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Current topics and perspectives on the use of aromatase inhibitors in the treatment of breast cancer

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  • Current topics in endocrine therapy for breast cancer
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Abstract

Tamoxifen has played a central role in endocrine therapy for hormone-responsive breast cancer. Results of recent clinical trials have, however, clearly shown that third-generation aromatase inhibitors (AIs), such as anastrozole, letrozole and exemestane, are superior to tamoxifen in the treatment of postmenopausal patients with metastatic breast cancer, in an adjuvant setting and for early breast cancer. Many studies have been published that describe new results from clinical trials and how they fundamentally prove the efficacy of AIs. There are, however, still some unresolved issues concerning the applications of AIs, such as the optimal duration of the therapy, the optimal regimens (initial, adjuvant or switching from tamoxifen to AI), and combination with LH–RH agonists for premenopausal woman. These issues are discussed in this review. Additionally, further possibilities for the application of AIs, for example in combination therapy with pure antiestrogen aimed at complete estrogen blockade and in combination with new biological agents, as well as the pharmacogenomics of AIs will be discussed.

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References

  1. Iwase H, Zhang Z, Omoto Y, et al. Clinical significance of the expression of estrogen receptors alpha and beta for endocrine therapy of breast cancer. Cancer Chemother Pharmacol. 2003;52(Suppl 1):S34–8.

    Article  PubMed  CAS  Google Scholar 

  2. Gradishar WJ. Safety considerations of adjuvant therapy in early breast cancer in postmenopausal women. Oncology. 2005;69:1–9.

    Article  PubMed  Google Scholar 

  3. Howell A, Buzdar A. Are aromatase inhibitors superior to antiestrogens? J Steroid Biochem Mol Biol. 2005;93:237–47.

    Article  PubMed  CAS  Google Scholar 

  4. Buzdar AU, Jonat W, Howell A, et al. Anastrozole versus megestrol acetate in the treatment of postmenopausal women with advanced breast carcinoma: results of a survival update based on a combined analysis of data from two mature phase III trials. Arimidex Study Group. Cancer. 1998;83:1142–52.

    Article  PubMed  CAS  Google Scholar 

  5. Dombernowsky P, Smith I, Falkson G, et al. Letrozole, a new oral aromatase inhibitor for advanced breast cancer: double-blind randomized trial showing a dose effect and improved efficacy and tolerability compared with megestrol acetate. J Clin Oncol. 1998;16:453–61.

    PubMed  CAS  Google Scholar 

  6. Kaufmann M, Bajetta E, Dirix LY, et al. Exemestane is superior to megestrol acetate after tamoxifen failure in postmenopausal women with advanced breast cancer: results of a phase III randomized double-blind trial. The Exemestane Study Group. J Clin Oncol. 2000;18:1399–411.

    PubMed  CAS  Google Scholar 

  7. Rose C, Vtoraya O, Pluzanska A, et al. An open randomised trial of second-line endocrine therapy in advanced breast cancer. comparison of the aromatase inhibitors letrozole and anastrozole. Eur J Cancer. 2003;39:2318–27.

    Article  PubMed  CAS  Google Scholar 

  8. Nabholtz JM, Bonneterre J, Buzdar A, et al. Anastrozole (Arimidex) versus tamoxifen as first-line therapy for advanced breast cancer in postmenopausal women: survival analysis and updated safety results. Eur J Cancer. 2003;39:1684–9.

    Article  PubMed  CAS  Google Scholar 

  9. Milla-Santos A, Milla L, Portella J, et al. Anastrozole versus tamoxifen as first-line therapy in postmenopausal patients with hormone-dependent advanced breast cancer: a prospective, randomized, phase III study. Am J Clin Oncol. 2003;26:317–22.

    Article  PubMed  CAS  Google Scholar 

  10. Mouridsen H, Sun Y, Gershanovich M, et al. Superiority of letrozole to tamoxifen in the first-line treatment of advanced breast cancer: evidence from metastatic subgroups and a test of functional ability. Oncologist. 2004;9:489–96.

