Pharmacotherapy of Cancer and Anti-Cancer Drugs

The cell cycle - most important target in anticancer therapy.

1. G1 phase - preparatory phase for S, proteins involved in DNA
synthesis are transcribed and synthesized, e.g. histone proteins,
chaperone proteins, etc.
2. S (synthesis) phase - characterised by DNA synthesis.
3. G2 phase - preparatory phase, the cell is prepared for mitosis.
4. M (mitosis) phase - cell division occurs, involvement of
microtubules, since the cell stretches, genetic material is
separated and ultimately two daughter cells are produced from a
single mother cell.
5. Finally, the G1 phase starts again.
 At every transition between one phase and the following one,
checkpoints are present (G1 and G2). The latter are sorts of “cell
check-ups”, in which DNA repair may occur. If anything in
DNA repair fails, then cells may undergo apoptosis rather than
error correction.

Drugs specific for phases of the cell cycle:

1. Palbociclib and abemaciclib - specific for the G1 to S phase. They are known as CDK4/6
inhibitors. CDK4/6 is involved in the regulation of transcription. These drugs block cells in the S
phase, preventing cellular replication.
2. 5-fluorouracil - S-phase specific drug  inhibitor of the enzyme thymidylate synthase; which is
important as it catalyses the synthesis of the DNA precursor deoxythymidine triphosphate.
3. Methotrexate - S-phase specific drug. It is involved in the synthesis of tetrahydrofolate from
folate.
4. Vinca Alkaloids and Taxanes - specific to M-phase, by interfering with microtubules.

Drugs not specific for phases of the cell cycle:

1. Alkylating agents - not specific, able to form alkyle adducts with DNA independently from the
moment of the cell cycle in which the cell is in.

Molecular testing - the ideal “companion diagnostic tool”, as every single type of cancer is caused by
different mutations.
1. Expression levels of drug targets (e.g., HER2, estrogen receptors). For example, in breast cancer,
the expression levels of HER2 is a key information. The same applies to estrogen receptors (ER).
2. Drug target mutations – e.g. mutations in KRAS, a kinase expressed downstream to EGFR, which
is an important receptor in the development of colorectal cancer. If KRAS is mutated, the
blockage of EGFR would be useless, as the downstream pathway would continue to be activated.
3. Patient’s ability to metabolize a specific drug – e.g. 5-FU. The DPD enzyme (dehydropyrimidine
dehydrogenase) is necessary for 5-fluorouracil metabolization. Some patient don’t express it, and
can lead to toxic accumulation of 5-FU  can lead to death.
4. Levels of potential drug resistance - e.g. level of p53 (involved in DNA repair) or P-glycoprotein
(also known as multidrug-resistance protein). The latter is involved in drug efflux. It is usually
expressed on epithelial cells, and it is responsible for the quick efflux of drugs, therefore
preventing their absorption from the oral route. It may be overexpressed in cancer cells.

Examples for Molecular Testing Methods in Breast Cancer – the problem is that the result aren’t cost-
effective.
1. MammaPrint is a 70-gene assay: this implies that using this kit enables to assess the expression
levels of 70 different genes which are involved in drug resistance, carcinogenesis, etc.
2. Oncotype DX, a 21-gene assay – especially in early breast cancer, with ER+, HER-, node negative
or positive for 1-3nodes. The test gives a recurrence score:
a. If the recurrence score is < 11, the gold standard therapy is an endocrine one alone.
1
 b. If it is > 25 - chemoendocrine therapy, endocrine therapy is not sufficient and cytotoxic drugs
have to be used. The latter have many side effect.s
c. Intermediate (11 – 25) - matter of debate, the administration of chemotherapy is not necessary
for these patients as well. This is precious information for the patient.

Combination therapy - Very often, there is combination of therapies. It may include:

1. Cytotoxic drugs - usually block cellular replication, e.g. by forming adducts with DNA or by
blocking synthesis of DNA precursors.
2. Targeted drugs -small molecules or moAb –HER2 inhibitors or checkpoint inhibitors.
3. Hormonal therapy drugs - target specific hormones involved in cancer progression, e.g. ER.
4. Antiemetic drugs - some cytotoxic drugs induce severe vomiting.
5. Granulocyte colony stimulating drugs (filgrastim) - recombinant formulations of the human
granulocyte colony stimulating factor (GCSF). Filgrastim is important to stimulate the synthesis of
granulocytes when administering drugs which are heavily associated with myelotoxic effects.
6. Rescue drugs - to reduce the toxic effects of certain drugs.
a. MESNA (anti-oxidant) is administered to prevent the toxicity of acrolein, which is a metabolite
of cyclophosphamide. Acrolein can lead to development of injuries to the urinary bladder,
which lead to bleeding.
b. leucovorin and uridine - Able to minimize side effects of cytotoxic drugs.

Combination therapy has many advantages:

 Advanced efficacy, as multiple targeting results in additive or synergistic effects;
 Reduction of drug resistance - minimized with multiple drugs administration.
 Protection from adverse effects.

Example - We need to remember that when we administer doxirobucine and cyclophosphamide

together we should add anti-emetic drug.

