WO2009108361A1 - Méthodes permettant de traiter et de prévenir le cancer du sein - Google Patents

Méthodes permettant de traiter et de prévenir le cancer du sein Download PDF

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Publication number
WO2009108361A1
WO2009108361A1 PCT/US2009/001275 US2009001275W WO2009108361A1 WO 2009108361 A1 WO2009108361 A1 WO 2009108361A1 US 2009001275 W US2009001275 W US 2009001275W WO 2009108361 A1 WO2009108361 A1 WO 2009108361A1
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Prior art keywords
breast cancer
vpa
tamoxifen
inhibitor
endoxifen
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PCT/US2009/001275
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English (en)
Inventor
Peter J Kushner
Ira D Goldfine
Leslie Hodges-Gallagher
Cathleen D Valentine
Cyrus L Harmon
William Stafford
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The Regents Of The University Of California
Combithera, Inc.
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Publication of WO2009108361A1 publication Critical patent/WO2009108361A1/fr

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/13—Amines
    • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline

Definitions

  • tamoxifen therapy has the undesirable side effect of stimulating proliferation of uterine endometrial cells, putting women at a higher risk for developing uterine adenocarcinoma (Fisher, B., et al., B-14. J Natl Cancer Inst, 1994. 86(7): p. 527-37).
  • One therapeutic strategy is to combine hormonal therapies that target ER ⁇ -driven proliferation with agents that target separate biochemical pathways to determine if the combination would provide enhanced and more long-lived efficacy.
  • hormonal therapies that target ER ⁇ -driven proliferation with agents that target separate biochemical pathways to determine if the combination would provide enhanced and more long-lived efficacy.
  • these trials have produced disappointing results, perhaps because hormonal therapy can antagonize the effectiveness of chemotherapy, leading to the result that these combinations are no more or even less effective when combined than when the individual therapeutic compounds are administered separately (Gelber, R.D., et al., Lancet, 1996. 347(9008): p. 1066-71; Rivkin, S.E., et al., J Clin Oncol, 1994. 12(10): p. 2078-85).
  • a more effective strategy may be to combine hormonal therapy with a second therapy whose target is different from standard chemotherapy, so that the combined effects are more effective than any of the individual compounds administered separately.
  • Studies combining various therapies have shown some promise, though generally there is confusion in the literature (Johnston, S. R., Clin Cancer Res, 2006. 12(3 Pt 2): p. 106 Is- 1068s).
  • a recent trial of the combination of the aromatase inhibitor letrozole with temsirolimus, an inhibitor of mTOR, the downstream effector of IGF signaling was terminated for lack of benefit ⁇ Termination of phase 3 clinical program with oral temsirolimus in women with metastatic breast cancer. Press release, Wyeth Pharmaceuticals, 2006).
  • Histone deacetylase (HDAC) inhibitors are a structurally diverse group of pharmacological agents that inhibit proliferation, induce differentiation and/or apoptosis in a wide range of cancer cells and hold much promise as anti-neoplastic agents (Villar- Garea, A. and M. Esteller, Int J Cancer, 2004. 112(2): p. 171-8; Marks, P., et al., Nat Rev Cancer, 2001. 1(3): p. 194-202).
  • Hyperacetylation is associated with a transcriptionally permissive environment and HDAC inhibitors, although they affect only a small number of target genes, activate genes involved in cell cycle arrest, apoptosis and differentiation (Glaser, K.B., et al., MoI Cancer Ther, 2003. 2(2): p. 151-63; Richon, V.M., et al., Proc Natl Acad Sci USA, 2000. 97(18): p. 10014-9; Munster, P.N., et al., Cancer Res., 2001. 61(23): p. 8492-7).
  • HDAC inhibitors increase the efficiency of several anticancer drugs that target the DNA (Kim, M.S., et al., Cancer Res, 2003. 63(21): p. 7291-300; Castro-Galache, M.D., et al., Int J Cancer, 2003. 104(5): p. 579-86).
  • a variety of small molecule HDAC inhibitors are currently in preclinical development.
  • the present invention encompasses methods of treatment (as defined herein, including management of, amelioration of symptoms of, and preventing the progression of) for breast cancer, comprising administering to a subject a therapeutically effective amount of: endoxifen; and/ or a HDAC inhibitor, such as valproic acid, trichostatin A, or SAHA; and/ or an anti-IGFR inhibitor, such as EGCG; and/ or an mTOR inhibitor such as rapamycin and/or sulforaphane.
  • Endoxifen also called des-methyl 4-hydroxytamoxifen, is an active tamoxifen metabolite.
  • the method further comprises administering a therapeutically effective amount of sulforaphane (SFN).
  • the method comprises administering endoxifen, EGCG, and sulforaphane.
  • the method comprises administering endoxifen, rapamycin, and sulforaphane.
  • the method comprises administering endoxifen, EGCG, rapamycin, and sulforaphane.
  • sulforaphane is administered at 0.1- 10 ⁇ M, 0.5- 5 ⁇ M, 0.5- 2 ⁇ M, or about 1 ⁇ M.
  • the compounds are administered in combination, e.g., at least two or three or four compounds are administered at once. In some embodiments, the compounds are administered separately. Where more than two compounds are administered to the subject, any combination of the compounds can be added at once or separately, independent of the other compounds.
  • endoxifen and valproic acid are administered. In some embodiments, endoxifen, valproic acid, and EGCG are administered. In some embodiments, endoxifen, valproic acid, and rapamycin are administered. In some embodiments, endoxifen, valproic acid, EGCG, and rapamycin are administered.
  • endoxifen and trichostatin A are administered. In some embodiments, endoxifen, trichostatin A, and EGCG are administered. In some embodiments, endoxifen, trichostatin A, and rapamycin are administered. In some embodiments, endoxifen, trichostatin A, EGCG, and rapamycin are administered.
  • the invention provides a method of treating breast cancer, the method comprising the step of administering a therapeutically effective amount of endoxifen, tamoxifen, or hydroxy tamoxifen and a compound selected from the group consisting of a HDAC inhibitor or an IGF receptor inhibitor.
  • endoxifen, tamoxifen, or hydroxy tamoxifen, a HDAC inhibitor, and an IGF receptor inhibitor are administered.
  • the IGF receptor inhibitor is EGCG.
  • sulphoraphane is also administered.
  • the HDAC inhibitor is selected from the group consisting of: VPA, TSA, SSAHA, MS-275, PXDlOl, and sulforaphane.
  • the breast cancer is estrogen receptor positive.
  • the invention provides a method of treating breast cancer, the method comprising the step of administering a therapeutically effective amount of a hormonal therapy and sulforaphane.
  • the invention provides methods of treating breast cancer comprising administering a therapeutically effective amount of the combination of (i) a hormonal therapy selected from the group consisting of: the antiestrogen tamoxifen, and the aromatase inhibitors anastrozole, letrozole, and exemestane; and (ii) a histone deacetylase inhibitors selected from PXDlOl and MS-275.
  • a hormonal therapy selected from the group consisting of: the antiestrogen tamoxifen, and the aromatase inhibitors anastrozole, letrozole, and exemestane
  • a histone deacetylase inhibitors selected from PXDlOl and MS-275.
  • the method further comprises administering EGCG.
  • the hormonal therapy is antiestrogen therapy or aromatase inhibitor therapy.
  • the aromatase therapy is selected from the group consisting of: anastozole, letrozole, and exemestane.
  • the breast cancer is estrogen receptor positive.
  • the invention provides a method of treating breast cancer, the method comprising the step of administering a monotherapeutically effective amount of oral endoxifen.
  • the monotherapeutically effective amount of oral endoxifen is 5-80 mg per day.
  • the breast cancer is estrogen receptor positive.
  • the invention provides a method of treating breast cancer, the method comprising the step of administering a therapeutically effective amount a hormonal therapy and VPA, wherein the VPA is formulated and dosed to provide a window of exposure of between 6-20 hours, preferably 8-16 hours, every 24 hours, preferably during the time of sleep.
  • the hormonal therapy is antiestrogen therapy or aromatase inhibitor therapy.
  • the aromatase therapy is selected from the group consisting of: anastozole, letrozole, and exemestane.
  • the breast cancer is estrogen receptor positive.
  • the invention provides a method of preventing estrogen receptor positive breast cancer without attendant increase in risk of uterine cancer, the method comprising the step of administering to a subject a therapeutically effective amount of an HDAC inhibitor in combination with a course of anti-estrogen therapy using endoxifen.
  • the HDAC inhibitor is selected from the group consisting of: VPA, TSA, SSAHA, MS-275, PXDlOl, and sulforaphane.
  • the invention provides a method of treating estrogen receptor positive breast cancer without attendant increase in risk of uterine cancer, the method comprising the step of administering to a subject a therapeutically effective amount of an HDAC inhibitor in combination with a course of anti-estrogen therapy, wherein the anti-estrogen therapy has an estrogen-like effect on the uterus.
  • Attendant risk of uterine cancer refers to reducing or eliminating the risk of uterine cancer that typically exists with anti-estrogen therapy alone.
  • the HDAC inhibitor is selected from the group consisting of: VPA, TSA, SSAHA, MS-275, PXDlOl, and sulforaphane.
  • the antiestrogen therapy is with a triphenylethylene compound.
  • the triphenylethylene compound is selected from the group consisting of tamoxifen, endoxifen or a prodrug thereof, droloxifene, toremifene, idoxifene, clomiphene, and miproxifene phosphate.
  • the aromatase therapy is selected from the group consisting of: anastozole, letrozole, and exemestane.
  • Miproxiphene phosphate also called Tat-59, is the phosphate prodrug of 4- hydroxy tamoxifen isopropyl, ⁇ (E)-4-[l-[4-[2-(dimethylamino)ethoxy]-phenyl]-2-(4- isopropyl)phenyl-l-butenyl]-phenyl-monophosphate ⁇ (see, e.g., structure of page 12 of Toko et al, Cancer Chemother Pharmacol 37:7-13 (1995); see also page 849 of Heimbach et al, Pharmaceutical Research, 20:848-856 (2003) and US Patent 4,897,503).
  • Miproxiphene is a potent anti-tumor agent but is also a potent stimulator of mouse uterine weight (see, e.g., Toko et al., Cancer Chemother. Pharmocol. 39:390-398 (1997); Shibata et al., Cancer Chemother. Phamacol. 45: 133-141 (2000)).
  • a HDAC inhibitor e.g., VPA
  • a tryphenylethylene compound such as miproxiphene allows treatment of breast cancer without the attendant risk of uterine cancer.
  • the breast cancer is estrogen receptor positive. In some embodiments, the breast cancer is tamoxifen resistant or overexpresses Her2/Neu. In some embodiments, the breast cancer is recurring. In some embodiments, the breast cancer is prevented from progressing from ductal carcinoma in situ (DCIS) or atypical hyperplasia.
  • DCIS ductal carcinoma in situ
  • the subject has previously undergone treatment, and in some cases, the previous therapy has failed. In some embodiments, the subject is in remission. In some embodiments, the subject is post-menopausal. In some embodiments, the subject is at risk for breast cancer.
  • valproic acid and other HDAC inhibitors combine effectively with hormonal therapy, including antiestrogens and aromatase inhibitors, on human ER ⁇ -positive breast cancer cells.
  • the inventors have discovered that surprisingly, certain combinations of HDAC inhibitors combine effectively with hormonal therapy, and that the combinations do not reduce the activity of any single component, and that they combinations are more effective than either of the components alone. (See, e.g., FIG. 17)
  • HDAC inhibitors have also investigated the effects of various combinations of HDAC inhibitors in combination with mTOR inhibitors, EGFR inhibitors, and IGF-IR inhibitors, with and without hormonal therapy.
  • the findings indicate that combination with VPA combines effectively with the inhibitory actions of antiestrogens and aromatase inhibitors, and unlike compounds traditionally used in combination in the treatment and prevention of breast cancer, these combinations do not reduce the effectiveness compared to that of the individual components.
  • HDAC inhibitors such as VPA, counters the pro-proliferative action of tamoxifen on uterine cells.
  • HDAC inhibitors work effectively in combination with mTOR inhibitors, EGFR inhibitors, or IGF-IR inhibitors to treat breast cancer and further in combination with hormone therapy to treat estrogen receptor positive breast cancer.
  • VPA is effective in combining with tamoxifen in cells rendered tamoxifen- resistant by overexpression of HER2/neu.
  • HDAC inhibitors include, but not limited to IGF-IR inhibitors, EGFR inhibitors, and mTOR inhibitors combine effectively with each other and are superior to other combinations of compounds for the treatment and prevention of breast cancer, and for preventing the progression of breast cancer.
  • the present invention provides methods of treating and preventing estrogen receptor positive breast cancer, as well as pharmaceutical compositions comprising the compounds used in the combination therapies.
  • Endoxifen combinations are used to treat breast cancer that is refractory or less susceptible to tamoxifen treatment or suspected to be refractory or less susceptible to tamoxifen treatment, e.g., by genetic testing.
  • the present invention encompasses methods of treatment (as defined herein, including management of, amelioration of symptoms of, and preventing the progression of) for breast cancer, using certain combination therapies, as well as the pharmaceutical compositions comprising these combination therapies.
