Breast cancer: evaluation of the safety and efficacy of the first-line treatment in 20 cases

Evaluation of the safety and efficacy of the first-line treatment with somatostatin combined with melatonin, retinoids, vitamin D3, and low doses of cyclophosphamide in 20 cases of breast cancer: a preliminary report. ^{(full PDF)}

 

Abstract

 

OBJECTIVE: The current strategies for the treatment of breast cancer are essentially based on surgery, preceded and/or followed by chemotherapy often supplemented by radiotherapy and/or the administration of hormonal therapy and monoclonal antibodies. Their combined use has made it possible to increase an overall survival but they are still penalized by adverse effects and toxicity. The marked anti-cancer effects of biological molecule such as Somatostatin, Melatonin, Retinoid, Vitamin D3 and prolactin inhibitors have been studied and documented for several decades. Their integrated and synergic action have been demonstrated, but only a few studies have as yet been carried out on their combined application in humans. The aim of the present investigation was to evaluate both the objective clinical response and toxicity of the biological multimodal treatment named Di Bella Method (DBM).

MATERIAL AND METHODS: The clinical data from a total of 20 women with a certified diagnosis of breast cancer, defined disease stage, and who independently decided to follow the DBM as first-line treatment, were retrospectively reviewed.

RESULTS: The mean age of the patients was 51 years (min 30; max 73). Twelve (12) patients (60%) presented an early stage disease, while the other 40% had a locally advanced/metastatic stage. An overall clinical benefit was achieved in 75% of cases, with 55% of complete response and 20% of partial response. For metastatic patients, the overall survival rate was 71%. The main toxicity effects included leukopenia, gastrointestinal phenomena and drowsiness.

CONCLUSIONS: The preliminary results of this report confirm the positive action of the biological treatment in terms of efficacy and survival, showing a more than favorable profile of tolerability.

 

INTRODUCTION

In the last few decades, numerous biological molecules, including Somatostatin (SST) and its analogues, Melatonin (MLT) and various classes of vitamins, such as Retinoids, Vitamin D3 and Tocopherols, have been shown to be potentially useful both in the prevention and treatment of breast cancer (Seitz et al. 2013; Sanchez-Barcelo et al. 2012; Tang & Gudas 2012; Mehta et al. 2012; Frati et al. 2011; Fulan et al. 2011). Numerous studies in vitro carried out on different cell lines have shown their marked anti-cancer activities, clarifying on one hand the putative mechanisms of action and on the other paving the way for the achievement of encouraging results in clinical practice (Proietti et al. 2013; Margheri et al. 2012; Cescon et al. 2012; Ostendorf et al. 2012; Suhail et al. 2012; Zhang et al. 2012; Proietti at al. 2011; He et al. 2009; Watt et al. 2008; Lee et al. 2008). However, only a very limited number of long-term clinical studies have been carried out in humans, especially as regards the association of these molecules in a multitherapic context that enhances their synergism and interaction.

We report below an observational retrospective study carried out on 20 patients affected by breast cancer, who received the biological therapy (Di Bella Method, DBM) based on the combined use of low doses of Cyclophosphamide and estrogen inhibitors together with molecules with a confirmed anti-cancer effect, such as Somatostatin/Octreotide, Melatonin, prolactin inhibitors, Retinoids, Vitamin E, Vitamin C and Vitamin D3, Calcium and extracellular matrix (ECM) components (Di Bella 2010).

 

PATIENTS AND METHODS

Eligibility criteria

Only patients with an Eastern Cooperative Oncology Group (ECOG) status ≤3, with a histological diagnosis of breast cancer and with disease characteristics measurable according to Response Evaluation Criteria in Solid Tumors (RECIST) were assessed (Patrick et al. 2000 - see below).

 

 

Another criterion was that the patients had not undergone to any standard therapeutic protocols (surgery, poli-chemotherapy, radiation therapy, monoclonal antibodies), and that, after informed consent, they agreed to administrate the first-line biological treatment.

The patient sample described above was divided into two groups, according to their disease stage:

• Group A: Patients in early stage breast cancer (stages 0, I, IIA, IIB);
• Group B: Patients with locally advanced/metastatic stage disease (stages IIIA, IIIC, IV).