ESMO App - collection of protocols for antineoplastic therapy. It allows to distinguish among
different protocols according to cancer type, nature of the cancer (e.g., primary, advanced, etc.), and
further distinctions (e.g., breast cancer that is ER +/-, HER2 +/-, …). The results will be the guidelines
and administration protocols.

Cytotoxic drugs (Exam – identify and calssify a drug, differentiate between groups of drugs)
Anthracyclines – doxorubicin - one of the most used anthracyclines. Cell Cycle Non-Specific.
Characteristics:
 DNA/Topo2/Doxorubicin trimer - Doxorubicin interferes with DNA by forming a trimer together
with DNA and topoisomerase. This prevents the activity of DNA polymerase, which cannot
proceed with DNA replication  cells are stuck in the S phase. At this point, damage repair would
be the only possibility of the cancerous cell to go on: it should be capable of cutting the fragment
of DNA where doxorubicin has formed the trimer. Such activity should be carried out by p53.
However, if sufficient dosages of the drugs are administered and p53 is not overexpressed, the
available p53 amounts are not sufficient to repair all of the DNA  leading to apoptosis.
 DNA intercalation – structural distortion, drugs fit themselves between base pairs of DNA, which
inhibit RNA and DNA synthesis.
 Block in G2/M checkpoints (which is the checkpoint after the synthesis phase; it enables the cell
to realize that the DNA is “useless” and has to be repaired), p53 activation and induction of
apoptosis.

Absorption - Low oral bioavailability, due to high expression of P-glycoprotein efflux in the intestinal
epithelium (resistance)  poorly absorbed and IV administration is required, repeated after 2w.

Distribution

2
 Penetrates in various organs and tissues  effective in solid tumors.
 Liposomal formulations - have a slightly more favorable safety profile (reduced cardiotoxicity)
with respect to non-liposomal formulations. Allow a selective distribution of the drug, because
liposomes are uptaken by macrophages and released in areas of inflammation. Cancer is associated
with inflammation  selective release of the drug in the site where the cancer grows.

Metabolism - NADH dependent enzyme reactions producing cytotoxic and non-cytotoxic metabolites
and OH-radicals leading for cardiotoxicity.

Elimination - eliminated as metabolites into the bile and urine. In the latter, they provoke a red
discolouration, hence providing the suffix -rubicin. Such suffix characterises all anthracyclines.

Clinical uses of doxorubicin – restricted usage. Commonly used in malignant lymphoma, ovarian
cancer and breast cancer.

Adverse effects
 Myelosuppression - most relevant and frequent. Leukopenia and thrombocytopenia are responsible
for the reduced immune response (especially) and bleeding. Acute effect, even in hours.
 Diarrhea, oral ulcers, mucositis, alopecia - consequences of the block of cellular replication in
non-cancerous dividing cells: all of the epithelial cells (e.g., in hair follicles and mucosa).
 Cardiac toxicity - by hydroxyl metabolites of doxorubicin and anthracyclines. It is usually chronic
cumulative effect in the body and being dose-dependent.
 Chronic adverse effects: organ injury (lungs, liver, heart), due to the accumulation of the drugs in
the body and usually dose-related.

Vinca alkaloids: vinorelbine, vincristine – M Phase specific.

Characteristics:
 Target: β-tubulin. Both vinca alkaloids and taxanes target tubulin, but via different mechanisms;
with the same result. Vinca alkaloids are associated with an inhibition of tubulin polymerization. If
microtubules aren’t functioning, there’s no mitosis.
 Arrest in M checkpoint, leading to apoptosis;
 Resistance: higher levels of P-gp (in cancer cells)  increase in drug efflux, even when given IV.

Absorption – IV is preferred, while oral is barely used. IV allow to better control the target plasmatic
concentration.

Metabolism – extensively metabolized by hepatic CYPs.

1. If CYP-inducers (e.g., rifampicin, barbiturates, phenytoin, carbamazepine, antiepileptic drugs,
anxiolytics) are administered concomitantly, vinca alkaloids are not going to be effective.
2. If CYP-inhibitor (e.g. azoles) is administered, they will not be metabolized  toxic. The
administration of CYP-inhibitors is the most dangerous drug interaction.
3. Hepatic Function - a patient with hepatic insufficiency  greater accumulation of drug  toxicity
and side effects.
Therefore, with regards to side effects, the
co-administration of CYP-inhibitors and
hepatic insufficiency are equivalent. In
these cases, dosages must be reduced.

Elimination – H-L is long, 20 to 40 hours.

 Bile excretion;
 Only a small fraction of drug is
eliminated unchanged in urine, due to
extensive hepatic metabolism.
3
Clinical uses of vinorelbine – breast cancer, lung cancer. This restricted utilization does not
completely stand true for the rest of vinca alkaloids, which have a slightly wider range of clinical uses.

