2359-3997000000385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/16/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate changes in bone density and architecture in postmenopausal women with breast cancer (BC) and use of aromatase inhibitor (AI). METHODS Thirty-four postmenopausal women with BC, without bone metastasis, renal function impairment and who were not receiving bone-active drugs were selected from a population of 523 outpatients treated for BC. According to the presence of hormonal receptors, HER2 and Ki67, seventeen had positive hormonal receptors and received anastrozole (AI group), and seventeen were triple-negative receptors (non-AI group), previously treated with chemotherapy. Areal bone mineral density (aBMD) and vertebral fracture assessment (VFA) analyses were performed by DXA; vBMD and bone microarchitecture were evaluated by HR-pQCT. Fracture risk was estimated using the FRAX tool. RESULTS No patient referred previous low-impact fracture, and VFA detected one moderate vertebral fracture in a non-AI patient. AI patients showed lower aBMD and BMD T-scores at the hip and 33% radius and a higher proportion of osteoporosis diagnosis on DXA (47%) vs non-AI (17.6%). AI group had significantly lower values for vBMD at the entire, cortical and trabecular bone compartments, cortical and trabecular thickness and BV/TV. They also had a higher risk for major fractures and for hip fractures estimated by FRAX. Several HR-pQCT parameters evaluated at distal radius and distal tibia were significantly associated with fracture risk. CONCLUSION AI is associated with alterations in bone density and microarchitecture of both the cortical and trabecular compartments. These findings explain the overall increase in fracture risk in this specific population.
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Affiliation(s)
- Frederico Arthur Pereira Nunes
- Divisão de Endocrinologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Departamento de Oncologia, Hospital Federal Cardoso Fontes, Rio de Janeiro, RJ, Brasil
| | | | - Felipe Peres Oliveira
- Divisão de Endocrinologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil,
| | - Leonardo Vieira
- Divisão de Endocrinologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luis Felipe Cardoso Lima
- Programa de Engenharia Nuclear, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | | | | | - Miguel Madeira
- Divisão de Endocrinologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil,
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Butani D, Gupta N, Jyani G, Bahuguna P, Kapoor R, Prinja S. Cost-effectiveness of Tamoxifen, Aromatase Inhibitor, and Switch Therapy (Adjuvant Endocrine Therapy) for Breast Cancer in Hormone Receptor Positive Postmenopausal Women in India. BREAST CANCER: TARGETS AND THERAPY 2021; 13:625-640. [PMID: 34866937 PMCID: PMC8636459 DOI: 10.2147/bctt.s331831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/15/2021] [Indexed: 11/26/2022]
Abstract
Background Breast cancer is the leading cause of cancer among women in India. Treatment with hormone therapy reduces recurrence. We undertook this cost-effectiveness study to ascertain the treatment option offering the best value for money. Methods The lifetime costs and health outcomes of using tamoxifen, AI and switch therapy were measured in a cohort of 50-year-old women with HR-positive early stage breast cancer. A Markov model of disease was developed using a societal perspective with a lifetime study horizon. Local, contralateral, and distant recurrence were modelled along with treatment related adverse effects. Primary data collected to obtain estimates of out-of-pocket expenditure (OOPE) and utility weights. Both health system cost and OOPE were included. The future costs and consequences were discounted at 3%. A probabilistic sensitivity analysis was used. Results The lifetime cost of hormone therapy with tamoxifen, AI and switch therapy was to be ₹1,472,037 (I$ 68,947), ₹1,306,794 (I$ 61,208) and ₹1,281,811 (I$ 60,038). The QALYs lived per patient receiving tamoxifen, AI and switch were 13.12, 13.42 and 13.32. tamoxifen was found to be more expensive and less effective. As compared to switch therapy, AI for five years incurred an incremental cost of ₹259,792 (I$12,168) per QALY gained. At the willingness to pay equals to per capita GDP of India, there is 55% probability of AI therapy to be cost-effective compared to switch therapy. Conclusion In postmenopausal women with HR-positive early-stage breast cancer, switch therapy is recommended for use on the basis of cost-effectiveness.
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Affiliation(s)
- Dimple Butani
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Gaurav Jyani
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Bahuguna
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kapoor
- Department of Radiation Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence: Shankar Prinja Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaTel +91 9872871978 Email
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Ban J, Fock V, Aryee DNT, Kovar H. Mechanisms, Diagnosis and Treatment of Bone Metastases. Cells 2021; 10:2944. [PMID: 34831167 PMCID: PMC8616226 DOI: 10.3390/cells10112944] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 12/24/2022] Open
Abstract
Bone and bone marrow are among the most frequent metastatic sites of cancer. The occurrence of bone metastasis is frequently associated with a dismal disease outcome. The prevention and therapy of bone metastases is a priority in the treatment of cancer patients. However, current therapeutic options for patients with bone metastatic disease are limited in efficacy and associated with increased morbidity. Therefore, most current therapies are mainly palliative in nature. A better understanding of the underlying molecular pathways of the bone metastatic process is warranted to develop novel, well-tolerated and more successful treatments for a significant improvement of patients' quality of life and disease outcome. In this review, we provide comparative mechanistic insights into the bone metastatic process of various solid tumors, including pediatric cancers. We also highlight current and innovative approaches to biologically targeted therapy and immunotherapy. In particular, we discuss the role of the bone marrow microenvironment in the attraction, homing, dormancy and outgrowth of metastatic tumor cells and the ensuing therapeutic implications. Multiple signaling pathways have been described to contribute to metastatic spread to the bone of specific cancer entities, with most knowledge derived from the study of breast and prostate cancer. However, it is likely that similar mechanisms are involved in different types of cancer, including multiple myeloma, primary bone sarcomas and neuroblastoma. The metastatic rate-limiting interaction of tumor cells with the various cellular and noncellular components of the bone-marrow niche provides attractive therapeutic targets, which are already partially exploited by novel promising immunotherapies.
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Affiliation(s)
- Jozef Ban
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
| | - Valerie Fock
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
| | - Dave N. T. Aryee
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
- Department of Pediatrics, Medical University Vienna, 1090 Vienna, Austria
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute, 1090 Vienna, Austria; (J.B.); (V.F.); (D.N.T.A.)
- Department of Pediatrics, Medical University Vienna, 1090 Vienna, Austria
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Cairns J, Kalari KR, Ingle JN, Shepherd LE, Ellis MJ, Goss PE, Barman P, Carlson EE, Goodnature B, Goetz MP, Weinshilboum RM, Gao H, Wang L. Interaction Between SNP Genotype and Efficacy of Anastrozole and Exemestane in Early-Stage Breast Cancer. Clin Pharmacol Ther 2021; 110:1038-1049. [PMID: 34048027 PMCID: PMC8449801 DOI: 10.1002/cpt.2311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/08/2021] [Indexed: 12/24/2022]
Abstract
Aromatase inhibitors (AIs) are the treatment of choice for hormone receptor-positive early breast cancer in postmenopausal women. None of the third-generation AIs are superior to the others in terms of efficacy. We attempted to identify genetic factors that could differentiate between the effectiveness of adjuvant anastrozole and exemestane by examining single-nucleotide polymorphism (SNP)-treatment interaction in 4,465 patients. A group of SNPs were found to be differentially associated between anastrozole and exemestane regarding outcomes. However, they showed no association with outcome in the combined analysis. We followed up common SNPs near LY75 and GPR160 that could differentiate anastrozole from exemestane efficacy. LY75 and GPR160 participate in epithelial-to-mesenchymal transition and growth pathways, in both cases with SNP-dependent variation in regulation. Collectively, these studies identified SNPs that differentiate the efficacy of anastrozole and exemestane and they suggest additional genetic biomarkers for possible use in selecting an AI for a given patient.