 

Treatment

All the patients received a daily combination of Somatostatin/Octreotide, Melatonin, Retinoids solubilised in Alfa-Tocopheryl acetate, dopamine sub-type 2 receptor (D2R) agonists, oestrogen inhibitors and minimal doses of Cyclophosphamide. Specifically, the components were administered as follows:

• Gradually increasing oral doses of All Trans Retinoic Acid (ATRA, 1 453 488.372 IU), Axerophtol palmitate (909000 IU) and Beta-carotene (3 334 000 IU) solubilized in Alfa-Tocopheryl acetate (1×106 IU);
• An oral dose of Dihydrotachysterol (Cholecalciferol Vitamin D3, trade name Atiten©) 15 200 IU together with retinoids;
• Increasing doses of Somatostatin 1 mg a day for the first 7 days, increasing to 3 mg a day at 21 days;
• Tetracosactide acetate 1 mg (Brand name Synachten® – synthetic ACTH), initially administered intramuscularly every 7 days, constantly monitoring blood pressure and blood sugar, after 30 days 1/2 vial/week;
• Slow-release Octreotide 20 mg every 3 weeks intramuscularly;
• Melatonin: 10 mg in the morning, at midday, and in the evening with meals, plus 40 mg before going to bed (average total daily dose = 70 mg);
• Cabergoline (Brand name Dostinex®) orally during the main meal 1 mg (1\2 tablet), twice a week;
• Bromocriptine (Brand name Parlodel®) 2.5 mg orally, half a tablet morning and evening;
• Cyclophosphamide (Trand name Endoxan®) 50-100 mg orally, gradually increasing doses, starting with 1 tablet with the main meal and increasing to 1 tablet morning and evening after 1 week;
• L-ascorbic acid (Vitamin C) orally, gradually increasing doses: 1/2 spoonful (2 g = 4×103 IU) in a glass of water at midday and in the evening with the meal together with Calcium lactate gluconate + Calcium carbonate equal to 1 000 mg of calcium in the same glass;
• Chondroitin sulphate 500 mg, one tablet with meals in the morning, at midday and in the evening.

More details as regards methods of administration and the respective doses are shown in the Table1 (see below).

 

Evaluation of the response to treatment of the target lesions (Efficacy): Statistical and analytical methods

The criteria for evaluation of the objective response refer to the guidelines adopted by the World Health Organization ("Who handbook for reporting results of cancer treatment", see below) and by the Response Evaluation Criteria In Solid Tumors (RECIST). These are classified as: Overall Response (OR); Complete Response (CR); Partial Response (PR); Progression of Disease (PD); Stable Disease (SD), expressed as absolute frequency (n), relative frequency (%), and 95% confidence interval (95% CI). Radiological exams i.e. NMR (Nuclear Magnetic Resonance), PET-CT (Positron Emission Tomography–Computed Tomography) total body and Breast ultrasound every 4 months were routinely performed. Overall Survival (OS) has been evaluated as primary end-point. This latter analyses were performed using the Kaplan–Meier method (see "Understanding survival analysis: Kaplan-Meier estimate"), with a 95% CI (R© software package; version 2.15.12, 2012).

 

 

Safety and toxicity evaluation

Only the adverse events that could be correlated to the treatment (degrees of correlation: possible, probable or certain) expressed as absolute frequency (n) and relative frequency (%), were considered when evaluating the toxicity; as described by the National Cancer Institute (NCI-CTC criteria, see below).

 

 

Note: this is a study on the combined use of drugs that have already passed all the tests of reliability and proven antitumor activity. Therefore, because all the products are already widely tested and whose use is approved by the international health organizations, but in this context are only used in a new combination, it was decided not to submit to any ethical committee. The therapeutic methodology used in such investigation is therefore strictly designed on the basis of the concept of Evidence-Based Medicine (EBM) (see Sackett et al. 1996, "Evidence based medicine: what it is and what it isn't"). All the other prerogatives of this investigation are also in accordance with the fundamental principles of the Declaration of Helsinki (see below). Therefore, all patients gave their informed written consent.

 

 

RESULTS

A total of 29 patients accrued over a 5 year period (from March 2006 to December 2012) were consecutively treated with a biological therapy (DBM) and monitored for 26 months (min 9, max 51).

Twenty (20) of these patients satisfied the eligibility criteria and were retrospectively reviewed (see Flowchart). Table 2 shows the clinical characteristics of the patients at baseline: the median age was 51 years (range: 30–73 years). The main histotype of the primary lesion was Infiltrating Ductal Carcinoma (IDC, 15 cases, 75%), while lung, lymph nodes and bones represented the sites of secondary lesions (10%, 60% and 30% respectively). The molecular biological profile has been assessable only in 60% of the patients (12 cases).

