Postmenopausal Advanced Breast Cancer Patients Research Articles

An aromatase inhibitor in combination with Zinc(II) phthalocyanine for targeted therapy of post-menopausal breast cancer

As a third-generation steroidal aromatase inhibitor, exemestane (EXE) has been clinically used for postmenopausal advanced breast cancer patients whose condition has progressed after treatment of tamoxifen. However, the further development and application of EXE was limited due to its low solubility and oral bioavailability, inevitable drug resistance and side effects. Based on the unique therapeutic advantages of photodynamic therapy (PDT), a novel aromatase-targeted photosensitizer EX-Pc was synthesized by the combination of EXE and the phthalocyanine photosensitizer. The compound EX-Pc still maintains the superior optical properties of the phthalocyanine photosensitizer upon the introduction of EXE and triethylene glycol chain. Meanwhile, the results of targeted uptake in vitro and in vivo indicated that EX-Pc exhibited high selectivity and affinity for breast cancer cells and tumor tissues, which have the overexpression of aromatase. More importantly, the compound EX-Pc exhibits significant photocytotoxicity and tumor regression ability on breast cancer cells and tumor. In addition, the compound EX-Pc shows negligible side effects and high biological safety. We believe that this is a potential strategy for the treatment of postmenopausal breast cancer.

PDG68 An Incremental Effectiveness Analysis of Palbociclib for the Treatment of HR-Positive, HER2-Negative Locally Advanced or Metastatic Breast Cancer in Portugal

To evaluate the effectiveness of palbociclib plus letrozole or fulvestrant in HR+/HER2- post-menopausal advanced or metastatic breast cancer patients. The effectiveness analysis of palbociclib plus letrozole/fulvestrant was based on a partitioned survival model, using data from PALOMA-1, PALOMA-2 and PALOMA-3 clinical trials. A combined analysis with KM data and parametric projections was used to estimate progression-free survival (PFS) and overall survival (OS) curves, defining patients’ distribution between the health states pre-progression, progressed disease and death. EQ-5D-3L utility weights were derived from EQ-5D-3L questionnaires from PALOMA-2 and PALOMA-3 for PFS and post-progression in active treatment and from the literature for post-progression in Best Supportive Care (BSC). Health outcomes were estimated for a lifetime horizon. Deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of results. Adding palbociclib to letrozole in patients without prior treatment for advanced disease increases average life expectancy by 0.41 life-years (LY) enabling a gain of 0.57 quality adjusted life years (QALY). Adding palbociclib to fulvestrant in patients who progressed or relapsed during previous endocrine therapy increases average life expectancy by 0.76 LY enabling a gain of 0.52 QALY. In both cases most gains of palbociclib are due to increased PFS. Deterministic sensitivity analyses show that results are robust to most scenarios but sensitive to parametric extrapolation of both PFS and OS and utility weights. The treatment with palbociclib plus letrozole/fulvestrant showed a relevant incremental effectiveness both in terms of LY and QALY in the treatment of HR+/HER2- locally advanced or metastatic breast cancer in Portugal.

394 (PB-027) - A real-life study on everolimus plus exemestane therapy in a cohort of HR-positive, HER2-negative postmenopausal advanced breast cancer patients; A study of the SOutheast Netherlands Advanced BREast cancer (SONABRE) Registry

394 (PB-027) - A real-life study on everolimus plus exemestane therapy in a cohort of HR-positive, HER2-negative postmenopausal advanced breast cancer patients; A study of the SOutheast Netherlands Advanced BREast cancer (SONABRE) Registry

Abstract OT2-6-01: Phase 2 study of palbociclib (CDK 4/6 inhibitor) for ER positive, HER2- negative post-menopausal advanced breast cancer patients recurring after hormonal therapy (to reverse endocrine resistance - TREnd trial)