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Affiliation(s)
- Junmei Cairns
- Division of Clinical PharmacologyDepartment of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | - Krishna R. Kalari
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - James N. Ingle
- Division of Medical OncologyDepartment of OncologyMayo ClinicRochesterMinnesotaUSA
| | | | - Matthew J. Ellis
- Department of MedicineBaylor University College of MedicineHoustonTexasUSA
| | - Paul E. Goss
- Massachusetts General Hospital Cancer CenterHarvard UniversityBostonMassachusettsUSA
| | - Poulami Barman
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - Erin E. Carlson
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - Barbara Goodnature
- Patient AdvocateMayo Clinic Breast Cancer Specialized Program of Research ExcellenceRochesterMinnesotaUSA
| | - Matthew P. Goetz
- Division of Medical OncologyDepartment of OncologyMayo ClinicRochesterMinnesotaUSA
| | - Richard M. Weinshilboum
- Division of Clinical PharmacologyDepartment of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | - Huanyao Gao
- Division of Clinical PharmacologyDepartment of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | - Liewei Wang
- Division of Clinical PharmacologyDepartment of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
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30
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Abstract
Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.
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Affiliation(s)
- Matthew R D Brown
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | | | - David J Magee
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.
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Gnant M, Fitzal F, Rinnerthaler G, Steger GG, Greil-Ressler S, Balic M, Heck D, Jakesz R, Thaler J, Egle D, Manfreda D, Bjelic-Radisic V, Wieder U, Singer CF, Melbinger-Zeinitzer E, Haslbauer F, Sevelda P, Trapl H, Wette V, Wimmer K, Gampenrieder SP, Bartsch R, Kacerovsky-Strobl S, Suppan C, Brunner C, Deutschmann C, Soelkner L, Fesl C, Greil R. Duration of Adjuvant Aromatase-Inhibitor Therapy in Postmenopausal Breast Cancer. N Engl J Med 2021; 385:395-405. [PMID: 34320285 DOI: 10.1056/nejmoa2104162] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND For postmenopausal women with hormone-receptor-positive breast cancer, the most effective duration for adjuvant therapy with an aromatase inhibitor remains unclear. METHODS In this prospective, phase 3 trial, we randomly assigned postmenopausal women with hormone-receptor-positive breast cancer who had received 5 years of adjuvant endocrine therapy to receive the aromatase inhibitor anastrozole for an additional 2 years (2-year group, receiving a total of 7 years) or an additional 5 years (5-year group, receiving a total of 10 years). The primary end point was disease-free survival. The primary analysis included all the patients who were still participating in the trial and who had no recurrence 2 years after randomization (i.e., when treatment in the 2-year group had ended). Secondary end points were overall survival, contralateral breast cancer, second primary cancer, and clinical bone fracture. RESULTS Among the 3484 women who were enrolled in the trial, 3208 remained in the trial without disease progression after the first 2 years of extended anastrozole treatment following randomization. Among these women, disease progression or death occurred in 335 women in each treatment group in the primary-analysis set at 8 years (hazard ratio, 0.99; 95% confidence interval [CI], 0.85 to 1.15; P = 0.90). No between-group differences occurred in most secondary end points, and subgroup analyses did not indicate differences in any particular subgroup. The risk of clinical bone fracture was higher in the 5-year group than in the 2-year group (hazard ratio, 1.35; 95% CI, 1.00 to 1.84). CONCLUSIONS In postmenopausal women with hormone-receptor-positive breast cancer who had received 5 years of adjuvant endocrine therapy, extending hormone therapy by 5 years provided no benefit over a 2-year extension but was associated with a greater risk of bone fracture. (Funded by AstraZeneca and the Austrian Breast and Colorectal Cancer Study Group; ABCSG-16/SALSA ClinicalTrials.gov number, NCT00295620.).
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Affiliation(s)
- Michael Gnant
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Florian Fitzal
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Gabriel Rinnerthaler
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Guenther G Steger
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Sigrun Greil-Ressler
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Marija Balic
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Dietmar Heck
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Raimund Jakesz
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Josef Thaler
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Daniel Egle
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Diether Manfreda
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Vesna Bjelic-Radisic
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Ursula Wieder
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Christian F Singer
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Elisabeth Melbinger-Zeinitzer
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Ferdinand Haslbauer
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Paul Sevelda
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Harald Trapl
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Viktor Wette
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Kerstin Wimmer
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Simon P Gampenrieder
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Rupert Bartsch
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Stephanie Kacerovsky-Strobl
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Christoph Suppan
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Christine Brunner
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Christine Deutschmann
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Lidija Soelkner
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Christian Fesl
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
| | - Richard Greil
- From the Comprehensive Cancer Center (M.G., C.F.S., C.D., F.F., K.W., S.K.-S.), the Department of General Surgery (F.F., K.W., S.K.-S.), the Department of Internal Medicine I, Division of Oncology (G.G.S., R.B.), and the Department of Obstetrics and Gynecology (C.F.S., C.D.), Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group (M.G., R.J., L.S., C.F.), Breast Care Center, Hanusch Hospital (U.W.), the Department of Gynecology, Hospital Hietzing, and Karl Landsteiner Institute for Gynecological Oncology and Senology (P.S.), Vienna, the Department of Internal Medicine III and Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Paracelsus Medical University Salzburg, Salzburg (G.R., S.G.-R., S.P.G., R.G.), the Departments of Oncology (M.B., C.S.) and Gynecology (V.B.-R.), Medical University Graz, Graz, the Department of Surgery, Ordensklinikum Linz, Linz (D.H.), the Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels (J.T.), the Department of Gynecology, Medical University Innsbruck, Innsbruck (D.E., C.B.), Doctor's Office Manfreda, Klagenfurt (D.M.), the Department of Surgery, Hospital Wolfsberg, Wolfsberg (E.M.-Z.), the Department of Internal Medicine, Hospital Vöcklabruck, Vöcklabruck (F.H.), the Department of Surgery, General Hospital Baden, Baden (H.T.), and the Breast Center, Doctor's Office Wette, Sankt Veit an der Glan (V.W.) - all in Austria; and the Breast Unit, University Hospital Helios, University Witten Herdecke, Wuppertal, Germany (V.B.-R.)