The disease stages at the time of evaluation were as follows:

• Early stage disease (Group A): Stage 0, 2 cases (10%); Stage I, 2 cases (10%); Stage II, 8 cases (40%). The Gleason score grading were: G1 20%; G2 40%, G3 13.3% and n.a. (26.7%);
• Locally Advanced/Metastatic disease (Group B): Stage IIIA, 3 cases (15%); Stage IIIC, 2 cases (10%); Stage IV, 3 cases (15%). Of these patients, 4 cases (50%) were grade G3.

Taken together, an overall objective response (OR) [Complete response (CR) + partial response (PR)] was observed in 75% (11+4 cases; 53.1–88.8; 95% CI) of the patients, with a CR in 55% of cases (n=11; 30–70; 95% CI). In addition, 85% (16 cases; 58–92; 95% CI) of the patients achieved an objective clinical benefit (CR+PR+SD) (Table 3). The 2 years Overall survival (OS) rate of the patients was 100% (Figure 1).

• Group A: Early Breast Carcinoma, NA=12. An OR (CR+PR) was achieved in 91% of the patients (7+4 cases; 64–98; 95% CI), with CR in 58% of the cases (n=7, 32–81; 95% CI). In addition, all the patients achieved a clinical benefit (CR+PR+SD) (Table 4). The 2 years Overall survival (OS) rates of the patients were 100% (Figure 2);
• Group B: Locally Advanced/Metastatic Carcinoma, NB=8. The 2 years OS rate of the patients was 71% (Figure 3). The OR (CR+PR) was 50% (3+1 cases; 21–78; 95% CI) of the patients, with CR in 37.5% of the cases (Table 5). In addition, the 62.5% of the patients achieved a clinical benefit (CR+PR+SD).

 

Safety evaluation

The most frequent toxicity phenomena observed in the study (grade II) were the following: haematological toxicity (leukopenia, 35%), gastrointestinal toxic ity (nausea, 25%), and drowsiness (40%). A reduction, delay or temporary discontinuation of the treatment due to toxicity was necessary in patients with leuko penia (discontinuation of Cyclophosphamide until the leukocyte count returned to within the normal range), and in the cases of gastrointestinal effects. No deaths due to the treatment occurred (Table 6).

 

DISCUSSION

Rationale of the treatment, review of the literature and brief discussion of the clinical data

Numerous experimental studies and clinical investigations clearly indicate that some pituitary hormones, including the Growth Hormone (GH) and Prolactin (PRL), have a crucial role in the development and progression of human breast cancer (Schally et al. 2001; Kamenicky et al. 2010; Perry et al. 2008; Harvey 2012; Bernichtein et al. 2010; Faupel-Badger et al. 2010; Raccurt et al. 2002).

While on one hand the ubiquitous expression of PRL and GH represents a clear confirmation of the direct, generalized and synergized mitogenic role of these hormones (Wu et al. 2011; Xu et al. 2012), the causal dose-dependent relationship between the receptorial expression of GH and the processes of tumour induction and progression has on the other hand has been also demonstrated.

The distribution of GHR and GHRHR are in fact markedly superior in breast tumour tissues with respect to their physiological and peritumoral receptorial expression, further confirming the potent mitogenic role of GH with a dose-dependent proliferative index (Gebre-Medhin et al. 2001; Chatzistamou et al. 2004).

The temporal mechanism of this etiopathogenetic process is currently being studied: the most probable being mechanisms of autocrine and/or paracrine signalling, on the basis of the detection of local production of GH, Insulin Growth Factor I (IGFI), and ES in breast cancer, peritumoral tissues stromal area (Kaulsay et al. 2001; Siriwardana et al. 2006).

Both physiological and tumour cell proliferation take place by means of these same molecules, which a tumour cells uses to a much greater extent than normal cells. It can thus be deduced that the PRL-GH-IGF1 axis has a determining influence on neoplastic biological development. In addition, it is now confirmed that sex hormones play a key role in the etiology and progression of breast cancer, as well as in various hormone-dependent tumours such as prostate and ovarian cancer.

The main mechanism at the basis of these tumours is the result of the prolonged hormonal stimulation, with serious long-term repercussions on the normal growth and function of the target tissues. Considerable experimental evidence has demonstrated that both the contribution of sex hormones and the growth factors regulated by them carry out a profound gene modulation (Zheng et al. 2010; Rasmussen et al. 2010).