Abstract Background: Palbociclib (PD-0332991) is an orally active, potent and highly selective inhibitor of CDK4/6 that prohibits progression of the cell cycle from G1 into S phase and has shown activity in ER positive breast cancer in vivo and in vitro. Recently, in phase 2 settings, palbocilcib extended PFS in combination with letrozole as first-line hormonal treatment for advanced breast cancer (ABC) (Finn R.S. et al. Cancer Res., Dec 2012; 72: S1-6) and showed single agent activity in patients with ER positive ABC relapsed to several lines of therapy (DeMichele A. et al., ASCO 2013). Given pre-clinical evidence on the relevance of Cyclin D-CDK4/6-E2F signalling in the development of acquired resistance to hormonal therapy, CDK4-6 inhibition might be a strategy to overcome resistance in tumors who have progressed after hormonal therapy for metastatic disease. Study design: This is an investigator initiated, open-label, multicenter, randomized, Phase 2 trial for patients with ER+ HER2 negative ABC who have experienced progression on first or second line hormonal therapy. Other eligibility criteria include: ≤1 previous line of chemotherapy for ABC; measurable disease; and available archival tumor tissue for translational studies. Consenting patients are randomized (1:1) to receive, until progression of disease, unacceptable toxicity or consent withdrawal, either ARM A) palbociclib 125 mg/d orally for 3 weeks followed by 1 week off treatment or ARM B) palbociclib in combination with the hormonal therapy to which the patient has experienced progression in the previous line of treatment (anastrozole 1 mg/d, letrozole 2.5 mg/d, exemestane 25 mg/d, fulvestrant 500mg/4 weeks). Patients are stratified according to: number or prior lines of hormonal therapy (1 vs. 2); disease site (visceral vs. non visceral); duration of prior line of hormonal therapy (>6 vs. ≤6 months); treating center. The primary endpoint is clinical benefit (CB) (i.e. complete response, partial response, stable disease≥ 24 weeks), based on local assessment of response using RECIST 1.1 criteria. Key secondary endpoints are: objective response rate, duration of response, time to progression, progression-free survival, overall survival and assessment of exploratory tissue markers of response. Statistical methods: A two-stage optimal phase 2 design is used to assess the activity of each of the two treatment regimens. Assuming P0≤20% (inactivity), P1≥ 40% (activity) and α = 10%, a sample size of 50 evaluable patients per treatment arm is required for a statistical power equal to 90%. In case of inactivity, enrolment could be stopped in each arm after 25 evaluable patients. This study does not provide adequate power for a two arm comparison. Target accrual: the study is actively recruiting in 3 Italian centers and is expected to involve additional 7 centers in Italy by the end of 2013. The first patient was enrolled in October 2012 and, as per June 2013, a total of 9 patients have been enrolled, 8 remain on treatment. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-6-01.

Benefits of early and prolonged fulvestrant treatment in 848 postmenopausal advanced breast cancer patients

Response to fulvestrant and survival in postmenopausal hormone-sensitive advanced breast cancer was investigated within a non-randomized, In-Practice Evaluation Program, with the aim of optimizing treatment decisions. 848 patients (median age 64 years; 52% co-morbidity; 78% prior palliative therapy; median 4 prior regimens) received monthly fulvestrant injections (250 mg/month) and were followed-up three-monthly for 9 months. Clinical benefit (PFS ≥ 24 weeks) occurred in 532/848 (62.7%); stable disease (SD) in 627/848 patients (74%), including 62 complete and 177 partial responses. Best response was delayed in 115 patients. Estimated 9-month overall survival (OS) was 89%; 9-month event-free survival (EFS) was 71%. Indicators of disease aggressiveness affected response and survival, but number of fulvestrant cycles was the key OS and EFS determinant. The patients with SD at 3 months benefitted from continued fulvestrant. Excluding deaths, 7 serious adverse events occurred (none attributable to fulvestrant). No new or unexpected safety issues arose; 90% of the patients and physicians rated fulvestrant tolerability as "very good" or "good". In the largest prospective, fulvestrant-treated cohort to date, advanced breast cancer patients achieving SD or better after 3 months of treatment gained survival benefit by prolonging fulvestrant therapy-independent of disease and treatment history.