Adverse effects - Side effects vary according to the type of vinca alkaloid which is being administered.
 Reduced granulocytopenia (vincristine); on the other hand, vinblastine has a strong
granulocytopenic effect (always mention it as a side effect during the exam).
 Reduced neurotoxicity (vinorelbine) - Local neuropathy is one of the typical side effects of these
drugs because of the inhibition of axonal transport, being mediated by microtubules (transport
nutrients from the cell body to the terminal portion of the neuron)  terminal part of the neuron
will not be provided with nutrients and will therefore undergo degeneration. Specific for alkaloids.
 Allergy;
 Mild, reversible hepatotoxicity.

Taxanes: Paclitaxel - Cell-cycle specific;

 Microtubule stabilization – block the de-polymerization and stabilize microtubules  inhibit cell
division  arrest in the M phase, leading to apoptosis;
 Resistance: increased P-gp efflux.

Absorption
 Insoluble, high molecular weight;
 Nab-paclitaxel is a new, albumin-bound formulation, characterized by a better distribution
(increase cellular uptake) and safety profile (as allow a usage of lower dose).

Metabolism - Extensive CYP2C8- and CYP3A4-mediated hydroxylation.

1. Sensitive to drug-drug interactions - phenytoin, barbiturates, rifampicin, azoles. They are
cytochrome inducers (important for exam like all drug interactions).
2. As with vinca alkaloids, low hepatic function calls for a 50-75% dose reduction, as the patient has
a reduced rate of metabolization, leading to drug accumulation.

Clinical uses – metastatic ovarian

cancer, breast cancer, lung cancer, GI
cancer, genitourinary cancer, head and
neck cancer.

Adverse effects
 Severe bone marrow depression - CI in patients with low neutrophil count. A “rescue” drug
(filgrastim), aimed at stimulating bone marrow production of granulocytes, requires to be
administered. If filgrastim is not administered, the dose-limiting side effect is BM depression.
 If filgrastim is administered, the dose-limiting side effect is peripheral neuropathy, due to the
blockage of microtubular functions.
 GI mucositis;

Pyrimidine analogs: capecitabine and 5-FU

Characteristics - Capecitabine is a 5-FU prodrug. They are S phase-specific drugs and act via
inhibition of thymidylate synthase, which is necessary for dTMP synthesis, a DNA precursor. DNA
cannot be synthesized, uridine will be added in place of thymidine  requires DNA repair, leading to
p53 activation  enters apoptosis.

Absorption:
 Capecitabine (the prodrug) - good oral administration; then, thanks to intestinal enzymes, it enters
the transformation process which ultimately leads to 5-FU.
 5-FU is only administered IV.
4
Metabolism - thanks to the activity of DPD (dihydropyrimidine dehydrogenase). The DPD role is so
important that patients who are affected by a DPD deficiency (due to homozygous mutation) cannot
receive the medication, due to toxicity (Uridine rescue is indicated in case of severe toxicity).
To diagnose DPD deficiency, different methods are available:
 Enzymatic method, cheap (phenotypic analysis) - DPD is required for the transformation of
dihydrouridine into uridine  measure the relative concentrations of these two metabolites.
 Genetic method (DNA extraction, amplification and sequencing, or RNA extraction and RT-
PCR); the results are the same of the enzymatic method, but the cost is significantly higher.

Clinical use - 5-FU and capecitabine are

not used in monotherapy.
5-FU is often used in combination with:
 Oxaliplatin (Thymidylate Synthase
downregulation);
 Leucovorin (which enhances TS
inhibition).
One of the most important drug
combinations is FOLFOX: FOL=folinic
acid (leucovorin), F=fluorouracil (5-FU),
OX=oxaliplatin.
5-FU is administered in case of: Prof won’t ask the difference between them.
 Metastatic colorectal and gastric cancer;
 Metastatic breast cancer.

Side effects
 Nausea, Diarrhea;
 Mucositis, which may be lethal in DPD deficiency; Bolus infusion
 Myelosuppression (leukopenia, thrombocytopenia);
 Alopecia, dermatitis, nail changes (effect on replicating cells);
 Hand-foot syndrome: aggressive erythema and pain upon touching of the palm and sole (infusion
regimen). Associated with slow infusion.

Alkylating agents - cyclophosphamide - cell cycle nonspecific.

Mechanism – Bifunctional mechanism:
1. alkyl group is attached to DNA  DNA fragmentation by repair enzymes after trying to replace
the alkylated bases (like anthracycline). DNA polymerase has to stop in the replicating process,
blocking the cell at the G2/S checkpoint. If DNA mechanism is not sufficient to repair such
damage, the cell will have to undergo apoptosis.
2. Phosphoramide mustard is responsible for the binding to two filaments of DNA, locking them
together. Prevents from DNA polymerase to proceed with DNA replication, as the “lock” prevents
the separation of the two filaments. Not all alkylating agents are bifunctional: some of them are
monofunctional, or more generally display different mechanisms of action.

Resistance - p53 overexpression (ensure DNA repair), accelerated metabolism of activated form of
cyclophosphamide, Decrease permeation of actively transported drugs, impaired apoptosis (increase
BCL-2).

Absorption – good oral bioavailability, given also IV. with T1/2 of parent drug is 7h.

Distribution – freely crosses cellular membrane, and phosphoramide mustered is ionized it is trapped
inside the cells, good for therapy. It has good tissue penetration, including CSF.