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Salvo EM, Ramirez AO, Cueto J, Law EH, Situ A, Cameron C, Samjoo IA. Risk of recurrence among patients with HR-positive, HER2-negative, early breast cancer receiving adjuvant endocrine therapy: A systematic review and meta-analysis. Breast 2021; 57:5-17. [PMID: 33677313 PMCID: PMC8089079 DOI: 10.1016/j.breast.2021.02.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND A systematic review and meta-analysis was conducted to assess breast cancer (BC) outcomes among patients with early-stage hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) BC, receiving adjuvant endocrine therapy. METHODS Randomized controlled trials (RCTs) and real-world evidence (RWE) studies were identified using Ovid MEDLINE®, Embase, and Evidence-Based Medicine Reviews. Clinical and methodological similarities including alignment of outcome definitions with standardized definitions for efficacy endpoints criteria were assessed to evaluate feasibility of conducting a meta-analysis. Where feasible, 5-year probabilities of BC recurrence or death were estimated using a Bayesian hierarchical arm-based model. RESULTS Of 21 included studies, 8 RCTs and 4 RWE studies reported outcome data of interest. There was heterogeneity in outcome reporting, as well as variation in recurrence risk amongst studies with aligned reporting. Of the 12 studies, 10 were considered for inclusion in a meta-analysis of BC recurrence or death. Only a subgroup analysis of node-positive patients (3 studies; n = 7307) was deemed feasible. The 5-year probability of BC recurrence or death was 17.2% (95% credible interval: 14.6%-20.3%). CONCLUSION Although studies reporting recurrence outcomes were limited, there remains a high risk of BC recurrence, especially among node-positive patients. Approximately 1 in 6 women with node-positive HR+/HER2- early-stage BC receiving endocrine therapy experience recurrence or death within 5-years of initiating treatment, suggesting a need for novel treatments for this population.
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Affiliation(s)
| | | | - Jenilee Cueto
- Patient & Health Impact, Pfizer Inc, New York, NY, USA
| | - Ernest H Law
- Patient & Health Impact, Pfizer Inc, New York, NY, USA
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Lu H, Lei X, Zhao H, Elting L, Siricilla M, Ursani MA, Giordano SH, Suarez-Almazor M. Bone Mineral Density at the Time of Initiating Aromatase Inhibitor Therapy Is Associated With Decreased Fractures in Women With Breast Cancer. J Bone Miner Res 2021; 36:861-871. [PMID: 33484602 DOI: 10.1002/jbmr.4250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 11/05/2020] [Accepted: 12/06/2020] [Indexed: 12/31/2022]
Abstract
Women with estrogen receptor-positive breast cancer who receive an aromatase inhibitor (AI) are at risk for fractures. We aim to determine if dual-energy X-ray absorptiometry (DXA) scans made at the time of AI initiation are associated with decreased fractures. We retrospectively identified 25,158 women with local or regional breast cancer diagnosed between 2005 and 2013 who received AI therapy between 2007 and 2013 from the Medicare-linked Surveillance, Epidemiology, and End Results Program and Texas Cancer Registry databases. We defined baseline DXA screening using claims made between 1 year before and 6 months after each patient's first AI claim to examine determinants of baseline screening using a multivariable GENMOD model. We included a propensity score adjustment in Cox proportional hazard models to assess the association between time-varying DXA screening and the risk of fractures. Additionally, we compared the use of antiresorptive therapy drugs between the two groups. Of the study cohort, 14,738 (58.6%) received DXA screening. The screening rates increased annually from 52.1% in 2007 to 61.7% in 2013. Higher screening rates were observed in patients with younger age, married status, non-Hispanic white race, localized disease, fewer comorbidities, more than one type of aromatase inhibitor drug claim, no state buy-in (surrogate for low socioeconomic status), higher education level, and prior osteoporosis diagnosis. Baseline DXA screening was associated with decreased risk of subsequent fractures (hazard ratio = 0.91; 95% confidence interval, 0.86-0.97, p < .001) after multivariable and propensity score adjustment. Bone-modifying drugs were prescribed to 4440 (30.1%) patients with screening compared with 1766 (16.9%) without (p < .001). Of the 4440 patients who received treatment, 95% received bisphosphonates. Our study demonstrated baseline DXA screening was associated with a decreased risk of fractures and a higher likelihood of receiving antiresorptive therapies. Improvement of the baseline DXA screening is still needed in practice. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linda Elting
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mamatha Siricilla
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohammad Ali Ursani
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Suarez-Almazor
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Diana A, Carlino F, Giunta EF, Franzese E, Guerrera LP, Di Lauro V, Ciardiello F, Daniele B, Orditura M. Cancer Treatment-Induced Bone Loss (CTIBL): State of the Art and Proper Management in Breast Cancer Patients on Endocrine Therapy. Curr Treat Options Oncol 2021; 22:45. [PMID: 33864145 PMCID: PMC8052225 DOI: 10.1007/s11864-021-00835-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT About 70-80% of early breast cancer (BC) patients receive adjuvant endocrine therapy (ET) for at least 5 years. ET includes in the majority of cases the use of aromatase inhibitors, as upfront or switch strategy, that lead to impaired bone health. Given the high incidence and also the high prevalence of BC, cancer treatment-induced bone loss (CTIBL) represents the most common long-term adverse event experimented by patients with hormone receptor positive tumours. CTIBL is responsible for osteoporosis occurrence and, as a consequence, fragility fractures that may negatively affect quality of life and survival expectancy. As recommended by main international guidelines, BC women on aromatase inhibitors should be carefully assessed for their fracture risk at baseline and periodically reassessed during adjuvant ET in order to early detect significant worsening in terms of bone health. Antiresorptive agents, together with adequate intake of calcium and vitamin D, should be administered in BC patients during all course of ET, especially in those at high risk of osteoporotic fractures, as calculated by tools available for clinicians. Bisphosphonates, such as zoledronate or pamidronate, and anti-RANKL antibody, denosumab, are the two classes of antiresorptive drugs used in clinical practice with similar efficacy in preventing bone loss induced by aromatase inhibitor therapy. The choice between them, in the absence of direct comparison, should be based on patients' preference and compliance; the different safety profile is mainly related to the route of administration, although both types of drugs are manageable with due care, since most of the adverse events are predictable and preventable. Despite advances in management of CTIBL, several issues such as the optimal time of starting antiresorptive agents and the duration of treatment remain unanswered. Future clinical trials as well as increased awareness of bone health are needed to improve prevention, assessment and treatment of CTIBL in these long-term survivor patients.
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Affiliation(s)
- Anna Diana
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy.
- Medical Oncology Unit, Ospedale del Mare, 80147, Naples, Italy.