    Article  PubMed  CAS  Google Scholar 

  11. Mouridsen HT. Letrozole in advanced breast cancer: the PO25 trial. Breast Cancer Res Treat. 2007;105(Suppl 1):19–29.

    Article  PubMed  CAS  Google Scholar 

  12. Paridaens R, Dirix L, Lohrisch C, et al. Mature results of a randomized phase II multicenter study of exemestane versus tamoxifen as first-line hormone therapy for postmenopausal women with metastatic breast cancer. Ann Oncol. 2003;14:1391–8.

    Article  PubMed  CAS  Google Scholar 

  13. Carlini P, Michelotti A, Ferretti G, et al. Clinical evaluation of the use of exemestane as further hormonal therapy after nonsteroidal aromatase inhibitors in postmenopausal metastatic breast cancer patients. Cancer Invest. 2007;25:102–5.

    Article  PubMed  CAS  Google Scholar 

  14. Del Mastro L, Dozin B, Aitini E, et al. Timing of adjuvant chemotherapy and tamoxifen in women with breast cancer: findings from two consecutive trials of Gruppo Oncologico Nord-Ovest-Mammella Intergruppo (GONO-MIG) Group. Ann Oncol. 2008;19:299–307.

    Article  PubMed  CAS  Google Scholar 

  15. Yamamoto Y, Kawazoe T, Iwase H. Experience of high-dose toremifene treatment for postmenopausal women with metastatic breast cancer. Gan To Kagaku Ryoho. 2005;32:1415–9.

    PubMed  Google Scholar 

  16. Skeel RT. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;365:1687–717.

    Google Scholar 

  17. Baum M, Budzar AU, Cuzick J, et al. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet. 2002;359:2131–39.

    Article  PubMed  CAS  Google Scholar 

  18. Baum M, Buzdar A, Cuzick J, et al. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early-stage breast cancer: results of the ATAC (Arimidex, Tamoxifen Alone or in Combination) trial efficacy and safety update analyses. Cancer. 2003;98:1802–10.

    Article  PubMed  CAS  Google Scholar 

  19. Howell A, Cuzick J, Baum M, et al. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years’ adjuvant treatment for breast cancer. Lancet. 2005;365:60–2.

    Article  PubMed  CAS  Google Scholar 

  20. Forbes JF, Cuzick J, Buzdar A, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the ATAC trial. Lancet Oncol. 2008;9:45–53.

    Article  PubMed  CAS  Google Scholar 

  21. Toi M. Long-term outcomes of aromatase inhibition for breast cancer. Lancet Oncol. 2008;9:8–10.

    Article  PubMed  CAS  Google Scholar 

  22. Omoto Y, Kobayashi Y, Nishida K, et al. Expression, function, and clinical implications of the estrogen receptor beta in human lung cancers. Biochem Biophys Res Commun. 2001;285:340–7.

    Article  PubMed  CAS  Google Scholar 

  23. Thurlimann B, Keshaviah A, Coates AS, et al. A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med. 2005;353:2747–57.

    Article  PubMed  Google Scholar 

  24. Coates AS, Keshaviah A, Thurlimann B, et al. Five years of letrozole compared with tamoxifen as initial adjuvant therapy for postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1–98. J Clin Oncol. 2007;25:486–92.

    Article  PubMed  CAS  Google Scholar 

  25. Coombes RC, Hall E, Gibson LJ, et al. A randomized trial of exemestane after two to three years of tamoxifen therapy in postmenopausal women with primary breast cancer. N Engl J Med. 2004;350:1081–92.

    Article  PubMed  CAS  Google Scholar 

  26. Coombes RC, Kilburn LS, Snowdon CF, et al. Survival and safety of exemestane versus tamoxifen after 2–3 years’ tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial. Lancet. 2007;369:559–70.

    Article  PubMed  CAS  Google Scholar 

  27. Jakesz R, Jonat W, Gnant M, et al. Switching of postmenopausal women with endocrine-responsive early breast cancer to anastrozole after 2 years’ adjuvant tamoxifen: combined results of ABCSG trial 8 and ARNO 95 trial. Lancet. 2005;366:455–62.

    Article  PubMed  CAS  Google Scholar 

  28. Boccardo F, Rubagotti A, Puntoni M, et al. Switching to anastrozole versus continued tamoxifen treatment of early breast cancer: preliminary results of the Italian Tamoxifen Anastrozole Trial. J Clin Oncol. 2005;23:5138–47.