5
Metabolism - Cyclophosphamide is not inactivated by CYPs, but actually activated by them.
It is a prodrug  hydroxylated by hepatic cytochromes into hydroxyl-cyclophosphamide  then into
aldophosphamide  spontaneously separates into two molecules, active phosphoramide mustard and
acrolein (toxic substance  serious side effect hemorrhagic cystitis).

Drug Interactions:
 CYP inducers increase cyclophosphamide activation rate (phenytoin, rifampicin, phenobarbital);
 Hepatic dysfunction and CYP inhibitors (azoles) reduce the activation rate.

Elimination
 In urine, 10% in unchanged form;
 Acrolein in the urine causes hemorrhagic cystitis. It is a very strong oxidant  give anti-oxidant
(MESNA – eliminated in urine) to reduce such side effect. It neutralizes the effect of acrolein in
the urinary bladder. Acrolein is present in cigarette smoke and in oil brought to smoking point.

Clinical use - broad-spectrum

chemotherapeutic agent.
1. Drug combinations, it is used in –
Non-Hodgkin’s and other lymphoid
malignancies, breast and ovarian
cancer, solid tumors in children.
2. Single agent - Burkitt lymphoma.
3. Used as an immunosuppressant in
autoimmune disorders.
4. MM, Mycosis fungoid,
Neuroblastoma, Retinoblastoma.

Adverse effects
1. Phosphoramide mustard – myelosuppression (cellular and humoral immunity), mucositis (oral
ulcers, alopecia), intestinal denudation, sterility (inhibition of germinal cells), teratogenic (induce
DNA mutations), Leukemogenesis (p53 mutations, chromosome depletions), neurotoxicity.
2. Acrolein
a. Hemorrhagic cystitis, requiring IV hydration and MESNA. Nephrotxocity.
b. Organ fibrosis (lung) – the lung is very sensitive for oxygen stress, month after therapy.

Oxaliplatin - platinum compound.

Mechanism - similar to cyclophosphamide. The difference is that, oxaliplatin and platin compounds
are very simple proteins which are
capable of forming adducts with DNA
but these are not alkyl adducts: they are
metal adducts with DNA  DNA
polymerase is incapable of proceeding
with DNA replication due to the presence
of this double lock on DNA filaments. It
is a covalent bone  difficult to break, requires a great amount of energy. Excision of the affected
DNA segment is usually required. Cancer cells with elevated expression of p53 are able to correct
numerous DNA errors induced by these molecules.

Clinical use - It is used in colorectal cancer, with 5-FU and cetuximab.

Adverse effects
 Mild hematological issues;
 Dose-limiting peripheral neurotoxicity: paresthesia, dysesthesias (needle or burning sensations),
ataxia, numbness. Due to different mechanism of taxanes.
6
 Long- term: leukemia, pulmonary fibrosis.

Methotrexate – in Immunosuppression.

G-CSF Drugs - Filgrastim and lenograstim -

recombinant forms of human G-CSF  not
effective against cancer cells, and their role is to stimulate bone marrow  reducing side effect. They
are administered intravenously or subcutaneously. May present with side effects:
 Mild bone pain, local skin reactions, allergy;
 They are contraindicated in sickle cell anemia.

Antiemetic drugs - NK1 antagonists;

Serotonin (5-HT3) antagonists;
Dexamethasone, Olanzapine.
It is possible to use them singularly or in
combination.
1. Low risk of vomiting - a single antiemetic
agent  dexamethasone or serotonin
antagonist.
2. Moderate risk:
 Dexamethasone alone;
 Dexamethasone + serotonin
antagonist;
 Dexamethasone + serotonin antagonist
+ NK1 antagonist.
3. High risk - combination of olanzapine +
dexamethasone + serotonin antagonist +
NK1 antagonist is used.

For example, cyclophosphamide is associated with a high risk of nausea

and vomiting when administered as a combination therapy with
anthracyclines, but also sometimes as monotherapy (Exam question).
 Among drugs displaying moderate risk, anthracyclines, doxorubicin and daunorubicin are present.
Cyclophosphamide in monotherapy is present too.
 Low risk of nausea and vomiting - taxanes (paclitaxel and nab-paclitaxel), methotrexate,
gemcitabine (another Capectiabine/5-FU).

5-HT3 (serotonin) receptor antagonists (1st generation) - They are highly effective on acute vomiting,
less effective on acute nausea. They are not effective on delayed nausea and vomiting, as their half-
time is too short. Among serotonin receptor antagonists, one exception on delayed nausea and
vomiting is the 2nd generation drug palonsetron, which indeed has a half-time of 40 hours.
 Ondansetron (half-time: 4 hours);
 Granisetron (half-time: 11 hours).

Adverse Effects - QT prolongation in 1st generation agents - carefully administered if given together
with other drugs displaying cardiac toxicity (e.g. doxorubicin, anthracyclines).

Dexamethasone - It is effective on delayed nausea.

