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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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Wang F, Eikeland E, Reidunsdatter RJ, Hagen L, Engstrøm MJ, Geisler J, Haanpää M, Hämäläinen E, Giskeødegård GF, Bathen TF. Quantification of multiple steroid hormones in serum and human breast cancer tissue by liquid chromatography-tandem mass spectrometry analysis. Front Oncol 2024; 14:1383104. [PMID: 38863629 PMCID: PMC11165045 DOI: 10.3389/fonc.2024.1383104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/06/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction Systemic and local steroid hormone levels may function as novel prognostic and predictive biomarkers in breast cancer patients. We aimed at developing a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous measurement of multiple, biologically pivotal steroid hormones in human serum and breast cancer tissue. Methods The quantitative method consisted of liquid-liquid extraction, Sephadex LH-20 chromatography for tissue extracts, and analysis of steroid hormones by liquid-chromatography-tandem mass spectrometry. We analyzed serum and tissue steroid hormone levels in 16 and 40 breast cancer patients, respectively, and assessed their correlations with clinical parameters. Results The method included quantification of nine steroid hormones in serum [including cortisol, cortisone, corticosterone, estrone (E1), 17β-estradiol (E2), 17α-hydroxyprogesterone, androstenedione (A4), testosterone and progesterone) and six (including cortisone, corticosterone, E1, E2, A4, and testosterone) in cancer tissue. The lower limits of quantification were between 0.003-10 ng/ml for serum (250 µl) and 0.038-125 pg/mg for tissue (20 mg), respectively. Accuracy was between 98%-126%, intra-assay coefficient of variations (CV) was below 15%, and inter-assay CV were below 11%. The analytical recoveries for tissue were between 76%-110%. Tissue levels of E1 were positively correlated with tissue E2 levels (p<0.001), and with serum levels of E1, E2 and A4 (p<0.01). Tissue E2 levels were positively associated with serum E1 levels (p=0.02), but not with serum E2 levels (p=0.12). The levels of tissue E2 and ratios of E1 to A4 levels (an index for aromatase activity) were significantly higher in patients with larger tumors (p=0.03 and p=0.02, respectively). Conclusions The method was convenient and suitable for a specific and accurate profiling of clinically important steroid hormones in serum. However, the sensitivity of the profile method in steroid analysis in tissue samples is limited, but it can be used for the analysis of steroids in breast cancer tissues if the size of the sample or its steroid content is sufficient.
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Affiliation(s)
- Feng Wang
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Breast and Endocrine of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eline Eikeland
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Randi J. Reidunsdatter
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Hagen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Laboratory Medicine, St. Olavs Hospital, Trondheim, Norway
- PROMEC Core Facility for Proteomics and Modomics, Norwegian University of Science and Technology, and the Central Norway Regional Health Authority Norway, Trondheim, Norway
| | - Monica J. Engstrøm
- Department of Breast and Endocrine of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway & Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mikko Haanpää
- HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Esa Hämäläinen
- Department of Clinical Chemistry, University of Eastern Finland, Kuopio, Finland
| | - Guro F. Giskeødegård
- Department of Breast and Endocrine of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tone F. Bathen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Mansour B, Ngo C, Schlemmer D, Robidou P, Blondel J, Marin C, Noé G, Procureur A, Jamelot M, Gligorov J, Salem JE, Zahr N. Simultaneous quantification of four hormone therapy drugs by LC-MS/MS: Clinical applications in breast cancer patients. J Pharm Biomed Anal 2024; 242:116032. [PMID: 38367520 DOI: 10.1016/j.jpba.2024.116032] [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: 01/05/2024] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Aromatase inhibitors such as anastrozole, letrozole, exemestane and selective estrogen down-regulator (SERD) fulvestrant are used mostly to treat breast cancer estrogen receptor positive in post-menopausal women. These drugs are given either through the oral route or by intramuscular injection. They have shown great inter-individual variability with a risk of cardiometabolic disorders. Hence the importance of their therapeutic drug monitoring not only for exposure-efficacy but also exposure-toxicity. We describe here a LC-MS/MS method for the simultaneous quantification of anastrozole, letrozole, exemestane and fulvestrant in human plasma. MATERIAL AND METHODS Plasma samples were prepared by a single-step protein precipitation. The liquid chromatography system was paired with a triple quadrupole mass spectrometer. Quantification were achieved in Multiple Reactions Monitoring mode and the electrospray ionization was in positive mode. RESULTS The method demonstrated consistent analytical performance across various parameters, including linearity, specificity, sensitivity, matrix effect, upper and lower limits of quantification, extraction recovery, precision, accuracy, hemolysis effect, dilution integrity, and stability under different storage conditions, in accordance with established guidelines. The analysis time for each run was 4 min. Calibration curves exhibited linearity within the 1-100 ng/mL range, with correlation coefficients > 0.99 for the four analytes. Plasma concentrations from 42 patients were integrated into the selected calibration. Stability assessments indicated that the four drugs remained stable at - 20 °C for three months, 15 days under refrigeration, up to 7 days at room temperature, and after three freeze-thaw cycles. CONCLUSION We have developed and validated this quantitative method for therapeutic drug monitoring of those four hormone therapy drugs:anastrozole, letrozole, fulvestrant and exemestane. This method can be also used for future clinical pharmacokinetics /pharmacodynamics studies.