    Article  PubMed  CAS  Google Scholar 

  29. Jonat W, Gnant M, Boccardo F, et al. Effectiveness of switching from adjuvant tamoxifen to anastrozole in postmenopausal women with hormone-sensitive early-stage breast cancer: a meta-analysis. Lancet Oncol. 2006;7:991–6.

    Article  PubMed  CAS  Google Scholar 

  30. Kaufmann M, Jonat W, Hilfrich J, et al. Improved overall survival in postmenopausal women with early breast cancer after anastrozole initiated after treatment with tamoxifen compared with continued tamoxifen: the ARNO 95 Study. J Clin Oncol. 2007;25:2664–70.

    Article  PubMed  CAS  Google Scholar 

  31. Fisher B, Jeong JH, Bryant J, et al. Treatment of lymph-node-negative, oestrogen-receptor-positive breast cancer: long-term findings from National Surgical Adjuvant Breast and Bowel Project randomised clinical trials. Lancet. 2004;364:858–68.

    Article  PubMed  CAS  Google Scholar 

  32. Peto R: ATLAS (Adjuvant Tamoxifen, Longer Against Shorter): international randomized trial of 10 versus 5 years of adjuvant tamoxifen among 11,500 women—preliminary results. In: San Antonio Breast Cancer Symposium 2007 (Late Breaking Session 48), San Antonio, TX, 13–16 Dec 2007.

  33. Goss PE, Ingle JN, Martino S, et al. A randomized trial of letrozole in postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. N Engl J Med. 2003;349:1793–1802.

    Article  PubMed  CAS  Google Scholar 

  34. Goss PE, Ingle JN, Martino S, et al. Randomized trial of letrozole following tamoxifen as extended adjuvant therapy in receptor-positive breast cancer: updated findings from NCIC CTG MA.17. J Natl Cancer Inst. 2005;97:1262–71.

    Article  PubMed  CAS  Google Scholar 

  35. Ingle JN, Tu D, Pater JL, et al. Intent-to-treat analysis of the placebo-controlled trial of letrozole for extended adjuvant therapy in early breast cancer: NCIC CTG MA.17. Ann Oncol. 2008;19:877–82.

    Article  PubMed  CAS  Google Scholar 

  36. Goss PE, Ingle JN, Pater JL, et al. Late extended adjuvant treatment with letrozole improves outcome in women with early-stage breast cancer who complete 5 years of tamoxifen. J Clin Oncol. 2008;26:1948–55.

    Article  PubMed  CAS  Google Scholar 

  37. Mamounas EP, Jeong JH, Wickerham DL, et al. Benefit from exemestane as extended adjuvant therapy after 5 years of adjuvant tamoxifen: intention-to-treat analysis of the National Surgical Adjuvant Breast And Bowel Project B-33 trial. J Clin Oncol. 2008;26:1965–71.

    Article  PubMed  CAS  Google Scholar 

  38. Jakesz R, Greil R, Gnant M, et al. Extended adjuvant therapy with anastrozole among postmenopausal breast cancer patients: results from the randomized Austrian Breast and Colorectal Cancer Study Group Trial 6a. J Natl Cancer Inst. 2007;99:1845–53.

    Article  PubMed  CAS  Google Scholar 

  39. Fisher B, Dignam J, Wolmark N, et al. Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet. 1999;353:1993–2000.

    Article  PubMed  CAS  Google Scholar 

  40. Fisher ER, Land SR, Saad RS, et al. Pathologic variables predictive of breast events in patients with ductal carcinoma in situ. Am J Clin Pathol. 2007;128:86–91.

    Article  PubMed  Google Scholar 

  41. Iddon J, Bundred NJ. To switch or not to switch: should the updated Intergroup Exemestane Study alter our decision? Expert Rev Anticancer Ther. 2008;8:9–13.

