Tamoxifen, Aminoglutethimide and Danazol: Effect of Therapy on Hormones in Post-Menopausal Patients with Breast Cancer R

Br. J. Cancer (1982) 46, 30

TAMOXIFEN, AMINOGLUTETHIMIDE AND DANAZOL: EFFECT OF THERAPY ON HORMONES IN POST-MENOPAUSAL PATIENTS WITH BREAST CANCER R. C. COOMBES1 2 T. J. POWNLES2, L. H. REES3, WV. A. RATCLIFFE4*, A. G. NASH5, M. HENK2, H. T. FORD2, J.-C. GAZET2 AND A. M. NEVILLE1 From the ILudwig Institute for Cancer Research (London Branch), Royal Marsden Hospital, Sutton, Surrey SM25 PX, 2Royal Marsden Hospital, Sutton, Surrey SM2 5PT, 3St Bartholomew's Ho.spital, West Smithfield. London EC1, the 4Department of Biochemistry, Glasgow Royal Infirmary, Glasgow and 5St Helier Hospital, Carshalton, Surrey

Receive(d 26 Jantuary 1982 Accepted 5 March 1982

Summary.-Gonadotrophins, oestradiol, androstenedione, testosterone and dehydro- epiandrosterone sulphate (DHAS) were measured sequentially in 72 patients with advanced breast cancer receiving endocrine therapy of various types. Tamoxifen significantly reduced gonadotrophins but did not effect other hormones. Danazol also reduced gonadotrophins. Aminoglutethimide (AGT) reduced oestradiol and DHAS but had no effect on gonadotrophins. The effects of administering tamoxifen, AGT and danazol together (TAD) together were therefore examined. This combination reduced gonadotrophins, oestradiol and DHAS, but no further than tamoxifen and AGT alone. The degree and duration of hormone suppression were similar in both responders and non-responders to tamoxifen, AGT or TAD, though patients responding to AGT showed more complete suppression at the end of the course of treatment, perhaps because they were treated longer. On relapse, adequate gonadotrophin and steroid suppression was demonstrated in patients receiving tamoxifen and AGT respectively. We conclude that (a) response to endocrine therapy is unlikely to be related to the degree of endocrine suppression produced by the therapy; (b) combination endocrine therapy does not further reduce serum-hormone concentrations and (c) relapse is unlikely to be due to escape from the hormone-inhibitory effects of endocrine agents.

ENDOCRINE THERAPY is an effective pression by endocrine therapy is respon- form of treatment in patients with ad- sible for lack of effect in these patients. vanced breast cancer. However, only a Few studies have been carried out to proportion of patients respond, and their elucidate the mechanism of relapse. It is response is often transient. Patients whose not known whether endocrine therapy is tumours contain a high concentration of still effective at the time of relapse, nor oestrogen receptor are more likely to whether relapse is due to premature respond to endocrine therapy (McGuire et inactivation of endocrine agents. Studies al., 1975) but a moderate proportion of from our unit have indicated that relapse patients whose tumours contain receptor is not often due to proliferation of an do not respond, and it may be that in oestrogen-receptor negative (RE-) cell these patients inadequate hormone sup- population, since most relapsing tumours