 Glucocorticoid - direct activation of glucocorticoid receptors in the solitary nucleus. This leads to
the control of nausea instinct.
 Glucocorticoid-induced 5-HT3-receptor downregulation  act as a sort of serotonin antagonist.
This is not immediate and may require some days.
7
 Positive regulation of the hypothalamic-pituitary-adrenal axis.
It is a potent CYP3A4 inhibitor  possible drug interactions (e.g. dexamethasone, warfarin).

Olanzapine – antipsychotic, acts by blocking the serotonin receptors in the solitary nucleus and area
postrema. It is effective on delayed nausea. Potent CYP3A4 inhibitor (warfarin and dexamethasone).

Hormone therapy targeted drugs - In premenopausal women, unlike post-menopausal, estrogen is

primarily produced by the ovaries in addition to the extra-ovarian tissues. Estrogen synthesis
modulators alone do not suppress estrogen synthesis because the reduced
feedback of estrogen to the hypothalamus and pituitary leads to an increase in
gonadotropin secretion and the subsequent ovarian stimulation  GnRH agonists
are added (e.g., Triptorelin and Goserelin), to prevent it. Side effects of the
hypoestrogenism state  hot flashes, vaginal dryness, decreased libido,
osteoporosis, amenorrhea.
There are 3 major classes of hormone therapy drugs:
1. Aromatase inhibitors (e.g., Anastrozole)
2. Selective estrogen receptor modulators (e.g., Tamoxifen)
3. Selective estrogen receptor down-regulators (e.g., Fulvestrant)

Aromatase inhibitors (AIs) - Third generation AIs can be sub-divided into:

1. Third generation non-steroidal imidazoles – Anastrozole, Letrozole.
2. Third generation steroidal (permanent bond with aromatase) - Exemestane
Both subclasses have similar efficacy and safety profile.

Anastrozole:
1. Pharmacokinetics:
a. Absorption and Distribution - Good absorption. Aromatase inhibitors are lipophilic molecules
with widespread distribution in tissues and fluids which are able to cross the intracellular
membrane and reach their intracellular target.
b. Metabolism - metabolized by N-dealkylation, hydroxylation (hepatic cytochromes) and
glucuronidation reactions.
c. Elimination - The drug is eliminated by the biliary tract with T1/2 of 50 hours.
2. Drug-to-drug interaction - when co-administering drugs that are cytochrome inhibitors like azoles.
3. Side effects - estrogen-related effects (hypoestrogenism state) which consists of hot flashes,
vaginal dryness and bleeding, endometrial cancer and ischemic cerebrovascular and
thromboembolic events with a lower incidence with respect to Tamoxifen. The incidence of
osteoporosis in post-menopausal women, arthralgia and vaginal dryness is higher.

Selective estrogen receptor modulators (SERMs) – Tamoxifen:

1. Mechanism:
a. A direct inhibitor of the estrogen (competitive antagonist) receptor in cancerous tissues as it has
a structure similar to estradiol and hence a good affinity for the receptor. Tamoxifen partially
inactivates the receptor by inhibiting only one of two monomers, since the dimerization of the
ER produces two different isoforms.
b. Partial agonist in non-cancerous tissues - due to some differences in estrogen receptor isoforms
present in different tissues that may have different co-factors and pathways. Induces some
additional side effects on the uterine endometrium (endometrial hypertrophy, vaginal bleeding,
endometrial cancer), on the coagulation system (increased risk of thromboembolic events) and
bones (higher mineral density).
2. Resistance – different possible mechanisms:
a. Loss of ERα expression and function, which leads to disappearance of the molecular target for
Tamoxifen. During therapy, some change can occur  tumor develops resistance by finding
different ways to activate the pathway. Hence, even though the cancer started as estrogen
receptor positive it may become estrogen receptor insensitive.
8
 b. Altered expression of coactivators or co-regulators that play a critical role in ER-mediated gene
transcription, can evolve after the treatment has been started.
c. Ligand-independent estrogen receptor activation by HER2 signaling may confer resistance
(Cross-talk between HER2 and ER).
d. Impaired metabolism - Tamoxifen when metabolized by cytochromes, is activated, and not
inactivated. Elimination H-L, isn’t long, but the metabolites are active and potent. Therefore,
by inhibiting the cytochromes which are responsible of Tamoxifen metabolization, its
metabolites are not formed and their potent effect as estrogen receptor antagonists is omitted.
3. Pharmacokinetics:
a. Metabolism – activation by CYP2D6 and CYP3A4. Mainly CYP2D6, induce the
metabolization of Tamoxifen to 4OH-Tamoxifen, which is a highly potent metabolite. Later
metabolized to Endoxifen, another highly potent metabolite. Both are responsible for the
majority of the effects of Tamoxifen. Paradoxically, CYP2D6 polymorphisms and CYP2D6
inhibitors have not been found to reduce Tamoxifen clinical efficacy.
b. H-L – not long.
4. Side effects:
a. Estrogen depletion side effects - hot flashes, menstrual disorders, vaginal bleeding and
discharge.
b. Side effects due to the partial activity of Tamoxifen in non-cancerous tissues including the
increased incidence of endometrial cancer and thromboembolic events.
5. Indications - Tamoxifen and Anastrozole are used in ER+ breast cancer with or without
chemotherapy. They are also used in chemoprevention in people at high risk of developing breast
cancer. Often the difference between the two isn’t so evident, but there are some:
a. In early stage breast cancer Anastrozole is associated with a more delayed recurrence
b. Metastatic breast cancer Anastrozole has some advantage over Tamoxifen.
c. In pre-menopausal breast cancer, Tamoxifen seems to have some advantage on Anastrozole in
combination with GnRH analogues. On the contrary, in post-menopausal breast cancer,
Anastrozole is preferred.