    Article  PubMed  CAS  Google Scholar 

  42. Goss P. Update on the MA.17 extended adjuvant trial. Best Pract Res Clin Endocrinol Metab. 2006;20:S5–13.

    Article  CAS  Google Scholar 

  43. Mamounas EP, Lembersky B, Jeong JH, et al. NSABP B-42: a clinical trial to determine the efficacy of five years of letrozole compared with placebo in patients completing five years of hormonal therapy consisting of an aromatase inhibitor (AI) or tamoxifen followed by an AI in prolonging disease-free survival in postmenopausal women with hormone receptor-positive breast cancer. Clin Breast Cancer. 2006;7:416–21.

    Article  PubMed  CAS  Google Scholar 

  44. Kafali H, Iriadam M, Ozardali I, Demir N. Letrozole-induced polycystic ovaries in the rat: a new model for cystic ovarian disease. Arch Med Res. 2004;35:103–8.

    Article  PubMed  CAS  Google Scholar 

  45. Regan MM, Pagani O, Walley B, et al. Premenopausal endocrine-responsive early breast cancer: who receives chemotherapy? Ann Oncol 2008;19(7):1231–41.

    Google Scholar 

  46. Hadji P, Bundred N. Reducing the risk of cancer treatment-associated bone loss in patients with breast cancer. Semin Oncol. 2007;34:S4–10.

    Article  PubMed  CAS  Google Scholar 

  47. Monnier A. Refining the postmenopausal breast cancer treatment paradigm: the FACE trial. Expert Rev Anticancer Ther. 2006;6:1355–9.

    Article  PubMed  Google Scholar 

  48. Ellis MJ, Coop A, Singh B, et al. Letrozole is more effective neoadjuvant endocrine therapy than tamoxifen for ErbB-1- and/or ErbB-2-positive, estrogen receptor-positive primary breast cancer: evidence from a phase III randomized trial. J Clin Oncol. 2001;19:3808–16.

    PubMed  CAS  Google Scholar 

  49. Dowsett M, Cuzick J, Wale C, et al. Retrospective analysis of time to recurrence in the ATAC trial according to hormone receptor status: an hypothesis-generating study. J Clin Oncol. 2005;23:7512–7.

    Article  PubMed  CAS  Google Scholar 

  50. Viale G, Regan MM, Maiorano E, et al. Prognostic and predictive value of centrally reviewed expression of estrogen and progesterone receptors in a randomized trial comparing letrozole and tamoxifen adjuvant therapy for postmenopausal early breast cancer: BIG1-98. J Clin Oncol. 2007;25:3846–52.

    Article  PubMed  Google Scholar 

  51. Dowsett M, Allred C. Relationship between quantitative estrogen and progesterone receptor expression and HER2 status with recurrence in the ATAC trial. Breast Cancer Res Treat 2006;100.

  52. Osborne CK, Schiff R, Arpino G, et al. Endocrine responsiveness: understanding how progesterone receptor can be used to select endocrine therapy. Breast. 2005;14:458–65.

    Article  PubMed  Google Scholar 

  53. Rasmussen BB, Regan MM, Lykkesfeldt AE, et al. Adjuvant letrozole versus tamoxifen according to centrally-assessed ERBB2 status for postmenopausal women with endocrine-responsive early breast cancer: supplementary results from the BIG 1–98 randomised trial. Lancet Oncol. 2008;9:23–8.

    Article  PubMed  CAS  Google Scholar 

  54. Macedo LF, Sabnis GJ, Goloubeva OG, Brodie A. Combination of anastrozole with fulvestrant in the intratumoral aromatase xenograft model. Cancer Res. 2008;68:3516–22.

    Article  PubMed  CAS  Google Scholar 

  55. Howell SJ, Johnston SR, Howell A. The use of selective estrogen receptor modulators and selective estrogen receptor down-regulators in breast cancer. Best Pract Res Clin Endocrinol Metab. 2004;18:47–66.

    Article  PubMed  CAS  Google Scholar 

  56. Howell A. Fulvestrant (‘Faslodex’): current and future role in breast cancer management. Crit Rev Oncol Hematol. 2006;57:265–73.

    Article  PubMed  Google Scholar 

  57. Goss P, Bondarenko IN, Manikhas GN, et al. Phase III, double-blind, controlled trial of atamestane plus toremifene compared with letrozole in postmenopausal women with advanced receptor-positive breast cancer. J Clin Oncol. 2007;25:4961–6.

