Which patients benefit most from adjuvant aromatase inhibitors? Results using a composite measure of prognostic risk in the BIG 1-98 randomized trial.

BACKGROUND: On average, aromatase inhibitors are better than tamoxifen when used as initial or sequential therapy for postmenopausal women with endocrine-responsive early breast cancer. Because there may be contraindications to their use based on side-effects or cost, we investigated subgroups in which aromatase inhibitors may be more or less important. PATIENTS AND METHODS: Breast International Group 1-98 trial randomized 6182 women among four groups comparing letrozole and tamoxifen with sequences of each agent; 5177 (84%) had centrally confirmed estrogen receptor (ER) positivity. We assessed whether centrally determined ER, progesterone receptor (PgR), human epidermal growth factor receptor 2, and Ki-67 labeling index, alone or in combination with other prognostic features, predicted the magnitude of letrozole effectiveness compared with either sequence or tamoxifen monotherapy. RESULTS: Individually, none of the markers significantly predicted differential treatment effects. Subpopulation treatment effect pattern plot analysis of a composite measure of prognostic risk revealed three patterns. Estimated 5-year disease-free survival for letrozole monotherapy, letrozole→tamoxifen, tamoxifen→letrozole, and tamoxifen monotherapy were 96%, 94%, 93%, and 94%, respectively, for patients at lowest risk; 90%, 91%, 93%, and 86%, respectively, for patients at intermediate risk; and 80%, 76%, 74%, and 69%, respectively, for patients at highest risk. CONCLUSION: A composite measure of risk informs treatment selection better than individual biomarkers and supports the choice of 5 years of letrozole for patients at highest risk for recurrence.

Bone fractures among postmenopausal patients with endocrine-responsive early breast cancer treated with 5 years of letrozole or tamoxifen in the BIG 1-98 trial.

BACKGROUND: To compare the incidence and timing of bone fractures in postmenopausal women treated with 5 years of adjuvant tamoxifen or letrozole for endocrine-responsive early breast cancer in the Breast International Group (BIG) 1-98 trial. METHODS: We evaluated 4895 patients allocated to 5 years of letrozole or tamoxifen in the BIG 1-98 trial who received at least some study medication (median follow-up 60.3 months). Bone fracture information (grade, cause, site) was collected every 6 months during trial treatment. RESULTS: The incidence of bone fractures was higher among patients treated with letrozole [228 of 2448 women (9.3%)] versus tamoxifen [160 of 2447 women (6.5%)]. The wrist was the most common site of fracture in both treatment groups. Statistically significant risk factors for bone fractures during treatment included age, smoking history, osteoporosis at baseline, previous bone fracture, and previous hormone replacement therapy. CONCLUSIONS: Consistent with other trials comparing aromatase inhibitors to tamoxifen, letrozole was associated with an increase in bone fractures. Benefits of superior disease control associated with letrozole and lower incidence of fracture with tamoxifen should be considered with the risk profile for individual patients.

Effect of progesterone on cell proliferation in the MXT mouse hormone-sensitive mammary neoplasm.

The transplantable MXT mouse mammary tumor is an experimental model for which the growth is modulated by ovarian hormones; because of scant knowledge about the effects of progesterone (Pg) alone on cancer cells, the present investigation was made. By measuring the percentage of cells with labeled nuclei after tritiated thymidine ([3H]dThd) injection 1 hour prior to sacrifice [dThd labeling index (TLI)], a study was made of the effect (in vivo) of a near physiologic dose of Pg (125 micrograms ip) on cell proliferation in uteri (as the control Pg target organ) and on tumors of spayed (C57BL female X DBA/2F male)F1 mice. Pg induced a significant and transient rise in TLI, which increased from the 12th to the 24th hour after its injection. This mitogenic effect on tumors was comparable to that elicited by 0.25 microgram 17 beta-estradiol injected under similar conditions. In vivo brief exposure of castrated mice to Pg induced a significant mitogenic effect on MXT tumors. These observations might have important consequences for a better understanding of the endocrine mechanisms involved in human hormone-dependent breast cancer.

Synergism or antagonism between estradiol and progesterone on the cell kinetic parameters of the MXT mouse mammary tumor.