  • the invention is based, in part, on the recognition that certain combinations of compounds combine effectively with each other, and are superior to other combinations of compounds, as well as improving the tolerance of, and/or reducing the side effects caused by at least one of the compounds in the combination.
  • Subjects are mammalian, and preferably are human, and more preferably are human females.
  • the present invention provides methods of treating estrogen receptor positive breast cancer, comprising administering to a subject a therapeutically effective amount of an HDAC inhibitor in combination with a course of hormonal therapy.
  • the hormonal therapy is selected from antiestrogen therapy and antiaromatase therapy.
  • the HDAC inhibitor is selected from the group consisting of: VPA, TSA, SSAHA, MS-275, PXDlOl, and sulforaphane.
  • the antiestrogen therapy is with a triphenylethylene compound selected from the group consisting of tamoxifen, endoxifen or a prodrug thereof, droloxifene, toremifene, idoxifene, clomiphene, and miproxifene phosphate.
  • the aromatase therapy is selected from the group consisting of: anastozole, letrozole, and exemestane.
  • the HDAC inhibitor is not VPA or SAHA.
  • the present invention also encompasses methods and compositions for preventing breast cancer, particularly in subjects who are at risk for breast cancer that is greater than the average risk for breast cancer.
  • Risk factors considered in preventing breast cancer in subjects include family history of breast cancer (relatives with breast cancer), genetic markers for breast cancer such as BRCAl and BRCA2, age at menarche, age at first live birth, the number of breast biopsies, presence of atypical hyperplasia on breast biopsy, population rates of breast cancer and death from other causes.
  • the present invention also provides methods and compositions for preventing the progression of breast cancer to a later stage for those who already have breast cancer or precancerous indicators, as well as preventing the recurrence of breast cancer for those in remission from breast cancer.
  • the invention contemplates methods of preventing the progression of DCIS to breast cancer, and methods of preventing the progression of atypical hyperplasia to breast cancer. In some preferred embodiments, the invention encompasses treating or preventing estrogen receptor positive breast cancer. [0034] In yet another embodiment, the present invention encompasses treating DCIS and, in another embodiment, the present invention encompasses treating atypical hyperplasia.
  • the present invention also encompasses methods of treating breast cancer comprising administering to a subject suffering therefrom a therapeutically effective amount of an HDAC inhibitor in combination with a therapeutically effective amount of one or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • the HDAC inhibitor is not VPA when in combination with an EGFR inhibitor.
  • methods are provided for treating breast cancer, comprising administering to a subject suffering therefrom a therapeutically effective amount of an HDAC inhibitor in combination with a course of hormonal therapy as well as an additional active ingredient that is effective to treat breast cancer in the combination.
  • the method comprises administering a combination comprising an HDAC inhibitor, a course of hormonal therapy, and one or more of an IGF- 1 receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • methods for treating breast cancer comprising administering to a subject suffering therefrom a therapeutically effective amount of a course of hormonal therapy in combination with one or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • kits comprising the combinations.
  • the HDAC inhibitors encompassed by the present invention can be any known to those of skill in the art, particularly those shown in FIGS. 8A-8F and those described in Minucci et al, Nature 6:38-51 (2006).
  • the HDAC inhibitor is valproic acid, either the free acid or the sodium or magnesium salt.
  • the HDAC inhibitor may be TSA, SAHA, or any other HDAC inhibitor known by the skilled practitioner to be effective.
  • the patient is treated with a combination of tamoxifen and VPA.
  • the patient is treated with tamoxifen, VPA, and EGCG.
  • the patient is treated with tamoxifen, VPA, and rapamycin.
  • the daily dose of valproic acid is from about 15/mg/kg to about 60 mg/kg.
  • the daily dose of valproic acid is sufficient to achieve about 300 to about 867 micromolar in patient serum. In another embodiment, the daily dose of valproic acid is sufficient to achieve about 300 to about 1000 micromolar in patient serum, and in another embodiment, the daily dose of valproic acid is sufficient to achieve about 500 to about 1000 micromolar in patient serum.
  • the dose of SAHA is from about 200 mg/day to about 600 mg/day. In another embodiment, the dose of SAHA is about 400 mg/day.
  • the hormonal therapy is anti-estrogen therapy, which can be, but is not limited to, tamoxifen, raloxifene, fulvestrant, toremifene or endoxifen.
  • the hormonal therapy can also be estrogen ablation therapy, including an aromatase inhibitor.
  • the aromatase inhibitor can be, but is not limited to, exemestane, letrozole, or anastrozole.
  • the dose of tamoxifen is from about 10 mg/day to about 50 mg/day. In another embodiment, the dose of tamoxifen is about 20 mg/day. In one embodiment in which a patient has metastatic breast cancer, the dose of tamoxifen is from about 20 mg/day to about 40 mg/day.
  • the dose of letrozole is from about 1 mg/day to about 5 mg/day. In another embodiment, the dose of letrozole is about 2.5 mg/day.
  • the dose of exemestane is from about 10 mg/day to about 40 mg/day. In another embodiment, the dose of exemestane is about 25 mg/day.
  • the dose of anastrozole is from about 0.5 mg/day to about 3 mg/day. In another embodiment, the dose of anastrozole is about 1 mg/day.
  • compounds are administered in combination, with ratios of those compounds which preserve the recommended daily doses of the compounds. In some embodiments, compounds are administered in combination, with ratios of those compounds which preserve the ranges of doses as described herein. [0050] In one embodiment, the ratio of tamoxifen to VPA is 1 part tamoxifen to 45-180 parts VPA, for a 60 kg patient.
  • the ratio of tamoxifen to VPA is 1 part tamoxifen to 22.5-180 parts VPA, for a 60 kg patient.
  • the combination comprises administering tamoxifen or raloxifen along with an HDAC inhibitor
  • an HDAC inhibitor in combination with tamoxifen, raloxifene or endoxifen will reduce or eliminate the risk of uterine cancer. In some embodiments, this risk is reduced by 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, or it is virtually or wholly eliminated.
  • the present invention further contemplates that the combination therapies as described herein can also reduce or eliminate other side effects of treatment, at least in part because lower doses of compounds can be used in treatment or prevention protocols.
  • the IGF-IR inhibitor can be picropodophyllin (see, e.g., Girnita, A. et al., Cancer Res., 2004. 64(1): 236-242) or the green tea polyphenol, EGCG (see, e.g., Shimizu, M. et al, Biochem. Biophys. Res. Commun., 2005. 334(3): 947-953; Li, M. et al., Cancer Epidemiol. Biomarkers Prev., 2007. 16(3): 598- 605.
  • the EGFR inhibitor may be gefitinib, and the mTOR inhibitor may be rapamycin or rapamycin derivatives (see, e.g., Johnston, S.R., Clin. Cancer Res., 2006. 12(3 Pt. 2): 1061 -1069s).
  • the skilled practitioner will be able to use a variety of IGF-IR, EGFR, and mTOR inhibitors in the invention, to provide therapeutically effective combinations with various HDAC inhibitors.
  • the dose of EGCG is from about 300 mg/day to about 800 mg/day.
  • the dose of rapamycin is from about 0.125 mg/day to about 1 mg/day.
  • the dose of gefitinib is from about 200 mg/day to about 300 mg/day. In another embodiment, the dose of gefitinib is about 250 mg/day. [0058] In one embodiment, the dose of erlotinib is from about 100 mg/day to about 150 mg/day.
  • the additional "active ingredient” that can be used in combination with an HDAC inhibitor and hormonal therapy can be chosen from among a variety of compounds.
  • the additional active ingredient can be an IGF-IR inhibitor, an EGFR inhibitor, an mTOR inhibitor, or other chemotherapeutic agent, biologic, radiation therapy, or other agents and procedures useful in the treatment of cancer.
  • the HDAC inhibitor is administered on a daily basis, while the hormonal therapy, or IGF-IR inhibitor, EGFR inhibitor, or mTOR inhibitor is administered every other day.
  • the hormonal therapy or IGF-IR inhibitor, EGFR inhibitor, or mTOR inhibitor is administered on a daily basis and the HDAC inhibitor is administered every other day.
  • the invention also contemplates administering the HDAC inhibitor and the hormonal therapy or IGF-IR inhibitor, EGFR inhibitor, or mTOR inhibitor concurrently.
  • the invention it is within the scope of the invention to treat breast cancer that is tamoxifen resistant, as well as to treat breast cancer that overexpresses Her2/Neu.
  • the invention also contemplates treating subjects with breast cancer for whom previous therapy has failed, or for whom the cancer is recurring.
  • the invention is to treat subjects with breast cancer who are post-menopausal, and in some embodiments, the invention contemplates treating subjects who are genetically predisposed to breast cancer or otherwise at increased risk.
  • the invention also encompasses methods of treating subjects to prevent progression of breast cancer, and in some embodiments, the invention encompasses treating or preventing breast cancer in patients with pre-cancerous growths or benign tumors. It is within the scope of the invention to treat subjects that are in remission from breast cancer, and to treat subjects with breast cancer that have previously undergone treatment.
  • FIGS. 1A-1C VPA inhibits cell proliferation and enhances the antiproliferative effect of tamoxifen in ERa positive breast cancer cells.
  • MCF-7 (A), T47D (B) and ZR- 75-1 (C) cells were grown for 6-7 days and counted electronically. Cells were treated with 750 ⁇ M VPA, 10 nM OH-Tam and 100 pM E2, as indicated. Bars represent the average of three independent experiments presented as a percentage of E2 alone and error bars represent S. E. M. from the three experiments.
  • FIGS. 2A-2C VPA enhances the efficacy of tamoxifen and other antiestrogens.
  • VPA and OH-Tam have an additive effect in inhibiting MCF-7 cell proliferation (A).
  • Cells were treated with 100 pM E2 with and without 750 ⁇ M VPA in the presence of OH- Tam, ranging from 0 to 500 nM.
  • proliferation was measured using a fluorescent DNA-binding assay and values represent the percentage of fluorescence of E2 alone (control) with bars representing the S. E. M. from triplicate wells.
  • VPA enhances the inhibition of cell growth of two other antiestrogens, raloxifene and fulvestrant (B).
  • MCF-7 cells were treated with OH-Tam, raloxifene (RaI) or fulvestrant (FuIv) in the presence of lOOpM E2 either plus or minus 750 ⁇ M VPA for 7 days and electronically counted. Bars represent the average proliferative response relative to E2 alone (control) from three independent experiments with error bars representing S.E.M. VPA enhances the efficacy of letrozole (C). MCF-7aro cells were treated with either 10OnM E2 or InM testosterone (T) with the indicated concentrations of letrozole (Let) for 5 days with or without 750 ⁇ M VPA and assayed as described above. [0064] FIGS.
  • HDAC inhibitors enhance tamoxifen antiproliferative action.
  • MCF-7 cells were treated in the presence of 100 pM E2 with a range of doses of VPA (A), TSA (B) or SAHA (C), alone and in the presence of 10 nM OH-Tam. Proliferation was measured on day 7 using a fluorescent DNA-binding assay and values represent the percentage of fluorescence of 100 pM E2 alone (control) and bars represent the S.E.M. from triplicate wells.
  • FIGS. 4A-4F VPA enhances the antiproliferative effect of tamoxifen primarily by increasing apoptosis.
  • MCF-7 cells were treated with 100 pM E2 alone (A) and with 7501 ⁇ M VPA (B), or 10 nM OH-Tam (C) or a combination of both VPA and OH-Tam (D) for a 6-day period and a representative field analyzed by phase microscopy at 10x magnification.
  • the arrow points to a group of cells with apop to tic-like morphology.
  • VPA alone or in combination with OH-Tam does not alter E2-induced cell cycle distribution (E).
  • FIGS. 5A-5B Effect of VPA on tamoxifen-induced gene expression. VPA activates transcription and enhances tamoxifen activity of an ERE reporter gene (A).
  • MCF-7 cells were transiently transfected with ERE-Luc and treated with and without 1OnM OH-Tam along with the indicated concentrations of ligands for 24 hours and assayed for lucifererase activity. Bars represent fold-induction relative to vehicle from a representative experiment and error bars represent the S.E.M. from triplicate wells. VPA and tamoxifen cooperate in upregulating the pro-apoptotic protein Bik, (B).
  • MCF-7 cells were treated for 72 hours with vehicle or 100 pM E2, 750 ⁇ M VPA, and/or 10 nM OH- Tam and protein lysates immunoblotted with ERa, CD 1, Bik, or Bcl-2 antibodies, with ⁇ -tubulin serving as a loading control.
  • FIG. 6 VPA enhances the efficacy of tamoxifen in MCF-7 cells overexpressing HER2/neu.
  • MCF-7/neo and MCF-7/HER2 cells were treated with 10 pM E2 and either 750 ⁇ M VPA and/or 1OnM OH-Tam for 7 days and counted electronically. Bars represent the average cell number of three replicates from a representative experiment and error bars represent S.E.M.