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Affiliation(s)
- Bochra Mansour
- AP-HP. Sorbonne Université, Laboratoire de suivi thérapeutique pharmacologique spécialisé, F-75013 Paris, France
| | - Clarice Ngo
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Dimitri Schlemmer
- AP-HP. Sorbonne Université, Laboratoire de suivi thérapeutique pharmacologique spécialisé, F-75013 Paris, France
| | - Pascal Robidou
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Juliette Blondel
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Clémence Marin
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Gaëlle Noé
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Adrien Procureur
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Mathieu Jamelot
- Department of Medical Oncology, Institut Universitaire de Cancérologie, Sorbonne University, AP-HP, Tenon Hospital, Paris, France
| | - Joseph Gligorov
- Department of Medical Oncology, Institut Universitaire de Cancérologie, Sorbonne University, AP-HP, Tenon Hospital, Paris, France
| | - Joe-Elie Salem
- AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France
| | - Noël Zahr
- AP-HP. Sorbonne Université, Laboratoire de suivi thérapeutique pharmacologique spécialisé, F-75013 Paris, France; AP-HP Sorbonne Université, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Pharmacokinetics and Therapeutic Drug Monitoring Unit, UMR-S 1166, F-75013 Paris, France.
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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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Eliassen FM, Blåfjelldal V, Helland T, Hjorth CF, Hølland K, Lode L, Bertelsen BE, Janssen EAM, Mellgren G, Kvaløy JT, Søiland H, Lende TH. Importance of endocrine treatment adherence and persistence in breast cancer survivorship: a systematic review. BMC Cancer 2023; 23:625. [PMID: 37403065 DOI: 10.1186/s12885-023-11122-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/28/2023] [Indexed: 07/06/2023] Open
Abstract
PURPOSE Adjuvant endocrine treatment is essential for treating luminal subtypes of breast cancer, which constitute 75% of all breast malignancies. However, the detrimental side effects of treatment make it difficult for many patients to complete the guideline-required treatment. Such non-adherence may jeopardize the lifesaving ability of anti-estrogen therapy. In this systematic review, we aimed to assess the consequences of non-adherence and non-persistence from available studies meeting strict statistical and clinical criteria. METHODS A systematic literature search was performed using several databases, yielding identification of 2,026 studies. After strict selection, 14 studies were eligible for systematic review. The review included studies that examined endocrine treatment non-adherence (patients not taking treatment as prescribed) or non-persistence (patients stopping treatment prematurely), in terms of the effects on event-free survival or overall survival among women with non-metastatic breast cancer. RESULTS We identified 10 studies measuring the effects of endocrine treatment non-adherence and non-persistence on event-free survival. Of these studies, seven showed significantly poorer survival for the non-adherent or non-persistent patient groups, with hazard ratios (HRs) ranging from 1.39 (95% CI, 1.07 to 1.53) to 2.44 (95% CI, 1.89 to 3.14). We identified nine studies measuring the effects of endocrine treatment non-adherence and non-persistence on overall survival. Of these studies, seven demonstrated significantly reduced overall survival in the groups with non-adherence and non-persistence, with HRs ranging from 1.26 (95% CI, 1.11 to 1.43) to 2.18 (95% CI, 1.99 to 2.39). CONCLUSION The present systematic review demonstrates that non-adherence and non-persistence to endocrine treatment negatively affect event-free and overall survival. Improved follow-up, with focus on adherence and persistence, is vital for improving health outcomes among patients with non-metastatic breast cancer.
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Affiliation(s)
- Finn Magnus Eliassen
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway.
| | - Vibeke Blåfjelldal
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Thomas Helland
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Cathrine Fonnesbech Hjorth
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Kari Hølland
- Division of Research, University of Stavanger, Stavanger, Norway
| | - Lise Lode
- Department of Gastrointestinal Surgery, Hvidovre Hospital, Copenhagen, Denmark
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Emiel A M Janssen
- Department of Pathology, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Chemistry, Biosciences and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Research, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Tone Hoel Lende
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
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