Selective estrogen receptor down-regulators – Fulvestrant - steroidal anti-estrogen that binds to the
ER with an affinity more than 100 times that of Tamoxifen, inhibits its dimerization, and increases its
degradation.
1. Mechanism - complete inactivation because it is able to recognize and inactive both monomers of
the estrogen receptor. Furthermore, Fulvestrant is able to reduce ER concertation in cancerous
tissues by triggering degradation mediated by a recruitment of proteasomes. On the contrary,
Tamoxifen does not have an effect on ER expression and elimination. Fulvestrant also has an
effect on downregulation of the genes responsible for ER synthesis. The cumulative result of all
this is that Fulvestrant is able to suppress the downstream pathways in a more complete, efficient
and evident way than Tamoxifen.
2. Indications:
a. Effective in Tamoxifen-resistant ER+ breast cancer, so it is usually given to subjects that are
not responding to Tamoxifen.
b. Not inferior to Anastrozole in postmenopausal women with metastatic breast cancer.
3. Side effects - well tolerated. Can lead to hypoestrogenism-mediated effects; nausea, asthenia, pain,
hot flashes, arthralgia, headache.

Targeted drugs - monoclonal antibodies and small molecule drugs. Both classified based on their
target as receptor inhibitors, intracellular kinase inhibitors or angiogenesis inhibitors.
Monoclonal antibodies - are big proteins, effect distribution and absorption.
1. Cannot be given orally as they cannot be absorbed, and cannot cross cellular membrane 
monoclonal antibodies are always administered IV (usually), subcutaneous or intramuscular
routes.
2. Distributed by convection - result of hydrostatic pressure and osmotic pressure, and sieving effect
contributes to the net driving force for the extravasation of these antibodies. This process is
9
 dependent on the width of endothelial fenestrations. Through pores, monoclonal antibodies are
transferred from the vascular space to the interstitial space. Then, from interstitial into the lymph,
thru same mechanism, but much more efficient due to less resistance attributed to the lager lymph
duct pores and relying on pressure gradients, fluid flow rate, and sieving. Unbound antibody
concentrations are much lower in the interstitial space of tissues than in the vascular space and
lymphatic system. As a result, the volume of the central compartment (Vc) for most mAbs is in the
range of 2–3 L, similar to the plasma water, and the overall volume of distribution at steady‐state
is in the range of 8–20 L.
3. Metabolism - monoclonal antibodies are not metabolized by cytochromes  no drug-to-drug
interactions.
4. Elimination:
a. No glomerular filtration because these molecules are too large. If low molecular weight
antibody fragments are filtered, they are usually reabsorbed and metabolized in the proximal
tubule of the nephron. Biliary excretion accounts for a very small amount of them.
b. Eliminated by intracellular catabolism by lysosomal degradation to amino acids after uptake by
either unspecific pinocytosis or receptor-mediated endocytosis.
5. Industrial production - Monoclonal antibodies are synthetized using biological processes, by
injecting a particular antigen in species like mice, rats, sheep and inducing antibodies production.
The antibodies are isolated, purified and engineered (humanization). Consequently, the costs are
different, the industrial production of monoclonal antibodies is a costly process.

Small molecules - more common from pharmaceutical point of view.

1. Good oral absorption and necessarily high cellular distribution, because these drugs have to reach
their intracellular targets (kinase) to interact and block it.
2. Metabolism - usually metabolized by CYP3A4-mediated  drug-to drug- interaction with azole,
macrolides and other drugs that inhibit CYP3A4.
3. Elimination with/without metabolization occurs via urine and to a lesser extent bile.

Inhibitors of Growth Factors and Receptors - They are either molecular antibodies that are able to
recognize and stabilize the inactive form of HER2 receptor or EGF receptor, or some small molecules
that are usually able to inhibit the intracellular kinase domain of these cellular membrane receptors.

HER2 inhibitors (Trastuzumab, Pertuzumab, Lapatinib, Neratinib) - HER2 is known to be highly

expressed in 20-30% breast cancers. HER2 is a transmembrane receptor with no identified ligand
which is usually present as an inactive monomer and is activated when it forms dimers; either
heterodimers (HER3, EGFR) or homodimers  intracellular kinase domain is able to bind with ATP
and trigger the downstream pathway  usually involving the activation of RAS-RAF pathway or
inositol phosphate kinase pathway.