  • FIG. 7 VPA antagonizes tamoxifen-induced proliferation in endometrial cells. Ishikawa endometrial adenocarcinoma cells were grown for 6-7 days and counted electronically. Cells were treated with 750 ⁇ M VPA, 10 nM OH-Tam and 100 pM or InM E2, as indicated. Bars represent the average of three experiments and error bars represent S.E.M. [0069] FIGS. 8A-8E: These figures present representative HDAC inhibitors. [0070] FIG. 9: This figure shows that carbamazepine combines effectively with rapamycin, picropodophyllin, and tamoxifen to slow breast cancer cell growth.
  • FIG. 10 This figure shows that valproic acid, a HDAC inhibitor, picropodophyllin, an IGF-IR inhibitor, and rapamycin, an mTOR inhibitor, combine effectively with each other and with tamoxifen to inhibit breast cancer cell growth.
  • FIG. 11 This figure shows that valproic acid combines effectively with gefitinib, an EGFR inhibitor, and with rapamycin, but also shows that the latter two drugs fail to combine effectively with each other to inhibit breast cancer cell growth.
  • FIGS. 12A - 12C Effect of the combination of compounds (valproic acid in (A), TSA in (B), and carbamazepine in (C)) with EGCG and rapamycin, with or without tamoxifen, on the inhibition of breast cancer cells. Combinations of the four agents are more efficacious than treatment with any single agent alone.
  • FIG. 13 The active tamoxifen metabolite endoxifen (4-hydroxy-N- Desmethyltamoxifen) cooperates with the antiproliferative effects of HDAC inhibitor VPA and with the IGF-IR inhibitor EGCG.
  • MCF-7 breast cancer cells were treated with the indicated doses of drugs for 6 days in the presence of lOOpM E2 and proliferation was measured using a DNA-binding fluorescent dye. Note that the combination of all three drugs is more efficacious than any single drug or any two drugs used in combination.
  • FIG. 14 A combination of VPA, EGCG and rapamycin enhances tamoxifen's ability to inhibit cell growth in tamoxifen-resistant breast cancer cells.
  • MCF-7 cells engineered to overexpress Her/neu (MCF7-Her2) were used as an in vitro model of tamoxifen-resistance.
  • MCF7-Her2 and their parental cells (MCF7-neo) were treated with the indicated doses of drugs for 7-8 days in the presence of lOOpM E2 and proliferation was measured using a DNA-binding fluorescent dye. Data is the average from 3 independent experiments and presented as a percentage of vehicle control (10OpM E2).
  • FIG. 15 The HDAC inhibitor sulforaphane (SFN) cooperates with the IGF-IR inhibitor EGCG and hydroxytamoxifen to inhibit breast cancer cell proliferation.
  • MCF-7 breast cancer cells were treated for 6 days with the indicated doses of drugs and proliferation was measured using a DNA-binding fluorescent dye.
  • FIG 16 MCF-7 cells were treated twice a day with the cocktail treatments or its vehicle control equivalent (750 ⁇ M Valproic Acid [VPA], 1OnM Tamoxifen [OH-Tam]. Cells were treated in 2.5% ISCS IMEM media + lOOpM Estrogen. After 7 days, proliferation was measured using a DNA-binding fluorescent dye.
  • FIG. 17 MCF-7-Aro cells (2500 cells/well on a 96-well plate) were treated for 5 days in 2.5% CDSS Ham's/F12 media +1OnM Androstenedione. 50OnM MS-275, 10OnM PXDlOl, and lO ⁇ M Anastrazole.
  • FIG. 18 MCF-7-Tx cells (1250 cells/well on a 96-well plate) were treated for 6 days in 2.5% IMEM media +10OpM 17- ⁇ -Estradiol. 10OnM MS-275, 10OnM PXDlOl, 1OnM OH-Tamoxifen.
  • FIG. 19 Fifty Nu/Nu female mice, 7-9 weeks old, 20-25g in weight had MCF- 7-Clonel8 Xenografts implanted (10,000,000 cells/xenograft) into the right flank. Treatments began on day 14 from xenografts with four groups of 8 randomized mice. Mice were treated for 28 days, a) Different from Veh (p ⁇ 0.05). b) Different from Tarn (p ⁇ 0.05).
  • HDAC inhibitors include, but not limited to IGF-IR inhibitors, EGFR inhibitors, and mTOR inhibitors combine effectively with each other for the treatment and prevention of breast cancer, and for preventing the progression of breast cancer.
  • IGF-IR inhibitors include IGF-IR inhibitors, EGFR inhibitors, and mTOR inhibitors combine effectively with each other for the treatment and prevention of breast cancer, and for preventing the progression of breast cancer.
  • mTOR inhibitors combine effectively with hormonal therapy, and that the combinations are more effective than either of the components alone.
  • the present invention provides methods of treating and preventing estrogen receptor positive breast cancer, as well as pharmaceutical compositions comprising the compounds used in the combination therapies disclosed herein.
  • the present invention is based on the discovery that VPA, which is an HDAC inhibitor, enhances the anti-proliferative effect of tamoxifen in three estrogen receptor alpha (ER ⁇ )-positive breast cancer cells lines, MCF-7, T47-D and ZR-75-1. VPA also enhances the antiproliferative actions of two other antiestrogens, fulvestrant and raloxifene, as well as the antiproliferative effects of the aromatase inhibitor letrozole.
  • ER ⁇ estrogen receptor alpha
  • HDAC inhibitors Two other HDAC inhibitors, trichostatin A (TSA) and suberoylanilide hydroxamic acid (SAHA), also enhance the efficacy of tamoxifen, indicating that cooperation, or effective combination, among HDAC inhibitors and antiestrogens may be a general phenomenon.
  • VPA also increases tamoxifen sensitivity of a tamoxifen-resistant MCF-7 derivative cell line overexpressing HER2/neu.
  • VPA reverses the proliferative effect of tamoxifen in Ishikawa endometrial cells.
  • the invention provides methods for treating both estrogen-sensitive tumors and tamoxifen-resistant breast tumors, while protecting the uterus from the negative proliferative effects observed with tamoxifen and other compounds.
  • the present invention shows that VPA combines effectively with picropodophyllin and with rapamycin, as well as combining effectively with each other and with tamoxifen or endoxifen to inhibit breast cancer cell growth.
  • VPA combines effectively with gef ⁇ tinib, an EGFR inhibitor, and with rapamycin, to slow breast cancer cell growth.
  • the invention also provides combinations of HDAC inhibitors, including but not limited to TSA, SAHA, MS-275, PXDlOl, and valproic acid; inhibitors of the mammalian target of rapamycin (mTOR) protein, such as rapamycin or derivatives thereof; and inhibitors of the insulin-like growth factor receptor (IGF-IR) signaling pathway such as picropodophyllin, and inhibitors of EGFR.
  • HDAC inhibitors including but not limited to TSA, SAHA, MS-275, PXDlOl, and valproic acid
  • inhibitors of the mammalian target of rapamycin (mTOR) protein such as rapamycin or derivatives thereof
  • IGF-IR insulin-like growth factor receptor
  • the combination of HDAC inhibitor, IGF-IR inhibitor, and mTOR inhibitor can also be used, as well as other combinations as described herein, including combinations with hormonal therapy. Each of these combinations can further be used in combination with hormone therapy, or other therapies to treat estrogen receptor positive breast cancer, as described
  • the individual compounds in the combination therapies combine effectively with each other, and in other embodiments, the individual compounds in the combination therapies synergize with each other. Definitions
  • cancer refers to a disease involving cells that have the potential to metastasize to distal sites and exhibit phenotypic traits that differ from those of non-cancer cells. Cancer cells acquire a characteristic set of functional capabilities during their development, albeit through various mechanisms. Such capabilities include evading apoptosis, self-sufficiency in growth signals, insensitivity to anti-growth signals, tissue invasion/metastasis, limitless replicative potential, and sustained angiogenesis. The term “cancer cell” is meant to encompass both pre-malignant and malignant cancer cells. [0086] "Estrogen receptor positive breast cancer” refers to breast cancers that are in the positive or intermediate range for the estrogen receptor protein.
  • estrogen receptor protein when estrogen receptor protein can be measured as femtomoles per milligram of cytosol protein. In this assay, values above 10 are positive, values from 3 to 10 are intermediate, and values less than 3 are negative.
  • Other assays known in the art can be used to determined if the breast cancer is estrogen receptor positive, in particular assays based on antibodies to estrogen receptors alpha and beta and their use in biochemical or histological assays.
  • histone deacetylase inhibitor and “inhibitor of histone deacetylase” mean a compound which is capable of interacting with a histone deacetylase and inhibiting its enzymatic activity.
  • HDAC inhibitors see the HDAC inhibitors in FIGS 8A-8F.
  • a non-limiting list of HDAC inhibitors includes: valproic acid (VPA), TSA, SAHA, VPA derivatives, MS-275 (also called entinostat and SNDX-275), cyclic hydroxamic acid- containing peptide, Apicidin, sulforaphane, and Trapoxin.
  • “Inhibiting histone deacetylase enzymatic activity” means reducing the ability of a histone deacetylase to remove an acetyl group from a histone. (see, e.g., FIG. 8 and Minucci et al., Nature 6:38-51 (2006). In some preferred embodiments, such reduction of histone deacetylase activity is at least about 50%, more preferably at least about 75%, and still more preferably at least about 90%. In other preferred embodiments, histone deacetylase activity is reduced by at least 95% and more preferably by at least 99%. Assays for determining inhibition are described in Phiel, C.J., et al., J Biol Chem., 2001. 276(39): p. 36734-41 and Gottlich, M., et al., Embo J., 2001. 20(24): p. 6969-78.
  • the histone deacetylase inhibitor reduces the ability of a histone deacetylase to remove an acetyl group from a histone at a concentration that is lower than the concentration of the inhibitor that is required to produce another, unrelated biological effect.
  • the concentration of the inhibitor required for histone deacetylase inhibitory activity is at least 2-fold lower, more preferably at least 5-fold lower, even more preferably at least 10- fold lower, and most preferably at least 20-fold lower than the concentration required to produce an unrelated biological effect.
  • active ingredient includes having a therapeutic or prophylactic effect on breast cancer in the combinations. This does not include inactive ingredients such as pharmaceutical carriers, excipients, and the like.
  • Mammalian target of rapamycin protein inhibitor or “mTOR inhibitor” includes drugs such as rapamycin, temsirolimus, and everolimus that selectively inhibit the mammalian target of rapamycin (mTOR).
  • IGF-I receptor inhibitor refers to drugs such as picrophodophyllin and podophyllotoxin that selectively inhibit the IGF- 1 receptor.
  • EGF receptor inhibitor of "EGFR inhibitor” refers to drugs such as gefitinib and eroltinib that selectively inhibit the EGF receptor.
  • Insufficient to fully prevent production of estrogen refers to the inability of an aromatase inhibitor to fully prevent a tumor cell from converting an estrogen precursor into a functional estrogen that can stimulate tumor proliferation.
  • Less than estrogen receptor-saturating amounts refers to amounts of fulvestrant less than 100 fold molar excess to the amounts of estradiol or less than 10 nanomolar in patient circulation.
  • “Hormonal therapy” refers to drugs or treatments that block the effect of, or reduce the levels of hormones, and in particular which block the effect of estrogen or lower estrogen levels, including anti-estrogen therapy, aromatase inhibitor therapy, and estrogen ablation therapy.
  • Aromatase inhibitors include those compounds capable of inhibiting the aromatase enzyme, which converts androgens (e.g. testosterone and androstenedione) into estrogens (e.g., estradiol and estrone).
  • a non-limiting list of aromatase inhibitors includes: anastrozole, letrozole, and exemestane.
  • the terms “treat,” “treating,” and “treatment” refer to any amelioration of breast cancer symptoms, reduction of tumor volume, enhancing treatment, reduction in growth or metastasis rate, prevention or delayed onset, prevention of recurrence, delayed recurrence, reduced likelihood of developing breast cancer or metastasis, improved patient comfort, reduction in side effects, etc.
  • the terms are not meant to be absolute, but refer to amelioration of breast cancer symptoms, etc., relative to an appropriate control. Appropriate controls are well within the skill in the art, and depend on the particular patient and circumstances. For example, an individual receiving a breast cancer treatment according to the invention can be compared, e.g., to a known average of other similar patients, to the same individual before treatment, or a different individual or group of individuals that are not undergoing the same treatment.
  • treatments include but are not limited to: prevention of breast cancer; prevention of breast cancer in individuals at increased risk of breast cancer; active treatment of locally advanced or metastatic breast cancer; reduction of risk of recurrence after surgery, e.g., as an adjuvant; and to reduce tumor volume before surgery.
  • the terms “prevent,” “preventing” and “prevention” refer to the prevention of the recurrence, worsening, or spread of a disease in a subject resulting from the administration of a prophylactic or therapeutic agent.
  • treatment the term is not absolute, and refers to any reduction of symptoms, e.g., as compared to the same individual or a different individual or a group of individuals that are not undergoing the same treatment/ prevention regimen.
  • overexpress refers to a protein or nucleic acid (RNA) that is translated or transcribed at a detectably greater level, usually in a cancer cell, in comparison to a normal cell.
  • the term includes overexpression due to transcription, post transcriptional processing, translation, post- translational processing, cellular localization (e.g., organelle, cytoplasm, nucleus, cell surface), and RNA and protein stability, as compared to a normal cell.