This means that tumor cell proliferation is closely connected to the PRL-GH axis, in association with the steroid Hormones and to GH-dependent mitogenic molecules (Growth Factors, GFs), such as Epidermal Growth Factor (EGF), Fibroblast Growth Factor (FGF), Hepatocyte Growth Factor (HGF), Insulin Growth Factor (IGF1-2), Nerve Growth Factor (NGF), Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF) and Transforming Growth Factor (TGF), as well as to GFs produced by the gastrointestinal tract (Vasoactive Intestinal Peptide, VIP) (Li et al. 2011; Frank et al. 2008; Fürstenberger et al. 2003; Laban et al. 2003; Milewicz et al. 2011; Carver et al. 2010; Haines et al. 2009; Smith et al. 2011; Moody et al. 2003).

It therefore seems evident that the use of biological antagonists of GH and PRL, such as Somatostatin, its analogues and D2R agonists; not only downregulate both the expression and the secretion of mitogenic GFs, but also extend their negative regulation to the signalling pathways of the respective receptorial targets, with sub-sequent antiproliferative and antiangiogenic effects.

This concept of a "multi-targeted biological approach", is slowly emerging through the increasingly frequent research, although still with very few models in vivo (Tejeda et al. 2006; Jacobson et al. 2010; Schally et al. 2008). The suppressive effect of SST and its analogues on the serum levels of IGF1 is both direct, through inhibition of the IGF gene, and indirect, by suppression of the GH and thus of its hepatic induction of IGF1 (Pollak 1997).

It has been observed that breast tumours express the receptorial subclasses SSTR1-5 (Kumar et al. 2005, Cameron et al. 2003). This representing a further rational indication for the use of SST, already fully justified by the aforementioned negative regulation on GH, of the GH–correlated GF and oestrogen regulation.

The inhibitory activity of SST, is directed to another mitogenic growth factor, the EGF, through multiple mechanisms: by blocking of the dose-dependent signalling (inhibition of tyrosine phosphorylation), its gene down-regulation along with its plasma concentration (Watt et al. 2009, Hofland et al. 1995, Ruscica et al. 2012).

The same mechanisms have been included within the retinoid anticancer action. Expecially as regards retinoic acid compounds (Salvatori et al. 2011). This interference is shown to reinforce by the concomitant administration of MLT and Vitamin D3 in vitro (Proietti at al. 2011). In addition, Angiogenesis and neoangiogenesis, necessary conditions for tumour progression, as well as the cascade of monocytes, the paracrine release of interleukin 8 (IL-8) and the contribution of GFs (whose synergism is essential), are specific molecular targets negatively regulated by Somatostatin and its analogues (Ruscica et al. 2012).

The inhibition of angiogenesis induced by SST is synergically reinforced by MLT, Retinoids and Vitamin D3 (Kim et al. 2013; Lissoni et al. 2001; Sogno et al. 2009; Picotto et al. 2012). Furthermore, the local conditions of hypoxia/anoxia and acidosis promote angiogenesis, and are mostly corrected by the improvement in the blood tissue exchanges induced by the differentiating components of the DBM.

At the same time, the cytostatic, antiproliferative, and antimetastatic effects of Somatostatin are synergically increased by the other components of the DBM. An additional contribution is provided by the daily administration of low doses (50–100 mg/die per os) of Cyclophosphamide (Endoxan). As well as drastically reducing the known anitblastic/myelosuppressive effects, this dosage induces a marked turnaround of its mechanisms of action: triggering of the mitochondrial-dependent apoptotic cascade, antiangiogenetic action by drastically down-regulating the VEGF gene expression (Loven et al. 2013, Pasquier et al. 2010).

Numerous preclinical investigations have also demonstrated the mechanisms of action of MLT. The use of such indole extends to all histotypes of breast cancer due to its high membrane receptorial/nuclear distribution (Oprea-Ilies et al. 2012; Rögelsperger et al. 2011). Since the molecule is associated with the signalling pathways of both the physiological and neoplastic epithelial development, this substance has the properties to selectively neutralize the proliferative signals of estrogens and negatively modulate their local biosynthesis (Hill et al. 2011; Girgert et al. 2009).

The administration of low doses of second generation aromatase inhibitors (Anastrozole©), already used in clinical practice, combined with MLT, SST and Retinoids, negatively regulates the hormone-dependent processes of proliferation of breast tumours (Alvarez-García et al. 2013; Margheri et al. 2012; Wang et al. 2012; Knower et al. 2012; Ciolino et al. 2011). The literature has therefore confirmed anticancer anctivity throught their differentiating, antiproliferative, antiangiogenetic and antimetastatic mechanisms of action, of all the compounds covered by the DBM both in vitro and in vivo.