* Priesent address: Department of Chemical Patlhology, Hope Hospital, Eccles Old Road, Salford, Manchester M16 8HD Address for reprints: Dr R. C. Coombes, Ludwig TInstitute for Cancer Research (London Branch), Royal Marsden Hospital, Sutton, Surrey SM2 5PX. EFFECT OF ENDOCRINE THERAPY ON HORMONES 31 contain significant quantities of RE (Tay- Danazol. DHAS was assayed in unextracted lor et al., 1982). We therefore examined serum, with separation by a double-antibody whether relapse or non-response was due method, and the between-batch CV was 13%. to an inadequate effect of endocrine Serum LH and FSH was measured by radioimmunoassay using MRC standards agents on gonadotrophins and steroid 68/40 for LH and 69/104 for FSH, and anti- hormones in patients treated with tamoxi- sera F87 and M93 kindly provided by fen, aminoglutethimide (AGT) and dana- Professor W. Butt. All assays were quality zol, all of which are effective endocrine controlled on the Supra-regional Assay agents (Ward, 1973; Smith et al., 1978; Service, Quality Control System. Coombes et al., 1980a) and are known to Assessment.-Full staging investigations lower hormone concentrations (Golder et (Coombes et al., 1980b) were carried out al., 1976; Santen et al., 1977; Franchi- before, and at 2-3-monthly intervals during mont & Cramilion, 1977). therapy. Assessment of response was carried out using standard UICC criteria (Hayward et al., PATIENTS, MATERIALS AND METHODS 1977). Patients and therapy.-Samples were ob- RESULTS tained from 72 postmenopausal patients with locally advanced or metastatic breast Tamoxifen cancer. No patient had received endocrine Tamoxifen reduced FSH and LH in therapy or chemotherapy within 3 weeks of the start of therapy. Hormones were meas- 40143 patients after 2 months of therapy, ured at 2-3 months and 6-12 months or, in and this suppression continued to 9-12 the case of patients who failed to respond, at months in all patients. No effects were 4-6 months after starting therapy. seen on other hormones. The addition of In 18 patients who had responded to AGT and danazol did not further reduce endocrine therapy, serum samples were the gonadotrophins (Table; Fig. 1). obtained at the time of relapse. All these Gonadotrophin suppression was still patients were still taking endocrine therapy found to be effective in the 7 patients in at the time of sampling. whom hormones were measured at relapse Patients received tamoxifen (Nolvadex: = 13-38 ICI) 10 mg twice daily (24 patients), danazol following response (serum LH (Danol: Sterling-Winthrop) 200 mg 3 x daily iu/l (mean 24.3) and serum FSH= 13-26 (12 patients) or aminoglutethimide (Orimeten: iu/l (mean 19.9). Ciba) 250 mg 4 x daily (16 patients). Amino- glutethimide was administered with hydro- Aminoyltutethimide cortisone (20 mg twice daily). AGT caused a reduction in plasma Nineteen patients received a combination of DHAS and oestradiol in all patients in tamoxifen, danazol and AGT with hydro- these hormones were measurable at cortisone supplements (TAD). whom Hormone measurements.-Blood was ob- the start oftherapy (Table). More respond- tained from non-fasting patients, separated ers than non-responders showed a con- within 30 min, and plasma and serum stored tinued almost complete suppression of at -70°C until assay. DHAS, and DHAS values were 0-046 + 0*03 Androstenedione and oestradiol were meas- -M (n = 8) and 0-25 + 0-09 tM (n = 6) respec- ured in serum extracts by conventional tively but non-responders received therapy immunoassays, and between-batch coeffici- for an average of 3-5 months, compared ents of variation (CV) were 15 and 12.5% with responders who received treatment respectively. Testosterone was assayed in for 9.75 months (Fig. 1). The addition of serum extracts using a 125J-radioligand with whilst separation by a double-antibody method, and tamoxifen and danazol, significantly the between-batch CV was 11%. Danazol was reducing gonadotrophins, did not further shown to cross-react in the testosterone reduce plasma DHAS or oestrogen (Fig. 1; assay, and the magnitude of this interference Table). would depend on therapeutic levels of DHAS was measured up to and at the 32 R. C. COOMBES ET AL.