  • Overexpression can be detected using conventional techniques for detecting mRNA (i.e., RT-PCR, PCR, hybridization, microarray) or proteins (i.e., ELISA, immunohistochemical techniques).
  • Overexpression can be 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or more in comparison to a normal cell. In certain instances, overexpression is 1-fold, 2-fold, 3-fold, 4-fold or more higher levels of transcription or translation in comparison to a normal cell.
  • the term “in combination” refers to the use of more than one prophylactic and/or therapeutic agents.
  • the use of the term “in combination” does not restrict the order in which prophylactic and/or therapeutic agents are administered to a subject with cancer, especially breast cancer.
  • a first prophylactic or therapeutic agent can be administered prior to (e.g., 1 minute, 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks before), concomitantly with, or subsequent to (e.g., 1 minute, 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks after) the administration of a second prophylactic or therapeutic agent to a subject which had, has, or is susceptible to cancer, especially breast cancer.
  • the prophylactic or therapeutic agents are administered to a subject in a sequence and within a time interval such that the agent of the invention can act together with the other agent to provide an increased benefit than if they were administered otherwise. Any additional prophylactic or therapeutic agent can be administered in any order with the other additional prophylactic or therapeutic agents.
  • the term “combine effectively” refers to a combination of therapies (e.g., a combination of prophylactic or therapeutic agents) which is more effective than any single agent administered alone at the same dose. Combining effectively may also refer to combinations of therapies that are not less effective than any single agent or even less effective than any single agent, but which also eliminate or reduce the adverse effects of one or more of the agents, such as eliminating or reducing the risk of uterine cancer associated with one or more of the agents.
  • the term “synergistic” refers to a combination of therapies (e.g., a combination of prophylactic or therapeutic agents) which is more effective than the additive effects of any two or more single agents.
  • a synergistic effect of a combination of therapies permits the use of lower dosages of one or more of the therapies and/or less frequent administration of said therapies (e.g., agents) to a subject with a disease or disorder, in particular, cancer, or a condition or symptom associated therewith.
  • said therapies e.g., agents
  • the ability to utilize lower dosages of therapies and/or to administer said therapies less frequently reduces the toxicity associated with the administration of said therapies to a subject without reducing the efficacy of said therapies in the prevention, management, or treatment of a disease or disorder, in particular, cancer or a condition or symptom associated therewith.
  • synergistic effect can result in improved efficacy of therapies in the prevention, management, or treatment of a disease or disorder, in particular, cancer or a condition or symptom associated therewith.
  • the synergistic effect of a combination of therapies may avoid or reduce adverse or unwanted side effects associated with the use of any single therapy.
  • side effects encompasses unwanted and adverse effects of a prophylactic or therapeutic agent. Adverse effects are always unwanted, but unwanted effects are not necessarily adverse. An adverse effect from a prophylactic or therapeutic agent might be harmful or uncomfortable or risky. Side effects can refer specifically to an increase in uterine cell proliferation, as well as to an increase in the frequency of uterine cancer and an increase in the risk of developing uterine cancer.
  • Side effects from chemotherapy include, but are not limited to, gastrointestinal toxicity such as, but not limited to, early and late-forming diarrhea and flatulence, nausea, vomiting, anorexia, leukopenia, anemia, neutropenia, asthenia, abdominal cramping, fever, pain, loss of body weight, dehydration, alopecia, dyspnea, insomnia, dizziness, mucositis, xerostomia, and kidney failure, as well as constipation, nerve and muscle effects, temporary or permanent damage to kidneys and bladder, flu-like symptoms, fluid retention, and temporary or permanent infertility.
  • Side effects from radiation therapy include but are not limited to fatigue, dry mouth, and loss of appetite.
  • Side effects from biological therapies/imrnunotherapies include but are not limited to rashes or swellings at the site of administration, flu-like symptoms such as fever, chills and fatigue, digestive tract problems and allergic reactions.
  • Side effects from hormonal therapies include but are not limited to nausea, fertility problems, depression, loss of appetite, eye problems, headache, and weight fluctuation. Additional undesired effects typically experienced by patients are numerous and known in the art. Many are described in the Physicians' Desk Reference (56 th ed., 2002).
  • “Monotherapeutically effective” refers to a therapy with only one cancer drug administered in the course of the particular therapy rather than a combination therapy.
  • therapeutically effective amount or dose or “therapeutically sufficient amount or dose” or “effective or sufficient amount or dose” herein is meant a dose that produces therapeutic effects for which it is administered, in the context of the combination therapy in which it is administered.
  • therapeutically effective or sufficient amount or dose of the compounds comprising the pharmaceutical compositions of the invention will be lower when administered in the specific combinations, than the doses that would be therapeutically effective or sufficient when the compounds are administered separately.
  • the exact dose will depend on the purpose of the treatment, and will be ascertainable by one skilled in the art using known techniques ⁇ see, e.g.,
  • a therapeutically effective amount refers to that amount of the therapeutic agent sufficient to destroy, modify, control or remove primary, regional or metastatic cancer tissue.
  • a therapeutically effective amount may refer to the amount of therapeutic agent sufficient to delay or minimize the spread of cancer.
  • a therapeutically effective amount may also refer to the amount of the therapeutic agent that provides a therapeutic benefit in the treatment or management of cancer.
  • a therapeutically effective amount with respect to a therapeutic agent of the invention means that amount of therapeutic agent alone, or in combination with other therapies, that provides a therapeutic benefit in the treatment or management of cancer. In sensitized cells, the therapeutically effective dose can often be lower than the conventional therapeutically effective dose for non-sensitized cells.
  • a therapeutically effective amount refers to the amount of a therapeutic agent that, e.g., reduces the proliferation of cancer cells, increases the death of cancer cells or, reduces the size of a tumor or spread of a tumor in a subject.
  • a therapeutically effective amount of a therapeutic agent reduces the size of a tumor or the spread of a tumor in a subject by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, ate least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95% or at least 99% relative to a control such as PBS.
  • a therapeutically effective amount refers to the amount of a therapeutic agent that increases survival by 1 month, 2 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, 8 years, 9 years, 10 years, or more. In some embodiments, a therapeutically effective amount refers to the amount of a therapeutic agent that prevents the progression from DCIS or atypical hyperplasia to breast cancer. Diagnosis and treatment
  • the HDAC inhibitors encompassed by the methods and compositions of the present invention can be any known to those of skill in the art, particularly those shown in FIGS. 8A-8F, and described in Minucci et al, Nature 6:38-51 (2006).
  • the HDAC inhibitor is valproic acid.
  • the HDAC inhibitor may be TSA, SAHA, VPA derivatives, MS-275 (also called entinostat and SNDX-275), cyclic hydroxamic acid-containing peptide, Apicidin, Trapoxin, or other HDAC inhibitors known by the skilled practitioner to be effective.
  • Other HDAC inhibitors encompassed by the methods and compositions of the invention include the VPA derivatives as described in U.S. Patent Application Nos.
  • HDAC inhibitors encompassed by the methods and compositions of the invention include the sulfonyl derivatives as described in U.S. Patent No. 7,205,304 to Van Emelen, the alpha-ketoepoxide compounds of U.S. Patent No.
  • the present invention provides a method of treating and methods of preventing estrogen receptor positive breast cancer, comprising administering to a subject a therapeutically effective amount of an HDAC inhibitor in combination with a course of hormonal therapy.
  • Various combinations of HDAC inhibitors and hormonal therapies are contemplated as useful in treating estrogen receptor positive breast cancer.
  • the HDAC inhibitor is not valproic acid and in some embodiments the HDAC inhibitor is not SAHA.
  • the daily dose of valproic acid is from about 15/mg/kg to about 60 mg/kg.
  • the dose of valproic acid is sufficient to achieve from about 300 to about 1000 micromolar in patient serum. In another embodiment, the dose of valproic acid is sufficient to achieve from about 300 to about 867 micromolar in patient serum. In another embodiment, the dose of valproic acid is sufficient to achieve from about 500 to about 1000 micromolar in patient serum.
  • the dose of SAHA is from about 200 mg/day to about 600 mg/day. In another embodiment, the dose of SAHA is about 400 mg/day.
  • Hormonal agents are a group of drugs that regulate the growth and development of their target organs. Most of the hormonal agents used in the treatment of breast cancer are sex steroids and their derivatives and analogs thereof, such as estrogens, androgens, and progestins. These hormonal agents may serve as antagonists of receptors for the sex steroids to down regulate receptor expression and transcription of genes.
  • hormonal therapy agent include, but are not limited to synthetic estrogens (e.g. diethylstibestrol), antiestrogens (e.g.
  • tamoxifen fulvestrant, fluoxymesterol, raloxifene, and torimefene
  • antiandrogens bicalutamide, nilutamide, flutamide
  • aromatase inhibitors e.g., aminoglutethimide, anastrozole, letrozole, and tetrazole
  • ketoconazole goserelin acetate, leuprolide, megestrol acetate and mifepristone.
  • the hormonal therapy is anti -estrogen therapy, which can be, but is not limited to tamoxifen, raloxifene, fulvestrant, torimefene and metabolites such as endoxifen.
  • the antiestrogen therapy is endoxifen.
  • the hormonal therapy can be estrogen ablation therapy, including an aromatase inhibitor.
  • the aromatase inhibitor can be, but is not limited to exemestane, letrozole, fadrozole, retrozole, and anastrozole. Any form of hormonal therapy known to one of skill in the art for the treatment of breast cancer is contemplated as useful in the combination therapies of the present invention.
  • the dose of tamoxifen is from about 10 mg/day to about 50 mg/day. In another embodiment, the dose of tamoxifen is about 20 mg/day. In one embodiment in which a patient has metastatic breast cancer, the dose of tamoxifen is from about 20 mg/day to about 40 mg/day.
  • the dose of letrozole is from about 1 mg/day to about 5 mg/day. In another embodiment, the dose of letrozole is about 2.5 mg/day. [0120] In one embodiment, the dose of exemestane is from about 10 mg/day to about 40 mg/day. In another embodiment, the dose of exemestane is about 25 mg/day. [0121] In yet another embodiment, the dose of anastrozole is from about 0.5 mg/day to about 3 mg/day. In another embodiment, the dose of anastrozole is about 1 mg/day.
  • compounds are administered in combination, with ratios of those compounds which preserve the recommended daily doses of the compounds. In some embodiments, compounds are administered in combination, with ratios of those compounds which preserve the ranges of doses as described herein.
  • the ratio of tamoxifen to VPA is 1 part tamoxifen to 45-180 parts VPA, for a 60 kg patient.
  • the ratio of tamoxifen to VPA is 1 part tamoxifen to 22.5-180 parts VPA, for a 60 kg patient.
  • the combination comprises administering tamoxifen or raloxifene along with an HDAC inhibitor
  • Treatment with tamoxifen or raloxifene is compromised by an increased risk in uterine cancer.
  • Administration of a HDAC inhibitor with endoxifen also prevents the increased risk of uterine cancer.
  • a distinct advantage of the present invention is reduced risk of uterine cancer by administration of an HDAC inhibitor in combination with tamoxifen, raloxifene, endoxifen, or other antiestrogen therapies with a partial estrogen-like effect on the uterus. This same advantage is thought to apply to endoxifen as well. In some embodiments, this risk is reduced by 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, or it is virtually or wholly eliminated.
  • the present invention also encompasses methods of treating and methods of preventing breast cancer comprising administering to a subject suffering therefrom a therapeutically effective amount of an HDAC inhibitor in combination with a therapeutically effective amount of one or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • the HDAC inhibitor is not VPA when the HDAC inhibitor is in combination with an EGFR inhibitor.
  • methods for treating and for preventing breast cancer, comprising administering to a subject suffering therefrom a therapeutically effective amount of an HDAC inhibitor in combination with a course of hormonal therapy as well as an additional active ingredient that is effective to treat breast cancer in the combination.
  • the method comprises administering a combination comprising an HDAC inhibitor, a course of hormonal therapy, and one or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • methods for treating and for preventing breast cancer, comprising administering to a subject suffering therefrom a therapeutically effective amount of a course of hormonal therapy in combination with one or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • methods for treating and for preventing breast cancer, comprising administering to a subject suffering therefrom a therapeutically effective amount a combination of two or more of an IGF-I receptor inhibitor, an EGFR inhibitor, or an mTOR inhibitor.
  • the combination comprises VPA and tamoxifen. In another embodiment, the combination comprises TSA and tamoxifen. In another embodiment, the combination comprises SAHA and tamoxifen.
  • the IGF-IR inhibitors contemplated in the methods and compositions of the present invention can be any known to one of skill in the art.
  • the IGF-IR inhibitor may be for example, picropodophyllin, podophyllotoxin, podophyllotoxin derivatives, including those disclosed in U.S. Patent Application No. 20070123491 to Axelson, EGCG, cyclolignans such as those disclosed in U.S. Patent Application No. 2004/0186169 to Larsson, and IGF-IR inhibitors such as those disclosed in U.S. Patent Application No. 20060193772 to Ochiai.
  • the EGFR inhibitors contemplated in the methods and compositions of the present invention can be any known to one of skill in the art.