| | - Francesca Carlino
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy
| | - Emilio Francesco Giunta
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy
| | - Elisena Franzese
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Pascale, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy
| | - Luigi Pio Guerrera
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy
| | - Vincenzo Di Lauro
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Pascale, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy
| | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy
| | - Bruno Daniele
- Medical Oncology Unit, Ospedale del Mare, 80147, Naples, Italy
| | - Michele Orditura
- Medical Oncology, Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, 80131, Naples, Italy
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Dose modifications of ribociclib and endocrine therapy for treatment of ER+ HER2- metastatic breast cancer. Breast Cancer Res Treat 2021; 188:799-809. [PMID: 33837869 DOI: 10.1007/s10549-021-06215-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/27/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Treatment for estrogen receptor positive (ER+), human epidermal receptor 2 negative (HER2-) metastatic breast cancer (MBC) has improved with the approval of CDK 4/6 inhibitors. Clinical trials with the CDK4/6 inhibitor ribociclib, suggest that 35% to 57.5% of the patients require a dose reduction during ribociclib treatment. Data on the possible consequences of dose reduction concerning efficacy is needed. METHODS A retrospective cohort study on patients with ER+ HER2- MBC from three Danish oncology departments. Data on tolerability and progression-free survival were collected from electronic health records. RESULTS One hundred and twenty-eight patients with ER+ HER2- MBC who initiated ribociclib treatment between 1st of January 2018 to 31st of March 2020 were included in our analysis. Of these patients, 48.4% required one or more dose reductions. Overall median PFS was 19.2 months (CI-95% 14.3-NR). Patients with one or more dose reductions did not have decreased median PFS (19.2 months, CI-95% 14.3-NR compared to 12.2 months, CI-95% 7.3-NR, p = 0.078). Frequency of adverse events were as previously reported, with grade III and IV neutropenia occurring in 45.3% and 7% of patients, respectively. Patients treated with fulvestrant versus an aromatase inhibitor and patients with lymph node involvement at baseline had lower odds of requiring a dose reduction (ORa = 0.30, CI-95% 0.12-0.73 & ORa = 0.41, CI-95% 0.18-0.89, respectively). CONCLUSION Our results indicate that dose reduction of ribociclib is safe and do not compromise the efficacy of the treatment. Furthermore, the study supports translation of results from the MONALEESA trials to patients treated in real-world clinical settings.
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Hyder T, Marino CC, Ahmad S, Nasrazadani A, Brufsky AM. Aromatase Inhibitor-Associated Musculoskeletal Syndrome: Understanding Mechanisms and Management. Front Endocrinol (Lausanne) 2021; 12:713700. [PMID: 34385978 PMCID: PMC8353230 DOI: 10.3389/fendo.2021.713700] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/12/2021] [Indexed: 12/31/2022] Open
Abstract
Aromatase inhibitors (AIs) are a key component in the chemoprevention and treatment of hormone receptor-positive (HR+) breast cancer. While the addition of AI therapy has improved cancer-related outcomes in the management of HR+ breast cancer, AIs are associated with musculoskeletal adverse effects known as the aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) that limit its tolerability and use. AIMSS is mainly comprised of AI-associated bone loss and arthralgias that affect up to half of women on AI therapy and detrimentally impact patient quality of life and treatment adherence. The pathophysiology of AIMSS is not fully understood though has been proposed to be related to estrogen deprivation within the musculoskeletal and nervous systems. This review aims to characterize the prevalence, risk factors, and clinical features of AIMSS, and explore the syndrome's underlying mechanisms and management strategies.
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Affiliation(s)
- Tara Hyder
- University of Pittsburgh Physicians, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christopher C Marino
- Mario Lemieux Center for Blood Cancers, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Pittsburgh, PA, United States
| | - Sasha Ahmad
- Department of Sciences, Sewickley Academy, Pittsburgh, PA, United States
| | - Azadeh Nasrazadani
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA, United States
| | - Adam M Brufsky
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA, United States
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Rachner TD, Göbel A, Jaschke NP, Hofbauer LC. Challenges in Preventing Bone Loss Induced by Aromatase Inhibitors. J Clin Endocrinol Metab 2020; 105:5872610. [PMID: 32674135 DOI: 10.1210/clinem/dgaa463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT Aromatase inhibitors have become a mainstay in the adjuvant treatment regimen in postmenopausal women with hormone receptor-positive breast cancer. While many of these patients have an excellent long-term prognosis, adverse effects on bone represent an emerging complication of aromatase inhibitor treatment, resulting in substantial bone loss and fragility fractures. Treatment approaches to prevent aromatase inhibitor-induced bone loss typically consist of an antiresorptive approach with bisphosphonates or the RANKL antibody denosumab. However, different guidelines vary with respect to treatment thresholds, duration, and dosing. The choice of antiresorptive regime is further complicated by comorbidities and potential disease-modifying effects of individual agents. OBJECTIVE This review summarizes the evidence of how aromatase inhibitors affect bone health and provides an update of clinical approaches to preserve bone strength in affected women. (J Clin Endocrinol Metab XX: 0-0, 2020).
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Affiliation(s)
- Tilman D Rachner
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andy Göbel
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nikolai P Jaschke
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology and Metabolism, Medical University of Innsbruck, Austria
| | - Lorenz C Hofbauer
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Cairns J, Ingle JN, Dudenkov TM, Kalari KR, Carlson EE, Na J, Buzdar AU, Robson ME, Ellis MJ, Goss PE, Shepherd LE, Goodnature B, Goetz MP, Weinshilboum RM, Li H, Bari MG, Wang L. Pharmacogenomics of aromatase inhibitors in postmenopausal breast cancer and additional mechanisms of anastrozole action. JCI Insight 2020; 5:137571. [PMID: 32701512 PMCID: PMC7455128 DOI: 10.1172/jci.insight.137571] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/15/2020] [Indexed: 01/09/2023] Open
Abstract
Aromatase inhibitors (AIs) reduce breast cancer recurrence and prolong survival, but up to 30% of patients exhibit recurrence. Using a genome-wide association study of patients entered on MA.27, a phase III randomized trial of anastrozole versus exemestane, we identified a single nucleotide polymorphism (SNP) in CUB And Sushi multiple domains 1 (CSMD1) associated with breast cancer–free interval, with the variant allele associated with fewer distant recurrences. Mechanistically, CSMD1 regulates CYP19 expression in an SNP- and drug-dependent fashion, and this regulation is different among 3 AIs: anastrozole, exemestane, and letrozole. Overexpression of CSMD1 sensitized AI-resistant cells to anastrozole but not to the other 2 AIs. The SNP in CSMD1 that was associated with increased CSMD1 and CYP19 expression levels increased anastrozole sensitivity, but not letrozole or exemestane sensitivity. Anastrozole degrades estrogen receptor α (ERα), especially in the presence of estradiol (E2). ER+ breast cancer organoids and AI- or fulvestrant-resistant breast cancer cells were more sensitive to anastrozole plus E2 than to AI alone. Our findings suggest that the CSMD1 SNP might help to predict AI response, and anastrozole plus E2 serves as a potential new therapeutic strategy for patients with AI- or fulvestrant-resistant breast cancers. A germline variation within the CSMD1 gene predicts aromatase inhibitor response in breast cancer.
