title: Phase III, double-blind, controlled trial of atamestane plus toremifene compared with letrozole in postmenopausal women with advanced receptor-positive breast cancer.
abstract: OBJECTIVE
  To compare time to progression (TTP) with a steroidal aromatase inhibitor (AI) atamestane (ATA) combined with toremifene (TOR; complete estrogen blockade) versus letrozole (LET) in receptor-positive advanced breast cancer (ABC).
  
  
  METHODS
  Eligibility included postmenopausal receptor-positive ABC and adjuvant hormonal therapy completed more than 12 months prior to study entry. Participants received daily ATA 500 mg with TOR 60 mg (ATA + TOR), or letrozole 2.5 mg (LET). The primary end point was TTP, whereas secondary objectives included objective response (OR), overall survival (OS), and time to treatment failure (TTF). The study had 80% power to detect a 25% increase in TTP assuming a TTP of 9.4 months in the LET population.
  
  
  RESULTS
  A total of 865 patients were randomly assigned (434 to ATA + TOR and 431 to LET) in 60 centers in the United States, Canada, Russia, and Ukraine. Baseline characteristics were balanced. Median TTP was identical in the two arms at 11.2 months (P < .92). Median TTF was similar at 9.24 months (ATA + TOR) versus 10.44 months (LET). The hazard ratios (LET/ATA + TOR) were 1.00 (95% CI, 0.92 to 1.08) for TTP, 0.99 (95% CI, 0.92 to 1.06) for TTF, and 0.98 (95% CI, 0.87 to 1.11) for OS. OR occurred in 30% of patients receiving ATA + TOR and in 36% of patients receiving LET (P < .1). Adverse events (AEs) were similar for patients receiving ATA + TOR versus LET, and serious AEs were 10% v 11%, respectively.
  
  
  CONCLUSIONS
  TTP for patients receiving ATA + TOR was identical to that for patients receiving LET, representing the first endocrine therapy comparable to LET in ABC. Unlike in the Anastrozole, Tamoxifen, and Combined trial, addition of an antiestrogen did not decrease efficacy of the AI. Future studies of AIs in combination with more effective selective estrogen receptor modulators or selective receptor downregulators is warranted.
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. pgoss@partners.org
authors.forename: Paul
authors.initials: P
authors.lastname: Goss
authors.forename: Igor N
authors.initials: IN
authors.lastname: Bondarenko
authors.forename: Georgiy N
authors.initials: GN
authors.lastname: Manikhas
authors.forename: Kelly B
authors.initials: KB
authors.lastname: Pendergrass
authors.forename: Wilson H
authors.initials: WH
authors.lastname: Miller
authors.forename: Peter
authors.initials: P
authors.lastname: Langecker
authors.forename: Dennis
authors.initials: D
authors.lastname: Blanchett
mesh_terms: D000368:Aged; D000735:Androstenedione / Q000008:administration & dosage / Q000031:analogs & derivatives*; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000378:metabolism; D018450:Disease Progression; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D000077289:Letrozole; D008875:Middle Aged; D009570:Nitriles / Q000008:administration & dosage*; D017698:Postmenopause; D011987:Receptors, Steroid / Q000378:metabolism; D017312:Toremifene / Q000008:administration & dosage*; D014230:Triazoles / Q000008:administration & dosage*
chemical_list: D000970:Antineoplastic Agents; D009570:Nitriles; D011987:Receptors, Steroid; D014230:Triazoles; D000735:Androstenedione; C048751:atamestane; D000077289:Letrozole; D017312:Toremifene