This retrospective study confirms the objective response of breast cancer to the concomitant treatment of the aforesaid biological molecules. Another issue worth mentioning is that the objective response obtained in 15 cases was achieved without recourse to conventional chemo-radio therapy and/or surgery, especially considering that recurrence and post-operative metastases are the main cause of mortality correlated to breast cancer, by inducing a systemic dissemination (Naumov et al. 2002; Demicheli et al. 1996; Fisher et al. 1989; Tyzzer et al. 1913; Marie et al. 1910) and that the use of massive doses of antiblastic agents and of radiation therapy not only increases the mutations but also provides a fertile ground for the activation of factors that promote the growth and progression of hormone-dependent tumors (Sun et al. 2012 "Treatment-induced damage to the tumor microenvironment promotes prostate cancer therapy resistance through WNT16B"; Lagadec et al. 2012 "Radiation-induced reprogramming of breast cancer cells", see below).

 

 

The combined use of the DBM molecules in local advance/metastatic patients allowed a complete survival rate at the first year of follow-up. Furthermore, in the 8 cases observed, the OS is currently at several months (24). The objective response, without severe toxicity, achieved by the progressive reduction and disappearance of the initial eteroplastic lesions, the axillary adenopathies, is unequivocal proof of the efficacy of this treatment and confirms the preliminary positive results already published on the use of the DBM in lymph proliferative disorders (Di Bella et al. 2013; Todisco et al. 2001), in advanced stage lung cancer and in cervical-facial tumours (Di Bella et al. 2012; Norsa et al. 2007; Norsa et al. 2006).

Without toxicity and without in any way reducing working activities, the DBM avoids surgical trauma and the significant side effects of the usual chemotherapy and radiation therapy protocols. The early application of the DBM as first-line therapy, in patients not weakened by the toxic, mutagenic and immunodepressive effects of chemo- and radiotherapy. Thus greatly facilitated the possibilities of achieving an objective response, both promoting survival and improving a better quality of life.

 

CONCLUSIONS

The rationale for the use of biological molecules to treat breast cancer, supported by the clinical results reported above, is proof of the logic and efficacy of DBM’s multi-therapy concept as a biological treatment for tumours: the synergic interaction of its components supports and enhances the vital reactions and anticancer homeostasis, allowing them to counter the anarchy of the neoplastic processes of the tumour’s microenvironment.

In short, the aim of the biological therapy is to counter the progression of the neoplastic phenotype:

1. by Inhibiting the neoplastic proliferation by means of apoptosis/necrosis and deprivation of hormones and cell growth factors;
2. by contrasting the marked mutagenic tendency by direct activation of DNA repair system and through epigenetic cell reprogramming;
3. by blocking tumour progression, by halting the formation of blood vessels (Neoangiogenesis-Lymphangiogenesis) and of cell motility (migration), essential for the spread of tumour cells to distant sites;
4. by providing defence against neoplastic aggression by reinforcing the natural defence mechanisms (innate and acquired immunity).

Tumors can in fact be considered an aimless deviation of cellular homeostasis, meaning that it is necessary to restore the abnormal biochemical reactions to normal status by the reinforcement and modulation of all the means physiologically considered essential to sustain life.

The documented antiangiogenic synergism of all the components of the DBM, together with the antiproliferative effect of SST and PRL and ES inhibitors and the differentiating, immunomodulating, trophic and homeostatic effects of the other components of the DBM, achieved this result while avoiding on one hand the severe toxicity and sometimes permanent damage of the usual medical treatments for cancer, and on the other notably increasing the PS and quality of life and survival.

In conclusion, we believe it useful and necessary to report this observational study in order to encourage greater interest in the scientific community. We also believe that the few clinical studies carried out on the multitherapy and synergic use of these biological molecules should be extended to the various forms of cancer in order to provide a documented confirmation. Future randomized and double-blind clinical studies investigating this treatment should be encouraged.

 

About this publication.

 

Evaluation of the safety and efficacy of the first-line treatment with somatostatin combined with melatonin, retinoids, vitamin D3, and low doses of cyclophosphamide in 20 cases of breast cancer: a preliminary report

 

 

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Manish Kumar Goel, Pardeep Khanna, and Jugal Kishore - Understanding survival analysis: Kaplan-Meier estimate. Int J Ayurveda Res. 2010 Oct-Dec; 1(4): 274–278.

 

About this publication.

 

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. - Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2.

 

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