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Affiliation(s)
- Junmei Cairns
- Department of Molecular Pharmacology and Experimental Therapeutics
| | | | - Tanda M Dudenkov
- Department of Molecular Pharmacology and Experimental Therapeutics
| | - Krishna R Kalari
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin E Carlson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jie Na
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Aman U Buzdar
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark E Robson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Paul E Goss
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Barbara Goodnature
- Patient advocate, Mayo Clinic Breast Cancer Specialized Program of Research Excellence, Rochester, Minnesota, USA
| | | | | | - Hu Li
- Department of Molecular Pharmacology and Experimental Therapeutics
| | | | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics
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Komorowski AS, MacKay HJ, Pezo RC. Quality of adverse event reporting in phase III randomized controlled trials of breast and colorectal cancer: A systematic review. Cancer Med 2020; 9:5035-5050. [PMID: 32452660 PMCID: PMC7367648 DOI: 10.1002/cam4.3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical trial reports often emphasize efficacy over harms, leading to misinterpretation of the risk-to-benefit ratio of new therapies. Clear and sufficiently detailed reporting of methods and results is especially important in the abstracts of trial reports, as readers often base their assessment of a trial on such information. In this study, we evaluated the quality of adverse event (AE) reporting and abstract quality in phase III randomized controlled trials (RCTs) of systemic therapies in breast and colorectal cancer. METHODS Medline, EMBASE, Cochrane Database of RCTs, and Cochrane Database of Systematic Reviews were searched from November 2005 to September 2018. Phase III RCTs evaluating systemic therapies in breast or colorectal cancer were included. Each article was independently reviewed by two investigators using a standardized data extraction form based on guidelines developed by the Consolidated Standards of Reporting Trials (CONSORT) group. Descriptive statistics, bivariate analysis, and multivariable linear regression were used to analyze data. All statistical tests were two-sided. RESULTS Of 166 RCTs identified, 99.4% reported harms in the manuscript body, and 59.6% reported harms in the abstract. Reporting was restricted to severe harms in 15.6% of RCTs. Statistical comparison of AE rates went unreported in 59.0% of studies. Information regarding AEs leading to dose reductions, treatment discontinuations, or study withdrawals went unreported in 59.3%, 18.7%, and 86.8% of studies, respectively. Recently published RCTs (P = .009) and those sponsored at least partially by for-profit companies (P = .003) had higher abstract quality scores. CONCLUSIONS Breast and colorectal cancer phase III RCTs inadequately report CONSORT-compliant AE data. Improved guideline adherence and abstract reporting is required to properly weigh benefits and harms of new oncologic therapies. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42019140673.
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Affiliation(s)
- Adam S. Komorowski
- Division of Medical MicrobiologyMcMaster UniversityHamiltonONCanada
- Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoONCanada
| | - Helen J. MacKay
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Rossanna C. Pezo
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
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Dempsey JM, Kidwell KM, Gersch CL, Pesch AM, Desta Z, Storniolo AM, Stearns V, Skaar TC, Hayes DF, Henry NL, Rae JM, Hertz DL. Effects of SLCO1B1 polymorphisms on plasma estrogen concentrations in women with breast cancer receiving aromatase inhibitors exemestane and letrozole. Pharmacogenomics 2020; 20:571-580. [PMID: 31190621 DOI: 10.2217/pgs-2019-0020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: This study tested for associations between SLCO1B1 polymorphisms and circulating estrogen levels in women with breast cancer treated with letrozole or exemestane. Patients & methods: Postmenopausal women with hormone-receptor positive breast cancer were genotyped for SLCO1B1*5 (rs4149056) and rs10841753. Pretreatment and on-treatment plasma estrogens and aromatase inhibitor (AI) concentrations were measured. Regression analyses were performed to test for pharmacogenetic associations with estrogens and drug concentrations. Results: SLCO1B1*5 was associated with elevated pretreatment estrone sulfate and an increased risk of detectable estrone concentrations after 3 months of AI treatment. Conclusion: These findings suggest SLCO1B1 polymorphisms may have an effect on estrogenic response to AI treatment, and therefore may adversely impact the anticancer effectiveness of these agents.
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Affiliation(s)
- Jacqueline M Dempsey
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA
| | - Kelley M Kidwell
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Christina L Gersch
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Andrea M Pesch
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Zeruesenay Desta
- Department of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | | | - Vered Stearns
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Todd C Skaar
- Department of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - N Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - James M Rae
- Department of Internal Medicine, Division of Hematology/Oncology, Medical School, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109-1065, USA
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Paleari L, Rutigliani M, Siri G, Provinciali N, Colombo N, Decensi A. Aromatase Inhibitors as Adjuvant Treatment for ER/PgR Positive Stage I Endometrial Carcinoma: A Retrospective Cohort Study. Int J Mol Sci 2020; 21:E2227. [PMID: 32210157 PMCID: PMC7139521 DOI: 10.3390/ijms21062227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Although endometrial cancer (EC) is a hormone dependent neoplasm, there are no recommendations for the determination of steroid hormone receptors in the tumor tissue and no hormone therapy has ever been assessed in the adjuvant setting. The purpose of this study was to explore the effect of adjuvant aromatase inhibitors (AIs) on progression-free survival (PFS) and overall survival (OS) in patients with early stage and steroid receptors-positive EC. METHODS We retrospectively analyzed clinical and pathological factors in 73 patients with high-risk (49.3%) or low-risk (50.7%) stage I (n = 71) or II (n = 2) endometrial cancer who received by their preference after counseling either no treatment (reference group) or AI. Prognostic factors were well balanced between groups. Expression of estrogen receptor (ER), progesterone receptor (PgR), and Ki-67 index was correlated with clinical outcomes. RESULTS Univariate and multivariate Cox proportional regression analyses, adjusted for age, grade, stage, depth of myometrial invasion, lymphovascular space invasion, BMI, ER, PgR and Ki-67 labeling index levels, showed that PFS and OS had a trend to be longer in patients receiving AI than in the reference group HR= 0.23 (95% CI; 0.04-1.27) for PFS and HR= 0.11 (95% CI; 0.01-1.36) for OS. CONCLUSION Compared with no treatment, AI exhibited a trend toward a benefit on PFS and OS in patients with early stage hormone receptor-positive EC. Given the exploratory nature of our study, randomized clinical trials for ER/PgR positive EC patients are warranted to assess the clinical benefit of AI and the potential predictive role of steroid receptors and Ki-67.
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Affiliation(s)
- Laura Paleari
- A.Li.Sa., Liguria Region Health Authority, 16121 Genoa, Italy
| | | | - Giacomo Siri
- Office of the Scientific Director, Galliera Hospital, 16128 Genoa, Italy;
| | | | - Nicoletta Colombo
- Gynecology Program, European Institute of Oncology, 20141 Milan, Italy;
- School of Medicine and Surgery, University Milan Bicocca, 20126 Milan, Italy
| | - Andrea Decensi
- Medical Oncology Unit, Galliera Hospital, 16128 Genoa, Italy; (N.P.); (A.D.)
- Barts School of Medicine, Queen Mary University of London, London E1 4NS, UK
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Ingle JN, Cairns J, Suman VJ, Shepherd LE, Fasching PA, Hoskin TL, Singh RJ, Desta Z, Kalari KR, Ellis MJ, Goss PE, Chen BE, Volz B, Barman P, Carlson EE, Haddad T, Goetz MP, Goodnature B, Cuellar ME, Walters MA, Correia C, Kaufmann SH, Weinshilboum RM, Wang L. Anastrozole has an Association between Degree of Estrogen Suppression and Outcomes in Early Breast Cancer and is a Ligand for Estrogen Receptor α. Clin Cancer Res 2020; 26:2986-2996. [PMID: 32098767 DOI: 10.1158/1078-0432.ccr-19-3091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/07/2020] [Accepted: 02/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine if the degree of estrogen suppression with aromatase inhibitors (AI: anastrozole, exemestane, letrozole) is associated with efficacy in early-stage breast cancer, and to examine for differences in the mechanism of action between the three AIs. EXPERIMENTAL DESIGN Matched case-control studies [247 matched sets from MA.27 (anastrozole vs. exemestane) and PreFace (letrozole) trials] were undertaken to assess whether estrone (E1) or estradiol (E2) concentrations after 6 months of adjuvant therapy were associated with risk of an early breast cancer event (EBCE). Preclinical laboratory studies included luciferase activity, cell proliferation, radio-labeled ligand estrogen receptor binding, surface plasmon resonance ligand receptor binding, and nuclear magnetic resonance assays. RESULTS Women with E1 ≥1.3 pg/mL and E2 ≥0.5 pg/mL after 6 months of AI treatment had a 2.2-fold increase in risk (P = 0.0005) of an EBCE, and in the anastrozole subgroup, the increase in risk of an EBCE was 3.0-fold (P = 0.001). Preclinical laboratory studies examined mechanisms of action in addition to aromatase inhibition and showed that only anastrozole could directly bind to estrogen receptor α (ERα), activate estrogen response element-dependent transcription, and stimulate growth of an aromatase-deficient CYP19A1-/- T47D breast cancer cell line. CONCLUSIONS This matched case-control clinical study revealed that levels of estrone and estradiol above identified thresholds after 6 months of adjuvant anastrozole treatment were associated with increased risk of an EBCE. Preclinical laboratory studies revealed that anastrozole, but not exemestane or letrozole, is a ligand for ERα. These findings represent potential steps towards individualized anastrozole therapy.
