Avemar in hormone dependent breast cancer

Mate Hidvegi, PhD

Phytoestrogens in our foods

Phytoestrogens are natural compounds in foods of plant origin. Phytoestrogens are structurally similar to mammalian estrogens and may also show functional similarity to estrogens biosynthetized by mammals. Most of the phytoestrogens are phenolics, and are present in seeds (sunflower, sesame, flax), nuts (walnut, almonds), grains (oat,barley, wheat), herbs (licorice, hops, tea), fruits, such as apples, citrus fruits, pomegranate, berries (strawberry, cranberry), peaches, apricot, cherries, grapes, coffee, vegetables, such as carrots, sprouts, olives, legumes (lentils, beans) and, particularly in soy. Important phytoestrogens: resveratrol (grape skin, red wine), quercetin (onions, capers, lime, Hungarian wax pepper), luteolin (green pepper, chamomile, broccoli, oregano, artichoke), hesperetin (oranges,lemon), apigenin (chamomile, wheat germ, parsley, celery), myricetin (cranberry), kaempferol (tomatoes, potatoes, Brussels sprout, cucumber, green tea, peaches, Aloe vera, apples), genistein (soy), proanthocyanides (chocholate,cherries, apricots), coumestrol (spinach) just to mention a few.1 Despite the exhaustive scientific literature demonstrating their beneficial effects on human health, phytoestrogens are, for sake of simplicity, considered by many oncologists as forbidden foods in estrogen dependent breast cancers. Although it is true that phytoestrogens bind estrogen receptors with high affinity in vitro, under real life conditions however, phytoestrogens rather seem cancer chemopreventative or anti-cancer substances.

Avemar pulvis, also called in the literature as fermented wheat germ extract (FWGE) powder, the active ingredient of several FWGE products, is standardized to methoxy-substituted benzoquinone marker compounds, i. e. 2,6-dimethoxy-p-benzoquinone (2,6-DMBQ) and 2-methoxybenzoquinone (2-MBQ) which are the oxidation products of the corresponding hydroquinones. These compounds are present in raw wheat germ as glycosides and, during fermentation, are liberated as aglycones by the action of glycosidases of the fermenting organism. Avemar pulvis contains all the water-solublebioactive material of fermented wheat germ liquid (pure Avemar solids), encapsulated and spray-dried. A single dose (17 g) of the commercial Avemar granulate, as recommended for an approx. 70 kg body weight adult, contains 8.5 g Avemar pulvis plus added flavoring ingredients. The pure Avemar solids content of Avemar pulvis is 63.2%. Avemar pulvis is manufactured exclusively by Biropharma Kft, in its GMP certified pharmaceutical plant in Hungary at the Kunfeherto natural reserve area.

Another pharmaceutical form of FWGE is called Avemar lyophilisate, or Oncomar. Avemar lyophilisate is alsomanufactured solely by Biropharma Kft. This proprietary FWGE formula also comprises all of the pure Avemar solids,and is prepared by freeze-drying. A single dose of the commercial Avemar lyophilisate, as recommended for an approx. 70 kg body weight adult is 5.75 g. The pure Avemar solids content of Avemar lyophilisate is 95.6%.

As mentioned above, wheat germ contains phytoestrogen. Similarly to other phytoestrogen containing foods, FWGE, when mixed into the medium of estrogen dependent human breast cancer cells (MCF-7), increased estrogen receptoractivity in vitro. It was however shown that after a certain time (72 hours) of Avemar exposure, proliferation of MCF-7 cells was significantly inhibited, and apoptotic elimination of tumor cells was induced.2

Potential clinical activity of Avemar in the treatment of estrogen dependent human breast cancers

After a drug is ingested, it reaches a maximum concentration in blood plasma. This maximum level is termed peak plasma concentration, and is expressed as weight (physical mass) per volume.

The relative antitumor activity (RAA) of an anticancer agent is defined by the following ratio:3

peak plasma concentration (mg/ml)

RAA =                                                                                    ,

in vitro IC50 value (mg/ml)

where in vitro IC50 value denotes the characteristic half-maximal inhibitory concentration of the anticancer agent against certain cancer cell lines in vitro. The smaller the in vitro IC50 value the greater the potency of the compound. 

An anticancer agent is considered to have potential clinical activity if its relative antitumor activity value is greater than 1 (RAA > 1).4

The plasma volume of an average (70 kg body weight, BW) adult human person is approximately 3.5 L (liter).