  • the EGFR inhibitor may be for example, gefitinib, erlotinib, cetuximab, imatinib, genistein, genistin, quercetin, equol, staurosporine, aeroplysinin, indocarbazole, lavendustin, piceatannol, kaempferol, daidzein, erbstatin, and tyrphostins.
  • the mTOR inhibitors contemplated in the methods and compositions of the present invention can be any known to one of skill in the art.
  • the mTOR inhibitor may be for example, temsirolimus, everolimus, rapamycin and rapamycin derivatives, including those rapamycin derivatives disclosed in U.S. Patent Application No. 20040147541 to Lane.
  • the combination comprises tamoxifen and picropodophyllin.
  • the combination comprises tamoxifen, VPA, and picropodophyllin.
  • the combination comprises tamoxifen, VPA, and rapamycin.
  • the combination comprises tamoxifen, VPA, picropodophyllin, and rapamycin.
  • the combination comprises VPA and picropodophyllin. In another embodiment, the combination comprises VPA and rapamycin. In yet another embodiment, the combination comprises VPA, picropodophyllin, and rapamycin.
  • the combination comprises tamoxifen and picropodophyllin. In another embodiment, the combination comprises VPA and rapamycin.
  • the combination comprises tamoxifen, VPA, and gefitinib. In another embodiment, the combination comprises tamoxifen, VPA, rapamycin, and gefitinib. [0138] In one embodiment, the combination comprises rapamycin and gefitinib.
  • the combination comprises tamoxifen, EGCG, and rapamycin. In an additional embodiment, the combination comprises tamoxifen and EGCG. In one embodiment, the combination comprises tamoxifen, VPA, and EGCG. In another embodiment, the combination comprises tamoxifen, VPA, EGCG, and rapamycin. In another embodiment, the combination comprises VPA and EGCG. In yet another embodiment, the combination comprises VPA, EGCG, and rapamycin.
  • the dose of rapamycin is from about 0.125 mg/day to about 1 mg/day.
  • the dose of gefitinib is from about 200 mg/day to about 300 mg/day. In another embodiment, the dose of gefitinib is about 250 mg/day.
  • the dose of erlotinib is from about 100 mg/day to about 150 mg/day.
  • inhibitors described herein many different procedures can be used to specifically inactivate or silence a target gene or inhibit the activity of its gene product, as encompassed by the present invention. Inhibition of protein activity can be brought about at the level of gene transcription, protein translation or post-translational modifications. For instance, the activity of a protein can be inhibited by directly inhibiting the activity of the protein such as altering a catalytic domain or alternatively by reducing the amount of the protein in the cell by reducing the amount of mRNA encoding the protein. In each case, the level of protein activity in the cell is reduced.
  • Various techniques can be used to knock down the activity of a protein and these include knockout technologies (antibodies, antisense RNA, and RNA interference) and compounds that specifically inhibit the protein activity.
  • RNA interference (RNAi) molecule is used to decrease expression of a gene.
  • RNA interference (RNAi) is defined as the ability of double-stranded RNA (dsRNA) to suppress the expression of a gene corresponding to its own sequence.
  • dsRNA double-stranded RNA
  • PTGS post-transcriptional gene silencing
  • the antisense strand of the fragment separates enough from the sense strand so that it hybridizes with the complementary sense sequence on a molecule of endogenous cellular mRNA. This hybridization triggers cutting of the mRNA in the double-stranded region, thus destroying its ability to be translated into a polypeptide. Introducing dsRNA corresponding to a particular gene thus knocks out the cell's own expression of that gene in particular tissues and/or at a chosen time.
  • Double-stranded (ds) RNA can be used to interfere with gene expression in mammals (Wianny & Zemicka-Goetz, 2000, Nature Cell Biology 2: 70-75). dsRNA is used as inhibitory RNA or RNAi of the function of the gene of interest to produce a phenotype that is the same as that of a null mutant of the gene of interest (Wianny & Zernicka-Goetz, 2000, Nature Cell Biology 2: 70-75).
  • Any therapy e.g., chemotherapies, radiation therapies, hormonal therapies, and/or biological therapies/immunotherapies
  • chemotherapies e.g., radiation therapies, hormonal therapies, and/or biological therapies/immunotherapies
  • Any therapy e.g., radiation therapies, hormonal therapies, and/or biological therapies/immunotherapies
  • the anti-cancer agents contemplated in the methods and compositions of the present invention which can be administered in combination with the compositions of the present invention include, but are not limited to doxorubicin, epirubicin, the combination of doxorubicin and cyclophosphamide (AC), the combination of cyclophosphamide, doxorubicin and 5-fluorouracil (CAF), the combination of cyclophosphamide, epirubicin and 5-fluorouracil (CEF), herceptin, tamoxifen, the combination of tamoxifen and cytotoxic chemotherapy, taxanes (such as docetaxel and paclitaxel).
  • the combinations of the invention can be administered with taxanes plus standard doxorubicin and cyclophosphamide for adjuvant treatment of node -positive, localized breast cancer.
  • the dose of doxorubicin hydrochloride is 60-75 mg/m 2 on day 1 of treatment.
  • the dose of epirubicin is 100-120 mg/m 2 on day 1 of each cycle or divided equally and given on days 1-8 of the treatment cycle.
  • the dose of docetaxel is 60-100 mg/m 2 over 1 hour.
  • the dose of paclitaxel is 175 mg/m 2 over 3 hours.
  • the subject is a mammal.
  • Preferred mammals include primates such as humans and chimpanzees, domestic animals such as horses, cows, pigs, etc. and pets such as dogs and cats.
  • the invention encompasses treating humans, and in particular, human females.
  • the pharmaceutical compositions described herein may be used for the treatment of cancer, particularly for breast cancer.
  • the pharmaceutical compositions and methods of the present invention can be used to treat an individual with any type and/or stage of breast cancer.
  • breast cancers there are several types of breast cancer and there are several stages of breast cancer, all of which are contemplated as treated by the methods and compositions of the present invention.
  • the present invention can be used to treat a patient with any type of breast cancer.
  • Breast cancers may include carcinoma in situ, infiltrating (or invasive) ductal carcinoma, infiltrating (or invasive) lobular carcinoma, medullary carcinoma, colloid carcinoma, tubular carcinoma, and inflammatory carcinoma.
  • stages 0-IV In addition to the different types of breast cancer, there are also different stages of breast cancer, referred to as stages 0-IV.
  • the system most often used to describe the growth and spread of breast cancer is the TNM staging system, also known as the American Joint Committee on Cancer (AJCC) system.
  • TNM staging information about the tumor, nearby lymph nodes, and distant organ metastases is combined and a stage is assigned to specific TNM groupings. The grouped stages are described using Roman numerals from I to IV.
  • the clinical stage is determined by results from physical examination and tests.
  • the pathologic stage includes the findings of the pathologist after surgery. Most of the time, pathologic stage is the most important stage because usually the cancer isn't known to have spread to lymph nodes until the pathologist examines them under the microscope.
  • T stands for the size of the cancer (measured in centimeters; 2.54 centimeters 1 inch); N stands for spread to lymph nodes in the area of the breast, and M is for metastasis (spread to distant organs of the body).
  • the T category describes the original (primary) tumor.
  • Tis Tis is used only for carcinoma in situ or noninvasive breast cancer such as ductal carcinoma in situ, (DCIS) or lobular carcinoma in situ (LCIS).
  • Tl The cancer is 2 cm in diameter (about 3/4 inch) or smaller.
  • T2 The cancer is more than 2 cm but not more than 5 cm in diameter.
  • T3 The cancer is more than 5 cm in diameter.
  • T4 The cancer is any size and has spread to the chest wall, the skin, or lymphatics.
  • the N category is based on which of the lymph nodes near the breast, if any, are affected by the cancer.
  • NO The cancer has not spread to lymph nodes.
  • Nl The cancer has spread to lymph nodes under the arm on the same side as the breast cancer. Lymph nodes have not yet attached to one another or to the surrounding tissue.
  • N2 The cancer has spread to lymph nodes under the arm on the same side as the breast cancer and are attached to one another or to the surrounding tissue or enlarged, or the cancer can be seen to have spread to the internal mammary lymph nodes (next to the sternum), but not to the lymph nodes under the arm.
  • N3 The cancer has spread to lymph nodes above or just below the collarbone on the same side as the cancer, and may or may not have spread to lymph nodes under the arm, or the cancer has spread to internal mammary lymph nodes and lymph nodes under the arm, both on the same side as the cancer.
  • M categories The M category depends on whether the cancer has spread to any distant tissues and organs. MO: No distant cancer spread. Ml : Cancer has spread to distant organs.
  • Clinical staging estimates how much cancer there is based on the results of the physical exam, imaging tests (x-rays, CT scans, etc.) and sometimes biopsies of affected areas. For certain cancers the results of other tests, such as blood tests, are also used in staging.
  • Pathologic staging can only be done on patients who have had surgery to remove or explore the extent of the cancer. It combines the results of clinical staging (physical exam, imaging tests, etc.) with the results from the surgery. In some cases, the pathologic stage may be different from the clinical stage (for example, if the surgery shows the cancer is more extensive than it was previously thought to be). Restaging is sometimes used to determine the extent of the disease if a cancer recurs (comes back) after treatment.
  • the methods and compositions of the present invention are used to treat patients with stage I breast cancer.
  • the methods and compositions of the present invention are used to treat patients with stage II breast cancer.
  • the methods and compositions of the present invention are used to treat patients with stage III breast cancer.
  • the methods and compositions of the present invention are used to treat patients with stage IV breast cancer, i.e. patients with metastatic cancer.
  • the patient having breast cancer has already failed other treatment regimens such as chemotherapy.
  • the methods and pharmaceutical compositions of the present invention may be used to prevent the development of a cancer, particularly in an individual at higher risk than average to develop such cancer than other individuals, or to treat a patient afflicted with breast cancer.
  • any means of risk assessment is contemplated by the present invention as determining which subjects are at risk for breast cancer and can undergo treatment via the methods and compositions of the present invention.
  • the invention contemplates treatment for individuals with a higher than average lifetime risk for breast cancer, the average being about one in eight women in the U.S.
  • the invention provides methods treating asymptomatic patients who have a likelihood of benefiting from therapeutic treatment of breast cancer.
  • the asymptomatic patients can comprise patients in any of the many high risk groups for breast cancer.
  • the high risk groups can include e.g. patients with a family history of breast cancer, patients of increasing age (e.g, patients 40 years of age or older), menopausal patients, patients having at least one high risk parity factor (e.g. early start of menses, late onset of menopause, no pregnancies, or late-age pregnancy), patients having high risk gene status (e.g.
  • risk factors are continually being defined and can include such considerations, as geographic location (e.g. where women living in a particular region have been found to have a higher incidence of breast cancer). Diet is also thought to play a role in breast cancer risk; specifically women who include more fat in their diet may be more likely to develop breast cancer (see Kniget et al. Cancer Epidemiol Biomarkers Prev 8(2): 123-8, 1999).
  • the Gail model is a common means of determining risk for breast cancer, and was developed based on the Breast Cancer Detection Demonstration Project (see Gail, M. et al, J Natl Cancer Inst., 1989. 81: p. 1879-86).
  • the risk factors used in the Gail model are age, age at menarche, age at first live birth, number of previous breast biopsies, number of first-degree relatives with breast cancer. These risk factors are broadly consistent with those selected from other large population-based studies.
  • a revised Gail model also incorporates race, presence of atypical hyperplasia on breast biopsy, and 1987 population rates of breast cancer and death from other causes.
  • Claus model Another commonly used prediction model is the Claus model, based on the Cancer and Steroid Hormone Study (see Claus E. et al., Cancer, 1994. 73: 643-51) and incorporates more extensive information about family history.
  • the Claus model provides individual estimates of breast-cancer risk according to decade from 29-79 years of age. It takes into account factors such as the number of first-degree and number of second- degree relatives with breast cancer, as well as different combinations of different degree relatives with breast cancer.
  • the invention also contemplates treatment for early stages of cancer, for recurrent cancer, and for those in remission from cancer.
  • the present invention also encompasses treatment for subjects with markers for breast cancer, including, but not limited to having mutations or other alterations in the genes, BRCAl, BRCA2, P53, P65, ATM, or pS2, or a changed ratio of the expression of the genes HOXBl 3 and IL17BR, amplification of the AIBl/pCIP coactivator gene, overproduction of HER2 protein and/or gene, and alterations in levels of hormones, such as estrogen and progesterone, or their receptors.
  • markers for breast cancer including, but not limited to having mutations or other alterations in the genes, BRCAl, BRCA2, P53, P65, ATM, or pS2, or a changed ratio of the expression of the genes HOXBl 3 and IL17BR, amplification of the AIBl/pCIP coactivator gene, overproduction of HER2 protein and/or gene,
  • Markers can also include neoplastic ductal epithelial cells, transforming growth factor- ⁇ , carcinoma embryonic antigen (CEA), prostate specific antigen (PSA), Erb B2 antigen, gross cystic disease fluid protein- 15 (GCDFP- 15), lactose dehydrogenase (LDH), measured in the ductal fluid, or a chromosomal abnormality in the ductal epithelial cells.