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FiG. 1. Serum DHAS in responders (- OA 2 - and non-responders ( ) during treat- 0 2 6-12 o 2 6-12 ment with aminoglutethimide (left) and Months tamoxifen, aminoglutethimide and danazol FIG. 2.-Serum LH in responders (-----) and (right). non-responders ( ) during treatment with tamoxifen (left) and tamoxifen, time of relapse in 8 patients treated with aminoglutethimide and danazol (right). Similar results were obtained with measure- AGT alone, and in a further 4 patients ments of FSH. treated with TAD combination, and levels of DHAS were still undetectable in all but one patient. No significant effect on DISCUSSION any other hormone was seen. The major measurable effect of tamoxifen was found to be suppression of Danazol gonadotrophins, and that of AGT was Danazol suppressed gonadotrophins in suppression of DHAS. It was for this 10/12 patients (Table) but effects on reason that we examined these compounds steroid hormones were inconsistent. in greater detail in relation to outcome of Marked rises in testosterone were seen in therapy. In general there was no difference 6 patients but not in others. Similarly, in the extent to which hormones were marked falls in DHAS were seen in 4/12 suppressed by these agents in responders patients, but not in others. The rises in and non-responders to therapy. Respond- testosterone were difficult to evaluate in ers to AGT alone appeared to show a more view of possible danazol cross-reactivity complete suppression of DHAS, but this in the assay. was only demonstrated at the end of Insufficient numbers of patients were treatment, and could have been due to a monitored to determine whether there longer course of therapy. Suppression of was a relationship between degree of hormones appeared to continue as long as gonadotrophin suppression and response. the course of therapy, even when the TAD combination patient relapsed. Insufficient numbers of This reduced gonadotrophins to a simi- patients were treated with danazol to lar extent to tamoxifen alone, and also in establish whether relapse with danazol responders and non-responders (Fig. 2). therapy is due to failure of drug action, Suppression continued until 9-12 months and further studies are currently in of relapse in the 6 patients measured at progress to determine whether this is so. relapse (Table; Fig. 2). Relapse or non-response following endo- Suppression by the TAD combination crine therapy is therefore unlikely to be was similar to patients receiving AGT related to inadequate suppression of alone. steroid hormones or gonadotrophins, 34 R. C. COOMBES ET AL. though complete hormone suppression of may be responsible for relapse in these oestrogens has not been demonstrated, patients. mainly due to insufficiently sensitive We thank Ms M. Abbott for technical help and the assays. Thus, although suppression of surgeons and radiotherapists of The Royal Marsden oestradiol and oestrone are likely to be the Hospital for permission to study their patients. most important effects of AGT therapy, REFERENCES the former is difficult to measure in COOMBES, R. C., DEARNLEY, D. P., HUMPHREYS, J., GAZET, J. C., FORD, H. T., NASH, A. G., MASHITER. postmenopausal women due to lack of K. & POWLES, J. T. (1980a) Danazol treatment adequate sensitivity, and the levels of for advanced breast cancer. Canccr Treat. Rep. oestrone are affected by imbalanced 64, 1073. hepa- COOMBES, R. C., POWLES, T. J., GAZET, J.-C. & 4 tic function, invalidating this assay in others (1980b) Assessment of biochemical tests to patients with hepatic metastases (M. screen for metastases in patients with breast cancer. Lancet, i, 296. Dowsett, personal communication). We FRANCHIMONT, P. & CRAMILION, C. (1977) The have therefore measured drug action effect of danazol on anterior pituitary function. indirectly, by quantitating DHAS sup- Fertil. Steril., 28, 814. GOLDER, M. P., PHILLIPS, E. A., FAHMY, D. R. & 4 pression which is a measure of the steroid others (1976) Plasma hormones in patients with C-20 and 22 hydroxylase-desmolase en- advanced breast cancer treated with tamoxifen. zyme system. It appears that Eur. J. Cancer, 12, 719. adequate HAYWARD, J. L., CARBONE, P. P., HEUSON, J.-C., suppression still operates on relapse. KUMAOKA, S., SEGALOFF, A. & RUBENS, R. D. Similarly, the effect of tamoxifen on (1977) Assessment of response to therapy in advanced breast cancer. Cancer, 39, 1289. gonadotrophin concentrations is likely to JORDAN, V. C. & DOWSE, L. J. (1976) Tamoxifen as be a secondary effect, since it is known an anti-tumour agent: Effect on oestrogen bind- that the major site of action of the drug is ing. J. Endocrinol., 68, 297. McGUIRE, W. L., CARBONE, P. P. & VOLLMER, E. P. on RE (Jordan & Dowse, 1976). However, (1975) In Estrogen Receptors in Human Breast we have demonstrated that after tamoxi- Cancer, New York: Raven Press p. 6. fen therapy, the tumour is RE- (Taylor SANTEN, R. J., SAMOJLIK, E., LIPTON, A. & 4 others et (1977) Kinetic, hormonal and clinical studies with al., in press), suggesting that tamoxifen is aminoglutethimide in breast cancer. Cancer, 39, still capable of binding to RE on relapse or 2948. SMITH, I. E., FITZHARRIS, B. M., MCKINNA, J. A. & non-response. 6 others (1978) Aminoglutethimide in treatment Relapse is therefore almost certainly of metastatic breast carcinoma. Lancet, ii, 656. due to an inherent property of cancer cells TAYLOR, R. E., POWLES, T. J., HUMPHREYS, J. & 5 others (1982) Effects of endocrine therapy on which enables them to regrow in an steroid-receptor content of breast cancer. Br. J. initially unfavourable endocrine environ- Cancer, 45, 80. ment. Further studies are being carried WARD, H. W. C. (1973) Antioestrogen therapy for breast cancer: A trial of tamoxifen at two dose out to determine the other changes that levels. Br. Med. J., i, 13.