Pertuzumab and Trastuzumab - MoAB selective to HER2 extracellular domain. Pertuzumab binds
the extracellular domain number 2 and Trastuzumab the extracellular number 4  they inhibit HER2
dimerization and activation.
1. They have two different effects:
a. 1st - Related to the inhibition of kinase activity of HER2 (Fab-related function)  after
antibodies binding to the receptor, the receptor is not able to trigger kinase response in the
intracellular kinase domain.
b. 2nd - Fc-related immune cell mediated response. They have a domain that is able to recognize
the Fc receptor in immune cells, hepatocyte and endothelial cells. By binding to it  attract an
immune response that potentiate the action of the drug  Cytotoxic action via ADCC
(antibody-dependent cellular cytotoxicity) which results in tumor cells death, that is mediated
by immune cells including WBC, NK cells.
2. Side Effects:
a. Fc-related related adverse effects - fever, chills, nausea, dyspnea and rashes. Most moAB are
working like that, but not all. e.g. Bevacizumab, a monoclonal antibody that is selective for
10
 circulating VEGF, and not the VEGF receptor (VEGF-R). Works via a completely different
mechanism as it inhibits angiogenesis by inhibiting circulating factor and not thru Fc-related.
b. Fab-related adverse effects are related to the receptor function, e.g., cardiotoxic effects
because HER2 is expressed in cardiomyocytes. Therefore, a possible reduction in
cardiomyocyte contractility results in a reduction LVEF (monitor it). In case of a significant
reduction in this parameter, either the dose should be lowered, or another drug should be
prescribed. There is also a
contraindication for the use of this drug
in association with other cardiotoxic
drugs like anthracyclines (e.g.
Doxorubicin).

Lapatinib / Neratinib - Small-molecule HER2

kinase inhibitors act on transmembrane
receptors, competing with ATP for the binding
with the intracellular kinase domain of these
receptors  block the downstream pathway (receptor is dimerized, but pathway is blocked).
1. Good oral bioavailability - oral (usually) or intravenous route.
2. Metabolism - CYP3A4 and in this case the co-administration with CYP3A4 inhibitors (Azoles)
may require either stopping the administration of the cytochrome inhibitors or reducing the dose of
the small molecule.
3. Adverse effects - diarrhea, rash and cardiotoxicity. When given alone, the cardiotoxicity is less
pronounced.

Epidermal Growth Factor Receptor (EGFR) inhibitors - part of the HER receptors family, in fact, its
original name was HER1 receptor. Important in growth and proliferation of the epithelial cells which
explains the associated epithelial-related adverse effects.

Small molecules (Erlotinib, Gefitinib,

Afatinib) – the prototype is Erlotinib.
1. Mechanism - competitive inhibition of
ATP binding on EGFR tyrosine kinase
domain (similar mechanism as small
molecules HER2 inhibitors). Erlotinib and
Gefitinib are reversible antagonists
whereas Afatinib is an irreversible suicide
inhibitor.
2. Indications - most frequent use is in
NSCLC, specifically effective in L858R
mutants. These mutations make EGFR
constitutively active as a monomer, therefore anti EGFR monoclonal antibodies which prevent
dimerization are not effective. Additionally, these drugs are not effective in KRAS mutants (active
downstream kinase of EGFR receptor).
3. Adverse effects - diarrhea, skin and nail reactions (even severe), nausea, vomiting, anorexia,
fatigue and dyspnea.

Monoclonal antibodies (Cetuximab and Panitumumab) – Cetuximab is selective EGFR moAB.

1. Indications - metastatic colorectal cancer KRAS wild-type (not effective in KRAS mutated
cancers) and in head and neck squamous cell carcinoma.
2. Adverse effects - similar to those of small molecules and include skin and nails changes, anorexia,
fatigue, dyspnea, nausea and vomiting.

Intracellular protein kinase inhibitors

 RAF kinase inhibitors (Vemurafenib, Dabrafenib),
11
 MEK inhibitors (Trametinib, Cobimetinib),
 CDK 4/6 Inhibitors (Palbociclib, Abemaciclib),
 BCR/ABL kinase inhibitors (Imatinib).

RAF kinase inhibitors - Vemurafenib and Dabrafenib:

1. Indications - metastatic melanoma which is associated with a mutation in the RAF kinase i.e.,
metastatic V600E mutant melanoma. In these mutants, there is a constitutive and independent
activation of the intracellular kinase RAF which is located downstream to RAS.
2. Vemurafenib and Dabrafenib are always given with MEK inhibitors. MEK is another kinase that
is located downstream to RAF and is activated by RAF. It has been found that the administration
of Vemurafenib and Dabrafenib is associated with the development of resistance to these drugs in
6 months of treatment. To reduce the possibility of resistance development, two different drugs
acting in the same pathway should be used.
3. Adverse effects - rash and photosensitivity. Additionally, Dabrafenib lead to an increased risk to
develop cutaneous cell carcinoma
(10%), while, Vemurafenib much
less frequently.

MEK kinase inhibitors - Trametinib

and Cobimetinib are given together
with RAF kinase inhibitors to reduce
the possibility of resistance, so they
are not given in monotherapy. Their
use is the same as that of RAF kinase
inhibitors, and the adverse effects are
more or less the same, with the
addition of cardiomyopathy.