  • the marker is neoplastic ductal epithelial cells
  • the cells can be at a stage including hyperplasia, atypical hyperplasia, low grade ductal carcinoma in situ (LG-DCIS), high grade ductal carcinoma in situ (HG-DCIS) or invasive carcinoma.
  • the present invention encompasses providing the pharmaceutical compositions described herein to treat subjects with any of the described markers, and also to prevent the progression from DCIS and from atypical hyperplasia to breast cancer.
  • the combinations of the invention may be administered either prior to or following surgical removal of primary tumors and/or treatment such as administration of radiotherapy or conventional chemotherapeutic drugs.
  • Treatments for breast cancer are well known in the art and continue to be developed. Treatments include but are not limited to surgery, including axillary dissection, sentinel lymph node biopsy, reconstructive surgery, surgery to relieve symptoms of advanced cancer, lumpectomy (also called breast conservation therapy), partial (segmental) mastectomy, simple or total mastectomy, modified radical mastectomy, and radical mastectomy; immunotherapy, e.g.
  • HerceptinTM an anti-HER2 humanized monoclonal antibody developed to block the HER2 receptor
  • bone marrow transplantation peripheral blood stem cell therapy
  • bisphosphonates additional chemotherapy agents
  • radiation therapy acupressure
  • acupuncture any combination of therapies may be used in conjunction with the present invention.
  • the methods and compositions comprising the combination therapies described herein may also be used to reduce the proliferation of cancer cells, increase the death of cancer cells or, reduces the size of a tumor or spread of a tumor in a subject. It is contemplated by the present invention that the combination therapies described herein may reduce the size of a tumor or the spread of a tumor in a subject by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95% or at least 99% relative to a control such as PBS.
  • the combination therapies described herein may increase survival by 1 month, 2 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, 8 years, 9 years, 10 years, or more, it may render the subject disease-free, or it may prevent the progression from DCIS or atypical hyperplasia to breast cancer.
  • compositions of the present invention are determined in part by the particular composition being administered, as well as by the particular method used to administer the composition. Accordingly, there are a wide variety of suitable formulations of pharmaceutical compositions of the present invention ⁇ see, e.g., Remington' s Pharmaceutical Sciences, 20 th ed., 2003).
  • the compounds of the invention may be formulated into pharmaceutical compositions as natural or salt forms.
  • Pharmaceutically acceptable non-toxic salts include the base addition salts (formed with free carboxyl or other anionic groups) which may be derived from inorganic bases such as, for example, sodium, potassium, ammonium, calcium, or ferric hydroxides, and such organic bases as isopropylamine, trimethylamine, 2-ethylamino-ethanol, histidine, procaine, and the like.
  • Such salts may also be formed as acid addition salts with any free cationic groups and will generally be formed with inorganic acids such as, for example, hydrochloric, sulfuric, or phosphoric acids, or organic acids such as acetic, p-toluenesulfonic, methanesulfonic acid, oxalic, tartaric, mandelic, and the like.
  • Salts of the invention include amine salts formed by the protonation of an amino group with inorganic acids such as hydrochloric acid, hydrobromic acid, hydroiodic acid, sulfuric acid, phosphoric acid, and the like.
  • Salts of the invention also include amine salts formed by the protonation of an amino group with suitable organic acids, such as p-toluenesulfonic acid, acetic acid, and the like. Additional excipients which are contemplated for use in the practice of the present invention are those available to those of ordinary skill in the art, for example, those found in the United States Pharmacopeia Vol. XXII and National Formulary Vol. XVII, U.S. Pharmacopeia Convention, Inc., Rockville, Md. (1989), the relevant contents of which is incorporated herein by reference. [0177] In a preferred embodiment, a composition of the invention is a pharmaceutical composition.
  • compositions comprise a prophylactically or therapeutically effective amount of one or more prophylactic or therapeutic agents, including at least one HDAC inhibitor and at least one hormonal therapy agent and a pharmaceutically acceptable carrier.
  • compositions comprise a prophylactically or therapeutically effective amount of at least one HDAC inhibitor, and a prophylactically or therapeutically effective amount of one or more of an IGF-IR inhibitor, an EGFR inhibitor, or an mTOR inhibitor, and optionally a prophylactically or therapeutically effective amount of one or more hormonal therapy agents and a pharmaceutically acceptable carrier.
  • compositions comprise a prophylactically or therapeutically effective amount of one or more prophylactic or therapeutic agents, including at least one HDAC inhibitor, at least one hormonal therapy agent, an additional active ingredient as described herein, and a pharmaceutically acceptable carrier.
  • the term "pharmaceutically acceptable” means approved by a regulatory agency of the Federal or a state government or listed in the U.S. [0179] Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans.
  • carrier refers to a diluent, adjuvant (e.g., Freund's adjuvant (complete and incomplete)), excipient, or vehicle with which the therapeutic is administered.
  • Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like. Water is a preferred carrier when the pharmaceutical composition is administered intravenously.
  • Saline solutions and aqueous dextrose and glycerol solutions can also be employed as liquid carriers, particularly for injectable solutions.
  • suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, dried skim milk, glycerol, propylene, glycol, water, ethanol and the like.
  • the composition if desired, can also contain minor amounts of wetting or emulsifying agents, or pH buffering agents. These compositions can take the form of solutions, suspensions, emulsion, tablets, pills, capsules, powders, sustained-release formulations and the like.
  • Oral formulation can include standard carriers such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharine, cellulose, magnesium carbonate, etc. Examples of suitable pharmaceutical carriers are described in "Remington's Pharmaceutical Sciences” by E. W. Martin.
  • Such compositions will contain a prophylactically or therapeutically effective amount of a prophylactic or therapeutic agent preferably in purified form, together with a suitable amount of carrier so as to provide the form for proper administration to the patient.
  • the formulation should suit the mode of administration.
  • the pharmaceutical compositions are sterile and in suitable form for administration to a subject, preferably an animal subject, more preferably a mammalian subject, and most preferably a human subject.
  • compositions of the invention may be desirable to administer locally to the area in need of treatment; this may be achieved by, for example, and not by way of limitation, local infusion, by injection, or by means of an implant, said implant being of a porous, non-porous, or gelatinous material, including membranes, such as sialastic membranes, or fibers.
  • an implant being of a porous, non-porous, or gelatinous material, including membranes, such as sialastic membranes, or fibers.
  • care must be taken to use materials to which the prophylactic or therapeutic agents do not absorb.
  • the composition can be delivered in a vesicle, in particular a liposome (see Langer, Science 249: 1527-1533 (1990); Treat et al., in Liposomes in the Therapy of Infectious Disease and Cancer, Lopez -Berestein and Fidler (eds.), Liss, New York, pp. 353-365 (1989); Lopez-Berestein, pp. 317-327; see generally above.).
  • the composition can be delivered in a controlled release or sustained release system.
  • a pump may be used to achieve controlled or sustained release (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng.
  • polymeric materials can be used to achieve controlled or sustained release of the antibodies of the invention or fragments thereof (see e.g., Medical Applications of Controlled Release, Langer and Wise (eds.), CRC Pres., Boca Raton, FIa. (1974); Controlled Drug Bioavailability, Drug Product Design and
  • polymers used in sustained release formulations include, but are not limited to, poly(2-hydroxy ethyl methacrylate), poly(methyl methacrylate), poly(acrylic acid), poly(ethylene-co-vinyl acetate), poly(methacrylic acid), polyglycolides (PLG), polyanhydrides, poly(N-vinyl pyrrolidone), poly(vinyl alcohol), polyacrylamide, poly(ethylene glycol), polylactides (PLA), poly(lactide-co-glycolides) (PLGA), and polyorthoesters.
  • the polymer used in a sustained release formulation is inert, free of leachable impurities, stable on storage, sterile, and biodegradable.
  • a controlled or sustained release system can be placed in proximity of the therapeutic target, i.e., the lungs, thus requiring only a fraction of the systemic dose (see, e.g., Goodson, in Medical Applications of Controlled Release, supra, vol. 2, pp. 115-138 (1984)).
  • Controlled release systems are discussed in the review by Langer (1990, Science 249: 1527-1533). Any technique known to one of skill in the art can be used to produce sustained release formulations comprising one or more antibodies of the invention or fragments thereof. See, e.g., U.S. Pat. No. 4,526,938, International publication No. WO 91/05548, International publication No.
  • the nucleic acid can be administered in vivo to promote expression of its encoded prophylactic or therapeutic agents, by constructing it as part of an appropriate nucleic acid expression vector and administering it so that it becomes intracellular, e.g., by use of a retroviral vector (see U.S. Pat. No.
  • a pharmaceutical composition of the invention is formulated to be compatible with its intended route of administration.
  • suitable routes of administration include, but are not limited to, parenteral (e.g., intravenous, intramuscular, intradermal, intra-tumoral, intra-synovial, and subcutaneous), oral (e.g., inhalation), intranasal, transdermal (topical), transmucosal, intra-tumoral, intra-synovial, vaginal, and rectal administration.
  • parenteral e.g., intravenous, intramuscular, intradermal, intra-tumoral, intra-synovial, and subcutaneous
  • oral e.g., inhalation
  • intranasal e.g., transdermal (topical)
  • transmucosal intra-tumoral, intra-synovial, vaginal
  • rectal administration e.g., transmucosal, intra-tumoral, intra-synovial, vaginal, and rectal administration.
  • the composition is formulated in accordance with
  • compositions for intravenous administration are solutions in sterile isotonic aqueous buffer.
  • the composition may also include a solubilizing agent and a local anesthetic such as lignocaine to ease pain at the site of the injection.
  • compositions of the invention are to be administered topically, the compositions can be formulated in the form of, e.g., a toothpaste, ointment, cream, transdermal patch, lotion, gel, oral gel, shampoo, spray, aerosol, solution, emulsion, or other form well-known to one of skill in the art. See, e.g., Remington's Pharmaceutical Sciences and Introduction to Pharmaceutical Dosage Forms, 4.sup.th ed., Lea & Febiger, Philadelphia, Pa. (1985).
  • viscous to semi-solid or solid forms comprising a carrier or one or more excipients compatible with topical application and having a dynamic viscosity preferably greater than water are typically employed.
  • suitable formulations include, without limitation, solutions, suspensions, emulsions, creams, ointments, powders, liniments, salves, and the like, which are, if desired, sterilized or mixed with auxiliary agents (e.g., preservatives, stabilizers, wetting agents, buffers, or salts) for influencing various properties, such as, for example, osmotic pressure.
  • suitable topical dosage forms include sprayable aerosol preparations wherein the active ingredient, preferably in combination with a solid or liquid inert carrier, is packaged in a mixture with a pressurized volatile (e.g., a gaseous propellant, such as freon), or in a squeeze bottle.
  • a pressurized volatile e.g., a gaseous propellant, such as freon
  • Moisturizers or humectants can also be added to pharmaceutical compositions and dosage forms if desired. Examples of such additional ingredients are well-known in the art.
  • compositions of the invention are to be administered intranasally, the compositions can be formulated in an aerosol form, spray, mist or in the form of drops.
  • prophylactic or therapeutic agents for use according to the present invention can be conveniently delivered in the form of an aerosol spray presentation from pressurized packs or a nebuliser, with the use of a suitable propellant, e.g., dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas.
  • a suitable propellant e.g., dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas.
  • the dosage unit may be determined by providing a valve to deliver a metered amount.
  • Capsules and cartridges of, e.g., gelatin for use in an inhaler or insufflator may be formulated containing
  • compositions of the invention are to be administered orally, the compositions can be formulated orally in the form of, e.g., gum, tablets, capsules, cachets, gelcaps, solutions, suspensions and the like. Tablets or capsules can be prepared by conventional means with pharmaceutically acceptable excipients such as binding agents (e.g., pregelatinised maize starch, polyvinylpyrrolidone or hydroxypropyl methylcellulose); fillers (e.g., lactose, microcrystalline cellulose or calcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talc or silica); disintegrants (e.g., potato starch or sodium starch glycolate); or wetting agents (e.g., sodium lauryl sulphate).
  • binding agents e.g., pregelatinised maize starch, polyvinylpyrrolidone or hydroxypropyl methylcellulose
  • fillers e.g., lactose, microcrystalline cellulose
  • Liquid preparations for oral administration may take the form of, for example, solutions, syrups or suspensions, or they may be presented as a dry product for constitution with water or other suitable vehicle before use.
  • Such liquid preparations may be prepared by conventional means with pharmaceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives or hydrogenated edible fats); emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles (e.g., almond oil, oily esters, ethyl alcohol or fractionated vegetable oils); and preservatives (e.g., methyl or propyl-p-hydroxybenzoates or sorbic acid).
  • suspending agents e.g., sorbitol syrup, cellulose derivatives or hydrogenated edible fats
  • emulsifying agents e.g., lecithin or acacia
  • non-aqueous vehicles e.g., almond oil, oily esters, ethy
  • compositions of the invention may be formulated for parenteral administration by injection, e.g., by bolus injection or continuous infusion.
  • Formulations for injection may be presented in unit dosage form, e.g., in ampoules or in multi-dose containers, with an added preservative.
  • the compositions may take such forms as suspensions, solutions or emulsions in oily or aqueous vehicles, and may contain formulatory agents such as suspending, stabilizing and/or dispersing agents.