It has been estimated that peak plasma concentration of pure Avemar solids after the oral intake of a standard dose of a commercial Avemar product in patients is between 0.5-1 mg/ml.5

A broad and exhaustive in vitro anticancer study of Avemar has been carried out at the Cancer Center of the University of Halle.6 The institute investigated Avemar pulvis.7 One of the human cancer cell lines studied was MCF-7 breast cancer. MCF-7 is an estrogen hormone responding and also progesterone positive breast cancer cell line, derived in the early 1970’s in Detroit, from the pleural effusion of a 69-year-old white female suffering from metastatic mammary adenocarcinoma.8 The stable cell line, MCF-7, retained the characteristics of the original transformed phenotype including the cytoplasmic estrogen receptor and ribonucleotide reductase thus, has been used regularly in cancer research since. Avemar pulvis showed strong anticancer activity against MCF-7 cells, with an in vitro IC50 value of 0.31 mg/ml, which can be normalized to that of the pure Avemar solids by the formula:

(in vitro IC50 value of pure Avemar solids) = 0.632 x (in vitro IC50 value of Avemar pulvis), where the numeric factor accounts the pure Avemar solids content of Avemar pulvis. Thus, the in vitro IC50 value of pure Avemar solids is 0.20 mg/ml. Consequently, the relative antitumor activity of Avemar against MCF-7 breast cancer cells can be calculated as:

0.5-to-1 mg/ml

RAA (of Avemar against MCF-7) =-------------------------------- = 2.5-to-5

0.20 mg/ml

Since the RAA value of pure Avemar solids is considerably greater than 1, it can thus be concluded that Avemarcertainly has potential clinical activity in the treatment of estrogen dependent human breast cancers.

Avemar inhibits the dissemination of estrogen dependent human breast cancer cells 

In in vitro anticancer experiments carried out at the Medical University of Vienna, Avemar lyophilisate, due to its robust ribonucleotide reductase inhibitory activity,9 arrested estrogen dependent MCF-7 cells in the S phase of the cell cycle.10 Ribonucleotide reductase, the key enzyme of de novo DNA synthesis in tumor cells, is overexpressed inmalignancy.11 Avemar lyophilisate induced apoptosis via the activation of the proapoptotic protease caspase 8 in caspase-3 negative MCF-7 cells. In addition to its direct proapoptotic effects, Avemar lyophilisate inhibited the invasive capacity of estrogen dependent breast cancer cells in a dose-dependent manner. In a 3D co-culture model, Avemar significantly inhibited lymphendothelial motility, reducing tumor spheroid induced gap size by 43%. Thus,Avemar is able to inhibit cellular processes involved in tumor cell invasion and lymphatic spread of estrogen dependent breast cancer.

Avemar inhibits the growth of estrogen dependent murine and

HUMAN BREAST CARCINOMAS EQUAL OR BETTER THAN STANDARD ENDOCRINE DRUGS

In in vivo anticancer experiments (initiated by renowned Hungarian oncologist, academician Sandor Eckhardt12),carried out at the National Institute of Oncology (Budapest, Hungary),13 female, 8 week old (22-23 g) inbred BDF1 mice were used. The mice were kept under specific pathogen free (SPF) conditions. Estrogen dependent MXT mouse mammary carcinoma, obtained from the National Cancer Institute (NCI, Bethesda, MD), was injected into the dorsal skin of the experimental mice. Tumor growth was measured at certain time points throughout the experiments. Avemar (Biropharma), applied orally as aqueous solution via gastric tube, tamoxifen (Nolvadex, AstraZeneca), injected subcutaneously, anastrozole (Arimidex, AstraZeneca), and exemestane (Aromasin, Pfizer), both injected intraperitoneally, were used as test compounds. The control mice received saline, administered orally (in case of Avemar monotherapy), or intraperitoneally (in case of combination therapies).

All test doses of Avemar monotherapy significantly inhibited tumor growth and lengthened overall survival in estrogen dependent MXT tumor bearing mice. Highest levels of tumor growth inhibiton as well as of lengthening overall survival of animals were found with an Avemar dose what corresponded to the recommended single daily human dose of theproduct.

Tamoxifen, anastrozole and exemestane monotherapies also resulted prolongation of survival though, these values were not significant compared to the control. When however, these endocrine drugs were combined with Avemar, lengths ofoverall survival of the animals were similar or greater than those achieved by the endocrine drugs on their own.

All monotherapies and Avemar-drug combinations resulted in decrease of tumor volume compared to the control and, Avemar monotherapy proved to be the most effective among monotherapies. The tumor growth inhibitory efficacies of the Avemar plus endocrine drugs combinations were greater than those of the endocrine drugs on their own. TheAvemar plus exemestane combination resulted in more than 60% inhibition of tumor growth.

The T47-D human breast cancer cell line is a widely used model of estrogen and progesterone receptor positive mammary carcinoma.14 The tumor line has been isolated from pleural effusion of ductal breast cancer of an elderly patient. In xenograft models15, administration of Avemar on its own resulted in significant inhibition of tumor growth compared to control.

The efficacy of Avemar in terms of blocking the growth of hormone dependent human breast cancer was greater than that of the drug monotherapy treatments. Percentage inhibitions compared to control were: Avemar (50%), tamoxifen (42%), anastrozole (25%), exemestane (26%).16 When the hormonal drugs were combined with Avemar, the tumor growth inhibitory efficacies of the combinations exceeded those of the drug monotherapies by 3-to 10 percent.17

MDA-MB-231 is an estrogen-negative and progesterone-negative human breast cancer cell line thus, antiestrogen drugs are ineffective in this tumor. In xenograft models, orally administered Avemar significantly reduced MDA-MB-231 tumor growth by 55%, in a similar extent than in the hormone dependent T47-D xenograft model.18

The National Institute of Oncology study, led by chief medical oncologist Andras Telekes, MD, PhD, concluded as follows: The tumor growth inhibitory effect of Avemar on estrogen receptor positive MXT murine breast carcinoma as well as in T47-D human xenograft models are comparable (equal or better) to standard endocrine treatments. Avemar certainly did not reduce the effect of endocrine treatments. Avemar showed similar efficacy (50% inhibition of growth)when estrogen and progesterone dependent versus estrogen and progesterone receptor negative human breast cancer xenografts were compared. The antitumor activity of Avemar did not depend on the estrogen receptor status of breast tumors.

