1. Nano Curcumin for Breast Cancer Prevention Banu Arun, M.D. Professor, Breast Medical Oncology Co-Director Clinical Cancer Genetics

2. Background • Selective estrogen receptor modulators (SERMs): Tamoxifen and Raloxifene decrease breast cancer risk by ~50%; the only FDA approved drugs • Tamoxifen more effective than raloxifene in reducing risk of invasive cancer

3. Background • Side effects of SERMS: Risk of thromboembolic events, endometrial cancer, menopausal symptoms • Only 30% high risk women and 50% patients with DCIS opt to take tamoxifen • Raloxifene not indicated in postemenopausal women

4. Background • SERMs: No effect on ER negative (ER-) breast cancer risk reduction • ⇒ Need for ER- breast cancer risk reduction agents for pre-and postmenopausal women • Curcumin (turmeric) potential agent

5. Curcumin is derived from the plant Curcuma longa Is commonly used as a spice and flavoring agent Suppress proliferation, induce apoptosis, anti-inflammatory properties Clinical phase I studies: MTD 8000mg (no toxicity) - Reversal of oral leukoplakia (Sharma et.al 2001, Cheng et al. 2001) Phase I study at MDACC pancreatic cancer at 8 g/d: 2/25 had clinical benefit, COX-2 and NFkB expression was downregulated To date no prospective prevention study in breast cancer Background

6. Background-Nano curcumin • Despite no toxicity, concern about oral bioavailability • Recently drug delivery systems created using nanoparticle technology • Preclinical studies 60x higher bioavailability • Phase I study in patients with heart failure ongoing • Phase I study for solid tumors at MDACC at 500 mg/d ongoing

7. 2.0 1.0 MDA-MB-436 0.0 0 1 2 3 4 5 6 7 0.8 0 M 0.6 10 M Cell Proliferation (MTT, A570nm) 0.4 50 M 0.2 0.0 MDA MB 468 0 1 2 3 4 5 6 7 Days Days 0 M 10 M 50 M Preliminary Studies Curcumin Inhibits Proliferation of Human Breast Cancer Cell Lines Aggarwal

8. Preliminary Studies Curcumin prevents mammary tumor formation DMBA induced mammary tumor Singletary, K. et al. , 1996

9. Specific Aims • Specific Aim #1 To evaluate curcumin induced changes in cytology and proliferation pathways (NFkB, IGFBP, Ki-67, EGFR, PI3K) in breast tissue and serum of women at increased risk for breast cancer • Specific Aim #2 To evaluate changes in breast density before and after curcumin measured with mammogram and breast MRI

10. 0 2 4 8 12 24 Curcumin (h) Cyclin D1 COX-2 Bcl-2  actin Preliminary Studies Curcumin inhibits Nuclear NF-kB and NF-kB Regulated Genes NF-B 0 0.5 1 2 4 8 t (h) Curcumin downregulates the NF-kB regulated gene products in MDA-MB-436 cells Curcumin inhibits constitutive nuclear NF-kB in MDA-MB-436 cells Aggarwal et.al, 2003

11. Preliminary Studies Selected markers inhibited by Curcumin: •  NF-kB •  Ki-67 •  COX-2 •  EGFR, Her-2/Neu •  AP-1 Aggarwal et al. 2003

12. Preliminary Studies NFkB p65 expression in breast cancer Predominantly cytoplasmic staining by immunohistochemistry with focal nuclear positivity (using the anti-phospho-NFB p65 (Ser536) antibody (Cell Signaling Technology (Beverly, MA)).

13. Conduct of Study FNA FNA Nano curcumin 12 mo MTD from phase I Serum, urine Serum, urine • Endpoints: • Modulation of cytology (FNA) and proliferation pathway • Change in mammographic density and change in MRI • (Evaluation of curcumin metabolites in serum and urine)

14. Eligibility • Patients with ER negative breast cancer, stage I-III, NED for at least 3 months and intact opposite breast • No current endocrine, targeted therapy • Adequate organ function • Willing to undergo FNA x2 • Sign consent

15. Accrual: Preliminary data Phase II Celecoxib and Anastrozole study: 86 patients underwent FNA and DL at baseline • FNA: Samples obtained from 100% 96% adequate cells (>10 epithelial cells/slide) Total adequacy: 96% None of the patients dropped from the study! Procedure was very acceptable. Arun et al CCR 2007

16. Cytologic analysis FNA: Benign ductal epithelium Arun et al CCR 2007

17. Cytology Findings Cytology Findings • Hyperplasia: 26% • Atypical hyperplasia: 24.4 % Arun et al ASCO 2007

18. Modulation of IGFBP-1 with Celecoxib p=0.04 (Wilcoxon signed rank test) Post Pre No change was observed in IGF-1 and IGFBP-3 Arun et al ASCO 2007

19. Modulation of IGFBP-1 with Celecoxib Arun et al ASCO 2007

20. Biomarker changes • Increase of IGFBP-1 also shown in our Anastrozole phase II study (Arun ASCO 2009) • Also shown with Tamoxifen by D Euhus (UTSW) (Euhus et al AACR-Epidemiology and Prevention, 2007. Manuscript submitted) ⇒ Changes in cytology and IGFBP-1 will be used in Aim #1 as primary endpoint

21. Importance of this study • First! Phase II breast cancer prevention study that can be carried out in the community. Community MDs and their patients will be able to participate without needing to travel to major academic centers • Interest in NCAMs: My patients want this and they are taking it anyway: Curcumin, fish oil, palm tree oil • Information gained from this study will help to plan: • In patient with breast cancer: Secondary prevention • In high risk (including BRCA mutation carriers): Primary prevention

22. THANK YOU !