  • the active ingredient may be in powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.
  • a suitable vehicle e.g., sterile pyrogen-free water
  • compositions of the invention may also be formulated in rectal compositions such as suppositories or retention enemas, e.g., containing conventional suppository bases such as cocoa butter or other glycerides.
  • compositions of the invention may also be formulated as a depot preparation. Such long acting formulations may be administered by implantation (for example subcutaneously or intramuscularly) or by intramuscular injection.
  • the compositions may be formulated with suitable polymeric or hydrophobic materials (for example as an emulsion in an acceptable oil) or ion exchange resins, or as sparingly soluble derivatives, for example, as a sparingly soluble salt.
  • compositions of the invention can be formulated as neutral or salt forms.
  • Pharmaceutically acceptable salts include those formed with anions such as those derived from hydrochloric, phosphoric, acetic, oxalic, tartaric acids, etc., and those formed with cations such as those derived from sodium, potassium, ammonium, calcium, ferric hydroxides, isopropyl amine, triethylamine, 2-ethylamino ethanol, histidine, procaine, etc.
  • compositions of the invention are supplied either separately or mixed together in unit dosage form, for example, as a dry lyophilized powder or water free concentrate in a hermetically sealed container such as an ampoule or sachette indicating the quantity of active agent.
  • a hermetically sealed container such as an ampoule or sachette indicating the quantity of active agent.
  • the composition is to be administered by infusion, it can be dispensed with an infusion bottle containing sterile pharmaceutical grade water or saline.
  • an ampoule of sterile water for injection or saline can be provided so that the ingredients may be mixed prior to administration.
  • Kits [0194] The invention provides a pharmaceutical pack or kit comprising one or more containers filled with individual components (in pharmaceutical formulations) of the combination therapies described herein; for example, contained filled with an HDAC inhibitor and one or more hormonal therapy agents, and/or one or more therapeutic or prophylactic agents such as an IGF-IR inhibitor, an EGFR inhibitor, an mTOR inhibitor, or another active ingredient.
  • Containers may also be filled with an HDAC inhibitor, and one or more therapeutic or prophylactic agents such as an IGF-IR inhibitor, an EGFR inhibitor, an mTOR inhibitor, and/or another active ingredient.
  • the pharmaceutical pack or kit may further comprises one or more other prophylactic or therapeutic agents useful for the treatment of a disease or disorder.
  • the invention also provides a pharmaceutical pack or kit comprising one or more containers filled with one or more of the ingredients of the pharmaceutical compositions of the invention.
  • Optionally associated with such container(s) can be a notice in the form prescribed by a governmental agency regulating the manufacture, use or sale of pharmaceuticals or biological products, which notice reflects approval by the agency of manufacture, use or sale for human administration.
  • the present invention provides pharmaceutical packs or kits that can be used in the above methods.
  • a kit comprises at least one HDAC inhibitor and at least one hormonal therapy agent in one or more containers.
  • the kit may further comprises one or more other prophylactic or therapeutic agents, or active ingredients useful for the treatment of cancer in one or more containers.
  • the kit may comprise at least one HDAC inhibitor, and one or more of at least one or more of an IGF-IR inhibitor, an EGFR inhibitor or mTOR inhibitor. Examples of such agents and compounds are disclosed above. Articles of Manufacture
  • the present invention also encompasses a finished packaged and labeled pharmaceutical product.
  • This article of manufacture includes the appropriate unit dosage form in an appropriate vessel or container such as a glass vial or other container that is hermetically sealed.
  • the active ingredient is sterile and suitable for administration as a particulate free solution.
  • the unit dosage form may be a solid suitable for oral, transdermal, intratumoral, intra-synovial, topical or mucosal delivery.
  • the unit dosage form is suitable for intravenous, intramuscular, intratumoral, intra-synovial, or subcutaneous delivery.
  • the invention encompasses solutions, preferably sterile, suitable for each delivery route.
  • the packaging material and container are designed to protect the stability of the product during storage and shipment.
  • the products of the invention include instructions for use or other informational material that advise the physician, technician or patient on how to appropriately prevent or treat the disease or disorder in question.
  • the article of manufacture includes instruction means indicating or suggesting a dosing regimen including, but not limited to, actual doses, monitoring procedures (such as methods for monitoring mean absolute lymphocyte counts, tumor cell counts, calcium concentration, and tumor size) and other monitoring information.
  • the invention provides an article of manufacture comprising packaging material, such as a box, bottle, tube, vial, container, sprayer, insufflator, intravenous (i.v.) bag, envelope and the like; and at least one unit dosage form of a pharmaceutical agent contained within said packaging material.
  • packaging material such as a box, bottle, tube, vial, container, sprayer, insufflator, intravenous (i.v.) bag, envelope and the like
  • a unit dosage form of a pharmaceutical agent contained within said packaging material such as a box, bottle, tube, vial, container, sprayer, insufflator, intravenous (i.v.) bag, envelope and the like.
  • an article of manufacture comprises packaging material and a pharmaceutical agent and instructions contained within said packaging material, wherein said pharmaceutical agent comprises at least one HDAC inhibitor, at least one hormonal therapy agent, optionally another "active ingredient," and a pharmaceutically acceptable carrier, and said instructions indicate a dosing regimen for preventing, treating or managing a subject with cancer.
  • an article of manufacture comprises packaging material and a pharmaceutical agent and instructions contained within said packaging material, wherein said pharmaceutical agent comprises an HDAC inhibitor, and one or more of at an IGF-IR inhibitor, EGFR inhibitor, or mTOR inhibitor, and a pharmaceutically acceptable carrier, and said instructions indicate a dosing regimen for preventing, treating or managing a subject with a cancer.
  • the compounds utilized in the pharmaceutical method of the invention are administered at the initial dosage of about 0.001 mg/kg to about 1000 mg/kg daily.
  • the dosages may be varied depending upon the requirements of the patient, the severity of the condition being treated, and the compound being employed. For example, dosages can be empirically determined considering the type and stage of cancer diagnosed in a particular patient.
  • the dose administered to a patient should be sufficient to effect a beneficial therapeutic response in the patient over time.
  • the size of the dose also will be determined by the existence, nature, and extent of any adverse side-effects that accompany the administration of a particular compound in a particular patient. Determination of the proper dosage for a particular situation is within the skill of the practitioner. Generally, treatment is initiated with smaller dosages which are less than the optimum dose of the compound. Thereafter, the dosage is increased by small increments until the optimum effect under circumstances is reached. For convenience, the total daily dosage may be divided and administered in portions during the day, if desired. Doses can be given daily, or on alternate days, as determined by the treating physician. Characterization and demonstration of therapeutic or prophylactic utility
  • Toxicity and efficacy of the prophylactic and/or therapeutic treatments and protocols of the instant invention can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD 50 (the dose lethal to 50% of the population) and the ED 50 (the dose therapeutically effective in 50% of the population).
  • the dose ratio between toxic and therapeutic effects is the therapeutic index and it can be expressed as the ratio LD50/ED 5 0.
  • Prophylactic and/or therapeutic agents that exhibit large therapeutic indices are preferred. While prophylactic and/or therapeutic agents that exhibit toxic side effects may be used, care should be taken to design a delivery system that targets such agents to the site of affected tissue in order to minimize potential damage to uninfected cells and, thereby, reduce side effects.
  • the data obtained from the cell culture assays and animal studies can be used in formulating a range of dosage of the prophylactic and/or therapeutic agents for use in humans.
  • the dosage of such agents lies preferably within a range of circulating concentrations that include the ED 50 with little or no toxicity.
  • the dosage may vary within this range depending upon the dosage form employed and the route of administration utilized.
  • the therapeutically effective dose can be estimated initially from cell culture assays.
  • a dose may be formulated in animal models to achieve a circulating plasma concentration range that includes the IC 5O (i.e., the concentration of the test compound that achieves a half- maximal inhibition of symptoms) as determined in cell culture.
  • IC 5O i.e., the concentration of the test compound that achieves a half- maximal inhibition of symptoms
  • levels in plasma may be measured, for example, by high performance liquid chromatography.
  • any of the assays described herein including those described and illustrated in the Examples section below, as well as those known in the art.
  • Also encompassed by the invention to determine therapeutic or prophylactic utility are any relevant cancer, and more specifically, breast cancer animal models.
  • pending safety and efficacy are clinical trials to assess the combinations of the present invention.
  • MCF-7 cells were provided by C. Walker (MD Anderson Cancer Center, Houston, TX) and were routinely cultured in IMEM
  • fetal calf serum FBS
  • Ishikawa cells were also provided by C. Walker and cultured in DMEM/Ham's F12 with 10% FBS.
  • T47 -D cells were obtained from ATCC and were routinely cultured in DMBM (Invitrogen) plus 10% FBS.
  • ZR-75-1 cells were provided by B. Hahn (University of California, San Francisco) and were routinely cultured in RPMI (Invitrogen) plus 10% PBS.
  • MCF-7/neo and MCF-7/HER2 clone 18 cells were also obtained from B. Hahn and cultured in DMEM plus 10% FBS.
  • MCF-7aro cells were provided by S. Chen (Beckham Research Institute of the City of Hope) and routinely grown in DMEM/Ham's Fl 2 plus 10% FBS. For all experiments cells were switched to phenol red-free media containing 5% charcoal/dextran-stripped FBS (Hyclone) for 3-5 days prior to start of the experiment. Cells were treated with ligands in media containing 2-5% stripped PBS for the indicated times. 17 ⁇ -estradiol (E2), 4-trans-hydroxytamoxifen (OH-Tam), raloxifene, trichostatin A, valproic acid sodium salt (sodium 2-propylpentanoate) were obtained from Sigma- Aldrich (St. Louis, MO). Fulvestrant (ICI 182,780) was obtained from Tocris (Ellisvllle, MO) and suberoylanilide hydroxamic acid (SAHA) from BioVision (Mountain View, CA).
  • MCF-7 cells growing on coverslips were treated with ligands for 72 hours and unfixed cells were assayed with the Annexin-V-FLOUS Staining kit (Roche), according to manufacturer's instructions. Total cell number was determined by counting nuclei stained with Hoescht 33342 (Roche). Fluorescence was analyzed using a Zeiss Axioplan fluorescent microscope (Zeiss, Thomwood, NY).
  • ERE-Luc reporter gene has been previously described (Liu, M.M., et al., J Biol Chem., 2002. 277(27): p. 24353- 60; Webb, P., et al., MoI Endocrinol., 1999. 13(10): p. 1672-85).
  • MCF-7 cells were grown in 100 mm dishes and treated with ligands in triplicate. Cells were harvested 24 hours later using a lysis buffer containing 65.2 mM Tris-HCl, 154 mM NaCl, 1 : 100 NP-40,l:400 sodium doxycholate, 2 mM sodium orthovanadate, 1 mM sodium flouride, 1 mM phenylmethylsulphonylfluoride, and 1 ⁇ g/ml each of leupeptin, aprotinin and pepstatin.
  • a lysis buffer containing 65.2 mM Tris-HCl, 154 mM NaCl, 1 : 100 NP-40,l:400 sodium doxycholate, 2 mM sodium orthovanadate, 1 mM sodium flouride, 1 mM phenylmethylsulphonylfluoride, and 1 ⁇ g/ml each of leupeptin, aprotinin and pepstatin.
  • T47D and ZR-75-1 cells responded similarly to MCF-7 cells, with VPA and tamoxifen cooperating in their anti-proliferative effects, particularly in the presence of E2 (Fig. IB and 1C).
  • ZR-75-1 cells which exhibited a higher level of basal proliferation compared to the other two cell lines, were also significantly inhibited by co-treatment of VPA and tamoxifen in the absence of E2. Together, these results indicate that VPA and tamoxifen cooperate, combines effectively in their anti-proliferative effects for ER-positive breast cancer cells and suggest an enhanced efficacy over that of either ligand alone.
  • VPA enhances the potency and efficacy of both antiestrogen and aromatase inhibitor action on breast cancer cells
  • VPA Whether VPA could change the efficacy and/or potency of tamoxifen in a dose responsive proliferation assay was next investigated.
  • MCF-7 cells were treated with a range of concentrations of tamoxifen, both in the presence and absence of 750 ⁇ M VPA (FIG. 2A).
  • VPA treatment alone inhibited E2-stimulated cell proliferation by 25% and enhanced the relative efficacy of tamoxifen at all doses tested.
  • VPA also enhanced the IC 5 o for tamoxifen treatment to 3 nM, compared to 25 nM when tamoxifen was used alone.
  • VPA enhanced the potency as well as the efficacy of tamoxifen action on cell proliferation.
  • VPA farnesoid fulvestrant
  • FIG. 2B MCF-7 cells were treated with VPA in combination with the selective estrogen receptor modulator raloxifene or the pure antiestrogen fulvestrant.
  • Raloxifene substantially decreased E2-stimulated growth and VPA further enhanced its inhibitory effect, similar to that observed with tamoxifen.
  • Higher concentrations of fulvestrant decreased E2-induced proliferation, however, VPA did not further add to its inhibitory effect.
  • VPA enhanced the anti-proliferative effect of lower doses of fulvestrant in a dose responsive manner (Fig. 2C).
