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Recent Advances with SERM Therapies 4376s Vol. 7, 4376s-4387s, December 2001 (Suppl.) Clinical Cancer Research Endocrine Manipulation in Advanced Breast Cancer: Recent Advances with SERM Therapies Stephen R. D. Johnston e gynecological side effects may prove more beneficial than Department of Medicine, Royal Marsden Hospital and Institute of either tamoxifen or AI. The issue is whether the current Cancer Research, London SW3 6JJ, United Kingdom clinical data for SERMs in advanced breast cancer are sufficiently strong to encourage that further development. Abstract Tamoxifen is one of the most effective treatments for Introduction breast cancer through its ability to antagonize estrogen- Ever since evidence emerged that human breast carcinomas dependent growth by binding estrogen receptors (ERs) and may be associated with estrogen, attempts have been made to inhibiting breast epithelial cell proliferation. However, ta- block or inhibit estrogen's biological effects as a therapeutic moxifen has estrogenic agonist effects in other tissues such strategy for women with breast cancer. Estrogen has important as bone and endometrium because of liganded ER-activating physiological effects on the growth and functioning of hormone- target genes in these different cell types. Several novel an- dependent reproductive tissues, including normal breast epithe- tiestrogen compounds have been developed that are also lium, uterus, vagina, and ovaries, as well as on the preservation selective ER modulators (SERMs) but that have a reduced of bone mineral density and reducing the risk of osteoporosis, agonist profile on breast and gynecological tissues. These the protection the cardiovascular system by reducing cholesterol SERMs offer the potential for enhanced efficacy and re- levels, and the modulation of cognitive function and behavior. duced toxicity compared with tamoxifen. In advanced breast Thus, a strategy to block or reduce estrogen function in an cancer clinical data exist for three first-generation SERMs attempt to treat or prevent breast cancer could have a severe (toremifene, droloxifene, idoxifene), which are related to the impact on a woman's health by interfering with normal estro- triphenylethylene structure of tamoxifen. In Phase II trials gen-regulated tissues. in a total of 263 patients resistant to tamoxifen, the median For over 30 years, synthetic antiestrogens have been de- objective response rate to these SERMs was only 5% (range, veloped as treatment for ER+ve 3 breast cancer, and the tri- 0-15%), with stable disease for >--6 months in an additional phenylethylene tamoxifen was the first hormonal compound 18% (range, 9-23%). As first-line therapy for advanced with efficacy in advanced breast cancer (1). Tamoxifen is the breast cancer, the median response rate was 31% (range, most widely used and tested drug in breast cancer and is now 20-68%) with a median time to progression of 7 months. recognized to significantly improve survival as adjuvant therapy Randomized Phase III trials for toremifene and idoxifene in in early breast cancer (2), as well as to reduce the incidence of more than 1500 patients showed no significant difference breast cancer in healthy women at risk of the disease (3). compared with tamoxifen. Fewer clinical data exist for the Despite concerns about unfavorable antiestrogenic effects on structurally distinct second- and third-generation SERMs healthy tissues, paradoxically it was discovered that tamoxifen (raloxifene, arzoxifene, EM-800, and ERA-923), although a acted as an estrogen on bone, blood lipids, and the endometrium similarly low median response rate of 6% (range, 0-14%) (4). More recently, the molecular structure and function of ER was seen in Phase II trials in tamoxifen-resistant patients. It biology has been elucidated, revealing how tamoxifen and re- remains unclear whether any clinical advantage exists for lated drugs act as ligands to differentially switch on or off gene second- and third-generation SERMs over tamoxifen as expression in specific tissues (5, 6). The ability of antiestrogens first-line therapy. With the emergence of potent aromatase to have alternative effects on various estrogen-regulated targets inhibitors (AIs) that are superior to tamoxifen, the clinical led to the term "SERM" to describe this class of drugs. It is now questions in advanced disease have shifted to which anties- possible to develop SERMs that range from full estrogen ago- trogen (including SERMs) may be effective following failure nists to pure antagonists with different effects in separate target of AIs, and whether any merit exists for combined AI/SERM tissues. In this way, SERMs offer the potential to treat and therapy. The main advantage for SERM therapy probably prevent a number of conditions ranging