Efficacy and tolerability of high dose "ethinylestradiol" in post-menopausal advanced breast cancer patients heavily pre-treated with endocrine agents

BackgroundHigh dose estrogens (HDEs) were frequently used as endocrine agents prior to the introduction of tamoxifen which carries fewer side effects. Due to the development of resistance to available endocrine agents in almost all women with metastatic breast cancer, interest has renewed in the use of HDEs as yet another endocrine option that may have activity. We report our experience with one of the HDEs ("ethinylestradiol" 1 mg daily) in advanced breast cancer (locally advanced and metastatic) in post-menopausal women who had progressed on multiple endocrine agents.Patients and methodsAccording to a database of advanced breast cancer patients seen in our Unit since 1998, those who had complete set of information and fulfilled the following criteria were studied: (1) patients in whom further endocrine therapy was deemed appropriate i.e., patients who have had clinical benefit with previous endocrine agents or were not fit or unwilling to receive chemotherapy in the presence of potentially life-threatening visceral metastases; (2) disease was assessable by UICC criteria; (3) were treated with "ethinylestradiol" until they were withdrawn from treatment due to adverse events or disease progression.ResultsTwelve patients with a median age of 75.1 years (49.1 – 85 years) were identified. Majority (N = 8) had bony disease. They had ethinylestradiol as 3rd to 7th line endocrine therapy. One patient (8%) came off treatment early due to hepato-renal syndrome. Clinical benefit (objective response or durable stable disease for ≥ 6 months) was seen in 4 patients (33.3%) with a median duration of response of 10+ (7–36) months. The time to treatment failure was 4 (0.5–36) months.ConclusionYet unreported, high dose "ethinylestradiol" is another viable therapeutic strategy in heavily pre-treated patients when further endocrine therapy is deemed appropriate. Although it tends to carry more side effects, they may not be comparable to those of other HDEs (such as diethylstilbestrol) or chemotherapy.

Osteoprotegerin and osteopontin serum values in postmenopausal advanced breast cancer patients treated with anastrozole

Osteoprotegerin (OPG) is a potent antiresorptive molecule that binds NF-kappaB ligand, the final effector for osteoclastogenesis. OPG production is regulated by a number of cytokines and hormones. Osteopontin (OPN) is a secreted adhesive glycoprotein involved in tumour angiogenesis, and also a non-collagenous protein involved in bone turnover. OPN serum value is associated with tumour burden and survival in advanced breast cancer patients. The short-term effects of anastrozole on OPG and OPN serum values, and the usefulness of these analytes during follow-up were studied in 34 consecutive advanced breast cancer patients receiving anastrozole 1 mg/day. Blood samples were taken before treatment and at 2, 4, 8 and 12 weeks. OPG and OPN values were measured by ELISA. The results were analysed for all patients, and also separately for patients with (group A, 22 patients) and without (group B, 12 patients) bone metastasis. Whether the survival of all patients was related to their OPN serum values was also tested by placing patients into three groups (terciles) according to their baseline OPN values. No significant changes in OPG and OPN values were observed in the complete patient group. There was no difference in baseline OPG and OPN serum values between patients in groups A and B. In group A, a significant percentage increase in both OPG and OPN values from baseline was detected during treatment. No significant changes were reported for group B patients. Furthermore, in group A, a significant increase in both analytes was evident only for patients with progressive disease (PD). The Kaplan-Meier adjusted survival estimates for patients grouped according to tercile OPN values differed significantly (P = 0.001, log rank test). In conclusion, in the short term, anastrozole does not seem to affect OPG and OPN serum values in patients without bone disease. OPG and OPN appear to be useful predictors of the outcome of skeletal disease and elevated OPN values may be associated with short survival in advanced breast cancer patients.

Could exemestane affect insulin-like growth factors, interleukin 6 and bone metabolism in postmenopausal advanced breast cancer patients after failure on aminoglutethimide, anastrozole or letrozole?