CDK inhibitors - family of serine threonine kinases, they control cycle progression from G0/G1 to S
phase. The physiological substrate is Cyclin D. Healthy cells contain a protein named Rb
(Retinoblastoma, a tumor suppressor protein) which is active when it is not phosphorylated  it binds
and inhibit two cofactors: E2F (repair mechanism) and DP1  responsible for unblocking of cell
cycle  promoting cell proliferation. In cancer:
 Rb mutation - constitutively phosphorylated  activate E2F and DP1  promote synthesis of
cyclin and cell proliferation and survival.
 Cyclin D mutation - overexpressed  over-actives CDK4/6  it phosphorylates Rb and
inactivates it.

Palbociclib and Abemaciclib (Small

Molecules)- are competitive antagonists of
CDK 4/6 as they compete with cyclin D for the
binding of CDK 4/6.
1. Absorption - Oral bioavailability of 45%.
Absorption is reduced under fasting conditions in 13% of subjects.
2. Metabolism - hepatic metabolization mediated by CYP3A4  can have drug-to drug interactions
(azoles, grapefruit). Clotrimazole especially is a very potent CYP3A4 inhibitor  when co-
administering it with CDK4/6 inhibitors  a drug with less potent inhibition of CYP3A4 should
be administrated / or lower dose.
3. Adverse effects - diarrhea (especially Abemaciclib), Neutropenia (60%) and Leukopenia (25%).

BCR/ABL kinase inhibitors - abnormal chimeric kinase associated with CLL. BCR/ABL is able to
activate a wide range of kinases in an unregulated manner  cancerogenesis.

12
1. Types - Imatinib (the prototype drug), Dasatinib and Nilotinib inhibit BCR-ABL kinase activity.
Additionally, these drugs are also able to
inhibit PDGFR and KIT kinases.
2. Metabolism - CYP3A4.
3. Adverse effects - GI effects including
diarrhea, nausea and vomiting. Others,
fluid retention, edema, myelosuppression
(infrequent) and QT prolongation (more
associated with Dasatinib and Nilotinib).

VEGF inhibitors - affect circulating VEGF

and VEGF receptors  act on angiogenesis.
Monoclonal antibodies (Bevacizumab, Ramukirumab) - selectively binds to circulating VEGF.
1. Indications - metastatic colorectal cancer, non-small cell lung cancer (NSCLC), cervical and
ovarian cancer. There is also a historical off label use in macular degeneration.
2. Side Effects - no Fc-related adverse
effect. Hypertension that may be
severe and lead to heart failure, GI
perforation, thromboembolic events
and life-threatening lung hemorrhage.

Small molecules (Sorafenib and

Sunitinib) - effective on kinase
intracellular domain of the VEGF
transmembrane receptor type 2
(VEGFR2). Sunitinib and Sorafenib,
which are mainly VEGF receptor kinase
inhibitors, also have unspecific activity
on other kinases (they are multi-kinase
inhibitors) e.g., RAF kinase (of the MAPK-ERK pathway involved in cell division) and PDGFR
receptor pathway (involved in cell proliferation and differentiation)  additional side effects which
are associated to the inhibition of these kinases.
1. Indications - Sunitinib is used in metastatic renal cancer, neuroendocrine tumors and GIST.
Whereas Sorafenib was until recently the only drug approved for hepatocellular carcinoma.
2. Adverse effects - VEGF-related side effects: hypertension, bleeding, thromboembolism, GI
perforation, in addition to other effects such as fatigue, hypothyroidism, bone marrow suppression,
diarrhea, which are induced by activities on other kinases.

Pembrolizumab (PD-1 Receptor inhibitor):

1. Mechanism - IgG4 Ab, binds to cell surface receptor PD-1  prevent the inhibition of T cell
proliferation and cytokine production  increase immune reactivity and enhance anti-tumor
immune response.
2. Pharmacokinetics:
a. Absorption – complete BA when given IV.
b. Vd – extra-vascular distribution.
c. Metabolism – catzlayzed into small peptides by protein degradation, with H-L of 26days.
3. Side Effects – Fatigue, rash, pruritus, diarrhea, nausea, joint pain, increase inflammation.

Vismodegib:
1. Mechanism – inhibit hedgehog signaling pathways  for adult BCC.
2. Pharmacokinetics:
a. Absorption – BA of 31%.
b. Metabolism – CYP2C9 and CYP3A4, but more than 98% aren’t metabolized.
c. Elimination – usually excreted un-changed by feces > urine. H-L is 12days.
13
3. Side Effects – embryo-fetal death, birth defects, muscle spasm, alopecia, weight loss, fatigue,
diarrhea, constipation, arthralgia, vomiting.

Tretinoin - binds alpha, beta and gamma retinoic acid receptors  used for Acute Promyelocytic
Leukemia.

Arsenic Trioxide:
1. Mechanism – induce cancer cell apoptosis, and has an effect on APL.
2. Pharmacokinetics:
a. Metabolism – follow methylation in the liver. It is stored in liver, kidney, lung, heart.
b. Elimination – urine.
3. Side Effects – convulsions, muscle weakness, confusion.

14