Effects of adjuvant exemestane versus anastrozole on bone mineral density for women with early breast cancer (MA.27B): a companion analysis of a randomised controlled trial.

BACKGROUND: Treatment of breast cancer with aromatase inhibitors is associated with damage to bones. NCIC CTG MA.27 was an open-label, phase 3, randomised controlled trial in which women with breast cancer were assigned to one of two adjuvant oral aromatase inhibitors-exemestane or anastrozole. We postulated that exemestane-a mildly androgenic steroid-might have a less detrimental effect on bone than non-steroidal anastrozole. In this companion study to MA.27, we compared changes in bone mineral density (BMD) in the lumbar spine and total hip between patients treated with exemestane and patients treated with anastrozole. METHODS: In MA.27, postmenopausal women with early stage hormone (oestrogen) receptor-positive invasive breast cancer were randomly assigned to exemestane 25 mg versus anastrozole 1 mg, daily. MA.27B recruited two groups of women from MA.27: those with BMD T-scores of -2·0 or more (up to 2 SDs below sex-matched, young adult mean) and those with at least one T-score (hip or spine) less than -2·0. Both groups received vitamin D and calcium; those with baseline T-scores of less than -2·0 also received bisphosphonates. The primary endpoints were percent change of BMD at 2 years in lumbar spine and total hip for both groups. We analysed patients according to which aromatase inhibitor and T-score groups they were allocated to but BMD assessments ceased if patients deviated from protocol. This study is registered with ClinicalTrials.gov, NCT00354302. FINDINGS: Between April 24, 2006, and May 30, 2008, 300 patients with baseline T-scores of -2·0 or more were accrued (147 allocated exemestane, 153 anastrozole); and 197 patients with baseline T-scores of less than -2·0 (101 exemestane, 96 anastrozole). For patients with T-scores greater than -2·0 at baseline, mean change of bone mineral density in the spine at 2 years did not differ significantly between patients taking exemestane and patients taking anastrozole (-0·92%, 95% CI -2·35 to 0·50 vs -2·39%, 95% CI -3·77 to -1·01; p=0·08). Respective mean loss in the hip was -1·93% (95% CI -2·93 to -0·93) versus -2·71% (95% CI -4·32 to -1·11; p=0·10). Likewise for those who started with T-scores of less than -2·0, mean change of spine bone mineral density at 2 years did not differ significantly between the exemestane and anastrozole treatment groups (2·11%, 95% CI -0·84 to 5·06 vs 3·72%, 95% CI 1·54 to 5·89; p=0·26), nor did hip bone mineral density (2·09%, 95% CI -1·45 to 5·63 vs 0·0%, 95% CI -3·67 to 3·66; p=0·28). Patients with baseline T-score of -2·0 or more taking exemestane had two fragility fractures and two other fractures, those taking anastrozole had three fragility fractures and five other fractures. For patients who had baseline T-scores of less than -2·0 taking exemestane, one had a fragility fracture and four had other fractures, whereas those taking anastrozole had five fragility fractures and one other fracture. INTERPRETATION: Our results demonstrate that adjuvant treatment with aromatase inhibitors can be considered for breast cancer patients who have T-scores less than -2·0. FUNDING: Canadian Cancer Society Research Institute, Pfizer, Canadian Institutes of Health Research.

Barriers and motivations for women to participate in cardiovascular trials.

BACKGROUND: Cardiovascular disease is one of the major causes of mortality in Canadian women. However, the number of women recruited into cardiovascular clinical trials continues to be low relative to the prevalence of cardiovascular disease. To determine why the recruitment of women into cardiovascular trials continues to be problematic, we prospectively examined the barriers and motivations of women contacted for the Raloxifene Use for The Heart (RUTH) study. METHODS: Two hundred seventy postmenopausal women were surveyed. Regardless of study eligibility, women were asked to comment on their reasons for participating or not participating in cardiovascular trials in an open-ended single question format. All answers were recorded and grouped accordingly. RESULTS: Fifty-four percent of women surveyed indicated they would not participate in clinical research, and 46% indicated that they would. Motivations reported for participating in a cardiovascular clinical trial included personal health benefits (82.2%), interest in research (44.1%), and the possibility of benefiting society (29.1%). Reasons for declining participation included personal illness (24.8%), transportation issues (17.9%), reluctance to increase medication (15.2%), and concern about adverse health effects (13.1%). CONCLUSION: As reported by our cohort of postmenopausal women, the major barrier to entering a randomized controlled trial related to cardiovascular disease was the perception that participation would present an increased burden on health and time. Our experience suggests that researchers need to educate women on the importance of clinical trials and that they also need to provide practical solutions to barriers such as transportation.

AII amacrine cells express the MT1 melatonin receptor in human and macaque retina.

AII amacrine cells are critical interneurons in the rod pathway of mammalian retina, active primarily in dim lighting conditions. Melatonin, a neuromodulator produced at night in the retina, is believed to induce retinal adaptation to dim lighting conditions in most vertebrate species examined to date, including humans. We hypothesized that melatonin may influence retinal light adaptation by acting on AII cells directly and thus investigated whether melatonin receptors were expressed in AII neurons. Postmortem nonpathological eyes from four human donors as well as two eyes from two Macaque Fasicularis monkeys were analyzed. Double immunocytochemistry was performed using an anti-MT(1) antibody and an antibody to calretinin, an AII marker. Analysis utilized confocal microscopy. A polyclonal anti-calretinin antibody labelled amacrine cells exhibiting the distinct AII morphology, in both human and macaque retina. MT(1) immunoreactivity in macaque retina was similar to human staining, in that horizontal, amacrine and ganglion cell bodies were stained, as were inner segments of photoreceptors. In human retina 86% of calretinin positive cells expressed the MT(1) receptor peripherally, whereas centrally, 78% colocalization was observed. In the macaque retina, 100% of AII amacrine cells expressed MT(1) immunoreactivity both centrally and peripherally. That virtually all AII neurons express the MT(1) receptor in both human and macaque retina, may provide the first evidence demonstrating a role for melatonin in AII regulation, furthering the hypothesis of melatonin function in retinal light adaptation.

MT(1) melatonin receptor in the human retina: expression and localization.

PURPOSE: Melatonin's function in human vision is far from understood, in part because of the lack of information on its cellular targets. Therefore, expression and localization of the MT(1) melatonin receptor in human retina was examined. METHODS: Postmortem nonpathologic human eyes from nine donors were investigated, three by reverse transcription-polymerase chain reaction (RT-PCR) for MT(1) and MT(2) transcripts and six by immunocytochemistry, using a peptide-specific anti-MT(1) receptor antibody. RESULTS: RT-PCR suggested that both MT(1) and MT(2) transcripts had similar levels of expression. Vertical slices of human retina demonstrated MT(1) immunoreactivity in cell bodies along the outer border of the inner nuclear layer (INL), along the inner border of the INL, in cell bodies within the ganglion cell layer (GCL), and in the inner segments (IS) of photoreceptors. Double immunolabeling using anti-MT(1) and tyrosine hydroxylase revealed that 69% of CA1 and 63% of CA2 dopaminergic neurons exhibited MT(1) immunoreaction. Double immunolabeling with anti-parvalbumin, a horizontal cell marker, showed that MT(1)-positive cells along the outer INL border were exclusively horizontal cells, and that 18% of horizontal cells in central retina expressed MT(1). Double staining with MT(1) and markers for both rod and cone photoreceptors suggest that IS staining is present on rod cells. CONCLUSIONS: The MT(1) receptor is expressed in diverse neuronal cell types in the human retina, providing evidence of a significant role for melatonin and this receptor subtype in human vision.