Postmenopausal hormone-sensitive breast cancer is currently treated with either antioestrogens or aromatase inhibitors (AIs), due to the clinical efficacy and safety of these drugs. Today's challenge is the sequential use of AIs with different structure and no cross-resistance to improve the therapeutic outcome. The present study describes the biological action of the steroidal structure (SS)-AI exemestane (EXE), in patients progressing on aminoglutethimide (AG) or other non-steroidal structure (NSS)-AIs (letrozole or anastrozole). Thirteen patients were evaluated for serum insulin-like growth factor (IGF) components [total IGF-1, IGF-2 and IGF binding protein (IGFBP)-3], interleukin (IL)-6 system [IL-6 and soluble IL-6 receptor (sIL-6-R)] and bone metabolism markers [bone gla protein/osteocalcin (BGP), bone-specific isoform of alkaline phosphatase (BAP) and carboxy-telopeptide of type I procollagen (ICTP)]. IGF system components show a trend to increase both in patients progressing on AG and in patients progressing on other NSS-AIs. Such an increase depends on the wash-out length from the previous treatment and is strictly linked to the circulating oestrogen levels. Serum IL-6 and sIL-6-R are mainly related to the patients' clinical outcome. Bone formation (BGP and BAP) and bone resorption (ICTP) markers seem to be at equilibrium with oestrogen levels when starting EXE and do not appear to be uncoupled over treatment. The observed variations seem to be mainly linked to the circulating oestrogen levels rather than directly to the way of action of the AI employed.

Short-term effects of anastrozole treatment on insulin-like growth factor system in postmenopausal advanced breast cancer patients

Insulin-like growth factors (IGFs) play a fundamental role in cancer development by acting in both an endocrinal and paracrinal manner, and hormone breast cancer treatments affect the IGF system by modifying circulating growth factor levels. We evaluated total IGF-1, IGF-2, IGF binding protein (IGFBP)-1 and IGFBP-3 in the blood of 34 postmenopausal advanced breast cancer patients (median age 63 years, range 41–85) treated with anastrozole, a non-steroidal structure aromatase inhibitor (NSS-AI). The plasma samples were obtained at baseline, and after 2, 4, 8 and 12 weeks of treatment. The IGFs were quantitated by means of sensitive radioimmunoassays (RIAs). IGF-1 significantly increased during anastrozole treatment (baseline versus 12 weeks, P=0.031), IGF-2 showed a trend towards an increase, and IGFBP-1 constantly but not significantly decreased; IGFBP-3 did not seem to be affected at all. The anastrozole-induced changes in IGFs and IGFBP-1 appeared to be different in the patients receiving a clinical benefit from those observed in non-responders. We have previously shown that letrozole (a different type of NSS-AI) modifies blood IGF-1 levels, and the results of this study of the biological effects of anastrozole on the components of the IGF system confirm our previous observations.

Faslodex (ICI 182, 780), a novel estrogen receptor downregulator—future possibilities in breast cancer

Tamoxifen is an effective treatment for breast cancer; however, as well as exerting antagonistic effects on the estrogen receptor (ER), tamoxifen acts as a partial agonists in estrogen-sensitive tissues, resulting in stimulation of the endometrium and tumor growth in some patients who become resistant to treatment. ICI 182, 780 (Faslodex™), a steroidal estrogen antagonist, is the first in a new class of agent—an estrogen receptor downregulator. Pre-clinical breast cancer models show that ICI 182, 780 leads to a prolonged duration of response, and that it exerts its effects via a different mode of action to tamoxifen. This was confirmed in a small clinical study involving 19 post-menopausal advanced breast cancer patients, where ICI 182, 780 was highly effective after tamoxifen failure. Definitive evidence of the differing modes of action of ICI 182, 780 and tamoxifen, were provided in a study involving post-menopausal women with primary breast cancer, where analyses of tumor samples following short-term exposure to both drugs, showed that ICI 182, 780 reduced tumor ER levels in a dose-dependent manner, and to a significantly greater extent than tamoxifen. Additionally, unlike tamoxifen, ICI 182, 780 did not promote ER-mediated progesterone receptor expression, indicating that it lacks estrogen agonist activity. Ongoing studies in post-menopausal women with advanced breast cancer are comparing ICI 182, 780 to anastrozole and tamoxifen, respectively. Future studies being considered are whether ICI 182, 780 may also be effective in breast cancer in pre-menopausal women, in early breast cancer and in ductal carcinoma in situ in the breast, in combination with other hormonals, cytotoxics and biological modifiers.