Conclusion

The use of Avemar as a non-prescription medical nutriment for hormone dependent (estrogen or progesterone receptorpositive) and hormone receptor negative breast cancer patients seems beneficial and combined use with hormonal drugs appears reasonable.

Budapest, Hungary, January, 2022

References

1 Patisaul HB, Jefferson W: The pros and cons of phytoestrogens. Front Neuroendocrinol. 2010, 31: 400-419.

2 Marcsek Z, Kocsis Z, Jakab M, Szende B, Tompa A: The efficacy of tamoxifen in estrogen receptor–positive breast cancer cells is enhanced by a medical nutriment. Cancer Biother Radiopharm. 2004, 19: 746-753.

3 Ohe Y, Nakagawa K, Fujiwara Y, Sasaki Y, Minato K, Bungo M, Niimi S, Horichi N, Fukuda M, Saijo N: In vitro evaluation of the new anticancer agents KT6149, MX-2, SM5887, menogaril, and liblomycin using cisplatin- or adriamycin-resistant human cancer cell lines. Cancer Res. 1989, 49: 4098-4102.

4 Mueller T, Jordan K, Voigt W: Promising cytotoxic activity profile of fermented wheat germ extract (Avemar(R)) in human cancer cell lines. J Exp Clin Cancer Res. 2011, 30: 42.

5 Comin-Anduix B, Boros LG, Marin S, Boren J, Callol-Massot C, Centelles JJ, Torres JL, Agell N, Bassilian S, Cascante M: Fermented wheat germ extract inhibits glycolysis/pentose cycle enzymes and induces apoptosis through poly(ADP-ribose) polymerase activation inJurkat T-cell leukemia tumor cells. J Biol Chem. 2002, 277: 46408-46414.

6 Voigt W, Mueller T, Jordan K, Reipisch F, Nerger K, Schmoll HJ: Promising cytotoxic activity profile of fermented wheat germ extract (Avemar(R)) in human cancer cell lines. Eur J Cancer. 2009, S7: 110.

7 Avemar pulvis was delivered to the Halle laboratory by the author of the present article.

8 Soule HD, Vazquez J, Long A, Albert S, Brennan M: A human cell line from a pleural effusion derived from a breast carcinoma. J Natl Cancer Inst. 1973, 51: 1409-1416.

9 Saiko P, Ozsvar-Kozma M, Madlener S, Bernhaus A, Lackner A, Grusch M, Horvath Z, Krupitza G, Jaeger W, Ammer K, Fritzer-Szekeres M, Szekeres T: Avemar, a nontoxic fermented wheat germ extract, induces apoptosis and inhibits ribonucleotide reductase in human HL-60 promyelocytic leukemia cells. Cancer

Lett. 2006, 250: 323-328.

10 Bago-Horvath Z, Teichmann M, Forstner B, Komina O, Bedeir A, Wesierska-Gadek J, Grusch M, Szekeres T, Krupitza G, Mader RM: Avemar, a lyophilised fermented wheat germ extract inhibits breast cancer cell proliferation and invasion in vitro. Poster presented at the ESMO2011. European Cancer Congress. Stockholm, Sweden, 23 Sep - 27 Sep, 2011.

11 Szekeres T, Fritzer-Szekeres M, Elford HL: The enzyme ribonucleotide reductase: target for antitumor and anti-HIV therapy. Crit Rev Clin Lab Sci. 1997, 34: 503-528.

12 Deceased in 2016.

13 Tejeda M, Gaal D, Szucs I, Telekes A: Avemar inhibits the growth of mouse and human xenograft mammary carcinomas comparable to endocrine treatments. J Clin Oncol. 2007, 25: 21132.

14 Lacroix M, Leclercq G: Relevance of breast cancer cell lines as models for breast tumours: an update. Breast Cancer Res Treatment. 2004, 83: 249-289.

15 T47-D hormone dependent human breast tumor implanted in nude mice.

16 I. e., tumor growth was reduced by X% or, in other words, the average tumor size in the treated mice was X% smaller than in the control group.

17 Hidvegi M: Fermented wheat germ extract (Avemar). Lecture presented for the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) March 27, 2009 Oncology Interest Group Meeting.

18 Schachter MB: Supporting body defenses against breast cancer with Avemar & AHCC. 8th Annual Complementary Medicine Conference: “AHolistic Approach to Breast Health”: State University of New York, SUNY New Paltz, New Paltz, NY, April 19, 2009.