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Affiliation(s)
- James N Ingle
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Junmei Cairns
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Vera J Suman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Peter A Fasching
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital, Erlangen, Germany
| | - Tanya L Hoskin
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krishna R Kalari
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Ellis
- Department of Medicine, Baylor University College of Medicine, Houston, Texas
| | - Paul E Goss
- Massachusetts General Hospital Cancer Center, Harvard University, Boston, Massachusetts
| | | | - Bernhard Volz
- Department of Business Informatics, University of Applied Sciences Ansbach, Ansbach, Germany
| | - Poulami Barman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Erin E Carlson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Tufia Haddad
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Goetz
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Barbara Goodnature
- Patient advocate, Mayo Clinic Breast Cancer Specialized Program of Research Excellence, Rochester, Minnesota
| | - Matthew E Cuellar
- Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, Minnesota
| | - Michael A Walters
- Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, Minnesota
| | - Cristina Correia
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Scott H Kaufmann
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota.,Division of Oncology Research, Mayo Clinic, Rochester, Minnesota
| | - Richard M Weinshilboum
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota.
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Chien HC, Kao Yang YH, Kwoh CK, Chalasani P, Wilson DL, Lo-Ciganic WH. Aromatase Inhibitors and Risk of Arthritis and Carpal Tunnel Syndrome among Taiwanese Women with Breast Cancer: A Nationwide Claims Data Analysis. J Clin Med 2020; 9:jcm9020566. [PMID: 32092973 PMCID: PMC7074454 DOI: 10.3390/jcm9020566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 01/08/2023] Open
Abstract
Tamoxifen or aromatase inhibitor (AI) therapy may prevent breast cancer recurrence, however, adverse effects may lead to treatment discontinuation. Evidence regarding the occurrence of AI-associated musculoskeletal problems among Asians is scarce. We identified women with breast cancer-initiating tamoxifen or AIs from the Taiwan National Health Insurance Research Database (2007-2012). Using multivariable cause-specific hazard models, we examined the association between endocrine therapy and the risk of any arthritis and carpal tunnel syndrome, adjusting for age, prior cancer treatment, and other health status factors. Among 32,055 eligible women with breast cancer (mean age = 52.6 ± 11.5 years), 87.4% initiated tamoxifen, 3.9% initiated anastrozole, 8.0% initiated letrozole, and 0.7% initiated exemestane. AI users had a higher 1-year cumulative incidence for any arthritis (13.0% vs. 8.2%, p < 0.0001) and carpal tunnel syndrome (1.4% vs. 0.8%, p = 0.008). Compared to tamoxifen users, AI users had a higher risk of any arthritis [adjusted hazard ratio (aHR) = 1.21, 95%CI = 1.09-1.34] and carpal tunnel syndrome (aHR = 1.68, 95%CI = 1.22-2.32). No significant difference was observed in the risks of any arthritis and carpal tunnel syndrome across different AIs. Taxane use was not associated with any arthritis (aHR = 0.92, 95%CI = 0.81-1.05) or carpal tunnel syndrome (aHR = 0.97, 95%CI = 0.67-1.40) compared to other chemotherapies. Taiwanese women with breast cancer-initiating AIs had an increased risk of arthritis and carpal tunnel syndrome compared to those who initiated tamoxifen.
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Affiliation(s)
- Hsu-Chih Chien
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine and Health Outcome Research Center, National Cheng Kung University, Tainan 701, Taiwan;
- School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- University of Arizona Arthritis Center, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Yea-Huei Kao Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine and Health Outcome Research Center, National Cheng Kung University, Tainan 701, Taiwan;
- School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Correspondence: (Y.-H.K.Y.); (W.-H.L.-C.)
| | - C. Kent Kwoh
- Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- University of Arizona Arthritis Center, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Pavani Chalasani
- Division of Hematology and Oncology, College of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- University of Arizona Cancer Center, Tucson, AZ 85719, USA
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA;
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA;
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence: (Y.-H.K.Y.); (W.-H.L.-C.)
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BrintzenhofeSzoc K, Krok-Schoen JL, Canin B, Parker I, MacKenzie AR, Koll T, Vankina R, Hsu CD, Jang B, Pan K, Lund JL, Starbuck E, Shahrokni A. The underreporting of phase III chemo-therapeutic clinical trial data of older patients with cancer: A systematic review. J Geriatr Oncol 2020; 11:369-379. [PMID: 31932259 DOI: 10.1016/j.jgo.2019.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Inspired by the American Society of Clinical Oncology's recommendations to strengthen the evidence base for older adults with cancer, the purpose of this systematic review is to identify the reporting of treatment efficacy and adverse events specific to older adults with cancer in Phase III chemo-therapeutic clinical trials. This review also investigates the frequency with which these data points were reported in the literature to identify gaps in reporting and opportunities to expand the knowledge base on clinical outcomes for older adults with cancer. METHODS Chemo-therapeutic clinical trial data published from July 1, 2016 to June 30, 2017 was reviewed. Manuscripts (n = 929) were identified based on keyword searches of EMBASE and PubMed. After removal of duplicates (n = 116) and articles that did not meet this study's inclusion criteria (n = 654), 159 articles were identified for review. RESULTS Reviewed papers were published in 36 different scientific journals and included twenty-five different cancer types. Of the 159 articles, 117 (73.6%) reported age-specific medians and 75 (47.2%) included stratifications of data by age. Treatment efficacy was reported in 96.2% of the articles with 39.9% reporting effectiveness of treatment by age. Reporting of adverse events was included in 84.9% of the articles with only 8.9% reporting these events stratified by age. CONCLUSION Results suggest inadequate reporting of treatment efficacy and adverse events as well as basic descriptive statistics about the age distribution of study subjects. Conscious efforts are needed to address these deficiencies at every level of planning and conducting clinical trials as wells as reporting outcomes stratified by age. Ultimately, standardized reporting could lead to improved treatment decisions and outcomes for older adults with cancer.