Biological study of anastrozole in post-menopausal advanced breast cancer (ABC) patients: Effects on bone metabolism and oestrogen suppression

Biological study of anastrozole in post-menopausal advanced breast cancer (ABC) patients: Effects on bone metabolism and oestrogen suppression

Rivizor – A New Third-Generation Aromatase Inhibitor for the Treatment of Advanced Breast Cancer after Tamoxifen Failure

Rivizor^TM (vorozole) is a new, highly potent and selective third-generation aromatase inhibitor for treatment of advanced breast cancer. In an open-label study, 30 postmenopausal women failing tamoxifen therapy received Rivizor 2.5 mg once daily until disease progression. Rivizor produced clinical benefit (partial response or no change) in 16 of 27 evaluable patients (59.3%). Five patients (18.5%) had a partial response (UICC criteria) which lasted for a median of 15 months (range 14–42.5 months), 11 patients had disease stabilization for a median of 14 months (7–24 months), and 11 patients had disease progression. Median time to first response was 3.9 months (3–27.5 months): estimated median survival time for all patients was 22.8 months (2–52.8 months) and estimated median time to disease progression was 10.8 months (1.4–42.4 months). Estradiol levels decreased to below limits of detection from 1st month of treatment until study end. Androstenedione, 17α-hydroxyprogesterone, dehydroepiandrosterone, and free-testosterone levels were unaffected by Rivizor. ACTH stimulation tests demonstrated that Rivizor does not interfere with adrenal mineralocorticoid and glucocorticoid steroid synthesis. Adverse events were mild-to-moderate. Rivizor might be an effective and well-tolerated alternative treatment for postmenopausal advanced breast cancer patients following tamoxifen failure.

Double-blind, randomised, multicentre endocrine trial comparing two letrozole doses, in postmenopausal breast cancer patients

Letrozole is an orally competitive aromatase inhibitor. This double-blind, randomised, multicentre trial was carried out to evaluate the endocrine effects of two doses of letrozole, 0.5mg versus 2.5mg orally daily, in postmenopausal advanced breast cancer patients progressing after tamoxifen. The pharmacokinetics of letrozole was also assessed. 46 patients entered the trial, 22 on letrozole 0.5mg and 24 on 2.5mg. A significant suppression of oestrone and oestradiol levels was achieved by both letrozole doses. Neither letrozole dose induced any changes in cortisol and aldosterone production at rest or after Synacthen stimulation. Androstenedione, testosterone, 17α-OH progesterone, triiodothyronine (T3) thyroxine, (T4) and thyroid-stimulating hormone (TSH) plasma levels did not show any significant changes. Sex hormone binding globulin (SHBG), follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels increased significantly over time. Plasma letrozole concentrations increased until reaching steady-state values after 1 month at the dose of 0.5mg and after 2 months at 2.5mg. In conclusion, both letrozole doses suppressed oestrogen levels without affecting adrenal activity.

PP-8-4 An open, comparative randomized trial comparing formestane vs oral megestrol acetate as a second-line therapy in postmenopausal advanced breast cancer patients

PP-8-4 An open, comparative randomized trial comparing formestane vs oral megestrol acetate as a second-line therapy in postmenopausal advanced breast cancer patients

PP-8-5 A randomised study assessing oestrogen suppression with arimidex™ (Anastrozole) and formestane in postmenopausal advanced breast cancer (ABC) patients

PP-8-5 A randomised study assessing oestrogen suppression with arimidex™ (Anastrozole) and formestane in postmenopausal advanced breast cancer (ABC) patients

352 An open, comparative randomized trial comparing formestane vs oral megestrol acetate as a second-line therapy in postmenopausal advanced breast cancer patients

Formestane ( ® LENTARON), a synthetic steroid derivative of an-drostenedione is the first selective aromatase inhibitor to become available. The multicentre study of ® LENTARON (250mg i.m. fortnightly) vs megestrol acetate (160mg oral once daily) enrolled 547 patients. All patients had histologically proven advanced breast cancer, had documented relapse of disease while under adjuvant therapy with tamoxifen administered for at least 12 months or had experienced progression of advanced breast cancer after an initial response for at least 3 months while under first-line therapy with tamoxifen and had ER and/or PgR positive or unknown. The primary end-point was time to treatment failure. Secondary endpoints were objective tumour response (in accordance with UICC criteria), time to progression, and overall survival time. Efficacy analysis was performed for the intent to treat patients and for the eligible patients who were evaluable for tumour response and will be presented. Preliminary analysis of safety data indicate a trend of more serious adverse events in the Megace group (pulmonary embolism and vaginal bleeding) in comparison with the ® LENTARON group.