    Article  PubMed  CAS  Google Scholar 

  58. Robertson JF. Fulvestrant (Faslodex)—how to make a good drug better. Oncologist. 2007;12:774–84.

    Google Scholar 

  59. Chia S, Gradishar W, Mauriac L, et al. Double-blind, randomized placebo controlled trial of fulvestrant compared with exemestane after prior nonsteroidal aromatase inhibitor therapy in postmenopausal women with hormone receptor-positive, advanced breast cancer: results from EFECT. J Clin Oncol. 2008;26:1664–70.

    Article  PubMed  CAS  Google Scholar 

  60. Dodwell D, Coombes G, Bliss JM, et al (2008) Combining fulvestrant (FaslodexTM) with continued oestrogen suppression in endocrine-sensitive advanced breast cancer: the SoFEA trial. Clin Oncol (R Coll Radiol) 2008;20:321–4.

    Google Scholar 

  61. Schiff R, Massarweh S, Shou J, Osborne CK. Breast cancer endocrine resistance: how growth factor signaling and estrogen receptor coregulators modulate response. Clin Cancer Res. 2003;9:447S–54S.

    PubMed  CAS  Google Scholar 

  62. Johnston SR, Martin LA, Head J, et al. Aromatase inhibitors: combinations with fulvestrant or signal transduction inhibitors as a strategy to overcome endocrine resistance. J Steroid Biochem Mol Biol. 2005;95:173–81.

    Article  PubMed  CAS  Google Scholar 

  63. Bando H. Vascular endothelial growth factor and bevacitumab in breast cancer. Breast Cancer. 2007;14:163–73.

    Article  PubMed  Google Scholar 

  64. Geisler J. Aromatase inhibitors: from bench to bedside and back. Breast Cancer. 2008;15:17–26.

    Article  PubMed  Google Scholar 

  65. Robertson JF. Fulvestrant (Faslodex) how to make a good drug better. Oncologist. 2007;12:774–84.

    Article  PubMed  CAS  Google Scholar 

  66. Orman JS, Perry CM. Trastuzumab: in HER2 and hormone receptor co-positive metastatic breast cancer. Drugs. 2007;67:2781–9.

    PubMed  CAS  Google Scholar 

  67. Goetz MP, Rae JM, Suman VJ, et al. Pharmacogenetics of tamoxifen biotransformation is associated with clinical outcomes of efficacy and hot flashes. J Clin Oncol. 2005;23:9312–8.

    Article  PubMed  CAS  Google Scholar 

  68. Lim HS, Ju Lee H, Seok Lee K, et al. Clinical implications of CYP2D6 genotypes predictive of tamoxifen pharmacokinetics in metastatic breast cancer. J Clin Oncol. 2007;25:3837–45.

    Article  PubMed  CAS  Google Scholar 

  69. Ma CX, Adjei AA, Salavaggione OE, et al. Human aromatase: gene resequencing and functional genomics. Cancer Res. 2005;65:11071–82.

    Article  PubMed  CAS  Google Scholar 

  70. Colomer R, Monzo M, Tusquets I, et al. A single-nucleotide polymorphism in the aromatase gene is associated with the efficacy of the aromatase inhibitor letrozole in advanced breast carcinoma. Clin Cancer Res. 2008;14:811–6.

    Article  PubMed  CAS  Google Scholar 

  71. Ingle JN. Pharmacogenomics of tamoxifen and aromatase inhibitors. Cancer. 2008;112:695–9.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

This work was supported in part by a grant-in-aid (project number (19591513) for scientific research from the Ministry of Education, Science and Culture of Japan.

Disclosures of potential conflicts of interest

The author and his immediate family members declare their conflicts of interest as follows: employment, not applicable (N/A); leadership, N/A; consultant, N/A; stock, N/A; honoraria, AstraZeneca, Pfizer, Chugai-Roche, Takeda, Novartis; research funds, AstraZeneca, Pfizer, Chugai-Roche, Takeda; testimony, N/A; other, N/A.

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Correspondence to Hirotaka Iwase.

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Iwase, H. Current topics and perspectives on the use of aromatase inhibitors in the treatment of breast cancer. Breast Cancer 15, 278–290 (2008). https://doi.org/10.1007/s12282-008-0071-y

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