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Affiliation(s)
| | | | | | | | | | - Thuy Koll
- Department of Internal Medicine, University of Nebraska Medical Center, USA
| | | | | | - Brian Jang
- Tulane University School of Medicine, USA
| | | | | | - Edith Starbuck
- University of Cincinnati Libraries, University of Cincinnati, USA
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Telford C, Bertranou E, Large S, Phelps H, Ekman M, Livings C. Cost-Effectiveness Analysis of Fulvestrant 500 mg in Endocrine Therapy-Naïve Postmenopausal Women with Hormone Receptor-Positive Advanced Breast Cancer in the UK. PHARMACOECONOMICS - OPEN 2019; 3:559-570. [PMID: 31025302 PMCID: PMC6861400 DOI: 10.1007/s41669-019-0134-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The selective estrogen receptor degrader fulvestrant is approved for the first-line treatment of postmenopausal patients with hormone receptor-positive (HR+), locally advanced or metastatic breast cancer who have not received prior endocrine therapy. We evaluated the cost-effectiveness of fulvestrant versus comparator treatments in endocrine therapy-naïve patients with locally advanced or metastatic breast cancer. METHODS A three-health-state (progression free, progressed disease, and death) partitioned survival model from the UK National Health Service and Personal Social Services perspective was developed to extrapolate study data for the cumulative probability of progression-free survival and overall survival to a lifetime (30-year) horizon. Relative comparator data were derived from a systematic literature review-informed network meta-analysis. Sensitivity analyses were applied to assess the impact of uncertainty in the parameter input values on the results. RESULTS Over a lifetime horizon (30 years), the incremental cost (British pounds sterling) per patient associated with fulvestrant treatment was £18,867 versus anastrozole, £23,097 versus letrozole, and £17,131 versus tamoxifen, with incremental quality-adjusted life-years of 0.55, 0.77, and 0.76, respectively, and incremental cost-effectiveness ratios of £34,109, £29,827, and £22,532, respectively. The largest difference in costs between fulvestrant and the comparators was related to treatment costs. CONCLUSIONS Results suggest that fulvestrant could potentially be a cost-effective option compared with other endocrine monotherapies (anastrozole, letrozole, and tamoxifen) for treating endocrine therapy-naïve, postmenopausal women with HR+, locally advanced or metastatic breast cancer.
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Affiliation(s)
- Claire Telford
- AstraZeneca Pharmaceuticals, 101 ORD, Gaithersburg, MD, USA.
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He Y, Zhang J, Shen G, Liu L, Zhao Q, Lu X, Yang H, Hong D. Aromatase inhibitors and risk of cardiovascular events in breast cancer patients: a systematic review and meta-analysis. BMC Pharmacol Toxicol 2019; 20:62. [PMID: 31665091 PMCID: PMC6820915 DOI: 10.1186/s40360-019-0339-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiovascular events (CVEs) was considered as one of the primary cause to reduce the quality of life in breast cancer patients with aromatase inhibitors (AIs) treatment, which has not been sufficiently addressed. The aim of this study was to assess the correlation between risk of CVEs and AIs in patients with breast cancer. METHODS Included studies were obtained from the databases of Embase, Pubmed, Cochrane Library, Clinical Trials.gov, and reference lists. The main outcome measures were overall incidence, odds ratios (ORs), and 95% confidence intervals (CIs). Furthermore, the association and the risk differences among different tumor types, AIs,ages,or treatment regimens were conducted. Fixed-effect or random-effect models were applied in the statistical analyses according to the heterogeneity. Our analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS Seventeen studies, which included 44,411 subjects, were included in our analyses. The overall incidence of CVEs in AIs group was 13.02% (95% CI: 8.15-20.17%) and almost all of the high-grade CVEs occurred in patients treated with AIs. The pooled ORs of CVEs was 0.9940 (95% CI: 0.8545-1.1562). Under sub-group analysis, the incidence of CVEs related to exemestane was higher than that of controls (OR = 1.1564, 95% CI: 1.0656-1.2549), but no statistical differences in risk of CVEs were found in other sub-group analysis. No evidence of publication bias was found for incidence of CVEs in our meta-analysis by a funnel plot. CONCLUSIONS These results suggest that patients with breast cancer treated with AIs do not have a significant risk of developing CVEs in comparison with the controls, and exemestane might not be considered as the alternative AI to the breast cancer patients from the perspective of CVEs. Further studies are recommended to investigate this association and the risk differences among different tumor types, AIs or treatment regimens.
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Affiliation(s)
- Yang He
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,College of Medicine, Zhejiang University, 866 Yuhangtang Road, Hangzhou, 310003, People's Republic of China
| | - Jianhua Zhang
- Department of Management, the Logistics Service Center of Municipal Government, Hangzhou, 310019, People's Republic of China
| | - Guofang Shen
- Loma Linda University School of Pharmacy, Loma Linda, CA, 92354, USA
| | - Lin Liu
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China
| | - Qingwei Zhao
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China
| | - Xiaoyang Lu
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China
| | - Hongyu Yang
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.
| | - Dongsheng Hong
- Department of Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.
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Addeo A, Weiss GJ, Gyawali B. Association of Industry and Academic Sponsorship With Negative Phase 3 Oncology Trials and Reported Outcomes on Participant Survival: A Pooled Analysis. JAMA Netw Open 2019; 2:e193684. [PMID: 31074821 PMCID: PMC6512293 DOI: 10.1001/jamanetworkopen.2019.3684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/19/2019] [Indexed: 01/02/2023] Open
Abstract
Importance Only 3.4% of cancer drugs evaluated in phase 1 trials are approved by the US Food and Drug Administration, with most failing in phase 3 trials. Objective To investigate whether an association exists between the sponsorship and conduct of a negative phase 3 randomized clinical trial (RCT) investigating a cancer drug that lacked supporting phase 2 trial evidence for that drug, and to evaluate the association with overall survival among patients randomized to the experimental arm of such phase 3 trials. Data Sources Articles in the Lancet, Lancet Oncology, JAMA, JAMA Oncology, and Journal of Clinical Oncology published between January 2016 and June 2018 were searched. Study Selection Phase 3 RCTs of cancer drugs that failed to improve the primary end point were selected and any prior phase 2 trial of the same drug that supported the phase 3 trial was selected without any date or journal restrictions. Data Extraction and Synthesis Percentages of negative phase 3 RCTs of cancer drugs that lacked any phase 2 evidence, had a negative phase 2 trial, or had a positive phase 2 study were extracted. Associations were assessed using the Fisher exact test. Pooled hazard ratios and 95% CIs for the overall survival of patients enrolled in these negative phase 3 RCTs were estimated using a random-effects model. Main Outcomes and Measures Negative phase 3 RCTs with a lack of a phase 2 trial or the presence of a negative phase 2 trial and overall survival of enrolled patients in the phase 3 RCTs. Results In this meta-epidemiological study, 67 negative phase 3 RCTs on cancer drugs, which included 64 600 patients, met the criteria of being sponsored by industry or academic groups, of which 42 RCTs (63%) were industry sponsored and the remaining 25 RCTs (37%) were academic. A phase 2 trial was not available for 28 of these trials (42%). Of 29 trials (43%) with a phase 2 trial available, 8 trials (28%) failed to meet their primary end points and 5 of those were industry sponsored. There was no association with overall survival for patients participating in these negative phase 3 RCTs (pooled hazard ratio, 0.99; 95% CI, 0.96-1.02). When the pooled analysis was limited to the 27 RCTs with a hazard ratio above 1.00, the overall pooled hazard ratio for overall survival was 1.11 (95% CI, 1.06-1.16). No association between having a negative or undefined phase 2 trial and trial sponsorship was found using the Fisher exact test. Conclusions and Relevance More than 40% of the negative phase 3 RCTs in oncology published in these 5 journals were conducted without a supporting phase 2 trial and were sponsored by both academia and industry. Running such trials not only may risk loss of resources owing to a failed trial but also may be associated with decreased patient survival. Further research and regulations in this area appear warranted.