60 Tamoxifen and Toremifene: The beneficial hypolipemic effect in women is mediated by cholesterol biosynthesis inhibition

Tamoxifen (TAM) is an effective antiestrogenic anticancer drug. In longterm therapy it decreases serum cholesterol and LDL-cholesterollevels and decreases the risk of coronary artery disease. The mechanism of the hypolipemic effect has not been fully elucidated Toremifene (TOR) is a new antiestrogenic anticancer drug that has clinical efficacy equal to that of TAM. The structure of TOR is closely related to that of TAM and animal experiments suggest that also TOR can have hypolipemic effects. The effect of TAM and TOR therapy on serum lipid levels were studied in postmenopausal advanced breast cancer patients. The effect on cholesterol biosynthesis was evaluated by measuring cholesterol precursor levels by gas-liquid chromatography at pre-dose and after 2, 6 or 12 months therapy. Both drugs decreased cholesterol and LDL-cholesterol levels almost equally. This suggests that also TOR can be expected to have TAM-like beneficial antiatherogenic effect during long-term therapy. Of the cholesterol precursors Δ 8 -cholestenollevel was increased up to about 50-fold with both drugs; in other precursor levels only minor changes were seen. This indicates that these antiestrogens inhibit Δ 8 -cholestenol conversion to lathosterol and as a result the cholesterol biosynthesis is downregulated. This inhibition is suggested to be the main method for the hypolipemic effect of these drugs.

Endocrinological and clinical evaluation of exemestane, a new steroidal aromatase inhibitor

The androstenedione derivative, exemestane (FCE 24304), is a new orally active irreversible aromatase inhibitor. Fifty-six post-menopausal advanced breast cancer patients entered this study to evaluate the activity of four low exemestane doses in reducing oestrogen levels. The drug's tolerability and clinical efficacy were also assessed. Exemestane was orally administered to four consecutive groups at daily doses of 25, 12.5, 5 and 2.5 mg, and the changes in oestrogen, gonadotrophins, sex-hormone binding globulin and dehydroepiandrosterone sulphate levels were evaluated. Drug selectivity was studied by measuring 17-hydroxycorticosteroid urinary levels. After 7 days of treatment, mean oestrone and oestradiol levels had decreased by respectively 64% and 65% (a decrease which was maintained over time); in the 2.5 mg group, oestrone sulphate levels also decreased by 74%. Gonadotrophin levels were significantly higher, whereas no changes in the other serum hormone levels or any interference with adrenal synthesis were detected. Treatment tolerability was satisfactory: nausea and dyspepsia were reported in 16% of patients. The overall objective response rate was 18%. In conclusion, exemestane is effective in reducing oestrogen levels at all of the tested doses and shows interesting clinical activity.

69. An open, comparative randomized trial comparing formestane vs oral megestrol acetate as second-line therapy in postmenopausal advanced breast cancer patients

69. An open, comparative randomized trial comparing formestane vs oral megestrol acetate as second-line therapy in postmenopausal advanced breast cancer patients

Alternating sequential endocrine therapy: Tamoxifen and medroxyprogesterone acetate versus tamoxifen in postmenopausal advanced breast cancer patients

The effects of tamoxifen (TAM) versus the alternating sequential combination of TAM plus medroxy-progesterone acetate (MPA) has been evaluated in 20 postmenopausal patients with advanced breast cancer in a randomized controlled trial. In the TAM arm, patients received 20 mg b.i.d. of TAM. In the TAM-MPA arm, patients received only 20 mg b.i.d. of TAM for 7 days and, on the following 7 days. TAM plus an oral daily dose of 500 mg of MPA, in alternating sequence. Objective tumor reduction was achieved in 22 (41%) of the 54 patients in the TAM arm and in 25 (43%) of the 58 patients in the TAM-MPA arm. With regard to the stabilization of disease, a significant difference was observed between patients treated with the TAM-MPA combination and those treated with TAM alone (47% vs 22%). The percentage of nonresponders was also significantly higher in the TAM group (37%) than in the TAM-MPA group (10%). The time to progression was significantly shorter for the TAM arm than for the TAM-MPA arm (median, 7 vs 15 months), but the duration of remission was not significantly different for either treatment.