Impact of estetrol on breast cancer development, metastatic dissemination and angiogenesis

The increased risk of breast cancer and thromboembolism in women who take Hormone Replacement Therapy (HRT) currently is a major public health problem. The discovery of novel molecules with better safety profile would provide useful advances for patient care. Estretrol (E4) appears as a promising candidate for HRT. Indeed, in contrast to current treatment containing ethinyl estradiol or estradiol (E2), E4 has a minimal impact on liver cells activity supporting a decreased incidence on thromboembolic events. In preclinical studies, E4 has been effective against the main symptoms of menopause such as hot flushes, vaginal atrophy, and osteoporosis, from a starting dose of 0.3 mg/kg/day. The aim of this study was to define the impact of E4 on breast cancer development when it is used at concentrations effective for menopause symptom relief.
Treatment of estrogen receptor (ER)-positive breast cancer-developing mice (MMTV-PyMT) with several concentrations of E4 has shown that 0.3 mg/kg/day E4 did not increase tumor development and metastasis dissemination. However, at 3mg/kg/day, E4 increased the growth of hormone-dependent tumors and their metastatic dissemination in ovariectomized and intact mice. This effect was similar to the one observed with E2 used at 0.08 mg/kg/day. In an in vivo model of ER-negative tumors, we observed that 3mg/kg/day E4 improved tumor growth by increasing angiogenesis, and subsequently decreasing necrosis and tumor hypoxia. In contrast, 0.3 mg/kg/day E4 did not induce any of these effects on ER-negative tumors and tumor microenvironment.
In conclusion, we have shown that 0.3 mg/kg/day E4, already reported to prevent menopause symptoms, does not increase breast tumor growth, metastasis dissemination, and angiogenesis. However, similarly to E2, higher concentrations of E4 are pro-tumorous. These results support that E4, if it is used in strictly controlled clinical applications, could have no or only limited impact on breast cancer.