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Affiliation(s)
- Alfredo Addeo
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Glen J. Weiss
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bishal Gyawali
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Cancer Care and Epidemiology, Department of Oncology and Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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Elevated Risk of Cancer After Solid Organ Transplant in Childhood: A Population-based Cohort Study. Transplantation 2019; 103:588-596. [DOI: 10.1097/tp.0000000000002378] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Ulm M, Ramesh AV, McNamara KM, Ponnusamy S, Sasano H, Narayanan R. Therapeutic advances in hormone-dependent cancers: focus on prostate, breast and ovarian cancers. Endocr Connect 2019; 8:R10-R26. [PMID: 30640710 PMCID: PMC6365668 DOI: 10.1530/ec-18-0425] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/14/2019] [Indexed: 12/17/2022]
Abstract
Hormonal cancers affect over 400,000 men and women and contribute collectively to over 100,000 deaths in the United States alone. Thanks to advances in the understanding of these cancers at the molecular level and to the discovery of several disease-modifying therapeutics, the last decade has seen a plateauing or even a decreasing trend in the number of deaths from these cancers. These advanced therapeutics not only effectively slow the growth of hormonal cancers, but also provide an insight on how these cancers become refractory and evolve as an altogether distinct subset. This review summarizes the current therapeutic trends in hormonal cancers, with focus on prostate, breast and ovarian cancers. The review discusses the clinical drugs being used now, promising molecules that are going through various stages of development and makes some predictions on how the therapeutic landscape will shift in the next decade.
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Affiliation(s)
- Michael Ulm
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
- West Cancer Center, Memphis, Tennessee, USA
| | | | | | - Suriyan Ponnusamy
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Ramesh Narayanan
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
- West Cancer Center, Memphis, Tennessee, USA
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Johnston S, Puhalla S, Wheatley D, Ring A, Barry P, Holcombe C, Boileau JF, Provencher L, Robidoux A, Rimawi M, McIntosh SA, Shalaby I, Stein RC, Thirlwell M, Dolling D, Morden J, Snowdon C, Perry S, Cornman C, Batten LM, Jeffs LK, Dodson A, Martins V, Modi A, Osborne CK, Pogue-Geile KL, Cheang MCU, Wolmark N, Julian TB, Fisher K, MacKenzie M, Wilcox M, Huang Bartlett C, Koehler M, Dowsett M, Bliss JM, Jacobs SA. Randomized Phase II Study Evaluating Palbociclib in Addition to Letrozole as Neoadjuvant Therapy in Estrogen Receptor-Positive Early Breast Cancer: PALLET Trial. J Clin Oncol 2019; 37:178-189. [PMID: 30523750 DOI: 10.1200/jco.18.01624] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE CDK4/6 inhibitors are used to treat estrogen receptor (ER)-positive metastatic breast cancer (BC) in combination with endocrine therapy. PALLET is a phase II randomized trial that evaluated the effects of combination palbociclib plus letrozole as neoadjuvant therapy. PATIENTS AND METHODS Postmenopausal women with ER-positive primary BC and tumors greater than or equal to 2.0 cm were randomly assigned 3:2:2:2 to letrozole (2.5 mg/d) for 14 weeks (A); letrozole for 2 weeks, then palbociclib plus letrozole to 14 weeks (B); palbociclib for 2 weeks, then palbociclib plus letrozole to 14 weeks (C); or palbociclib plus letrozole for 14 weeks. Palbociclib 125 mg/d was administered orally on a 21-days-on, 7-days-off schedule. Core-cut biopsies were taken at baseline and 2 and 14 weeks. Coprimary end points for letrozole versus palbociclib plus letrozole groups (A v B + C + D) were change in Ki-67 (protein encoded by the MKI67 gene; immunohistochemistry) between baseline and 14 weeks and clinical response (ordinal and ultrasound) after 14 weeks. Complete cell-cycle arrest was defined as Ki-67 less than or equal to 2.7%. Apoptosis was characterized by cleaved poly (ADP-ribose) polymerase. RESULTS Three hundred seven patients were recruited. Clinical response was not significantly different between palbociclib plus letrozole and letrozole groups ( P = .20; complete response + partial response, 54.3% v 49.5%), and progressive disease was 3.2% versus 5.4%, respectively. Median log-fold change in Ki-67 was greater with palbociclib plus letrozole compared with letrozole (-4.1 v -2.2; P < .001) in the 190 evaluable patients (61.9%), corresponding to a geometric mean change of -97.4% versus -88.5%. More patients on palbociclib plus letrozole achieved complete cell-cycle arrest (90% v 59%; P < .001). Median log-fold change (suppression) of cleaved poly (ADP-ribose) polymerase was greater with palbociclib plus letrozole versus letrozole (-0.80 v -0.42; P < .001). More patients had grade 3 or greater toxicity on palbociclib plus letrozole (49.8% v 17.0%; P < .001) mainly because of asymptomatic neutropenia. CONCLUSION Adding palbociclib to letrozole significantly enhanced the suppression of malignant cell proliferation (Ki-67) in primary ER-positive BC, but did not increase the clinical response rate over 14 weeks, which was possibly related to a concurrent reduction in apoptosis.
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Affiliation(s)
- Stephen Johnston
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Shannon Puhalla
- 2 Univeristy of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA
| | - Duncan Wheatley
- 3 Royal Cornwall Hospitals National Health Service Foundation Trust, Treliske, United Kingdom
| | - Alistair Ring
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Peter Barry
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Chris Holcombe
- 4 Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | | | - Louise Provencher
- 6 Centre Hospitalier Université de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - André Robidoux
- 7 Centre Hospitalier Université de Montréal, Montreal, Quebec, Canada
| | | | | | - Ibrahim Shalaby
- 10 Joe Arrington Cancer Research and Treatment Center, Lubbock, TX
| | - Robert C Stein
- 11 National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
- 12 University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
| | | | - David Dolling
- 14 The Institute of Cancer Research, London, United Kingdom
| | - James Morden
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Claire Snowdon
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Sophie Perry
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Chester Cornman
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
| | - Leona M Batten
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Lisa K Jeffs
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Andrew Dodson
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Vera Martins
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Arjun Modi
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | | | | | | | - Norman Wolmark
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
| | - Thomas B Julian
- 16 Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Kate Fisher
- 17 International Drug Development Institute, Brussels, Belgium
| | | | - Maggie Wilcox
- 18 Independent Cancer Patients Voice, London, United Kingdom
| | | | | | - Mitch Dowsett
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Judith M Bliss
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Samuel A Jacobs
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
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