With the use of an in vivo tritiated thymidine ([3H]dThd) nuclear labeling followed by autoradiography, the effects at different times before sacrifice of single or paired injections of 17 beta-estradiol (E2) and/or progesterone (Pg), at different concentrations, were studied in (C57BL x DBA/2f)F1 (B6D2F1) mice transplanted with the MXT hormone-sensitive mammary tumor. Uteri were chosen as controls for the methodology. With regard to MXT tumors, E2 (0.25, 2.50, or 25.00 micrograms/animal) or Pg (125, 600, or 5,000 micrograms/animal) exerts almost a similar mitogenic influence that is dose related to the former and nor for the later, at least within the range of concentrations studied here; and the mitogenic effect of Pg seems to appear earlier than that of E2. When these steroids are concomitantly given, no obvious synergistic or antagonistic effect can be observed. A second E2 administration seems to have a less pronounced effect on cell proliferation as compared to that exerted by the first injection performed 12 or 24 hours earlier. On the contrary, the repetition of a Pg treatment would rather exert an additive or even a synergistic effect on the tumoral dThd labeling indices with regard to the total duration of stimulation. When one of these two steroids is administered first, it blocks totally the mitogenic effect of the second, provided the latter is given 24 hours later. It is concluded that E2 and Pg have almost a similar mitogenic effect on the MXT tumor and that these hormones exert complex interactions that are probably very important for the growth regulation of this cancer. Further investigations are needed to better understand the precise biochemical mechanisms involved in the modulating actions of these steroids on the MXT mammary growth.

Effect of castration and 17 beta-estradiol pulse on cell proliferation in the uterus and the MXT mouse mammary tumor.

The effects of a single 17 beta-estradiol (E2) injection on cell proliferation were studied in 3 groups of 30 mice transplanted with the MXT ovary-dependent mammary tumor. In group A, all animals were castrated prior to tumor implantation; groups B and C had intact ovaries at the time of transplantation, but group B was left intact throughout the experiment, while group C underwent castration 4 weeks later. On day 40 in groups B and C and on day 80 in group A, in which tumor development was significantly delayed, the same procedure for testing the effects of E2 was applied: Ten controls received 0.1 ml saline ip and were killed on the next day; 4 lots of 5 mice received 0.25 micrograms E2 ip and were killed one by one at 12-hour intervals. Exactly 1 hour prior to sacrifice, each animal received 25 microCi [methyl-3H]thymidine ip. Histologic sections of tumors and uteri were processed for autoradiography, and nuclear thymidine (dThd) labeling indices (LI) were determined. All tumors of group A grafted under unfavorable hormonal conditions were poorly differentiated, and E2 injection induced no appreciable changes in their dThd LI. Tumors B and C were well-differentiated adenocarcinomas, in which E2 induced significant modifications of cell proliferation. In group B, complex changes in dThd LI occurred in tumors as well as in uteri, probably due to interferences with the ovarian hormonal production. In group C, E2 produced a marked rise in dThd LI in tumors, lasting from the 12th to the 36th hour after its injection. Stimulation was maximum at the 24th hour, representing a 2.8-fold increase over mean basal dThd LI. It is concluded that the presence of an intact ovarian function at the time of transplantation is critical for maintaining the properties of hormone dependence in MXT tumors. In mice castrated after tumor implantation, a single E2 injection induces a marked and partially synchronous proliferation of neoplastic cells. The hypothesis that such hormonal manipulation might amplify the killing effect of cell cycle- or phase-specific cytotoxic drugs could be adequately tested with this model.

Effect of prolactin and estradiol on cell proliferation in the uterus and the MXT mouse mammary neoplasm.

With the use of an in vivo tritiated thymidine [( 3H]dThd) nuclear labeling followed by autoradiography, the effects at different times before sacrifice of prolactin (PRL) and/or 17 beta-estradiol (E2) were studied in C57BL X DBA/2f)F1 mice given transplants of the MXT hormone-sensitive mammary tumor whose growth was previously shown to be influenced by E2 and/or progesterone. Uteri were chosen as controls for the methodology. Experiments were conducted on ovariectomized mice submitted to endocrine manipulation to achieve plasma PRL modifications. In addition to E2, the proliferation of cancer cells, assessed by the measurement of thymidine labeling indices (TLIs), was demonstrated to be enhanced by ovine prolactin (oPRL) and Sulpiride and strongly slowed down by castration and 2-bromo-alpha-ergokryptin treatment, thus emphasizing the great importance of PRL in mammary cancer development. Moreover, a pulse of 1 mg oPRL/animal produced a marked TLI rise in tumors, lasting from the 6th to the 48th hour after its injection and reaching a maximum at 24 hours. PRL had no proliferative effect on the uterine luminal epithelium. When PRL and E2 were injected concomitantly, the profile of stimulation was quite similar to that obtained with E2 alone; i.e., a maximum stimulation was observed at the 24th and 36th hours after hormonal pulse. From these data it is concluded that, in spayed mice, not only E2 but also PRL is of major importance leading to enhanced proliferation of MXT mammary neoplastic cells. Further investigations are needed to throw light on the cellular events presiding over the action of PRL and E2 at the cancer cell level.