from osteoporosis, remains in early stage-disease (adjuvant therapy or preven- menopausal symptoms, cardiovascular disease, and breast and tion), in which the estrogenic effects on bone and reduced endometrial cancer. This article will review the development of SERMs in breast cancer, addressing in particular the limitations of tamoxifen that SERMs have attempted to overcome and the clinical data available to date for each of the SERM compounds. i Presented at the First International Conference on Recent Advances and Future Directions in Endocrine Therapy for Breast Cancer, June 21-23, 2001, Cambridge, MA. 2 To whom requests for reprints should be addressed, at Department of Medicine, Royal Marsden Hospital and Institute of Cancer Research, London, SW3 6JJ, UK. Phone: 44-(0)207-808-2748; Fax: 44-(0)207- 3 The abbreviations used are: ER, estrogen receptor; ER+ve, ER posi- 352-5441; E-mail: [email protected]. tive; SERM, selective ER modulator; CI, confidence interval. Downloaded from clincancerres.aacrjournals.org on September 29, 2021. © 2001 American Association for Cancer Research. Clinical Cancer Research 4377s Tamoxifen: The Prototype SERM AF1 AF2 The triphenylethylene nonsteroidal antiestrogen tamoxifen CoRp, was first synthesized in the 1960s and was found to have clinical §247 activity in postmenopausal women with advanced breast cancer (1). Tamoxifen antagonizes the effects of estrogen in breast | §247 cancer cells by binding ER, inducing G~ cell cycle arrest, and Estradiol inhibiting tumor growth. Although tamoxifen prevented growth of ER+ve breast tumor xenografts in vivo (7), at the same time it stimulated uterine growth (8) and supported the growth of endometrial xenografts in vivo (9). A similar spectrum of estro- CoR genic and antiestrogenic effects emerged in patients, with vag- § inal dryness and hot flushes the most frequently reported an- tiestrogenic toxicities (10). Because of estrogenic activity of Tamoxifen - ~. Idoxifene tamoxifen in the liver, total serum cholesterol levels were re- Raloxifene ......... duced by 10-15% (11). Likewise, bone mineral density was EM-800 ERE - preserved in tamoxifen-treated postmenopausal women, al- though in premenopausal women, this effect was not apparent CoR A CoA (12, 13). In patients, tamoxifen functioned as an estrogen on the endometrium, with endometrial thickening and hyperplasia to- gether with an increased risk of endometrial cancer (14). Al- Fulvestrant though some of these additional properties of tamoxifen are of potential benefit for women, SERMs were developed for breast ERE cancer with the aim of reducing some of tamoxifen's toxicities, Fig. 1 Concept diagram to explain spectrum of Ez/tamoxifen/SERM in particular eliminating any agonist effects on the gynecolog- activity through altered structure-function relationships between ligand, ical tract. In terms of breast cancer therapy, a meta-analysis of ER, and the coactivator/corepressor complex that activates or inhibits all clinical trials found that 5 years of tamoxifen in women with estrogen-regulated gene transcription. Representative SERMs are early stage ER+ve breast cancer significantly reduced the risk ranked on the left in order of increasing antagonistic effects. ERE, of recurrence (47% reduction in annual odds) and death (26% estrogen response elements; CoR, corepressor; CoA, coactivator; H12, helix 12 of ER; +/-, presence/absence of transcriptional activity at the reduction in annual odds; Ref. 2). This benefit was greatest in AF-1 and AF-2 sites. women with ER-rich tumors and occurred across all age groups, irrespective of nodal involvement. In addition, tamoxifen's an- tiestrogenic effects on normal breast epithelial cells resulted in a 50% reduction in new contralateral breast cancers, evidence ligands, including estrogen and tamoxifen, in different tissues that provided much of the impetus to developing a role for (reviewed in Refs. 5, 6). Estrogen-regulated gene transcription is tamoxifen in chemoprevention. At the same time, the estrogenic activated through two separate transactivation domains within effects of tamoxifen therapy on bone and cholesterol are of ER, termed AF-1 in the NH2-terminal A/B region and AF-2 in clinical benefit in reducing risk from osteoporosis and cardio- the COOH-termihal E region (18). At its simplest level, tamox- vascular disease (11, 12). In the adjuvant setting, tamoxifen's ifen functions as a competitive antiestrogen to inhibit estrogen increased risk of endometrial cancer has been perceived as small action. Tamoxifen-bound ER still dimerizes and binds DNA, in relation to the substantial benefit from reduction in breast although the downstream effects differ because of the altered cancer-related events (14). However, both in adjuvant and met- conformational shape
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