  • MCF-7 cells were used with stably expressed aromatase (MCF-7aro) to determine if VPA would enhance the inhibition of proliferation observed with aromatase inhibitors.
  • MCF-7aro stably expressed aromatase
  • testosterone stimulated proliferation as well as E2, indicating that aromatase is functional in MCF-7aro cells and converting testosterone to E2.
  • the aromatase inhibitor letrozole inhibited testosterone-induced proliferation in a dose responsive manner.
  • VPA inhibited proliferation more than that observed with letrozole alone, regardless of the dose tested.
  • EXAMPLE 3 Other HDAC inhibitors behave similarly to VPA in enhancing the actions of tamoxifen on breast cancer cells
  • tamoxifen was treated in combination with various doses of TSA and SAHA, two well-described HDAC inhibitors as well as VPA for comparison.
  • Treatment of MCF-7 cells with doses of VPA ranging from 50 ⁇ M to 5 M resulted in an IC 5O of 800 ⁇ M (FIG. 3A).
  • VPA also enhanced the action of tamoxifen, which inhibited cell proliferation about 25% by itself, and combined effectively with VPA at all doses tested.
  • tamoxifen co-treatment enhanced the potency of VPA, resulting in a slight shift of the IC 50 to 500 ⁇ M.
  • TSA and SAHA two well-known HDAC inhibitors, had actions similar to that of VPA (FIG. 3B- 3C). They enhanced the antiproliferative action of tamoxifen and their IC 5O was shifted by the presence of OH-T am. Thus, the IC50 of TSA alone was 51 nM and co-treatment with tamoxifen shifted the IC 50 to 32 nM. Similarly, tamoxifen shifted the IC 50 of SAHA from 300 nM to 125 nM. These data suggest that HDAC inhibitors in general cooperate, or combines effectively with the antiproliferative effects of tamoxifen.
  • VPA induces apoptosis and enhances the apoptotic activity of tamoxifen
  • VPA enhanced the antiproliferative effect of tamoxifen by halting cell cycle progression
  • flow cytometry was used to measure the number of cells in each phase of the cell cycle
  • MCF-7 cells were treated with ligands for 48 hours and the population of cells in Gl, S and G2 was estimated based on DNA content (FIG. 4E).
  • VPA treatment alone induced a small arrest in the Gl phase in the absence of E2, but had no effect when E2 was present. Tamoxifen had a dramatic effect of arresting cells in Gl in the presence of E2, as expected.
  • VPA may be enhancing the action of tamoxifen by some means other than altering cell cycle progression, for example by increasing cell death.
  • MCF-7 cells were observed with phase microscopy to determine whether VPA and tamoxifen induced morphological changes such as those observed in cells undergoing apoptosis. After 6 days in culture, E2-treated cells grew into a confluent monolayer, covering virtually every available space in the culture dish (FIG. 4A).
  • VPA- treated cultures exhibited fewer cells as well as an increased number of floating cells (FIG. 4B). Even fewer cells were observed with tamoxifen treatment than for cells treated with VPA (FIG. 4C). VPA and tamoxifen treatment in combination led to a dramatic decrease in cell number, leaving far fewer cells than after treatment with either tamoxifen or VPA alone (FIG. 4D). Additionally, VPA and tamoxifen co-treatment produced an increased proportion of cells exhibiting bright, condensed, and/or rounded cells with an increased number of floating cells, morphologies indicative of cells in late- stage apoptosis.
  • VPA slightly downregulated ERa protein expression and also attenuated the increased ERa expression that is typically seen with tamoxifen treatment. However, this effect was only observed in the absence of E2. ERa protein levels were undetectable in these lysates and expression was not altered with ligand treatment. VPA did not alter cyclin Dl expression nor did it alter tamoxifen- mediated down regulation of cyclin Dl, consistent with the lack of effect on cell cycle progression.
  • the pro-apoptotic gene Bik has been reported to be an essential mediator of apoptosis in MCF-7 cells where its expression is downregulated by E2 and upregulated by estrogen withdrawal or by the pure antiestrogen fulvestrant (Hur, J., et al., Proc Natl Acad Sci USA., 2004. 101(8): p. 2351-6). Under E2-deprived conditions, where Bik protein is expressed at high levels, cotreatment with VPA and tamoxifen had minimal effects on Bik expression (FIG. 5B).
  • VPA enhances the antiproliferative effect of tamoxifen in MCF-7 cells overexpressing HER 2/neu
  • VPA reverses the agonist activity of tamoxifen in endometrial cells
  • carbamazepine 50 ⁇ M combines effectively with the mTOR inhibitor, rapamycin (2nM), with picropodophyllin (100 nM), an IGF-IR inhibitor, and with tamoxifen (10 nM), to slow the growth of breast cancer cells (FIG. 9).
  • the HDAC inhibitor VPA (750 ⁇ M) combines effectively with the mTOR inhibitor, rapamycin (0.05 nM), with picropodophyllin (100 nM), an IGF-IR inhibitor, and with tamoxifen (100 nM), to slow the growth of breast cancer cells (FIG. 10).
  • the components other than tamoxifen combine effectively with each other and with tamoxifen.
  • the HDAC inhibitor VPA(750 ⁇ M) combines effectively with the mTOR inhibitor, rapamycin (0.025 nM), and with gefitinib (1 ⁇ M), an EGFR inhibitor, with and without tamoxifen (100 nM), to slow the growth of breast cancer cells (FIG. 11).
  • Example 12 illustrates that in MCF-7 cells, combinations of HDAC inhibitors with (-)-epigallocatechin-3-gallate (EGCG), rapamycin, and tamoxifen are more efficacious than treatment with any single agent alone to slow the growth of breast cancer cells.
  • FIG. 12 A The HDAC inhibitor is valproic acid (750 ⁇ M), EGCG was used at 20 ⁇ M, rapamycin was used at 1 nM, and OH-tamoxifen was used at 10 nM.
  • FIG. 12 A The HDAC inhibitor is valproic acid (750 ⁇ M)
  • EGCG was used at 20 ⁇ M
  • rapamycin was used at 1 nM
  • OH-tamoxifen was used at 10 nM.
  • FIG. 12B The HDAC inhibitor is trichostatin A (I nM), EGCG was used at 20 ⁇ M, rapamycin was used at 1 nM, and OH-tamoxifen was used at 10 nM.
  • FIG. 12C Carbamazepine (50 ⁇ M),
  • EGCG was used at 20 ⁇ M
  • rapamycin was used at 2 nM
  • OH-tamoxifen was used at 1O nM.
  • Endoxifen cooperates with the antiproliferative effects of the HDAC inhibitor VPA (750 ⁇ M) and the IGF-IR inhibitor EGCG (lO ⁇ M) in breast cancer cells.
  • Endoxifen (4-hydroxy-N-Desmethyltamoxifen) is an active metabolite of tamoxifen and inhibits ER ⁇ -positive breast cancer cell growth at comparable doses (1OnM).
  • a combination of all three drugs is more efficacious at inhibiting breast cancer cell growth than treatment with any single drug or any two drugs used in combination (FIG 13).
  • HDAC inhibitor 750 ⁇ M VPA
  • IGF- 1 R inhibitor (20 ⁇ M EGCG)
  • mTOR inhibitor (2nM rapamycin) enhances the antiproliferative effect of tamoxifen (1OnM) in tamoxifen-resistant breast cancer cells (MCF7-Her2). Note that a combination of all four drugs together is more efficacious at inhibiting tamoxifen- resistant breast cancer cell growth than any single drug alone.
  • MCF7-neo cells parental cells from which MCF7-Her2 cells were derived
  • data from MCF7-neo cells that illustrates that the same combination of the drugs (VPA, EGCG, rapamycin and tamoxifen) is more effective at inhibiting cell proliferation when treated together than any drug alone or in double or triple combination (FIG 14).
  • MCF-7 cells were cultured in 2.5% ISCS IMEM media + lOOpM Estrogen. The cells were treated twice a day with a valproic acid (750 ⁇ M VPA) + tamoxifen (1OnM OH-Tam) cocktail or vehicle control equivalent. The treatments lasted for 7 days as indicated in FIG. 16. After 7 days, proliferation was measured using a DNA-binding fluorescent dye.
  • EXAMPLE 17 The HDAC inhibitors MS-275 and PXDlOl combine effectively with hydroxytamoxifen or aromatase therapy to reduce growth of MCF-7 cells
  • MCF-7-Aro cells (2500 cells/well on a 96-well plate) were cultured in 2.5% CDSS Ham's/F12 media + 1OnM Androstenedione.
  • the HDAC inhibitors MS-275 (50OnM) and PXDlOl (10OnM), and the aromatase inhibitor Anastrazole (10 ⁇ M) were applied to the cells as indicated in FIG. 17. The treatments continued for 5 days.
  • the combination of either HDAC inhibitor with Anastrazole was more effective in reducing growth of the human breast cancer cells than any agent alone.
  • combination of an HDAC inhibitor with hydroxytamoxifen was more effective than any single agent alone at the same dose.
  • MCF-7-Tx cells (1250 cells/well on a 96-well plate) were cultured in 2.5% IMEM media +10OpM 17- ⁇ -Estradiol.
  • EXAMPLE 18 In vivo reduction of tumor volume with the HDAC inhibitor VPA and tamoxifen
  • mice Fifty immunocompromised (Nu/Nu) female mice, 7-9 weeks old, and 20-25g in weight were used to confirm the in vitro results described herein. The mice were divided into four groups with 8 mice/ group, and treated as indicated in FIG. 19. MCF-7-Clonel8 xenografts were implanted (10,000,000 cells/xenograft) into the right flank of each animal. Treatments began on day 14 and lasted for 28 days, a) Different from Veh (p ⁇ 0.05). b) Different from Tarn (p ⁇ 0.05).

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Abstract

La présente invention concerne des inhibiteurs HDAC pouvant être utilisés en combinaison avec une thérapie hormonale pour traiter et prévenir un cancer du sein positif aux récepteurs des oestrogènes. Les inhibiteurs HDAC peuvent également être combinés avec des inhibiteurs IGF-IR, des inhibiteurs mTOR et des inhibiteurs EGFR pour traiter un cancer du sein, éventuellement en combinaison avec une thérapie hormonale, si nécessaire. Des combinaisons de composés avec ou sans les inhibiteurs HDAC et avec ou sans thérapie hormonale peuvent également être utilisées. Cette invention concerne également des méthodes thérapeutiques et des compositions pharmaceutiques.
PCT/US2009/001275 2008-02-27 2009-02-27 Méthodes permettant de traiter et de prévenir le cancer du sein WO2009108361A1 (fr)

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Cited By (3)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2012104241A1 (fr) * 2011-01-31 2012-08-09 LUCOLAS-M.D. Ltd Combinaisons d'inhibiteurs de l'aromatase et d'antioxydants
US20150025049A1 (en) * 2013-07-19 2015-01-22 The Johns Hopkins University Compositions comprising exemestane and novel methods of use
WO2016054511A1 (fr) * 2014-10-02 2016-04-07 The Board Of Regents Of The University Of Texas System Utilisation d'inhibiteurs de mtor pour la prévention d'un dysfonctionnement lié au vieillissement de cellules souches

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US20060025337A1 (en) * 2003-07-01 2006-02-02 President And Fellows Of Harvard College Sirtuin related therapeutics and diagnostics for neurodegenerative diseases
US20060241178A1 (en) * 2002-12-30 2006-10-26 Immuneguard Llc Compositions and methods for treating lung cancer
US20070015787A1 (en) * 2003-11-13 2007-01-18 Milan Bruncko Apoptosis promoters

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* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US20060241178A1 (en) * 2002-12-30 2006-10-26 Immuneguard Llc Compositions and methods for treating lung cancer
US20060025337A1 (en) * 2003-07-01 2006-02-02 President And Fellows Of Harvard College Sirtuin related therapeutics and diagnostics for neurodegenerative diseases
US20070015787A1 (en) * 2003-11-13 2007-01-18 Milan Bruncko Apoptosis promoters

Cited By (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2012104241A1 (fr) * 2011-01-31 2012-08-09 LUCOLAS-M.D. Ltd Combinaisons d'inhibiteurs de l'aromatase et d'antioxydants
EP2649994A1 (fr) * 2011-01-31 2013-10-16 LUCOLAS-M.D. Ltd. Combinaisons d'inhibiteurs de l'aromatase et d'antioxydants
JP2014507419A (ja) * 2011-01-31 2014-03-27 ルコラス−エム．ディー．リミテッド 医薬的使用
US10835540B2 (en) 2011-01-31 2020-11-17 Lucolas-M.D. Ltd. Pharmaceutical use
US20150025049A1 (en) * 2013-07-19 2015-01-22 The Johns Hopkins University Compositions comprising exemestane and novel methods of use
US9585894B2 (en) * 2013-07-19 2017-03-07 The Johns Hopkins University Compositions comprising exemestane and novel methods of use
WO2016054511A1 (fr) * 2014-10-02 2016-04-07 The Board Of Regents Of The University Of Texas System Utilisation d'inhibiteurs de mtor pour la prévention d'un dysfonctionnement lié au vieillissement de cellules souches

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