Phenotypic change of the transplantable MXT mammary adenocarcinoma into mixed bone producing sarcoma-like tumors.

The B6D2F1 mouse mammary adenocarcinoma was adapted to grow in vitro as monolayer. After in vitro passaging of tumor cells, phenotypic changes occurred that were expressed in vivo. Following intraperitoneal inoculation of tumor cells, bone-forming tumors developed. These tumors consisted of undifferentiated adenocarcinoma mixed with large amount of cartilagenous and osseous tissue. The etiology of these phenotypic changes was not yet determined. However, hypothesis of the possible origin of the cartilage and bone forming tissue was formulated. The biologic characterization of the intraperitoneally bone-forming tumor was achieved and the experimental conditions to preserve and induce the reproducible sarcoma-like bone forming tumors were defined. Our data support the usefulness of this new original model for fundamental research as well as for screening of anticancer drugs.

Effects of aminoglutethimide plus hydrocortisone on the genital tract of postmenopausal women with advanced breast cancer. A clinical and cytologic survey.

In this study we compared the effects of either Aminoglutethimide (AGL) or Tamoxifen (TAM) therapy on the genital tract of postmenopausal women with advanced breast cancer. Thus, 15 patients treated with AGL, and 10 patients treated with TAM underwent gynaecological examination, during which vaginal smears were taken. All smears were reviewed in blind by one pathologist for determination of karyopycnotic indices (KI). Under TAM, no significant clinical abnormality was observed, except in one patient who had a small (histologically benign) endocervical polyp, easily removed during the examination. As reported by others, smears made under TAM therapy were generally characterized by high KI, indicating that an hormonal, estrogen-like stimulation remained present in these patients. On the contrary, most women under AGL had some evidence of vulvovaginal atrophy, which was unvariably associated with low KI on smears. Among the latter, four had severe dystrophic lesions consisting of leukoplasia (1), kraurosis (2) or lichen sclerous and atrophicus (1). It is therefore recommended not to neglect the systematic practice of gynaecological examination in patients with advanced breast cancer under endocrine therapy. These observations also indicate that AGL and TAM exert entirely opposite effects on the vaginal mucosa, which is a very sensitive estrogen-target tissue. In good agreement with former endocrine studies, AGL acts as a potent suppressor of estrogens resulting in severe mucosal atrophy. On the contrary, TAM seems nearly always to display some agonistic hormonal stimulation.

Influences of dihydrotestosterone, testosterone, estradiol, progesterone, or prolactin on the cell kinetics of human hyperplastic prostatic tissue in organ culture.

In an effort to characterize the hormone sensitivity of human benign prostatic hyperplasia (BPH) maintained in organ cultures for 12-72 h, the influence of 5-alpha-dihydrotestosterone (DHT), testosterone (T), 17-beta-estradiol (E2), progesterone (Pg), or prolactin (PRL) was assessed on the cell proliferation rate of 25 BPH specimens by the use of tritiated thymidine incorporation followed by autoradiography. Significant increases in the thymidine-labeling index (TLI: percentage of labeled nuclei) were observed in glandular tissue after a 36-h incubation period in presence of DHT, E2, Pg, or PRL in 52%, 44%, 28%, and 60% of BPH cases, respectively. Nonparametric statistics (Spearman and Kendall rank correlation tests) have shown that 1) the steroid-induced TLI increases are dependent on the basal rate of cell proliferation, while the PRL-induced effect is independent of it, and 2) all the steroid-mediated effects on BPH TLI are correlated together, whereas they seem to be independent of the PRL-induced TLI increase. When T was compared with DHT on nine BPH specimens, three were found to be sensitive to both hormones, and two responded to DHT only. We propose that our study methods are suitable as a means to assess the hormone sensitivity of individual cases of BPH and possibly prostatic tumors.